Inhalation – Dry and Moist Inhalation
Purpose, Procedure and Nurse’s Responsibility
DEFINITION
Inhalation is the act of drawing in air, vapour or gas into the lungs. Drugs are inhaled either for a local effect (e.g., steam inhalation to relieve congestion in the respiratory tract) or for a general effect e.g., inhalation of oxygen and anaesthetics. Inhalations are given either dry or moist.
DRY INHALATIONS
It is the inhalation of gases, fumes from volatile drugs or burning drugs. Example of dry inhalation are:
1. Inhalation of general anaesthetics: ether, chloroform, nitrous oxide etc., are given by using a mask.
2. Oxygen and carbon dioxide inhalations: these are administered by using a mask, tent or catheter.
3. Inhalation of volatile drugs: amyl nitrate contained in an ampoule is broken and emptied into a gauze piece or handkerchief and is held under the nose of the patient and the patient inhales the fumes. This is used to relieve the pain in angina pectoris.
Volatile drugs such as menthol, aromatic spirits of ammonia, eucalyptus; etc., are administered in the same way. When aromatic spirits are administered, care should be taken that the drug neither touch the skin nor its fumes irritate the conjunctiva of the eyes. Therefore, it be held away from the nose and eyes.
4. Inhalation of strammonium and belladonna: these are burned and the patient breathes the fumes.
5. Aerosol spray: an aerosol is a fine suspension of liquid or a powder that deliver medications topically into the respiratory tract. Atomizers and nebulizers are used for spraying medication into the respiratory passages.
MOIST INHALATIONS
Breathing down and moist air produced by a vaporizer is called stream/moist inhalation. The value of steam inhalation lies chiefly in the moisture and heat, although the medicines used are also helpful as they are acting as respiratory antiseptics.
Purpose of Steam Inhalations:
1. To relieve the inflammation and congestion of the mucus membranes of the respiratory tract and paranasal sinuses, thus to produce symptomatic relief in acute cold and sinusitis.
2. To soften thick, tenacious mucus and help its expulsion from the respiratory tract, thus to relieve cough in bronchitis, and in post-operative cases etc.
3. To provide heat and moisture and to prevent the dryness of the mucus membranes of the lung and upper respiratory passages following operations such as tracheostomy.
4. To aid in the absorption of oxygen.
5. To relieve spastic conditions of the larynx and bronchi.
6. To provide antiseptic action on the respiratory tract e.g. by using menthol, tr. Benzoin, eucalyptus etc.
Drugs Used:
1. Tr. Benzoin 5 ml per 500 ml of boiling water.
2. Eucalyptus 2 ml per 500 ml of boiling water.
3. Methyl salicylate few drops per 500 ml of boiling water.
4. Menthol few crystals per 500 ml of boiling water.
5. Camphor few crystals per 500 ml of boiling water.
METHODS FOR GIVING STEAM INHALATION
JUG METHOD 2. BY STEAM TENT 3. BY ELECTRIC STEAM INHALER.
Jug Method:
In this method, a Nelson’s inhaler is used. The type of the inhalant required and the boiling water is filled in the jug and the patient breathes a vapor.
At Home: when Nelson’s inhaler is not available the patients can be advised to improvise a jug. A tea kettle or a mug is filled with boiling water and the inhalant. A ‘cone’ is made with a card board paper and is fitted over the kettle or the mug. Through a small hole made on the top of the cone the patient breathes in the stream.
Stream Tent:
When a high concentration of stream is required, a steam tent may be used. There are different ways of making a tent. A quick and easy method is to place a screen on either sides on the patient’s bed and stretch blankets or sheets across them, fixing them with safety pains, and forming a canopy. Wooden blankets are preferred to sheet because they absorb moisture and will not drip over the patient. For a child, the blankets can be stretched across the top of the cot. The stream can then be directed into the tent from the spout of a kettle.
Care must be taken that the stove and the kettle are placed far away from the screen and the bed clothes to prevent the danger of catching fire. Never point the spout towards the face of the patient. A child should never be near enough to the steam generating apparatus to get his hands into the steam jet.
The steam may be given for 20 to 30 minutes at a time and it may be repeated every four hours or it may be given continuously in special cases. Tr. Benzoin and water are added necessarily. Continuous observation is essential to avoid scalding of the patient.
Electric Steam Inhaler:
Small electric vaporizers can be used to give steam inhalation. It consists of a small jar with a heating element extending into the jar. The jar is filled with water. On the top of the jar is a removable perforated cup to which is attached a small metal spout. Cotton saturated with medication is placed inside the cup and the metal spout is fitted over the cup. As the water boils, the medicated steam is directed through the spout which is inhaled by the patient.
NURSE’S RESPONSIBILITY IN THE ADMINISTRATION OF STEAM INHALATION
Using A Nelson’s Inhaler:
Preliminary Assessment:
1. Check the patient’s name, bed number and other identifications.
2. Check the diagnosis and the general condition of the patient.
3. Check the physician’s orders to see the specific precautions for the patient’s movement and positioning.
4. Assess the patient’s ability for self care, his ability to move and to maintain the desired position.
5. Assess the level of consciousness and the ability to follow instructions.
6. Check the articles available in the patient’s unit.
PREPARATION OF ARTICLES
Articles:
A tray containing:
Nelson’s inhaler with a mouth piece tightly fit to the neck of the inhaler.
Purpose: to use as a vaporizer.
Bowl or basin large enough to hold the inhaler.
Purpose: to place the inhaler safely.
A flannel piece or a towel.
Purpose: to wrap around the inhaler to prevent the heat loss.
Face towel.
Purpose: to wipe the face of the patient.
Bath blanket or bath towel.
Purpose: to put over the patient’s head and the jug to prevent the loss of steam.
Tr. Benzoin or any other inhalant ordered.
Purpose: used as a respiratory antiseptic.
Teaspoon or a minim glass.
Purpose: to measure the inhalant.
Kettle with boiling water.
Gauze piece in a container.
Purpose: to wrap around the mouth pieces.
Cotton swabs in a container.
Purpose: to plug the spout.
Kidney tray and paper bag.
Purpose: to receive the wastes.
Preparation of the Patient and the Environment
1. Explain the procedure to the patient to win his confidence and co-operation. Explain the sequence of the procedure and tell him how he can take the inhalation.
2. Make the patient to understand that he has to remain in the bed one to two hours more after the inhalation.
3. Ask the patient to go to the toilet and empty the bladder and bowels, if necessary. For a bed ridden patient, offer bed pan or urinal, so that he will not be disturbed during the procedure. Emptying the bladder and bowels ensures that the patient will remain on the bed for several hours after the inhalation.
4. Place the patient in a Fowler’s position with a cardiac table in front. If the movements are restricted, place him in a sidelying position, or place him in any position which is comfortable to him (e.g. sitting with a pillow on the lap).
5. Close the doors and windows and put off the fan to prevent draught.
6. Place the sputum cup in a convenient place within the easy reach the patient.
7. Provide a face towel to the patient to wipe the sweating from the face during the inhalation.
PROCEDURE
1. Measure the capacity of the inhaler with cold water. Measure the capacity when it is filled half to two thirds full.
Purpose: to determine the amount of inhalant.
2. Warm the inhaler by pouring a little hot water into the jug and emptying it.
Purpose: to maintain the temperature of the water, constant for a longer period.
3. Pour the required amount of inhalant into the inhaler and fill the jug 2/3 with hot water. The water should remain just below the spout.
Purpose: if the inhaler is filled to the brim, there is possibility of drawing water into the mouth and cause scalds. If the spout is filled with water, it will not act as an air inlet. The patient will not get warm air.
4. Place the mouth piece with a gauze piece and plug the spout with a cotton ball.
Purpose: covering the mouth piece with a gauze piece will prevent burns of the lips. Cotton ball in the spout will prevent escape of steam.
5. the jug with a flannel piece or a towel.
Purpose: to insulate the jug and to prevent the heat loss.
6. Place the inhaler in the basin and take it to the bedside without losing time.
Purpose: placing the jug in the basin reduces the chances for burns.
7. Place the apparatus conveniently in front of the patient with the spout opposite to the patient. Remove the cotton plug and discard it into the paper bag.
Purpose: keeping the spout opposite to the patient reduces the chances of burns. Removing the cotton plug strips to keep up the patency of the spout for the air.
8. Instruct the patient to place the lips on the mouth piece and breath in the vapour. After removing the lips from the mouth piece, breath out the air. Alternately, he should breath in the steam through the nostrils.
Purpose: directing the steam through the nostrils relieves the congestion of the mucus membranes of the nostrils.
9. Cover the patient’s head and jug with a bath blanket or a bath towel.
Purpose: to help to collect the steam around the face of the patient, thereby the concentration of the steam will be increased.
After Care of Patient and the Articles
1. Continue the treatment for 15 to 20 minutes, or as long as the patient gets the vapours.
2. Remove the inhaler from the patient after the stated time. Wipe off the perspiration from the face.
3. Remove the back rest and the cardiac table. Adjust the position of the patient in bed. Make him comfortable. Tidy up the bed.
4. Instruct him to remain in bed for 1 to 2 hours to prevent draught.
5. Take the articles to the utility room. Empty the inhaler, clean it inside with spirit to remove tr. Benzoin. Then wash it with warm soapy water. Rinse with clean water. Remove the gauze covering the mouth piece and clean the mouth piece thoroughly. Boil it to prevent cross infection. All the other articles are cleaned with warm soapy water and then with clean water. Dry and replace them in their proper places. Wash hands.
6. Record the procedure on the nurse’s record with date and time. Record the patient’s response to the procedure.
7. Return to the patient to assess his comfort and to observe any untoward reactions in him. Offer hot drinks if needed.
OXYGEN INHALATIONS
Patient with respiratory dysfunctions are treated with oxygen inhalations to relieve ‘anoxaemia’ or ‘hypoxaemia’ (deficiency of oxygen in the blood). The normal amount of oxygen in the arterial blood should be in the range of 80 to 100 mm of Hg. If it fails below 60 mm of Hg, irreversible physiologic effects may occur. Thus it is urgent to correct anoxaemia promptly. Tissues vary in their oxygen requirements. The cerebral cells receive 20 percent of the body’s oxygen supply and can live only for a few minutes (5 to 7 minutes) if their oxygen supply is cut off. Other cells such as myocardium can survive little more without a fresh supply of oxygen. Remember, that the oxygen administration treats the effects of oxygen deficiency but it does not correct the underlying causes.
Indications of Oxygen Therapy
Cyanosis, breathlessness of labored breathing, environment with low oxygen, anaemia, disease conditions, respiratory capacity diminished,, poisoning with chemical, shock and circulatory failure, haemorrhage and asphyxia.
Methods of Oxygen Administration
Nasal cannula.
Oxygen by Nasal Catheter
Oxygen by Mask
Oxygen Tent
Transtracheal Oxygen
NURSE’S RESPONSIBILITY IN THE ADMINISTRATION OF OXYGEN BY THE CATHETER METHOD
Preliminary Assessment:
1. Check the name, bed number and other identifications of the patient.
2. Check the diagnosis and the need for oxygen therapy.
3. Check the doctor’s orders for the initiation of the therapy, the dosage (litre/minute) etc.
4. Check the doctor’s orders for specific precautions regarding the movement and positioning of the patient.
5. Assess the patient for any signs of clinical anoxia, e.g. cyanosis.
6. Assess the patient’s vital signs and the breathing patterns carefully before starting the therapy. This will help to determine the patient’s response to therapy.
7. Check the results of arterial blood gas analysis.
8 Note any signs of pulmonary dysfunction.
9. Inspect the anterior nares for encrustation and irritation.
10. Inspect the skin on the nose and the surrounding areas for any skin lesions. The adhesive tapes may have to be used to fix the catheter in position.
11. Check the patient’s mental state and the ability to follow instructions.
12. Check the articles available in the unit. Check the oxygen cylinder and its accessories for their functions. (e.g. check for any leakage of oxygen).
PREPARATION OF ARTICLES
Articles:
a. Oxygen cylinder with its stand and accessories (the regulator, flow meter, humidifier, connecting tube etc). check and see whether the whole system works in good order.
A tray containing
b. Nasal catheter of appropriate size, clean and sterile or disposable type in a covered container.
Purpose: to administer oxygen without introducing infection into the respiratory passage.
Water soluble lubricating jelly.
Purpose: to lubricate the catheter before its insertion into the nares.
Adhesive tapes.
Purpose: to secure the catheter in place.
Bowl of water.
Purpose: to test the oxygen flow.
Flash light and tongue depressor.
Purpose: to help to assess the correct placement of the catheter.
Cotton applicators and normal saline in a container.
Purpose: to clean the nostrils.
Kidney tray and paper bag.
Purpose: to receive the wastes and the used tongue depressor.
Mackintosh and towel.
Purpose: to protect the garment and the end clothes.
Rag pieces or gauze pieces in a container.
Purpose: to wipe off the secretions from the nose and mouth during the procedure.
PROCEDURE
1. Wash hands.
Reason: to prevent cross infection.
2. Measure the length of the nasal catheter to be introduced into the nostrils. Measure the length of the catheter from the tip of the nose to ear lobe. Mark the length with ink.
Reason: the catheter should extend from the anterior nares to the level to the uvula. The tip should be visible only when the uvula is elevated. The distance from the tip of the nose to the ear lobe roughly equals the distance from the anterior nares to the uvula.
If the tip of the catheter is not reaching the oro-pharynx there is a chance for the oxygen loss through the open mouth. If the tip of the catheter goes beyond the level of the uvula into the oesophagus, there is a chance for the gas to be introduced into the stomach and cause distension of the abdomen.
3. Check the apparatus for the working condition. Open the main valve in an anti-clockwise direction. Look for the pressure reading on the gauge. Open the wheel valve on the regulator and see the reading on the flow meter and adjust the flow of oxygen 2 to 4 litres for adults or as desired. When the wheel valve is opened, the oxygen will start bubbling through the water in the Wolf’s bottle. Attach the catheter to the connecting tube and check the flow of oxygen through the catheter by submerging it under the water in the bowl.
Reason: check the apparatus before inserting the catheter will help to find out the amount of oxygen in the cylinder, the flow rate (litres per minute) and whether the whole apparatus is in good working order or not.
4. Lubricating the tip of the catheter sparingly with water soluble jelly and then check the flow by immersing it in the water.
Reason: lubricating the tube prevents irritation of the nasal mucosa. Checking the flow of oxygen again under the water helps to know whether the terminal holes are plugged with the lubricant.
5. Introducing catheter slowly into one of the nostrils to the previously marked distance. If any obstruction is encountered, withdraw the catheter a little, rotate it and introduce it again. Never use force.
Reason: forcing the catheter can cause injury to the mucus membranes. It can also cause kinking of the tube in the nasal cavity.
6. Check the position of the catheter in the oropharynx at the level of the uvula. It can be checked by asking the patient to open his mouth widely, depressing the tongue with a tongue depressor directing the flash light into the throat.
Reason: checking is done to make sure that the catheter is positioned in a correct place and not kinked.
7. Fix the catheter either over the forehead or at the cheek with adhesive straps. Secure the connecting tube to the bed clothes or the patient’s gown using an elastic band and a safety pin.
Reason: prevents displacement of the catheter when the patient moves in bed.
After Care of the Patient and the Articles
1. Stay with the patient till he is at ease.
2. Keep the patient warm and comfortable.
3. Evaluate the patient’s progress by observing the vital signs and color. Assess the vital signs very frequently.
4. Record the procedure with date and time on the nurse’s record. Record the time at which the oxygen therapy was started and the patient’s response to the therapy.
5. Check the apparatus for its good working order – the flow rate, level of the distilled water in the humidifier, the safety measures.
6. Arrange for blood gas analysis at specified intervals to make sure that state of anoxaemia is treated.
7. Change the nasal catheters at every 8 hours or more frequently, because the mucus may plug the opening of the catheter and block the oxygen supply. Replace it with a fresh one. Change the nostrils also.
8. When the oxygen is to be stopped, do it gradually. Reduce the volume of oxygen first, then give it intermittently.
9. To discontinue the oxygen inhalation, loosen the adhesive tapes and take out the catheter from the nostrils. Close the main valve first by turning it clockwise, then the wheel valves. Disconnect the catheter and put it in the kidney tray.
Take all articles to the utility room. Clean the catheter first with cold water and then with warm soapy water and finally with clean water. Boil it, dry it and store it in its place or send it for sterilization. All other articles used should be cleaned, dried and replaced in their proper places. Record the time of the oxygen inhalation discontinued, in the nurse’s record.
10. Watch the patient for any deteriorating symptoms after the removal of oxygen inhalation.