Lippincott Nursing Procedures

ISBN: 978-1-975178-58-1 | 9th_Edition

MANUAL VENTILATION
A handheld resuscitation bag is a self-inflating device that can be attached to a face mask or directly to an endotracheal (ET) or
tracheostomy tube 1 , allowing manual delivery of oxygen or room air to the lungs of a patient with absent or inadequate respirations.

During cardiopulmonary resuscitation (CPR), using a handheld resuscitation bag to administer rescue breaths is less important than
providing high-quality chest compressions. Lone rescuers should begin chest compressions first. After 30 compressions, the rescuer
should then administer two breaths. When a second person arrives, that person can use a handheld resuscitation bag to administer
two breaths after every 30 compressions. After an advanced airway (endotracheal tube or supraglottic device) is inserted, one breath
can be delivered every 6 seconds. Whenever an advanced airway is inserted during CPR, rescuers may perform continuous
compressions with positive pressure ventilation delivered through the handheld resuscitation bag without pausing chest
compressions. 2

Equipment
Handheld resuscitation bag with mask ▪ oxygen source ▪ oxygen tubing ▪ nipple adapter attached to oxygen flowmeter ▪
gloves ▪ suction equipment ▪ emergency resuscitation equipment (code cart with emergency medications, defibrillator, and
intubation equipment) ▪ Optional: gown, mask and goggles or mask and face shield, oropharyngeal airway, nasopharyngeal
airway, oxygen accumulator (oxygen reservoir).

Preparation of equipment

Unless the patient is intubated or has a tracheostomy, select a mask that fits snugly over the mouth and nose. Attach the mask to the
resuscitation bag.

(Print pagebreak 535)

If oxygen is readily available, connect the handheld resuscitation bag to the oxygen. Attach one end of the tubing to the bottom of
the bag and the other end to the nipple adapter on the flowmeter of the oxygen source.

Turn on the oxygen and adjust the flow rate to 15 L/minute. 3 The patient who has a low partial pressure of arterial oxygen will need
a higher fraction of inspired oxygen (FIO 2 ). To increase the concentration of inspired oxygen, you can add an oxygen accumulator
(also called an oxygen reservoir). This device, which attaches to an adapter on the bottom of the bag, permits an FIO 2 of up to
100%. If time allows, set up suction equipment. Make sure emergency resuscitation equipment is readily available.

Implementation
▪ Gather and prepare the necessary equipment and supplies

▪ Perform hand hygiene. 4 , 5 , 6 , 7 , 8 , 9

▪ Confirm the patient's identity using at least two patient identifiers. 10

▪ Provide privacy. 11 , 12 , 13 , 14

▪ Explain the procedure to the patient and family, if they're present and time allows, according to their individual
communication and learning needs, to increase their understanding, allay their fears, and enhance cooperation . 15

▪ Raise the bed to waist level before providing care to prevent caregiver back strain . 16

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 Lippincott Nursing Procedures
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▪ Put on gloves and other personal protective equipment, as needed, to comply with standard precautions . 17 , 18 , 19

▪ Before using the handheld resuscitation bag, inspect the patient's upper airway for foreign objects. If present, remove them,
because doing so may restore spontaneous respirations in some instances, and because foreign matter or secretions can
obstruct the airway and impede resuscitation efforts.

▪ Suction the patient to remove any secretions that may obstruct the airway. If necessary, insert an oropharyngeal or
nasopharyngeal airway to maintain airway patency. If the patient has a tracheostomy or ET tube in place, suction the tube.

▪ If appropriate, remove the bed's headboard and stand at the head of the bed to help keep the patient's neck extended and to
free space at the side of the bed for other activities, such as CPR.

EQUIPMENT

How to apply a handheld resuscitation bag and mask

Using your nondominant hand, create a C shape with the

thumb and index finger over the top of the mask and apply
gentle downward pressure. Hook the remaining fingers
around the mandible and lift it upward toward the mask,
Place the mask over the patient's face so that the apex of
creating an E shape (as shown below). Make sure that the
the triangle covers the bridge of the nose and the base lies
patient's mouth remains open underneath the mask. Attach
between the lower lip and chin to create a tight seal. Hold
the resuscitation bag to the mask and the tubing leading to
the mask in place (as shown below).
the oxygen source. Alternatively, if the patient has a
tracheostomy or endotracheal tube in place, remove the
mask from the bag and attach the handheld resuscitation
bag directly to the tube.

▪ Unless the patient shows evidence of head or neck trauma, use the head-tilt, chin-lift maneuver to open the patient's airway
to move the tongue away from the base of the pharynx and prevent obstruction of the airway . 20

▪ Apply the mask to the patient's face. (See How to apply a handheld resuscitation bag and mask.)

▪ Keeping your nondominant hand on the patient's mask, exert downward pressure to seal the mask against the face. For the
adult patient, use your dominant hand to compress the bag to deliver 600 mL of air over 1 second to produce a rise in the
patient's chest . 20

▪ Deliver breaths with the patient's own inspiratory effort, if any is present. Don't attempt to deliver a breath as the patient
exhales. During CPR, deliver cycles of 30 compressions and two breaths; deliver breaths during pauses in compressions, and
deliver each breath over 1 second. 20

▪ Observe the patient's chest to ensure that it rises and falls with each ventilation . 20 If ventilation fails to occur, check the fit
of the mask and the patency of the patient's airway; if necessary, reposition the patient's head and ensure patency with an oral
airway.

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 Lippincott Nursing Procedures
ISBN: 978-1-975178-58-1 | 9th_Edition

▪ Assist with advanced airway insertion, if necessary. (See the “Endotracheal intubation” procedure.) After advanced airway
insertion, remove the mask, connect the handheld resuscitation bag to the tube, and provide one breath every 6 seconds.
During CPR, deliver ventilations through the advanced airway without having the second rescuer pause chest compressions. 2

▪ Remove and discard your gloves and any other personal protective equipment worn. 19

▪ Return the bed to the lowest position to prevent falls and maintain patient safety . 21

▪ Perform hand hygiene. 4 , 5 , 6 , 7 , 8 , 9

▪ Document the procedure. 22 , 23 , 24 , 25

Special considerations
▪ Observe for vomiting through the clear part of the mask. 20 If vomiting occurs, stop the procedure immediately, lift the mask,
wipe and suction vomitus, and resume resuscitation.

▪ It isn't possible to deliver an accurate or exact tidal volume while using a handheld resuscitation bag and mask. 26

(Print pagebreak 536)

▪ Give the family the option to remain at the bedside during the procedure, because doing so helps meet the psychosocial
needs of the patient and family in a time of crisis . 27

Complications
Complications may include aspiration of vomitus, pneumonia, gastric distention, and increased intrathoracic pressure with a
subsequent decrease in coronary and cerebral perfusion pressures.

Documentation

In an emergency, record the date and time of the procedure, the reason for initiating the procedure, any complications, interventions
taken, and the patient's response to treatment using your facility's documentation system or cardiopulmonary resuscitation flow
sheet.

If it isn't an emergency, record the date and time of the procedure as well as the reason and length of time the patient was
disconnected from mechanical ventilation and received manual ventilation. Note the patient's tolerance of the procedure, along with
any complications, interventions taken, and the patient's response to those interventions. Document teaching provided to the patient
and family (if appropriate), their understanding of that teaching, and any need for follow-up teaching.

REFERENCES
1 Craven, R. F., et al. (2020). Fundamentals of nursing: Concepts and competencies for practice (9th ed.). Philadelphia, PA:
Wolters Kluwer.

2 Kleinman, M. E., et al. (2018). 2017 American Heart Association focused update on adult basic life support and cardiopulmonary
resuscitation quality: An update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care, Circulation, 137, e7-e13. [Link] (Level VII)

3 Wiegand, D. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis, MO: Elsevier.

4 The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,

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 Lippincott Nursing Procedures
ISBN: 978-1-975178-58-1 | 9th_Edition

IL: The Joint Commission. (Level VII)

5 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recommendations and Reports, 51(RR-16), 1-45. [Link] (Level II)

6 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean
care is safer care. [Link] (Level IV)

7 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

8 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Infection control. 42 C.F.R. § 482.42.

9 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

10 The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

11 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

12 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(c)(1).

13 DNV GL-Healthcare USA, Inc. (2020). [Link].5. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

14 The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL:
The Joint Commission. (Level VII)

15 The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

16 Waters, T. R., et al. (2009). Safe patient handling training for schools of nursing.
[Link] (Level VII)

17 Siegel, J. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in
healthcare settings. [Link] (Level II)

18 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

19 Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number 1910.1030. https://
[Link]/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)

uoma999 | [Link] | 22 January 2025 1:17:18 Utc

 Lippincott Nursing Procedures
ISBN: 978-1-975178-58-1 | 9th_Edition

20 Panchal, A. R., et al. (2020). 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, Part 3: Adult basic and advanced life support. Circulation, 142(6), S358-S365. [Link]
doi/10.1161/CIR.0000000000000898 (Level II)

21 Ganz, D. A., et al. (2013, reviewed 2021). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ
Publication No. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. [Link]
systems/hospital/fallpxtoolkit/[Link] (Level VII)

22 The Joint Commission. (2021). Standard RC.02.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

23 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Medical record services. 42 C.F.R. § 482.24(b).

24 Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

25 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

26 Lee, H. M., et al. (2008). Can you deliver accurate tidal volume by manual resuscitator? Emergency Medicine Journal, 25,
632-634. (Level VI)

27 American Association of Critical-Care Nurses. (2016). AACN practice alert: Family presence during resuscitation and invasive
procedures. [Link]
(Level VII)

MASSIVE INFUSION DEVICE USE

A massive infusion device is a mechanical device used in patients who need rapid fluid replacement with IV fluids or blood
products. It can warm IV fluids or blood products to room temperature to prevent hypothermia and then administer the fluid rapidly
at rates of up to 45,000 mL/hour. 1 The device requires specialized IV tubing that expands under pressure. 2

Examples of a massive infusion device include the Level 1 infuser, the Belmont infuser, and the ThermaCor 1200 Rapid Infuser.
The Level 1 infuser warms fluids through a sealed heat exchanger that contains recirculating solution. Pressure chambers apply
pressure and deliver the prescribed fluids at a rapid rate. The administration set tubing contains a gas vent filter and the heat
exchanger. An air detector clamp monitors for the presence of air; when it detects air, the clamp closes off the line and alerts the
clinician of the presence of air in the system. 3 The Belmont infuser administers the prescribed fluids through the administration set
tubing using a roller-type peristaltic fluid pump. Fluid passes through a heat exchanger that consists of a plastic device housing
stainless steel rings, which transfer heat to the fluid. The infuser also contains a pressure sensor that monitors the line pressure of the
infusate. If the sensor detects pressure that exceeds the limit set by the clinician, the pump automatically slows the infusion. If line
pressure suddenly increases, the device shuts down and an alarm sounds. 1 The ThermaCor 1200 Rapid Infusor (Print pagebreak
537) has a single-use disposable cassette that warms the fluid and provides an administration set with single and dual patient lines.
The system has an air-trapping capability that triggers the air volume sensors when enough air is trapped. 4

Patients with life-threatening conditions such as severe trauma, burns, or GI, postoperative, or postpartum hemorrhage may require
the use of a rapid infusion device to receive large volumes of fluids within a short period. 2 Sterile no-touch technique is required
during massive infusion administration to reduce the risk of vascular catheter-associated infection.

HOSPITAL-ACQUIRED CONDITION ALERT

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 Lippincott Nursing Procedures
ISBN: 978-1-975178-58-1 | 9th_Edition

Keep in mind that the Centers for Medicare and Medicaid Services considers vascular catheter-associated infection to
be a hospital-acquired condition because it can be reasonably prevented using best practices. Follow evidence-based
infection prevention practices, such as performing a vigorous mechanical scrub of the needleless connector and using
sterile no-touch technique, to reduce the risk of vascular catheter-associated infections. 5 , 6 , 7 , 8

Equipment
Massive infusion device ▪ prescribed IV fluids or blood products ▪ prefilled 10-mL syringe (or a syringe specifically designed
to generate lower injection pressure) containing preservative-free normal saline solution ▪ appropriate administration set with
warming device or heat exchanger 1 , 3 ▪ replacement filter or vent or large-capacity reservoir, as indicated 1 , 3 ▪ IV pole ▪
gloves ▪ antiseptic pads (chlorhexidine-based, povidone iodine, or alcohol) ▪ labels ▪ blankets ▪ stethoscope ▪ vital signs
monitoring equipment ▪ disinfectant pad ▪ Optional: indwelling urinary catheter, central venous access catheter or pulmonary
artery catheter insertion and monitoring equipment, arterial catheter insertion and monitoring equipment, supplies for blood
gas sampling, gown, mask with face shield or mask and goggles.

Preparation of equipment

Male sure that the equipment is safe for massive, rapid, or pressurized infusion.

Inspect all IV equipment and supplies; if a product is expired, is defective, or has compromised integrity, remove it from patient use,
label it as expired or defective, and report the expiration or defect as directed by your facility. 9

Set up and use the massive infusion device, warming device, or heat exchanger following the manufacturer's instructions for use.
Make sure that the system is plugged into an outlet to ensure that the infused fluid is heated properly. 1 , 3 Make sure that the device
alarm limits are set appropriately, and that the alarms are turned on, functioning properly, and audible to staff. 10 , 11 Troubleshoot
alarms according to the specific manufacturer's instructions for use. 1 , 3

Implementation
▪ Verify that the practitioner's orders for the prescribed solution, rate, and route of administration are appropriate for the
patient's age, condition, and access device. Address concerns about the order with the practitioner, the pharmacist, or your
supervisor, and (if needed) the risk management department, or as directed by your facility. 12

▪ Verify the baseline coagulation studies and hematocrit, electrolyte, and hemoglobin levels, and results of coagulation and
other studies, as ordered, to serve as benchmarks for comparison and help guide fluid replacement . 2

▪ Check the patient history for allergies, as indicated.

▪ Perform hand hygiene. 13 , 14 , 15 , 16 , 17 , 18

▪ Confirm the patient's identity using at least two patient identifiers. 19

▪ Provide privacy. 20 , 21 , 22 , 23

▪ Reinforce the practitioner's explanation of the procedure according to the patient's and family's individual communication
and learning needs to increase communication, allay their fears, and enhance cooperation . 24 Answer any questions.

▪ Raise the bed to waist level before providing care to prevent caregiver back strain . 25

▪ Perform a baseline physical assessment (before obtaining blood for transfusion, if ordered), including vital signs and
respiratory status. Assess for conditions that can increase the risk of adverse effects of therapy, such as heart failure, fever,
kidney disease, and risk of fluid volume excess. 26

▪ If the patient doesn't already have one in place, insert an indwelling urinary catheter, as ordered, to help monitor fluid
resuscitation efforts. (See the “Indwelling urinary catheter insertion” procedure.)

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 Lippincott Nursing Procedures
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▪ Perform hand hygiene. 13 , 14 , 15 , 16 , 17 , 18

▪ Put on gloves and other personal protective equipment as needed to comply with standard precautions . 27 , 28

▪ Make sure the patient has two patent, large-bore (14G to 18G) IV catheters. 15 If not, insert two IV catheters to administer IV
fluid and medications, as needed, until a central venous catheter is possible . 29 (See the “IV catheter insertion and removal”
procedure.) If you're unable to establish venous access, initiate intraosseous access, if indicated. 2 , 30 (See the “Intraosseous
infusion” procedure.)

▪ Assist the practitioner, as needed, with insertion of a central venous or pulmonary artery catheter to facilitate administration
of large fluid volumes and to help monitor the patient's hemodynamic status . 2

▪ Assist the practitioner, as needed, with arterial catheter insertion for continuous blood pressure assessment . 2

▪ Turn on the infusion device according to the manufacturer's instructions to allow the system to warm up . 2

▪ If you're infusing blood products, perform a pretransfusion blood verification with another qualified health care provider. A
pretransfusion verification by two qualitied health care providers is required to prevent life-threatening blood incompatibility
errors . 19 , 26 , 31 (See the “Transfusion of blood and blood products” procedure.)

HOSPITAL-ACQUIRED CONDITION ALERT

Keep in mind that the Centers for Medicare and Medicaid Services considers blood incompatibility errors to be
a hospital-acquired condition because they can be reasonably prevented using best practices. Be sure to follow
evidence-based prevention practices, such as carefully identifying the patient and the blood sample for
compatibility testing and participating in a two-person verification process before blood and blood products
administration, to reduce the risk of blood incompatibility errors. 5

▪ Remove the appropriate administration set from its packaging. Inspect the administration sets for loose or missing Luer and
spike caps to ensure sterility . 1 , 3

Using the Level 1 infuser

▪ Install the appropriate administration set into the infusion device according to the manufacturer's instructions. 3

▪ Secure the heat exchanger and gas vent filter in their proper positions and turn them on, following the manufacturer's
instructions. 2 , 3

▪ Close all of the clamps on the Y-administration set. 3

▪ Invert and spike the fluid or blood product bag. Squeeze the bag to remove all air and connect the ordered fluid or blood
product to the Y-set. Then hang the bag on the hooks provided within the rapid infuser pressure chambers. 2 Close the
pressure chamber door and secure the latch. Repeat for each fluid line you'll use. 3

▪ Open the clamps above the drip chamber for each IV fluid bag you'll use. 3 Fill the drip chambers on the administration set
halfway by squeezing them to prevent air from entering the tubing . 2 Repeat with each fluid line, as indicated. 3

▪ Open the remaining clamps above the heat exchanger so that fluid will flow into the gas vent filter assembly . 3

▪ Gently tap the gas vent filter assembly to dislodge air bubbles from the filter screen, according to the manufacturer's
instructions. Inspect the tubing and filter when finished to make sure there are no air bubbles . 2

▪ Remove the male Luer cap from the distal end of the administration set tubing. 3

▪ Open the pinch clamp below the gas vent filter assembly. Allow fluid to flow until you no longer observe air in the tubing
and the line is primed with fluid to prevent air embolism. Then close the roller clamp. Put a new needleless connector on the
end of the tubing. 3 , 32

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 Lippincott Nursing Procedures
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▪ Perform a vigorous mechanical scrub of the needleless connector on the vascular access device for at least 5 seconds using
an antiseptic pad, and allow it to dry completely. 6 , 32

▪ While maintaining sterility of the syringe tip, attach a 10-mL syringe or a syringe specifically designed to generate low
injection pressure containing preservative-free normal saline solution to the needleless connector. (Print pagebreak 538)
Unclamp the catheter and slowly aspirate for blood return that is the color and consistency of whole blood. If no blood return
occurs, take steps to locate an external cause of obstruction. 33

▪ If blood return occurs, slowly inject preservative-free normal saline solution into the catheter. Use a minimum volume of
twice the internal volume of the catheter system. Don't forcibly flush the device; further evaluate the device if you meet
resistance. 33

▪ Clamp the catheter and remove and discard the syringe in a puncture-resistant sharps disposal container. 34

▪ Carefully remove the needleless connector from the vascular access device. Perform a vigorous mechanical scrub of the
catheter hub for at least 5 seconds using an antiseptic pad; then allow it to dry completely. 6 , 35 , 36

▪ Trace the tubing from the patient to its point of origin to make sure that you're attaching the tubing to the proper port . 37 , 38

▪ Connect the distal end of the tubing to the patient's vascular access catheter. If the patient has other tubing and catheters that
have different purposes, route the tubing using a standardized approach. If you're using multiple IV lines, label each tubing at
the distal end (near the patient connection) and the proximal end (near the source container) to reduce the risk of
misconnection . 38

▪ Complete functional testing of all audible and visual alarms according to the manufacturer's instructions. If any visual
indicator doesn't illuminate or the audible signal doesn't sound, remove the device from service immediately. 3 , 39 , 40

▪ After confirming proper infusion device operation, unclamp the tubing and begin the infusion, adjusting the infusion rate as
needed. 2

Using the Belmont infuser

▪ Install the appropriate administration set into the infusion device according to the manufacturer's instructions. 1

▪ Confirm that the heat exchanger is secured properly. 1

▪ As needed for infusion of larger volumes of fluid, replace the reservoir chamber with the larger-capacity reservoir. Using
sterile technique, remove the reservoir chamber from the administration set by disconnecting the Luer connectors. 1

▪ Attach the reservoir holder onto the IV pole and place the larger reservoir into the holder. 1

▪ Attach the three fluid supply tails onto the top of the larger reservoir to be used. 1

▪ Connect the larger reservoir to the administration set. Adjust the reservoir holder to make sure that the connection leads
underneath the reservoir aren't stretched or kinked . 1

▪ Hang the fluid bag on the IV pole. 1

▪ Close the bag clamps and remove the bag spike cap. Perform a vigorous mechanical scrub of the port with an antiseptic pad
for at least 5 seconds and allow it to dry completely. Then spike the fluid bag, piercing it fully to ensure that fluids flow freely
.1

▪ Repeat with additional fluid lines that you'll use. 1

▪ Open the bag clamps. 1

▪ Prime the main system by pressing the prime button to recirculate 100 mL of fluid at 500 mL/minute to remove air and
replace the main system with fluid . 1

▪ Prime the remainder of the administration tubing by opening the roller clamp and removing the male Luer cap at the distal
end of the tubing. Press the pt. line prime button once to prime at 50 mL/minute and press and hold the button to prime at 200
mL/minute. Press the stop button after inspecting the tubing to make sure there are no air bubbles. Press the pt. line prime

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button again to remove any remaining air . 1

▪ Perform a vigorous mechanical scrub of the needleless connector of the vascular access device for at least 5 seconds with an
antiseptic pad, and allow it to dry completely. 6 , 32 , 35 , 36

▪ While maintaining sterility of the syringe tip, attach a prefilled 10-mL syringe or a syringe specifically designed to generate
low injection pressure containing preservative-free normal saline solution to the needleless connector. Unclamp the catheter
and slowly aspirate for blood return that is the color and consistency of whole blood. If no blood return occurs, take steps to
locate an external cause of obstruction. 33 , 35 , 36

▪ If blood return occurs, slowly inject preservative-free normal saline solution into the catheter. Use a minimum volume of
twice the internal volume of the catheter system. Don't forcibly flush the device; further evaluate the device if you meet
resistance. 33

▪ Clamp the catheter and remove and discard the syringe in a puncture-resistant sharps disposal container. 34

▪ Carefully remove the needleless connector from the vascular access device. Perform a vigorous mechanical scrub of the
catheter hub for at least 5 seconds using an antiseptic pad; then allow it to dry completely. 32 , 35 , 36

▪ Trace the tubing from the patient to its point of origin to make sure that you're attaching the tubing to the proper port . 37 , 38

▪ Connect the distal end of the tubing to the patient's vascular access catheter. 1 If the patient has other tubing and catheters
that have different purposes, route the tubing using a standardized approach. If you're using multiple IV lines, label each
tubing at the distal end (near the patient connection) and the proximal end (near the source container) to reduce the risk of
misconnection . 38

▪ Unclamp the catheter, press infuse to start infusing, and adjust the flow rate, as needed. 1

Using the ThermaCor 1200 Rapid Infuser

▪ Unlatch and remove the component guard from the unit. 41

▪ Turn the latch into the load position. Place the cassette on the load bar (at the bottom of the unit) at a 45-degree angle and
then lift and press the cassette directly into the unit. Close the latch into the lock position. 41

▪ Open the roller pump door and push the roller tubing all the way to the back to reduce the incidence of improper loading of
the tubing. Close the pump door. 41

▪ Connect the three-spike in-flow set to the cassette by following the color-coded caps. Connect the blue to blue and the
yellow to yellow . 41

▪ Connect the patient line by following the color-coded caps. Connect the red to red. 41

▪ Connect one or more of the spikes from the in-flow set to an IV fluid bag and hang it on the pole. 41

▪ Open the clamp closest to the fluid or blood bag and observe for fluid filling the filter. When the filter is ⅔ full, push the
prime button for the system to autoprime. As needed for infusion of larger volumes of fluid, replace the fluid infusion bag
with the larger-capacity reservoir. 41

▪ When the system beeps, push and hold the prime button and observe as fluid primes the tubing that connects to the patient to
ensure that all air is removed from the system . 41

▪ Perform a vigorous mechanical scrub of the needleless connector on the vascular access device for at least 5 seconds using
an antiseptic pad. Then let it dry completely. 6 , 32 , 35 , 36

▪ While maintaining sterility of the syringe tip, attach a prefilled 10-mL syringe or a syringe specifically designed to generate
lower injection pressure containing preservative-free normal saline solution to the needleless connector. Unclamp the catheter
and slowly aspirate for a blood return that's the color and consistency of whole blood. If you don't obtain a blood return, take
steps to locate an external cause of obstruction. 33 , 35 , 36

▪ If you obtain a blood return, inject preservative-free normal saline solution slowly into the catheter. Use a minimum volume
of twice the internal volume of the catheter system. Don't forcibly flush the device; further evaluate the device if you meet

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resistance. 33

▪ Clamp the catheter and remove and discard the syringe in a puncture-resistant sharps disposal container. 34

▪ Carefully remove the needleless connector from the vascular access device. Perform a vigorous mechanical scrub of the
catheter hub for at least 5 seconds using an antiseptic pad. Then let it dry completely. 32 , 35 , 36

▪ Trace the tubing from the patient to its point of origin to make sure that you're attaching the tubing to the proper port . 37 , 38

▪ Connect the distal end of the tubing to the patient's vascular access catheter. If the patient has other tubing and catheters that
have different purposes, route the tubing using a standardized approach. If you're using multiple IV lines, label each tubing at
the distal end (near the patient connection) and the proximal end (near the source container) to reduce the risk of
misconnection. 38

▪ Choose the mode of operation (slow, rapid, or bolus) for fluid delivery and then push the start button. 41

(Print pagebreak 539)

Completing the procedure

▪ Monitor the patient's vital signs every 5 to 15 minutes, as indicated. As the patient's condition stabilizes, monitor vital signs
less frequently (every 30 minutes until the patient's blood pressure is stable for longer than 2 hours). 2

▪ Monitor core temperature every 15 to 30 minutes and maintain a core temperature no lower than 96.8° F (36° C) to prevent
hypothermia-induced coagulopathies . 2

▪ Assess the patient's hemodynamic parameters every 15 to 30 minutes and urine output every 30 to 60 minutes, as ordered, to
evaluate the patient's fluid volume status, which indicates the effectiveness of fluid resuscitation and can be used to guide
therapy . 2

▪ Inspect IV sites every 15 minutes, because rapid infusion increases the risk of infiltration . 2

▪ If the patient is receiving blood products, monitor closely for signs of a transfusion reaction, such as fever, chills, flushing,
nausea, chest tightness, restlessness, apprehension, and back pain. 2 , 26

▪ Obtain an arterial blood gas sample, as ordered, to monitor oxygenation and acid-base balance. (See the “Arterial puncture
for blood gas analysis” procedure.)

▪ When the infusion is complete, change the IV fluid or blood bag according to the specific manufacturer's instructions.

▪ Discard the empty infusion bag in the proper receptacle 27 , 34 or, if required by your facility, return empty blood transfusion
bags to the blood bank.

▪ Obtain blood samples for hemoglobin level, hematocrit, lactic acid level, and electrolyte levels, and for coagulation studies
and thromboelastography, as ordered. (See the “Venipuncture” procedure.)

▪ Report all critical test results to the practitioner within the time frame established by your facility to prevent life-threatening
treatment delays . 42

▪ Return the bed to the lowest position to prevent falls and maintain patient safety . 43

▪ Discard used supplies in appropriate receptacles. 27 , 34 , 44

▪ Provide warming measures, such as additional blankets, to keep the patient warm and prevent hypothermia . 2

▪ Remove and discard your gloves and other personal protective equipment, if worn. 27 , 34 , 45

▪ Perform hand hygiene. 13 , 14 , 15 , 16 , 17 , 18

▪ Clean and disinfect your stethoscope with a disinfectant pad. 46 , 47

▪ Perform hand hygiene. 13 , 14 , 15 , 16 , 17 , 18

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▪ Document the procedure. 48 , 49 , 50 , 51

Special considerations
▪ Replace gas vent filters and reservoirs according to the manufacturer's instructions. 1 , 3 Change the tubing and filter of a
Level 1 transfuser according to the manufacturer's recommendations. 52 Clean and disinfect the device according to the
manufacturer's recommendations.

▪ If you're administering blood products, prime the system with a compatible IV solution; don't prime with the blood product.
1 ,3

Complications
Possible complications include electrolyte imbalances, fluid overload, acid-base imbalance, infiltration or extravasation,
pulmonary edema, heart failure, interstitial edema, acute respiratory distress syndrome, and hypothermia. 2

Documentation

Document the transfusion of all blood products in the patient's record, including the product type, date and time of the infusion, and
unique number or lot number for blood products. Document the infusion site used, access device, and site condition. Record the
patient's core temperature before the start of a massive infusion and at intervals during and after the procedure. Documentation
should include a meticulous account of the amounts and types of fluids and correlating vital signs. Record the patient's response to
the procedure, the practitioner notified of any complications of the procedure, and actions taken to address the complications.
Incorporate documentation of massive fluid infusion into the existing required documentation protocol for resuscitation
documentation. 48 , 49 Record teaching provided to the patient and family (if applicable), their understanding of that teaching, and any
need for follow-up teaching.

REFERENCES
1 Belmont Instrument Corporation. (n.d.). The Belmont ® Rapid Infuser, FMS2000: Operator's manual. http://
[Link]/uploads/1/5/2/4/15247360/[Link]

2 Wiegand, D. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). Elsevier.

3 Smiths Medical. (2006). Level 1 ® H-1200 Fast Flow Fluid Warmer: Operator's manual.
[Link]

4 Smisson-Cartledge Biomedical. (n.d.). Why ThermaCor 1200 Rapid Infuser. [Link]

cms

5 Jarrett, N., & Callaham, M. (2016). Evidence-based guidelines for selected hospital-acquired conditions: Final report. https://
[Link]/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/[Link]

6 Marschall, J., et al. (2014). SHEA/IDSA practice recommendation: Strategies to prevent central line-associated bloodstream
infections in acute care hospitals. Infection Control and Hospital Epidemiology, 35(7), 753-771. [Link]
10.1086/676533#metadata_info_tab_contents (Level I)

7 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.02. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

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8 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.19. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

9 Standard 12. Product evaluation, integrity, and defect reporting. Infusion therapy standards of practice (8th ed.). (2021). Journal of
Infusion Nursing, 44(Suppl. 1), S45-S46. (Level VII)

10 Zoremba, N., et al. (2011). Air elimination capability in rapid infusion systems. Anaesthesia, 66(11), 1031-1034. [Link]
10.1111/j. 1365-2044.2011.06899.x (Level IV)

11 The Joint Commission. (2021). Standard NPSG.06.01.01. Comprehensive accreditation manual for hospitals. (Level VII)

12 Standard 59. Infusion medication and solution administration. Infusion therapy standards of practice (8th ed.). (2021). Journal of
Infusion Nursing, 44(Suppl. 1), S180-S183. (Level VII)

13 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recommendations and Reports, 51(RR-16), 1-45. [Link] (Level II)

14 The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. (Level VII)

15 Standard 16. Hand hygiene. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44(Suppl. 1),
S53-S54. (Level VII)

16 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean
care is safer care. [Link] (Level IV)

17 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Infection control. 42 C.F.R. § 482.42.

18 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. (Level VII)

19 The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. (Level VII)

20 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

21 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(c)(1).

22 DNV GL-Healthcare USA, Inc. (2020). [Link].5. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. (Level VII)
(Print pagebreak 540)
23 The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. (Level VII)

24 The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. (Level VII)

25 Waters, T. R., et al. (2009). Safe patient handling training for schools of nursing.
[Link] (Level VII)

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26 Standard 64. Blood administration. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44
(Suppl. 1), S191-S194. (Level VII)

27 Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number 1910.1030. https://
[Link]/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)

28 Siegel, J. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in
healthcare settings. [Link] (Level II)

29 American College of Surgeons Committee on Trauma. (2012). Advanced trauma life support: Student course manual (9th
edition). American College of Surgeons.

30 Perron, C. E. (2021). Intraosseous infusion. In: UpToDate, Stack, A. M., & Wolfson, A. B. (Eds.).

31 The Joint Commission. (2021). Standard NPSG.01.03.01. Comprehensive accreditation manual for hospitals. (Level VII)

32 Standard 36. Needleless connectors. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44
(Suppl. 1), S104-S107. (Level VII)

33 Standard 41. Flushing and locking. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44
(Suppl. 1), S113-S118. (Level VII)

34 Standard 21. Medical waste and sharps safety. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion
Nursing, 44(Suppl. 1), S460-S62. (Level VII)

35 Infusion Nurses Society. (2016). Policies and procedures for infusion therapy (5th ed.). Infusion Nurses Society.

36 Infusion Nurses Society. (2017). Policies and procedures for infusion therapy of the older adult (3rd ed.). Infusion Nurses
Society.

37 U.S. Food and Drug Administration. (2017). Examples of medical device misconnections.
[Link]

38 The Joint Commission. (2014). Sentinel event alert: Managing risk during transition to new ISO tubing connector standards.
[Link] org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/
sea_53_connectors_8_19_14_final.pdf (Level VII)

39 Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing
nuisance alarms. American Journal of Critical Care, 19
(1), 28-37. [Link]
redirectedFrom=fulltext

40 The Joint Commission. (2013). Sentinel event alert 50: Medical device alarm safety in hospitals. https://
[Link]/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_50_alarms_4_26_16.pdf (Level
VII)

41 Medical Solutions, Inc. (n.d.). ThermaCor ® 1200 videos. [Link] com/our-products-thermacor-1200-videos/

42 The Joint Commission. (2021). Standard NPSG.02.03.01. Comprehensive accreditation manual for hospitals. (Level VII)

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43 Ganz, D. A., et al. (2013, reviewed 2021). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ
Publication No. 13-0015-EF). Agency for Healthcare Research and Quality. [Link]
fallpxtoolkit/[Link] (Level VII)

44 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.03.07. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

45 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

46 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.02.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. (Level VII)

47 Rutala, W. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://
[Link]/infection-control/pdf/guidelines/[Link] (Level I)

48 The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. (Level VII)

49 Standard 10. Documentation in the medical record. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion
Nursing, 44(Suppl. 1), S39-S42. (Level VII)

50 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Medical record services. 42 C.F.R. § 482.24(b).

51 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. (Level VII)

52 Smiths Medical. (2013). Level 1 ® H-1200 Fast Flow Fluid Warmer. [Link] com/˜/media/M/Smiths-
medical_com/Files/Import%20Files/TM194848EN-102013_LR.pdf

MECHANICAL VENTILATION, POSITIVE PRESSURE

Positive pressure mechanical ventilation promotes gas exchange in the lungs by producing positive intrathoracic pressure and
positive airway pressure. An endotracheal (ET) or tracheostomy tube delivers positive pressure mechanical ventilation to airways.
The amount of gas exchange depends on the resistance and compliance of the lung itself. Mechanical ventilators deliver ventilation
according to a specific mode. The mode may deliver a preset amount of tidal volume (V T ), a preset amount of peak inspiratory
pressure, or rates at high frequency through oscillation. Newer, more sophisticated modes of positive pressure ventilation are
currently evolving. 1

Positive pressure ventilation is indicated for the patient with apnea, ventilatory failure or impending failure, severe hypoxemia, and
respiratory muscle fatigue. 1 These signs and symptoms may result from acute or chronic lung injury; laryngeal angioedema;
neurologic disorders; trauma; chemical or medical respiratory depressants, such as sedation, anesthesia, or opioids; multiple organ
dysfunction syndrome; or such disease states as cardiogenic pulmonary edema, pulmonary hemorrhage, pulmonary
thromboembolism, acute severe asthma, sepsis, and septic shock. 2

The goals of positive pressure ventilation include maintaining adequate alveolar ventilation and oxygenation, correcting hypoxemia
and acid-base balance, and decreasing the work of breathing while providing adequate respirations and respiratory muscle rest, and
minimizing complications for the patient. 1 , 3 The practitioner may prescribe intermittent administration of continuous infusion of a
sedative or pain medication and a paralytic agent to decrease the patient's work of breathing and enable the ventilator to work
effectively.

A practitioner orders mechanical ventilation and, in collaboration with the respiratory therapist, sets ventilatory parameters to

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maintain pH, partial pressure of arterial carbon dioxide, partial pressure of arterial oxygen, and arterial oxygen saturation. The
practitioner, respiratory therapist, and nurse must collaborate to manage the moment-to-moment ventilatory needs of the patient.
The nurse must know how to assess, monitor, and care for patients on mechanical ventilation and understand basic ventilator
mechanisms of action. (See Mechanical ventilation terminology.)

Equipment
Oxygen source ▪ compressed air source ▪ flow meters ▪ blender or Y-connector ▪
large- and small-bore oxygen tubing (sterile) ▪ mechanical ventilator unit (with heated filtered humidifier, manometer and
inline thermometer) ▪ ventilator circuit tubing, connectors, and adapters ▪ condensation collection trap ▪ gloves ▪ handheld
resuscitation bag with reservoir and mask ▪ suction equipment ▪ sterile distilled water ▪ equipment for arterial blood gas
(ABG) analysis ▪ vital signs monitoring equipment ▪ stethoscope ▪ disinfectant pad ▪ pulse oximeter and probe ▪ capnography
device ▪ cardiac monitoring equipment ▪ oral care supplies ▪ emergency resuscitation equipment (code cart with emergency
medications, defibrillator, intubation equipment) ▪ ET tube securement supplies (tape, securement device or skin-barrier
product, hydrocolloid dressing, or soft silicone dressing) ▪ Optional: prescribed sedative, neuromuscular blocking agent, and
other medications; gown, mask and goggles or mask with face shield; peripheral nerve stimulation equipment; communication
board; eye covering; eye lubricant; exhaled carbon dioxide detector (Print pagebreak 541) or esophageal carbon dioxide
detector; replacement inserts or filters for heat and moisture exchangers; positive end-expiratory pressure (PEEP) valve for
resuscitation bag.

Mechanical ventilation terminology

Make sure you're familiar with the following mechanical ventilation terminologies:

Assist-control mode: The ventilator delivers a preset tidal volume (V T ) at a preset rate; however, the patient can
initiate additional breaths, which trigger the ventilator to deliver the preset V T at positive pressure. 1

Continuous positive airway pressure (CPAP): This setting prompts the ventilator to deliver positive pressure to the
airway throughout the respiratory cycle. It works only on patients who can breathe spontaneously. 3

Control mode: The ventilator delivers all of the patient's minute ventilation with a preset V T at a fixed rate, regardless
of whether the patient is breathing spontaneously. This mode isn't a standard mode on modern ventilators. 1

Fraction of inspired oxygen (FIO 2 ): This is the percentage of oxygen delivered to the patient by the ventilator. The
dial or digital display on the ventilator that sets this percentage is labeled OXYGEN CONCENTRATION or OXYGEN
PERCENTAGE. You should use the lowest possible FIO 2 to meet the patient's oxygenation goal. 2

Inspiratory-expiratory (I:E) ratio: This ratio compares the duration of inspiration to the duration of expiration. The
I:E ratio of normal, spontaneous breathing is 1:2, meaning that expiration is twice as long as inspiration. 3

Inspiratory flow rate (IFR): The IFR denotes the V T delivered within a certain time. Its value can range from 20 to
120 L/minute. You should adjust the ventilator to meet or exceed the IFR on the patient's spontaneous breaths. 3

Minute ventilation or minute volume (VE): This measurement results from the multiplication of respiratory rate and
V T . Minute ventilation is equivalent to the total volume per minute entering and exiting the lungs. 3

Peak inspiratory pressure (PIP): Measured by the pressure manometer on the ventilator, PIP reflects the amount of
pressure required to deliver a preset V T . It's the highest pressure produced during inspiration. 3

Plateau pressure: Airway pressure measured after a 0.5 second pause at the end of inspiration, plateau pressure
indicates the stiffness of the lungs. 3

Positive end-expiratory pressure (PEEP): In PEEP mode, the ventilator is set to maintain positive pressure at the end
of each expiration to increase the area for oxygen exchange by helping to inflate and keep open collapsed alveoli. The
practitioner typically initiates PEEP at 5 cm H 2 O but possibly as high as 24 cm H 2 O in acute respiratory distress
syndrome (ARDS). 2 , 4

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Pressure support: A ventilator adjunct, pressure support delivers positive pressure, supplementing the spontaneous
breath of a patient on the ventilator. It's used to reduce the work of breathing associated with the artificial airway or
increase the volume of the patient's spontaneous breath. 3

Respiratory rate: The number of breaths per minute delivered by the ventilator; also called frequency. The rate set is
dependent on the patient's condition and the ventilator mode, but it's typically 12 to 16 breaths per minute. 2

Sensitivity setting: A setting that determines the amount of effort the patient must exert to trigger the inspiratory cycle.
3

Sigh volume: A ventilator-delivered breath that's 1¼ times as large as the patient's V T .

Synchronized intermittent mandatory ventilation (SIMV): The ventilator delivers a preset number of breaths at a
specific V T . The patient's own breaths may supplement these mechanical ventilations, in which case the patient's
inspiratory ability determines the V T and rate. 1

Tidal volume (V T ): This refers to the volume of air delivered to the patient with each cycle, usually 8 to 10 mL/kg.
Low V T ventilation of 6 to 8 mL/kg predicted body weight has been associated with decreased mortality and improved
outcomes in patients with acute respiratory failure and ARDS. 2

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from use, label it as
expired or defective, and report the expiration or defect, as directed by your facility. In most facilities, respiratory therapists assume
responsibility for setting up a ventilator. If necessary, however, check the manufacturer's instructions for setting it up. In some cases,
you'll need to add sterile distilled water to the humidifier and connect the ventilator to the appropriate gas source.

Plug the ventilator into an emergency electrical outlet (with generator backup) and turn it on. Adjust the settings on the ventilator, as
ordered. Make sure the ventilator's alarms are set appropriately for the ventilator settings and the patient's current condition, and that
the alarms are turned on, functioning properly, and audible to staff. 5 , 6 , 7 Make sure that the humidifier is filled with sterile distilled
water, and that the heated humidifier is set to deliver an inspired gas temperature of greater than or equal to 93.2° F (34° C) but less
than 105.8° F (41° C) at the circuit Y-piece and provide a minimum of 33 mg/L of water vapor. 8

Attach a capnography device to measure carbon dioxide levels to confirm placement of the ET tube and detect any disconnection
from the ventilator or other complications. 9

Make sure that emergency equipment is functioning properly and readily available in case the ventilator malfunctions or the
patients is extubated accidently.

Implementation
▪ Verify the practitioner's order.

▪ If the patient isn't already intubated, prepare the patient for intubation.

▪ Gather and prepare the necessary equipment and supplies.

▪ Perform hand hygiene. 10 , 11 , 12 , 13 , 14 , 15

▪ Confirm the patient's identity using at least two patient identifiers. 16

▪ Provide privacy. 17 , 18 , 19 , 20

▪ When possible, explain the procedure to the patient and family (if appropriate) according to their individual communication
and learning needs to increase their understanding, allay their fears, and enhance cooperation . 21 Assure them that staff
members are nearby to provide care.

▪ Make sure the patient is being adequately oxygenated.

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▪ Raise the patient's bed to waist level before providing patient care to prevent caregiver back strain . 22

▪ Perform hand hygiene. 10 , 11 , 12 , 13 , 14 , 15

▪ Put on gloves and other personal protective equipment as needed to comply with standard precautions . 23 , 24 , 25 , 26

▪ As the patient's condition allows, perform a complete physical assessment and obtain blood for ABG analysis to establish
baselines for comparison.

▪ Assist with intubation (if necessary) and then connect the ET tube to the ventilator circuit. Trace the ventilator circuit from
the patient to its point of origin to make sure it's connected properly . 27 , 28

▪ Observe for chest expansion and auscultate for bilateral breath sounds to verify that the patient is being ventilated . 23

▪ Apply a skin barrier product, hydrocolloid dressing, or soft silicone dressing to the skin to prevent skin breakdown, and then
tape the tube securely to prevent accidental dislodgement. Alternatively, use an ET tube securement device. 1 , 29

▪ Monitor the patient's oxygen saturation level by pulse oximetry; make sure that the alarm limits are set appropriately for the
patient's current condition, and that the alarms are turned on, functioning properly, and audible to staff. 5 , 6 , 7 , 30

▪ Use waveform capnography, an exhaled-carbon dioxide detector, or an esophageal detector device in addition to a chest X-
ray to confirm ET tube placement . 31 , 32

▪ Position the patient with the head of the bed elevated 30 to 45 degrees, unless contraindicated by the patient's condition, to
reduce the risk of aspiration and consequent ventilator-associated pneumonia (VAP). If the patient can't bend at the waist, use
a reverse Trendelenburg position. 33

▪ Suction the patient's airway when necessary to maintain airway patency by removing accumulated pulmonary secretions . 32
Before performing (Print pagebreak 542) suctioning, hyperoxygenate the patient, as needed, with 100% oxygen for 30 to 60
seconds. Suction the patient with a closed-suction catheter, limiting suctioning to 15 seconds. After suctioning,
hyperoxygenate the patient for at least 1 minute using the same technique you used before suctioning. 32

▪ Observe the amount and consistency of the patient's secretions.

▪ Monitor the patient's ABG values after the initial ventilator setup, after changes in ventilator settings, and as the patient's
condition indicates, if ordered, to determine whether the patient is being adequately ventilated and to avoid oxygen toxicity.
Be prepared to adjust ventilator settings based on ABG analysis. Notify the practitioner of critical test results within your
facility's established time frame so the patient can receive prompt treatment . 34

▪ Check the ventilator tubing frequently for condensation, which can cause resistance to airflow and which the patient may
aspirate. As needed, drain the condensate into a collection trap. Keep the circuit closed during condensate drainage to prevent
bacterial contamination. Don't drain the condensate into the humidifier, because the condensate may be contaminated with
the patient's secretions. Also avoid accidental drainage of condensation into the patient's airway when moving the tubing or
the patient, because condensate is considered infectious waste . 8 , 23

▪ Inspect heat and moisture exchangers, and replace inserts or filters contaminated by secretions.

▪ Check the in-line thermometer to make sure the temperature of the air delivered to the patient is close to body temperature.

▪ If you're using a heated humidifier, monitor the inspired air temperature as close to the patient's airway as possible. The
heated humidifier should be set to deliver an inspired gas temperature of 93.2° F (34° C) or above, but less than 105.8° F (41°
C), with a 109.4° F (43° C) over-limit temperature, and the low temperature alarm should be set no lower than 3.6° F (2° C)
below the desired temperature at the circuit Y-piece. 8

▪ Change, clean, or dispose of the ventilator tubing and equipment when it's visibly soiled or malfunctioning, or at an interval
determined by your facility, to reduce the risk of bacterial contamination . 8 , 23

▪ Monitor the patient's vital signs and respiratory status at an interval determined by the patient's condition and your facility.
When monitoring the patient's vital signs, count spontaneous breaths as well as ventilator-delivered breaths.

▪ Provide emotional support to the patient during all phases of mechanical ventilation to reduce anxiety and promote
successful treatment. Even if the patient is unresponsive, continue to explain all procedures and treatments.

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▪ Confirm that the ventilator alarms are set appropriately for the patient's current condition. Make sure that the alarms are
turned on, functioning, and audible to staff. 5 , 6 , 7 , 30

▪ Unless contraindicated, turn the patient from side to side every 1 to 2 hours to facilitate lung expansion and removal of
secretions, and perform active or passive range-of-motion exercises for all extremities to reduce the hazards of immobility.

▪ Assess the patient's peripheral circulation, and monitor intake and output to assess for signs of decreased cardiac output.
Watch for signs and symptoms of fluid volume excess or dehydration.

▪ Brush the patient's teeth, gums, and tongue at least twice a day using a soft toothbrush to prevent VAP . 35 , 36

▪ Use a chlorhexidine rinse twice daily, as prescribed, to reduce colonization of the oropharynx and prevent subsequent VAP .
35 , 36 , 37
For a patient undergoing cardiac surgery, use the rinse before intubation and postoperatively twice a day. 35

▪ Moisten the patient's lips and oral mucosa every 2 to 4 hours to reduce oral inflammation and improve oral health . 35 , 36

▪ Institute measures to prevent venous thromboembolism (VTE) and peptic ulcer disease (PUD), if prescribed. 36

NURSING ALERT
Make sure that you follow evidence-based infection-prevention techniques (such as performing hand hygiene,
providing oral care, positioning the patient with the head of the bed elevated 30 to 45 degrees) when caring for
the patient receiving mechanical ventilation to reduce the risk of VAP . 23 , 38

▪ Place the call light within the patient's reach, and establish a method of communication, such as a communication board,
because intubation and mechanical ventilation impair the patient's ability to speak . 1

▪ Administer and titrate the patient's sedative or neuromuscular blocking agent as ordered following safe medication
administration practices. 39 , 40 , 41 , 42 Maintain target sedation levels to avoid oversedation . 43 Remember that the patient
receiving a neuromuscular blocking agent requires close observation, such as by using peripheral nerve stimulation, because
of the inability to breathe spontaneously or communicate . 1 (See the “Peripheral nerve stimulation” procedure.)

▪ Return the bed to the lowest position to prevent falls and maintain patient safety . 44

▪ Take steps to ensure the patient's safety, such as raising the side rails of the bed while turning the patient, and covering and
lubricating the patient's eyes.

▪ Discard used supplies in the appropriate receptacle. 26

▪ Remove and discard your gloves and any other personal protective equipment. 24 , 26

▪ Perform hand hygiene. 10 , 11 , 12 , 13 , 14 , 15

▪ Clean and disinfect your stethoscope using a disinfectant pad. 45 , 46

▪ Perform hand hygiene. 10 , 11 , 12 , 13 , 14 , 15

▪ Document the procedure. 47 , 48 , 49 , 50

Special considerations
▪ If signs of respiratory distress or hypoxemia develop, or if an alarm sounds and you can't easily identify the problem,
disconnect the patient from the ventilator and use a handheld resuscitation bag to ventilate the patient. (See Responding to
ventilator alarms.)

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▪ In a postoperative patient, screen for and assess for pain using facility-defined criteria that are consistent with the patient's
age, condition, and ability to understand. Treat the patient's pain, as needed and ordered, using nonpharmacologic or
pharmacologic approaches or a combination of approaches. Base the treatment plan on evidence-based practices and the
patient's clinical condition, past medical history, and pain management goals. 51

▪ If the patient is receiving enteral feedings, position the patient with the head of the bed elevated 30 to 45 degrees, unless
contraindicated by the patient's condition, to reduce the risk of aspiration . 52

Complications
Mechanical ventilation can cause damage to lungs as well as hemodynamic changes within in the body. Complications
include lung injuries, pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, and subcutaneous
emphysema. Positive pressure ventilation reduces venous return and increases pulmonary vascular resistance, which can
decrease cardiac output. Ventilator-associated pneumonia may also occur. 1 , 33 Gastric bleeding from stress ulcers is also a
potential complication. 2

Documentation

Document the date and time of initiation of mechanical ventilation. Name the type of ventilator you used for the patient and note its
settings. Record the artificial airway type and size, the method used to secure the airway, and the tube's location (such as oral, nasal,
or tracheal.) Describe the patient's response to mechanical ventilation, including vital signs, breath sounds, assessment findings, and
oxygen saturation levels. List any complications and nursing interventions you took and the patient's response to those interventions.
Record all pertinent laboratory data, including ABG analysis results. Describe the patient's LOC, respiratory effort, and skin color.
Note the patient's need for suctioning and the color and amount of secretions. Document interventions, such as head-of-bed
elevation, oral care, sedation interruption, and weaning. Record the patient's response to these interventions. Document teaching you
provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

If the patient was receiving pressure-support ventilation (PSV) or using a T-piece or tracheostomy collar, note the duration of
spontaneous breathing and the patient's ability to maintain the weaning schedule. If you're using intermittent mandatory ventilation
with or without PSV, record the control breath rate, time of each breath reduction, and rate of spontaneous respirations.

(Print pagebreak 543)

TROUBLESHOOTING

RESPONDING TO VENTILATOR ALARMS

Ventilator alarms alert the nursing staff to potentially hazardous conditions and changes in the patient's status. Use this table
as a guide to possible causes of ventilator alarms and how to respond.

SIGNAL POSSIBLE CAUSE NURSING INTERVENTIONS

▪ Endotracheal (ET) tube disconnected
▪ Reconnect the ET tube to the ventilator.
from ventilator
▪ Check ET tube placement and
reposition if needed. If extubation or
▪ ET tube displaced above vocal cords or
displacement has occurred, ventilate the
tracheostomy tube extubated
patient manually and call the practitioner
immediately.
▪ Listen for a whooshing sound around
▪ Leaking tidal volume from low cuff
the ET tube, indicating an air leak. If you
pressure (from an underinflated or
hear one, check cuff pressure. If you can't
Low-pressure alarm ruptured cuff or a leak in the cuff or one-
maintain pressure, call the practitioner,
way valve)
who may need to insert a new tube.

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▪ Disconnect the patient from the

▪ Ventilator malfunction ventilator and ventilate manually if
necessary. Obtain another ventilator.
▪ Make sure all connections are intact.
▪ Leak in ventilator circuitry (from loose
Check for holes or leaks in the tubing and
connection or hole in tubing, loss of
replace if necessary. Check the
temperature-sensitive device, or cracked
humidification device and replace if
humidification device)
cracked.
▪ Auscultate breath sounds for evidence
▪ Increased airway pressure or decreased
of increasing lung consolidation,
lung compliance caused by worsening
barotrauma, or wheezing. Notify the
disease
practitioner if indicated.
▪ Insert a bite block if needed.
▪ Patient biting on oral ET tube
▪ Consider pain medication or sedation if
appropriate.
▪ Look for secretions in the airway;
suction the patient's airway or have the
▪ Secretions in airway
patient cough to remove secretions as
necessary.
▪ Check tubing for condensate and drain
▪ Condensate in large-bore tubing the condensate from the tubing as
necessary.
▪ Auscultate for diminished or absent
▪ Intubation of right mainstem bronchus
breath sounds in the left lung fields.
▪ Check tube position. If it has become
▪ Patient coughing, gagging, or
displaced, call the practitioner, who may
attempting to talk
need to reposition it.
High-pressure alarm ▪ If the patient's breathing is
asynchronous with the ventilator, the
▪ Chest wall resistance practitioner may order a sedative or
neuromuscular blocking agent and
sedative.
▪ Reposition the patient to improve chest
expansion.

▪ Administer the prescribed analgesic if

needed following safe medication
administration practices. 39 , 40 , 41 , 42
▪ Failure of high-pressure relief valve
▪ Replace faulty equipment.

▪ Assess the patient to try to determine

the cause. Report your findings to the
▪ Bronchospasm
practitioner, and treat the patient as
ordered.

REFERENCES
1 Wiegand, D. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis, MO: Elsevier.

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 Lippincott Nursing Procedures
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2 Hyzy, R. C., & McSparron, J. I. (2021). Overview of initiating invasive mechanical ventilation in adults in the intensive care unit.
In: UpToDate, Parsons, P. E. (Ed.).

3 Kacmarek, R. M., et al. (2021). Egan's fundamentals of respiratory care (12th ed.). St. Louis, MO: Mosby.

4 ARDSnet. (n.d.) NIH NHLBI ARDS clinical network mechanical ventilation protocol summary. [Link]
ventilator_protocol_2008-[Link] (Level VII)

5 The Joint Commission. (2013). Sentinel event alert 50: Medical device alarm safety in hospitals. https://
[Link]/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_50_alarms_4_26_16.pdf (Level
VII)

6 Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing nuisance
alarms. American Journal of Critical Care, 19, 28-37.

7 The Joint Commission. (2021). Standard NPSG.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

8 Restrepo, R. D., & Walsh, B. K. (2012). AARC clinical practice guideline: Humidification during invasive and noninvasive
mechanical ventilation, 2012. Respiratory Care, 57(5), 782-788. [Link] (Level
VII)

9 American Heart Association. (2020). 2020 American Heart Association Guidelines for CPR and ECC- Part 3: Adult Basic and
Advances Life Support: Advanced Techniques for Resuscitation. [Link]
guidelines

10 The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

11 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recommendationsand Reports, 51(RR-16), 1-45. [Link] (Level II)
(Print pagebreak 544)
12 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean
care is safer care. [Link] (Level IV)

13 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Infection control. 42 C.F.R. § 482.42.

14 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

15 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

16 The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

17 The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL:
The Joint Commission. (Level VII)

uoma999 | [Link] | 22 January 2025 1:17:18 Utc

 Lippincott Nursing Procedures
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18 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(c)(1).

19 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

20 DNV GL-Healthcare USA, Inc. (2020). [Link].5. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

21 The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

22 Waters, T. R., et al. (2009). Safe patient handling training for schools of nursing.
[Link] (Level VII)

23 Centers for Disease Control and Prevention. (2004). Guidelines for preventing health-care-associated pneumonia, 2003:
Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recommendations and
Reports, 53(RR-3), 1-32. [Link] (Level II)

24 Siegel, J. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in
healthcare settings. [Link] (Level II)

25 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

26 Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number 1910.1030. https://
[Link]/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)

27 U.S. Food and Drug Administration. (2017). Examples of medical device misconnections.
[Link]

28 The Joint Commission. (2014). Sentinel event alert 53: Managing risk during transition to new ISO tubing connector standards. h
ttps://[Link]/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/
sea_53_connectors_8_19_14_final.pdf (Level VII)

29 LeBlanc, K., et al. (2013). International skin tear advisory panel: A tool kit to aid in the prevention, assessment, and treatment of
skin tears using a simplified classification system. Advances in Skin and Wound Care, 26, 459-476. (Level IV)

30 American Association of Critical-Care Nurses. (2018). AACN practice alert: Managing alarms in acute care across the life
span—electrocardiography and pulse oximetry. [Link]
care-across-the-life-span (Level VII)

31 Walsh, B. K., et al. (2011). Capnography/capnometry during mechanical ventilation, 2011. Respiratory Care, 56(4), 503-509.
[Link] com/content/respcare/56/4/[Link] (Level VII)

32 American Association for Respiratory Care. (2010). AARC clinical practice guidelines: Endotracheal suctioning of mechanically
ventilated patients with artificial airways 2010. Respiratory Care, 55(6), 758-764. [Link] com/content/respcare/55/6/
[Link] (Level VII)

uoma999 | [Link] | 22 January 2025 1:17:18 Utc

 Lippincott Nursing Procedures
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33 American Association of Critical-Care Nurses. (2017). AACN practice alert: Ventilator associated pneumonia. https://
[Link]/clinical-resources/practice-alerts/ventilator-associated-pneumonia-vap (Level VII)

34 The Joint Commission. (2021). Standard NPSG.02.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

35 American Association of Critical-Care Nurses. (2017). AACN practice alert: Oral care for acutely and critically ill patients. https:
//[Link]/clinical-resources/practice-alerts/oral-care-for-acutely-and-critically-ill-patients (Level VII)

36 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.02. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

37 Hillier, B., et al. (2013). Preventing ventilator-associated pneumonia through oral care, product selection, and application
method: A literature review. AACN Advanced Critical Care, 24, 38-58. (Level I)

38 Klompas, M., et al. (2014). Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection
Control and Hospital Epidemiology, 35(8), 915-936. [Link]
[Link]?refreqid=excelsior%3A05d9aadde774900c567534d3dbc7bf2e (Level I)

39 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Nursing services. 42 C.F.R. § 482.23(c).

40 Accreditation Association for Hospitals and Health Systems. (2020). Standard 16.01.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

41 The Joint Commission. (2021). Standard MM.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

42 DNV GL-Healthcare USA, Inc. (2020). [Link].3. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

43 Grap, M. J., et al. (2012). Sedation in adults receiving mechanical ventilation: Physiological and comfort outcomes. American
Journal of Critical Care, 21(3), e53-e64. [Link] (Level VI)

44 Ganz, D. A., et al. (2013, reviewed 2021). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ
publication no. 13-0015-EF). [Link] (Level VII)

45 Rutala, W. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://
[Link]/infection-control/pdf/guidelines/[Link] (Level I)

46 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.02.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

47 The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

48 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

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 Lippincott Nursing Procedures
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Medical record services. 42 C.F.R. § 482.24(b).

49 Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

50 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

51 The Joint Commission. (2021). Standard PC.01.02.07. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

52 Boullata, J. I., et al. (2017). ASPEN safe practices for enteral nutrition therapy. Journal of Parenteral and Enteral Nutrition, 41,
15-103. [Link] (Level VII)

(Print pagebreak 545)

METERED-DOSE INHALER USE

A metered-dose inhaler (MDI) delivers topical medications to the respiratory tract, producing local and systemic effects. 1 , 2 The
mucosal lining of the respiratory tract absorbs the inhalant almost immediately. Examples of common inhalants include
bronchodilators, which improve airway patency and facilitate drainage of mucus; mucolytics, which attain a high local concentration
to liquefy tenacious bronchial secretions; and corticosteroids, which decrease inflammation in the respiratory tract. 3

The use of MDIs may be contraindicated in patients who can't form an airtight seal around the device and in those who lack the
coordination or clear vision to assemble the device. Some patients use an MDI spacer to assist them with the airtight seal. 3 Specific
inhalants may also be contraindicated. 4 For example, bronchodilators are contraindicated in patients with tachycardia or a history of
cardiac arrhythmias associated with tachycardia.

Equipment
Prescribed MDI with mouthpiece ▪ stethoscope ▪ disinfectant pad ▪ Optional: gloves, MDI spacer, water for gargling, emesis
basin.

Implementation
▪ Avoid distractions and interruptions when preparing and administering medication to prevent medication errors . 5 , 6

▪ Verify the practitioner's order. 7 , 8 , 9 , 10

▪ Reconcile the patient's medications when the practitioner prescribes a new medication to help reduce the risk of medication
errors, including omissions, duplications, dosing errors, and drug interactions.

▪ Perform hand hygiene. 11 , 12 , 13 , 14 , 15 , 16

▪ Gather and prepare the necessary equipment and supplies.

▪ Compare the medication label with the order in the patient's medical record. 7 , 8 , 9 , 10

▪ Check the patient's medical record for an allergy or other contraindication to the medication. If an allergy or a
contraindication exists, don't administer the medication; notify the practitioner. 7 , 8 , 9 , 10

▪ Check the expiration date on the medication. If the medication has expired, return it to the pharmacy and obtain new

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medication. 7 , 8 , 9 , 10

▪ Inspect the medication container and MDI visually for loss of integrity; don't administer the medication if integrity has been
compromised. 7 , 8 , 9 , 10

▪ Discuss any unresolved concerns about the medication with the practitioner. 7 , 8 , 9 , 10

▪ Perform hand hygiene. 11 , 12 , 13 , 14 , 15 , 16

▪ Confirm the patient's identity using at least two patient identifiers. 17

▪ Provide privacy. 18 , 19 , 20 , 21

▪ Explain the procedure to the patient and family members (if appropriate) according to their individual communication and
learning needs to increase their understanding, allay their fears, and enhance cooperation . 22

▪ Teach the patient who is using the medication for the first time about potential adverse reactions, and discuss any other
concerns related to the medication. 7 , 8 , 9 , 10

▪ Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route to reduce
the risk of medication errors . 7 , 8 , 9 , 10

▪ If your facility uses bar code technology, use it as directed by your facility.

▪ Raise the patient's bed to waist level before providing care to help prevent caregiver back strain . 23

▪ Perform hand hygiene. 11 , 12 , 13 , 14 , 15 , 16

▪ Put on gloves, if needed, to comply with standard precautions . 24 , 25 , 26

▪ Assess the patient's respiratory status, including respiratory rate, breath sounds, and accessory muscle use, to obtain a
baseline for comparison . 27

▪ Insert the metal stem of the prescribed MDI into the small hole on the flattened portion of the mouthpiece.

▪ Shake the prescribed MDI to mix the medication and aerosol propellant. Prime the MDI, as needed, according to the
manufacturer's instructions. Requirements for priming an MDI (spraying one or more puffs into the air before use) vary
among devices and ensure that the MDI is ready to use and will dispense the correct amount of medication . 28

▪ Remove the mouthpiece cap. Attach the prescribed MDI to the spacer as indicated, making sure not to touch the mouthpiece.
Note that some MDIs have a spacer built in.

▪ Instruct the patient to exhale fully and then place the prescribed MDI or spacer into the patient's mouth, and tell the patient
to close the lips around it using a closed mouth technique (as shown below). 1 , 29 , 30 Alternatively, if directed by the
practitioner, use an open-mouth technique by holding the prescribed MDI 1″ to 2″ (2.5 cm to 5 cm) in front of the patient's
mouth. 29 , 30

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▪ Instruct the patient to press down on the prescribed MDI one time as the patient starts breathing in through the mouth
slowly. (If a spacer is being used, instruct the patient to press down on the prescribed MDI first and then begin to breathe in
slowly within 5 seconds.)

▪ Instruct the patient to continue breathing in slowly, as deeply as possible. 1 This action draws the medication into the lungs.

▪ Remove the mouthpiece from the patient's mouth, and instruct the patient to hold the breath and count to 10 slowly, if
possible, to allow the medication to reach the alveoli . 1 , 28

▪ Instruct the patient to exhale slowly through pursed lips to keep the distal bronchioles open, allowing increased absorption
and diffusion of the drug and better gas exchange.

▪ When inhaled corticosteroids (such as beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, and triamcinolone)
are administered, instruct the patient to rinse and gargle with water and then to expectorate using an emesis basin, if
necessary, after each dose to help prevent an infection in the mouth . 2 , 3 , 28

▪ When inhaled quick-relief medications (beta 2 -adrenergic agonists) are administered, the patient should wait about 15 to 30
seconds between inhalations. There's no need to wait between inhalations for other medications.

▪ When all the ordered inhalations have been administered, remove the spacer (if used) from the MDI, and wash the spacer
and mouthpiece according to the manufacturer's instructions.

▪ Put the cap back on the prescribed MDI after each use. Store the MDI and spacer, if used, with the patient's medication.

▪ Assess the patient's respiratory status, including respiratory rate, breath sounds, and accessory muscle use after medication
administration to determine the response to the medication . 27

▪ Allow the patient to gargle with water, if desired, to remove the medication from the mouth and the back of the throat.

▪ Return the bed to the lowest position to prevent falls and maintain patient safety . 31

▪ Remove and discard your gloves, if worn. 24 , 26

▪ Perform hand hygiene. 11 , 12 , 13 , 14 , 15 , 16

▪ Clean and disinfect your stethoscope using a disinfectant pad. 32 , 33

▪ Perform hand hygiene. 11 , 12 , 13 , 14 , 15 , 16

▪ Document the procedure. 34 , 35 , 36 , 37

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Special considerations
▪ MDIs with spacers may be recommended to provide greater therapeutic benefit for children and for patients who have
difficulty with coordination. (Print pagebreak 546) A spacer attachment is an extension to the MDIs mouthpiece that provides
more dead-air space for mixing the medication. Some MDIs have built-in spacers. 4

▪ Some spacers have built-in whistles. If a whistling sound is heard, the patient is inhaling too fast or too strongly. 28

Complications
Complications are related to the medication being administered by the MDI. Incorrect use of an MDI can cause overdosing or
underdosing of the prescribed medication. 38

Documentation

Document the medication strength, dose, and route of administration and the date and time of its administration. Document
respiratory status findings before and after MDI use and the patient's response to treatment. Document any adverse reactions that
occur, the date and time the practitioner was notified, any prescribed interventions, and the patient's response to those interventions.
39
Document any teaching provided to the patient and family (if applicable), their understanding of the teaching, and any need for
follow-up teaching.

REFERENCES
1 National Heart, Lung, and Blood Institute & National Asthma Education and Prevention Program. (2007). Expert panel report 3:
Guidelines for the diagnosis and management of asthma (NIH publication no. 07-4051). [Link]
NBK7232/ (Level VII)

2 National Asthma Education and Prevention Program. (2013). How to use a metered-dose inhaler.
[Link]

3 American Academy of Allergy, Asthma and Immunology. (2020). Inhaled asthma medications.
[Link]

4 Ari, A., & Restrepo, R. D. (2012). AARC clinical practice guideline: Aerosol delivery device selection for spontaneously
breathing patients—2012. Respiratory Care, 57(4), 613-626. [Link]
aerosol_delivery_2012.pdf (Level VII)

5 Westbrook, J., et al. (2010). Association of interruptions with an increased risk and severity of medication administration errors.
Archives of Internal Medicine, 170, 683-690. (Level IV)

6 Institute for Safe Medication Practices. (2012). Side tracks on the safety express: Interruptions lead to errors and
unfinished…Wait, what was I doing? Nurse Advise-ERR, 11(2), 1-4. [Link]
interruptions-lead-errors-and-unfinished-wait-what-was-i-doing? id=37

7 The Joint Commission. (2021). Standard MM.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

8 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Nursing services. 42 C.F.R. § 482.23(c).

uoma999 | [Link] | 22 January 2025 1:17:18 Utc

 Lippincott Nursing Procedures
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9 Accreditation Association for Hospitals and Health Systems. (2020). Standard 16.01.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

10 DNV GL-Healthcare USA, Inc. (2020). [Link].3. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

11 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recommendations and Reports, 51(RR-16), 1-45. [Link] (Level II)

12 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean
care is safer care. [Link] (Level IV)

13 The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

14 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Infection control. 42 C.F.R. § 482.42.

15 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

16 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

17 The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

18 The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL:
The Joint Commission. (Level VII)

19 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(c)(1).

20 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

21 DNV GL-Healthcare USA, Inc. (2020). [Link].5. NIAHO accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

22 The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

23 Waters, T. R., et al. (2009). Safe patient handling training for schools of nursing.
[Link] (Level VII)

24 Siegel, J. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in

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 Lippincott Nursing Procedures
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healthcare settings. [Link] (Level II)

25 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

26 Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number 1910.1030. https://
[Link]/pls/oshaweb/owadisp. show_document?p_id=10051&p_table=STANDARDS (Level VII)

27 Craven, R. F., et al. (2020). Fundamentals of nursing: Concepts and competencies for practice. (9th ed.). Philadelphia, PA:
Wolters Kluwer.

28 American Thoracic Society. (2020). Patient information series: Using your metered dose inhaler (MDI). https://
[Link]/patients/patient-resources/resources/[Link]

29 American College of Chest Physicians (2006). Using your MDI—Open-mouth technique. [Link]
images/Open_Mouth_inhaler_method.pdf

30 Hess, D., & Dhand, R. (2020). The use of inhaler devices in adults. In: UpToDate, Bochner, B. S. (Ed).

31 Ganz, D. A., et al. (2013, reviewed 2021). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ
publication no. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. [Link]
systems/hospital/fallpxtoolkit/[Link] (Level VII)

32 Rutala, W. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://
[Link]/infection-control/pdf/guidelines/[Link] (Level I)

33 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.02.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

34 The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

35 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Medical record services. 42 C.F.R. § 482.24(b).

36 Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)
(Print pagebreak 547)
37 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

38 Cho-Reyes, S., et al. (2019). Inhalation technique errors with metered-dose inhalers among patients with obstructive lung
diseases: A systematic review and meta-analysis of U.S. studies. Chronic Obstructive Pulmonary Diseases, 6(3), 267-280. https://
[Link]/jcopdf/id/1241/Inhalation-Technique-Errors-with-Metered-Dose-Inhalers-Among-Patients-with-
Obstructive-Lung-Diseases-A-Systematic-Review-and-Meta-Analysis-of-US-Studies (Level I)

39 The Joint Commission. (2021). Standard RC.02.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

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MIXED VENOUS OXYGEN SATURATION MONITORING

Mixed venous oxygen saturation (SVO 2 ) monitoring involves the use of a fiberoptic thermodilution pulmonary artery (PA) catheter
to continuously monitor oxygen delivery to tissues and oxygen consumption by tissues. Monitoring of SVO 2 allows rapid detection
of impaired oxygen delivery, such as from decreased cardiac output, hemoglobin level, or arterial oxygen saturation. It also helps
evaluate a patient's response to drug therapy, endotracheal tube suctioning, ventilator setting changes, positive end-expiratory
pressure (PEEP), and fraction of inspired oxygen. SVO 2 usually ranges from 60% to 80%. 1

NURSING ALERT
Keep in mind that the Centers for Medicare and Medicaid Services considers vascular catheter-associated infection a
hospital-acquired condition because it can be reasonably prevented using a variety of best practices. Make sure to follow
evidence-based infection prevention techniques, such as performing hand hygiene, using sterile technique when
accessing the device, and removing the catheter as soon as it's no longer necessary, to reduce the risk of vascular
catheter-associated infections. 2 , 3 , 4 , 5 , 6 , 7

Equipment
Fiberoptic PA catheter ▪ co-oximeter (monitor) ▪ optical module and cable ▪ gloves ▪ mixed venous blood sampling
equipment ▪ laboratory biohazard bag ▪ label ▪ Optional: gown, protective eyewear, laboratory request form.

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use,
label it as expired or defective, and report the expiration or defect as directed by your facility.

Review the manufacturer's instructions for assembly and use of the fiberoptic PA catheter. Connect the optical module and cable to
the monitor. Next, peel back the wrapping covering the catheter just enough to uncover the fiberoptic connector. Attach the
fiberoptic connector to the optical module while allowing the rest of the catheter to remain in its sterile wrapping. Calibrate the
fiberoptic catheter by following the manufacturer's instructions. Enter the patient's most recent hemoglobin level during the
calibration process. 8

To prepare for the rest of the procedure, follow the instructions for PA catheter insertion, as described in the “Pulmonary artery
pressure and pulmonary artery occlusion pressure monitoring” procedure. (See SVO 2 monitoring equipment, page 548.)

Implementation
▪ Verify the practitioner's order.

▪ Gather and prepare the necessary equipment and supplies.

▪ Perform hand hygiene. 10 , 11 , 12 , 13 , 14 , 15

▪ Confirm the patient's identity using at least two patient identifiers. 16

▪ Provide privacy. 17 , 18 , 19 , 20

▪ Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning
needs to increase their understanding, allay their fears, and enhance cooperation . 21

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▪ Raise the bed to waist level before providing care to prevent caregiver back strain . 22

▪ Perform hand hygiene. 10 , 11 , 12 , 13 , 14 , 15

▪ Put on gloves and other personal protective equipment, including a gown and protective eyewear, if indicated, to comply
with standard precautions . 23 , 24

▪ Assist with the insertion of the fiberoptic catheter just as you would for a PA catheter insertion.

▪ After the fiberoptic PA catheter is inserted, confirm that the light intensity tracing on the graphic printout is within normal
range to ensure correct positioning and function of the catheter.

▪ Observe the digital readout and record the SVO 2 on the graph paper or as required by your facility. Repeat readings at least
once each hour to monitor and document trends.

▪ Make sure the alarms limits are set appropriately for the patient's current condition, and that the alarms are turned on,
functioning, and audible to staff. 25 , 26 , 27 , 28

Recalibrating the monitor

▪ Trace the tubing from the patient to the point of origin to make sure that you're accessing the correct port . 29 , 30 Draw a
mixed venous blood sample from the distal port of the PA catheter.

▪ Label the specimen in the presence of the patient to prevent mislabeling . 16 Place it in a laboratory biohazard transport bag
and send it to the laboratory immediately with the appropriate laboratory request forms (if necessary). 24

▪ Compare the laboratory's SVO 2 reading with that of the fiberoptic PA catheter. If the fiberoptic PA catheter SVO 2 values
and the laboratory values differ by more than 4%, follow the manufacturer's instructions to enter the SVO 2 value obtained by
the laboratory into the co-oximeter.

▪ Recalibrate the monitor every 24 hours and whenever the catheter has been disconnected from the optical module.

Completing the procedure

▪ Return the bed to the lowest position to prevent falls and maintain patient safety . 31

▪ Remove and discard your gloves and other personal protective equipment, if worn. 24

▪ Perform hand hygiene. 10 , 11 , 12 , 13 , 14 , 15

▪ Document the procedure. 32 , 33 , 34 , 35

Special considerations
▪ If the patient's SVO 2 drops below 60% or varies by more than 10% for 3 minutes or longer, reassess the patient. If the SVO
2 doesn't return to the baseline value after nursing interventions, notify the practitioner. A decreasing SVO 2 , or a value less
than 60%, indicates impaired oxygen delivery, which can occur in hemorrhage, hypoxia, shock, sepsis, arrhythmias, and
suctioning. SVO 2 can also decrease as a result of increased oxygen demand from hyperthermia, shivering, and seizures. 1 , 8 , 36
, 37

▪ If the intensity of the tracing is low, ensure that all connections between the catheter and co-oximeter are secure, and that the
catheter is patent and not kinked. 1 , 38

▪ If the tracing is damped or erratic, try to aspirate blood from the catheter to check for patency. If you can't aspirate blood,
notify the practitioner to replace the catheter. Also check the PA waveform to determine whether the catheter has wedged . 1 ,
9 , 38
If the catheter has wedged, ensure that the balloon is fully deflated, and turn the patient from side to side and instruct the
patient to cough. 1 If the catheter remains wedged, notify the practitioner immediately. 1

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Complications
Potential complications may include catheter-related infection, catheter migration, and thromboembolism. Complications such
as pneumothorax, hemothorax, or arrhythmias can occur during catheter placement. 1

Documentation

Document the date and time of the SVO 2 value and place a waveform tracing in the documentation. Note significant changes in the
patient's status, the name of the practitioner notified, the date and time of notification, prescribed interventions, and the patient's
response to those interventions. For comparison, note the SVO 2 as measured by the fiber-optic PA catheter whenever a blood
sample is obtained for laboratory (Print pagebreak 548) analysis of SVO 2 . Document teaching provided to the patient and family (if
applicable), their understanding of that teaching, and any need for follow-up teaching.

EQUIPMENT

SVO 2 monitoring equipment

A mixed venous oxygen saturation (SVO 2 ) monitoring system consists of a flow-directed pulmonary artery (PA) catheter
with fiberoptic filaments, an optical module, and a co-oximeter. The co-oximeter displays a continuous digital SVO 2 value;
the strip recorder prints a permanent record.

Catheter insertion follows the same technique as with any thermodilution flow-directed PA catheter. The distal lumen
connects to an external PA pressure monitoring system, the proximal or central venous pressure lumen connects to another
monitoring system or to a continuous flow administration unit, and the optical module connects to the co-oximeter unit. 9

Normal SVO 2 waveform SVO 2 with patient activities SVO 2 with positive end-expiratory
pressure (PEEP) and fraction of
inspired oxygen (FIO 2 ) changes

REFERENCES
1 Wiegand, D. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.). St. Louis, MO: Elsevier.

2 Jarrett, N., & Callaham, M. (2016). Evidence-based guidelines for selected hospital-acquired conditions: Final report. https://
[Link]/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/[Link]

3 Association of Professionals in Infection Control and Epidemiology (APIC). (2015). Guide to preventing central line-associated
bloodstream infections. [Link] (Level IV)

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ISBN: 978-1-975178-58-1 | 9th_Edition

4 Marschall, J., et al. (2014). SHEA/IDSA practice recommendation: Strategies to prevent central line-associated bloodstream
infections in acute care hospitals. Infection Control and Hospital Epidemiology, 35, 753-771. [Link]
676533#metadata_info_tab_contents (Level I)

5 Centers for Disease Control and Prevention. (2011, revised 2017). Guidelines for the prevention of intravascular catheter-related
infections, 2011. [Link] (Level I)

6 Standard 50. Infection. Infusion therapy standards of practice. (8th ed.) (2021). Journal of Infusion Nursing, 44, S153-S157.
(Level VII)

7 The Joint Commission. (2021). Standard NPSG.07.04.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

8 Edwards Lifesciences. (n.d.). Swan-Ganz pulmonary artery catheters. [Link]

monitoring/swan-ganz-catheters

9 Edwards Lifesciences. (2018). Edwards clinical education: Quick guide to cardiopulmonary care (4th ed.). https://
[Link]/quick-guide-to-cardiopulmonary-care-4th-edition/220356#

10 The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

11 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recommendations and Reports, 51(RR-16), 1-45. [Link] (Level II)

12 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean
care is safer care. [Link] (Level IV)

13 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Infection control. 42 C.F.R. § 482.42.

14 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

15 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

16 The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

17 The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL:
The Joint Commission. (Level VII)

18 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(c)(1).

19 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health

uoma999 | [Link] | 22 January 2025 1:17:18 Utc

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Systems. (Level VII)

20 DNV GL-Healthcare USA, Inc. (2020). [Link].5. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

21 The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

22 Waters, T. R., et al. (2009). Safe patient handling training for schools of nursing.
[Link] (Level VII)

23 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

24 Occupational Safety and Health Administration. (2012). Bloodborne pathogens, standard number 1910.1030. https://
[Link]/pls/oshaweb/owadisp. show_document?p_id=10051&p_table=STANDARDS (Level VII)
(Print pagebreak 549)
25 American Association of Critical-Care Nurses. (2018). AACN practice alert: Managing alarms in acute care across the life span:
Electrocardiography and pulse oximetry. [Link]
across-the-life-span (Level VII)

26 The Joint Commission. (2013). Sentinel event alert: Medical device alarm safety in hospitals.
[Link]
(Level VII)

27 The Joint Commission. (2021). Standard NPSG.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

28 Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing
nuisance alarms. American Journal of Critical Care, 19, 28-37.

29 U.S. Food and Drug Administration. (2017). Examples of medical device misconnections.
[Link]

30 The Joint Commission. (2014). Sentinel event alert: Managing risk during transition to new ISO tubing connector standards.
[Link] org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/
sea_53_connectors_8_19_14_final.pdf (Level VII)

31 Ganz, D. A., et al. (2013, reviewed 2021). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ
Publication No. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. [Link]
systems/hospital/fallpxtoolkit/[Link] (Level VII)

32 The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

33 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Medical record services. 42 C.F.R. § 482.24(b).

34 Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL; Accreditation Association for Hospitals and Health

uoma999 | [Link] | 22 January 2025 1:17:18 Utc

 Lippincott Nursing Procedures
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Systems. (Level VII)

35 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

36 Rhodes, A., et al. (2017). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock:
2016. Critical Care Medicine, 45, 486-552. (Level VII)

37 Lee, C., & Bora, V. (2021). Anesthesia monitoring of mixed venous saturation. [Link]
NBK539835/

38 Edwards Lifesciences. (2012). Vigilance II monitor: Quick reference guide. [Link]

De/devices/monitoring/hemodynamic%20monitoring/ar07822-vigilance_ii_monitor_sell-sheet_6x9alr.pdf

MODERATE SEDATION
Previously referred to as conscious sedation, moderate sedation is a drug-induced depression of consciousness in which the patient
responds purposefully to verbal commands, either spontaneously or with light tactile stimulation. With moderate sedation, the
patient can maintain a patent airway, protective reflexes (such as the ability to handle secretions without aspiration), adequate
spontaneous ventilations, and cardiovascular function without interventions. 1 , 2

Moderate sedation is commonly administered to relieve anxiety, discomfort, or pain so that patients can tolerate unpleasant
procedures. 1 In children and uncooperative adults, it may be used to expedite procedures that aren't particularly uncomfortable but
that require the patient to remain still.

Because predicting a patient's response to sedation isn't always possible, health care providers must have an understanding of the
different levels of sedation. (See Levels of sedation, page 550.)

In addition to the health care practitioner administering moderate sedation, this procedure requires the presence of at least one other
person capable of establishing a patent airway, administering positive pressure ventilation to the patient, and summoning additional
assistance if necessary. A person with advanced life support skills should be immediately available. 1 , 4

A patient receiving moderate sedation requires sedation monitoring before the procedure, throughout the procedure, and during the
recovery period. Health care practitioners who are permitted by their scope of practice to administer moderate sedation should
receive special training. 2 , 4 , 5 , 6 Those administering the sedation and who are responsible for the patient's care should understand
the pharmacology of the agents as well as the role of reversal agents. Those monitoring the patient receiving moderate sedation
should be able to recognize associated complications, such as apnea and airway obstruction. 1 The health care practitioner
responsible for monitoring a patient receiving moderate sedation or analgesia shouldn't have other responsibilities that would require
leaving the patient unattended or that would compromise continuous monitoring during the procedure. 2 , 4

Some patients who require a procedure may not be appropriate candidates for moderate sedation and may require anesthesia that's
monitored by an anesthesia care provider. The American Society of Anesthesiologists (ASA) devised the ASA physical status
classification system to provide a uniform guideline for evaluating the severity of systemic diseases, physiologic dysfunction, and
anatomic abnormalities to determine a patient's risk of developing complications. 7 (See ASA physical status classification system,
page 550.) Patients classified as ASA I, ASA II, and medically stable ASA III are commonly considered appropriate for registered
nurse-administered moderate sedation. 4

Moderate sedation is commonly administered for procedures that are performed in many settings outside the operating room,
including GI procedure units, interventional radiology suites, bronchoscopy suites, emergency departments, interventional
cardiology suites, and critical care units. Regardless of the location, adequately trained staff and appropriate monitoring equipment
must be available to ensure the patient's safety.

Equipment

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Facility-approved sedation scale ▪ positive pressure oxygen delivery system ▪ supplemental oxygen administration equipment
1
▪ suction apparatus ▪ suction catheter ▪ pulse oximeter and probe ▪ vital signs monitoring equipment ▪ capnometer ▪
stethoscope ▪ cardiac monitoring equipment ▪ disinfectant pad ▪ emergency equipment (code cart with emergency
medications, defibrillator, handheld resuscitation bag with mask, and intubation equipment) 1 , 2 ▪ prescribed medications and
reversal agents ▪ Optional: gloves and other personal protective equipment, IV catheter insertion equipment.

Preparation of equipment

Make sure the room where the patient will be receiving the sedation has all the necessary equipment, including emergency care
supplies. 1 , 2 , 6 Make sure all emergency equipment is readily available and functioning properly. 6 Inspect all equipment and
supplies to ensure that they're in proper working order before attaching them to the patient. 1 If a product is expired, is defective, or
has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed
by your facility.

Implementation
▪ Avoid distractions and interruptions when preparing and administering medication to prevent medication errors . 9 , 10

▪ Verify the practitioner's order for the prescribed medication. 11 , 12 , 13 , 14

▪ Review the patient's medical record and verify documentation of preexisting medical conditions; a history of tobacco,
alcohol, or substance use or abuse; previous anesthesia and sedation experiences; history of a difficult airway; current
medications; allergies; frequent or repeated exposure to sedation or analgesia agents; the last time the patient ate or had oral
fluids; a recent height and weight (in metric units); 15 and physical examination findings, including evaluation of the airway,
cardiac and respiratory assessments, and vital signs. 1 , 2 , 4 , 6 , 16 , 17

NURSING ALERT
Contact the anesthesia care provider if the patient has any of the following conditions: a history of respiratory or
hemodynamic instability; one or more significant comorbidities; pregnancy; sleep apnea; inability to
communicate or cooperate; multiple drug allergies; multiple medications with potential for drug interactions
with sedative analgesia; or current substance abuse. Extra precautions may need to be taken with these patients,
including additional monitoring and medication management. 4

NURSING ALERT
Patients with obesity have special needs during moderate sedation because they're at increased risk for
complications owing to altered physiology. Consult with the anesthesia care provider. 1

(Print pagebreak 550)

▪ Check the patient's medical record for pregnancy test results, if applicable. 4

▪ Confirm that written informed consent has been obtained and that the signed consent form is in the patient's medical record.
2 , 4 , 6 , 18 , 19 , 20 , 21

▪ Conduct a preprocedure verification to make sure that all relevant documentation, related information, and equipment are
available and correctly identified to the patient's identifiers . 22 , 23

▪ Verify that the laboratory studies have been completed as ordered and that the results are in the patient's medical record to
evaluate whether the results will affect the management of moderate sedation. Notify the practitioner of any unexpected
results. 1

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▪ Compare the medication label with the order in the patient's medical record. 11 , 12 , 13 , 14

▪ Check the patient's medical record for allergy or a contraindication to the prescribed medication. If an allergy or a
contraindication exists, don't administer the medication, and notify the practitioner. 11 , 12 , 13 , 14

▪ Check the expiration date on the medication. If the medication is expired, return it to the pharmacy and obtain new
medication. 11 , 12 , 13 , 14

▪ Visually inspect the solution for particles or discoloration or other loss of integrity; don't administer the medication if its
integrity is compromised. 11 , 12 , 13 , 14

▪ Discuss any unresolved concerns about the medication with the patient's practitioner. 11 , 12 , 13 , 14

▪ Perform hand hygiene. 24 , 25 , 26 , 27 , 28 , 29

▪ Confirm the patient's identity using at least two patient identifiers. 30

▪ Provide privacy. 31 , 32 , 33 , 34

▪ Verify the scheduled invasive procedure and the correct site as stated by the patient, and compare it with the medical record.
22

▪ Reinforce the practitioner's explanation of the sedation administration procedure to the patient and family (if appropriate)
according to their individual communication and learning needs to increase their understanding, allay their fears, and
enhance cooperation . 35 Answer their questions. Teach the patient and family about potential adverse reactions or other
concerns related to the medication. 11 , 12 , 13 , 14

▪ If the patient is to be discharged after receiving sedation within a time frame determined by your facility (up to 24 hours
after completion of the procedure), verify that arrangements have been made to transport the patient home, and that an adult
will be available in case complications arise. 1 , 2

▪ Confirm the patient's nothing-by-mouth status before the procedure; 6 if the procedure is not an emergency, minimum
fasting recommendations include 2 hours for clear liquids, 6 or more hours for a light meal or nonhuman milk, and 8 or more
hours for fried or fatty foods or meat. If the need for the procedure is an emergency, collaborate with the practitioner to
compare the risks and benefits of the procedure, considering the amount and type of liquids or solids ingested. 36

▪ Assess the patient for conditions that might make ventilation difficult, such as significant obesity, history of snoring or sleep
apnea, facial hair, missing teeth, and stridor. 4

▪ When the patient is in the room where sedation will be administered, perform hand hygiene. 24 , 25 , 26 , 27 , 28 , 29

▪ Put on gloves and other personal protective equipment as needed to comply with standard precautions . 37 , 38

▪ Attach the patient to a pulse oximeter to monitor the patient's oxygen saturation level. Make sure that the alarm limits are set
appropriately for the patient's current condition, and that the alarms are turned on, functioning properly, and audible to staff. 4 ,
39 , 40 , 41 , 42 , 43

▪ Attach the patient to a cardiac monitor to monitor heart rate and rhythm . 4 , 39 Make sure that the alarm limits are set
appropriately for the patient's current condition, and that the alarms are turned on, functioning properly, and audible to staff. 1 ,
40 , 41 , 42 , 43

▪ Attach the patient to a capnometer to continuously monitor exhaled carbon dioxide during the procedure. Make sure that the
alarm limits are set appropriately for the patient's current condition, and that alarms are turned on, functioning properly, and
audible to staff. 1 , 4 , 6 , 39 , 40 , 41 , 42

▪ Obtain the patient's pulse, blood pressure, respiratory rate, exhaled carbon dioxide level by capnography, and oxygen
saturation level, and assess level of consciousness (LOC), pain level, and anxiety level to use as a baseline for comparison
during and after the procedure . 4 , 16

▪ Ensure that the patient has patent IV access. If a patent IV catheter isn't present, insert one. 1 , 6 (See the “IV catheter
insertion and removal” procedure.)

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Levels of sedation
Because a patient receiving sedation might not always respond as intended, make sure you can recognize the different
levels of sedation. The American Society of Anesthesiologists describes levels of sedation as follows: 3

▪ Minimal sedation (anxiolysis) is a drug-induced state during which a patient responds normally to verbal commands.
Cognitive function and physical coordination may be impaired, but airway reflexes and ventilatory and cardiovascular
functions aren't affected.

▪ Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which a

patient responds purposefully to verbal commands, unaided or accompanied by light tactile stimulation. (Reflex
withdrawal from a painful stimulus isn't considered a purposeful response.) The patient doesn't require intervention to
maintain a patent airway, has adequate spontaneous ventilation, and maintains cardiovascular function.

▪ Deep sedation/analgesia is a drug-induced depression of consciousness during which a patient can't be easily aroused
but responds purposefully to repeated or painful stimulation. The patient's ability to independently maintain ventilatory
function may be impaired. The patient may require assistance to maintain a patent airway and may not have adequate
spontaneous ventilation, but typically maintains cardiovascular function.

▪ General anesthesia is a drug-induced loss of consciousness during which a patient can't be aroused, even by painful
stimulation. The patient's ability to maintain ventilatory and cardiovascular function independently is typically
impaired. The patient is likely to require assistance to maintain a patent airway, and may need positive pressure
ventilation because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.

ASA physical status classification system

The American Society of Anesthesiologists (ASA) physical status classification system is widely used to estimate a
patient's risk of developing complications. 8

ASA I: normal, healthy patient

ASA II: patient with mild systemic disease

ASA III: patient with severe systemic disease

ASA IV: patient with severe systemic disease that's a constant threat to life

ASA V: moribund patient who isn't expected to survive without the procedure

ASA VI: patient declared brain dead whose organs are being removed for donation

▪ Confirm that the procedure site has been marked appropriately by the practitioner, if indicated. Involve the patient in the
process if possible. 23 , 44

▪ Confirm the medication dosage calculations based on the patient's weight or body surface area.

▪ If your facility uses a bar-code technology, use it as directed by your facility.

▪ After the patient is prepared and draped for the procedure, conduct a time-out immediately before starting the procedure to
perform a final assessment that the correct patient, site, positioning, and procedure are identified and, as applicable, all
relevant information and necessary equipment are available . 45

NURSING ALERT

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Medications used for moderate sedation are considered high-alert medications because they can cause significant
patient harm when used in error. 46 , 47

▪ Before administering moderate sedation, have another nurse perform an independent double-check to verify the patient's
identity and to make sure that the correct medication is being administered in the prescribed concentration, the medication's
indication corresponds with the patient's diagnosis, the dosage calculations are correct and the dosing formula used to derive
the final dose is correct, and the route of administration is safe and proper for the patient . 48

▪ Compare the results of the independent double-check with the other nurse and, if no discrepancies exist, begin administering
the medication. If discrepancies exist, rectify them before administering the medication. 48

(Print pagebreak 551)

TROUBLESHOOTING

RESPONDING TO COMPLICATIONS OF SEDATION

This table reviews nursing interventions for various complications of sedation.

COMPLICATION NURSING INTERVENTIONS

▪ Reposition the patient's head.

▪ Suction the patient.

▪ Insert an oral airway.

▪ Tell the patient to take a deep breath.

Airway obstruction or respiratory depression
▪ Stimulate the patient by rubbing the arms or legs.

▪ Administer oxygen.

▪ Manually ventilate the patient with a bag-valve mask

device.
▪ Maintain circulation, airway, and breathing.

▪ Have drugs to reverse sedation (such as naloxone for

opiates or flumazenil for benzodiazepines) immediately
available and administer, as ordered, following safe
medication practices, if the patient is too deeply sedated. 11 ,
Oversedation 12 , 13 , 14

▪ Monitor respiratory status until stable.

▪ Note baseline heart rate and rhythm.

▪ Obtain an apical pulse for 1 minute.

▪ Examine electrocardiogram patterns if indicated.

▪ Ensure that the patient has a patent airway.

▪ Monitor oxygen saturation levels.

Cardiac arrhythmias
▪ Administer oxygen, as ordered.

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▪ Administer fluids and antiarrhythmic drugs as ordered

following safe medication practices. 11 , 12 , 13 , 14

▪ Investigate possible causes.

▪ Support respiratory status.

▪ Administer fluids and vasopressors as ordered following

Hypotension safe medication practices. 11 , 12 , 13 , 14

▪ Administer additional sedation or analgesia as ordered

following safe medication practices. 11 , 12 , 13 , 14

Hypertension

▪ Administer each medication separately in incremental doses and titrate it to the desired effect following safe medication
administration practices to decrease the risk of overdose and respiratory and circulatory depression . 4 , 11 , 12 , 13 , 14

▪ Continuously monitor the patient's heart rate and rhythm (using a cardiac monitor), oxygenation (using pulse oximetry), and
respiratory rate and adequacy of ventilation (using continual observation of clinical status and capnography). 1 , 4 , 6 , 49

▪ Determine and evaluate the patient's blood pressure and heart rate at least every 5 minutes. 1 , 39 , 49

▪ Monitor the patient's LOC (by checking response to verbal commands when practical), depth of sedation (using a facility-
approved sedation scale), comfort level, and skin condition at regular intervals. 1 , 4 , 49

▪ Administer supplemental oxygen, as ordered, unless specifically contraindicated for the patient's condition or the procedure.
1
Determine the method and rate of flow using the patient's optimal oxygen saturation level according to pulse oximetry. 4
Hypoxemia may cause cardiopulmonary complications . 4

▪ Monitor the patient's temperature when clinically significant changes in body temperature are intended, anticipated, or
suspected. 39 , 49

▪ Monitor the patient for complications; intervene as indicated. 2 , 49

▪ When sedation administration is complete, use the same monitoring parameters used during the procedure and monitor the
patient until discharge criteria are met. The patient should remain awake for at least 20 minutes without stimulation before
being considered ready for discharge. The duration and frequency of monitoring should be individualized, depending on the
level of sedation achieved, the patient's overall condition, and the nature of the procedure for which sedation was
administered. If a reversal agent was given, monitor the patient for a sufficient time interval (for example, 2 hours) after the
last administration of an antagonist to make sure that the patient doesn't become resedated after the reversal effects have worn
off . 1 , 4

▪ Remove and discard your gloves and other personal protective equipment, if worn. 37

▪ Perform hand hygiene. 24 , 25 , 26 , 27 , 28 , 29

▪ Clean and disinfect your stethoscope using a disinfectant pad. 50 , 51

▪ Perform hand hygiene. 24 , 25 , 26 , 27 , 28 , 29

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▪ Document the procedure. 52 , 53 , 54 , 55 , 56

Special considerations
▪ The State Board of Nursing may have guidelines about the registered nurses' role in administering moderate sedation or
caring for a patient who has received moderate sedation. Check the regulations in your state.

▪ Use a recovery and discharge criteria scoring system, such as the Aldrete Post-Anesthesia Recovery Score and the Post-
Anesthesia Discharge Scoring System, to monitor the patient's status and to help determine when the patient is ready for
discharge; tailor use of the scoring system to the patient's specific needs. 4

▪ Before discharge, the patient should meet certain criteria, which may include a return to preprocedural baseline LOC and
stable vital signs; a sufficient time interval (for example, 2 hours) since the last administration of an antagonist; the use of an
objective patient assessment scoring system; absence of protracted nausea; intact protective reflexes (for example, gag or
cough reflex); adequate pain control; and return of sensory and motor control. 4

Complications
The patient can become oversedated during moderate sedation. Other complications of moderate sedation include aspiration
of gastric contents, respiratory depression or failure, and adverse reactions to the medication. Observe the patient for airway
obstruction, respiratory depression, hypotension, and drug-specific complications.

Age and general health, in addition to such preexisting respiratory conditions as chronic obstructive pulmonary disease and
asthma, and hepatic or renal dysfunction can increase the patient's risk of adverse reactions. In general, older adults, because
of decreased renal and hepatic function and relative loss of muscle, are at greater risk. Drug interactions may occur; opioids
when used in combination with sedatives may produce a synergistic effect. (See Responding to complications of sedation.)

Documentation

Document according to your facility's documentation system and stated parameters, including preprocedure assessment findings,
procedure and site verification, and time-out procedure; the name, dose, route, time, and effects of all medications administered; the
patient's LOC, ventilation, and oxygenation status; and the procedure start and end times. Documentation should also include vital
signs at intervals determined by the type and quantity of medication administered and the patient's condition. 4 Record any adverse
reactions, the date and time a practitioner was notified, prescribed interventions, and the patient's response to the interventions.
Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-
up teaching.

REFERENCES
1 American Society of Anesthesiologists. (2018). Practice guidelines for moderate procedural sedation and analgesia 2018.
Anesthesiology, 128, 437-479. [Link] 2670190 (Level VII)

2 American Society of PeriAnesthesia Nurses. (2020). 2021-2022 Perianesthesia nursing standards, practice recommendations and
interpretive statements. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses. (Level VII)

3 American Society of Anesthesiologists. (2019). Continuum of depth of sedation: Definition of general anesthesia and levels of
sedation/analgesia. [Link]
anesthesia-and-levels-of-sedationanalgesia (Level VII)
(Print pagebreak 552)
4 Guideline for perioperative practice: Moderate sedation/analgesia. (2021). In Wood, A. (Ed.), Guidelines for perioperative
practice, 2021 edition. Denver, CO: AORN, Inc. (Level VII)

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5 Accreditation Association for Hospitals and Health Systems. (2020). Standard 30.01.04. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

6 Standard 65. Moderate sedation/analgesia using intravenous infusion. Infusion therapy standards of practice (8th ed.). (2021).
Journal of Infusion Nursing, 44, S194-S1195. (Level VII)

7 Rothrock, J. C. (2019). Alexander's care of the patient in surgery (16th ed.). St. Louis, MO: Elsevier.

8 American Society of Anesthesiologists. (2020). ASA physical status classification system. [Link]
guidelines/asa-physical-status-classification-system (Level VII)

9 Westbrook, J., et al. (2010). Association of interruptions with an increased risk and severity of medication administration errors.
Archives of Internal Medicine, 170, 683-690. (Level IV)

10 Institute for Safe Medication Practices. (2012). Side tracks on the safety express: Interruptions lead to errors and
unfinished…Wait, what was I doing? Nurse Advise-ERR, 11(2), 1-4. [Link]
interruptions-lead-errors-and-unfinished-wait-what-was-i-doing? id=37

11 The Joint Commission. (2021). Standard MM.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

12 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Nursing services. 42 C.F.R. § 482.23(c).

13 Accreditation Association for Hospitals and Health Systems. (2020). Standard 16.01.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

14 DNV GL-Healthcare USA, Inc. (2020). [Link].3. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

15 Institute for Safe Medication Practices. (2020). 2020-2021 targeted medication safety best practices for hospitals. https://
[Link]/sites/default/files/attachments/2020-02/2020-2021% 20TMSBP-% 20FINAL_1.pdf

16 The Joint Commission. (2021). Standard PC.03.01.03. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

17 Accreditation Association for Hospitals and Health Systems. (2020). Standard 30.01.06. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

18 DNV GL-Healthcare USA, Inc. (2020). [Link].3. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

19 The Joint Commission. (2021). Standard RI.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL:
The Joint Commission. (Level VII)

20 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(b)(2).

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 Lippincott Nursing Procedures
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21 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.11. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

22 The Joint Commission. (2021). Standard UP.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

23 Accreditation Association for Hospitals and Health Systems. (2020). Standard 30.00.14. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

24 The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

25 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recommendations and Reports, 51(RR-16), 1-45. [Link] (Level II)

26 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean
care is safer care. [Link] (Level IV)

27 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Infection control. 42 C.F.R. § 482.42.

28 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

29 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

30 The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

31 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

32 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(c)(1).

33 DNV GL-Healthcare USA, Inc. (2020). [Link].5. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

34 The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL:
The Joint Commission. (Level VII)

35 The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

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 Lippincott Nursing Procedures
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36 American Society of Anesthesiologists. (2017). Practice guidelines for preoperative fasting and the use of pharmacologic agents
to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology, 126,
376-393. [Link] [Link]/[Link]?articleid=2596245(Level V)

37 Siegel, J. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in
healthcare settings. [Link] (Level II)

38 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

39 American Society of Anesthesiologists. (2020). Standards for basic anesthetic monitoring.

[Link] (Level VII)

40 The Joint Commission. (2013). Sentinel event alert 50: Medical device alarm safety in hospitals. https://
[Link]/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_50_alarms_4_26_16.pdf (Level
VII)

41 Graham, K. C., & Cvach, M. (2010). Monitor alarm fatigue: Standardizing use of physiological monitors and decreasing
nuisance alarms. American Journal of Critical Care, 19, 28-37.

42 The Joint Commission. (2021). Standard NPSG.06.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

43 American Association of Critical Care Nurses. (2018). AACN practice alert: Managing alarms in acute care across the life span:
Electrocardiography and pulse oximetry. [Link]
across-the-life-span (Level VII)

44 The Joint Commission. (2021). Standard UP.01.02.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

45 The Joint Commission. (2021). Standard UP.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

46 Institute for Safe Medication Practices. (2018). ISMP list of high-alert medications in acute care settings. [Link]
sites/default/files/attachments/2018-08/[Link] (Level VII)

47 Institute for Safe Medication Practices. (2019). Safety enhancements every hospital must consider in wake of another tragic
neuromuscular blocker event. [Link]
tragic-neuromuscular
(Print pagebreak 553)
48 Institute for Safe Medication Practices. (2019). Independent double-checks: Worth the effort if used judiciously and properly. htt
ps://[Link]/resources/independent-double-checks-worth-effort-if-used-judiciously-and-properly (Level VII)

49 The Joint Commission. (2021). Standard PC.03.01.05. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

50 Rutala, W. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://
[Link]/infection-control/pdf/guidelines/[Link] (Level I)

51 Accreditation Association for Hospitals and Health Systems. (2020). Standard 17.02.03. Healthcare Facilities Accreditation

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Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

52 The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

53 The Joint Commission. (2021). Standard RC.02.01.03. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

54 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Medical record services. 42 C.F.R. § 482.24(b).

55 Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

56 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

MUCUS CLEARANCE DEVICE

Patients with chronic respiratory disorders, such as cystic fibrosis, bronchitis, and bronchiectasis, require therapy to mobilize and
remove mucus secretions from the lungs. A handheld mucus clearance device can help such patients cough up secretions more
easily. The use of a mucus clearing device in patients with chronic obstructive pulmonary disease has been shown to improve the
response to bronchodilators when the device is used before bronchodilator therapy. 1 , 2

Currently, multiple types of mucus clearance devices are available on the market. These devices take a variety of forms, including
mouth pieces, masks, and vests, and they use various methods. They are designed to either increase the amount of air that moves
behind the obstruction or to modulate expiratory airflow so that secretions propel upward. 3 For example, some devices contain a
valve that vibrates as the patient exhales vigorously through it. The vibrations propagate throughout the patient's airways during
expiration, which loosens the mucus. As the patient repeats this process several times, the mucus progressively moves up the
airways until the patient can easily cough it out. Examples of mucus clearance devices include the Flutter, the Acapella, and the
Aerobika.

A licensed practitioner should individualize mucus clearance device use, including frequency and duration, according to the patient's
clinical, functional, and social factors. 3 A recent systematic review found no clear evidence that oscillation was a better intervention
than other forms of chest physiotherapy for people with cystic fibrosis. 4

Mucus clearance device use is contraindicated in patients with known pneumothorax or overt right-sided heart failure. 2 These
devices should be used with caution in patients with intolerance to the increased work of breathing; hemodynamic instability;
increased intracranial pressure; acute sinusitis; recent facial, oral, or skull surgery or trauma; epistaxis; esophageal surgery; active
hemoptysis; nausea; or known or suspected tympanic membrane rupture or other middle ear pathology. 5

Equipment
Mucus clearance device ▪ emesis basin or tissues ▪ gloves ▪ stethoscope ▪ disinfectant pad ▪ facility-approved disinfectant ▪
oral care supplies (see the “Oral care” procedure) ▪ Optional: gown, mask and goggles or mask with face shield.

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use,
label it as expired or defective, and report the expiration or defect as directed by your facility.

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Implementation
▪ Verify the practitioner's order.

▪ Gather and prepare the necessary equipment and supplies.

▪ Perform hand hygiene. 6 , 7 , 8 , 9 , 10 , 11

▪ Confirm the patient's identity using at least two patient identifiers. 12

▪ Provide privacy. 13 , 14 , 15 , 16

▪ Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning
needs to increase their understanding, allay their fears, and enhance cooperation . 17 Tell the patient that using the mucus
clearance device will help move the mucus through the airways so that it can eventually be expectorated.

▪ Perform hand hygiene. 6 , 7 , 8 , 9 , 10 , 11

▪ Put on gloves as needed to comply with standard precautions . 18 , 19

▪ Auscultate the patient's breath sounds to obtain a baseline assessment for comparison.

▪
Instruct the patient to sit with the back straight and head tilted backward slightly so that the throat and trachea are wide open.
This position allows exhaled air to flow smoothly from the lungs and out through the device. If the patient prefers, the patient
may place the elbows on a table at a height that prevents slouching, which would interfere with smooth breathing.

▪ For the Flutter mucus clearance device, tell the patient to hold the device so that the stem is parallel to the floor. This
position places the interior cone of the device at a 30-degree tilt, which allows the ball valve inside the device to bounce and
roll freely in the cone . 2 For the Acapella mucus clearance device, make sure the resistance dial is set as ordered, and tell the
patient to hold the device parallel with the floor. 5 For the Aerobika mucus clearance device, make sure the resistance
indicator is set as ordered; this device is not dependent on the patient maintaining it in a specific position. 20

▪ Instruct the patient to draw a deep breath and hold it for 2 to 3 seconds. This inhalation step is important, because it evenly
distributes the inspired air throughout the lungs, especially in the small airways, where infection and airway damage can
occur.

▪ After 2 to 3 seconds, instruct the patient to place the device in the mouth and then exhale at a steady rate for as long as
possible. Breathing out too quickly and forcefully, may cause the vibrations to be ineffective.

▪ Instruct the patient to keep the cheeks as flat and hard as possible while exhaling to direct the air out through the mucus
clearance device most effectively . 20 Suggest that the patient hold the cheeks lightly with the other hand to help learn the
proper technique.

▪ After the patient has completely exhaled, instruct the patient to repeat the use of the device for the number of breaths
recommended by the practitioner. Generally, the recommendation is 5 to 10 breaths for the Flutter device and 10 to 20 breaths
for the Acapella and Aerobika devices. 2 , 5 , 20

▪ Instruct the patient to remove the mucus clearance device from the mouth and then perform two or three coughs to clear the
airway. 2 , 5 , 20

▪ Instruct the patient to expectorate the mucus into an emesis basin or tissue.

▪ Instruct the patient to repeat the entire procedure several times or as recommended by the practitioner.

▪ Observe the type, amount, color, viscosity, and odor of expectorated secretions.

▪ Dispose of expectorated mucus appropriately. 18

▪ Auscultate the patient's breath sounds to determine the effectiveness of coughing, and compare your findings with the

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baseline assessment.

▪ Instruct the patient to perform oral care.

▪ Remove and discard your gloves, if worn. 18

▪ Perform hand hygiene. 6 , 7 , 8 , 9 , 10 , 11

▪ Put on gloves to comply with standard precautions . 18 , 19

▪ Using a facility-approved disinfectant, clean and disinfect the device according to the manufacturer's instructions.

▪ Remove and discard your gloves. 18

(Print pagebreak 554)

▪ Perform hand hygiene. 6 , 7 , 8 , 9 , 10 , 11

▪ Clean and disinfect your stethoscope using a disinfectant pad. 21 , 22

▪ Perform hand hygiene. 6 , 7 , 8 , 9 , 10 , 11

▪ Document the procedure. 23 , 24 , 25 , 26

Special considerations
▪ Patients routinely perform multiple sets of 10 to 15 exhalations over 12 to 20 minutes. After each series of exhalations, the
patient is instructed to “huff” (perform repeated, controlled, short, rapid exhalations) and cough, which aids expectoration . 20 ,
27 , 28

▪ Observe the patient over several sets and evaluate the patient's ability to self-administer the treatment.

▪ For the Flutter mucus clearance device, the oscillation frequency can be regulated by moving the device slightly up or down
from its horizontal position. 27

▪ All models of the Acapella mucus clearance device can be used with a mask or mouthpiece or in line with a nebulizer. 27

▪ The Aerobika mucus clearance device may be used with a small volume nebulizer. 29

▪ Patients with severe airway obstruction may not be able to generate sufficient airflow to cause the steel ball within the
Flutter ® device to vibrate, limiting its effectiveness. 29

Complications
The increased work of breathing caused by the use of a mucus clearance device may lead to hypoventilation and hypercarbia.
Other potential adverse events include increased intracranial pressure, cardiovascular compromise (myocardial ischemia,
decreased venous return), claustrophobia, and pulmonary barotrauma. Patients may also swallow excess air, increasing the
likelihood of vomiting and aspiration. 5

Documentation

Record the date, time, type of mucus clearance device, and patient's tolerance of the procedure. Record the amount, color, viscosity,
and odor of secretions that the patient expectorates. Document the patient's breath sounds before and after using the mucus clearance
device and coughing. Also record the number of times the patient repeated the procedure and the success of the coughing efforts.
Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-

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up teaching.

REFERENCES
1 Wolkove, N., et al. (2004). A randomized trial to evaluate the sustained efficacy of a mucus clearance device in ambulatory
patients with chronic obstructive pulmonary disease. Canadian Respiratory Journal, 11, 567-572. (Level II)

2 Aptalis Pharma US, Inc. (2013). FLUTTER ® mucus clearance device: Instructions for use. [Link]
actavis/media/allergan-pdf-documents/product-prescribing/[Link]

3 McIlwaine, M., et al. (2017). Personalising airway clearance in chronic lung disease. European Respiratory Review, 26(143),
160086.

4 Morrison, L., & Milroy, S. (2020). Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database of
Systematic Reviews, 4(4), CD006842. (Level I)

5 Smiths Medical ASD, Inc. (2014). Acapella ® Vibratory PEP Therapy System: Reference guide.
[Link]

6 The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

7 Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recommendations and Reports, 51(RR-16), 1-45. [Link] (Level II)

8 World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean
care is safer care. [Link] (Level IV)

9 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Infection control. 42 C.F.R. § 482.42.

10 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

11 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

12 The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

13 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Patient's rights. 42 C.F.R. § 482.13(c)(1).

14 Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

15 The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL:
The Joint Commission. (Level VII)

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16 DNV GL-Healthcare USA, Inc. (2020). [Link].5. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

17 The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

18 Siegel, J. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in
healthcare settings. [Link] (Level II)

19 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

20 Monaghan Medical Corporation. (n.d.). Aerobika OPEP. [Link] 1540812069002-

acaba3d3-ddd2d628-9b4b

21 Rutala, W. A., et al. (2008, revised 2019). Guideline for disinfection and sterilization in healthcare facilities, 2008. https://
[Link]/infectioncontrol/pdf/guidelines/[Link] (Level I)

22 Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.02.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

23 The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace,
IL: The Joint Commission. (Level VII)

24 Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:
Medical record services. 42 C.F.R. § 482.24(b).

25 Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation
Program: Accreditation requirements for acute care hospitals, Chicago, IL: Accreditation Association for Hospitals and Health
Systems. (Level VII)

26 DNV GL-Healthcare USA, Inc. (2020). [Link].1. NIAHO ® accreditation requirements, interpretive guidelines and surveyor
guidance—revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

27 Hristara-Papadopoulou, A., et al. (2008). Current devices of respiratory physiotherapy. Hippokratia, 12(4), 211-220. https://
[Link]. gov/pmc/articles/PMC2580042/ (Level V)

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