Nebulizer Administration

Respiratory

Pursuant to §167.627 RSMo. Possession and self-administration of medication in school — requirements. Each board of education and its employees and agents in this state shall grant any pupil in the school authorization for the possession and self-administration of medication to treat such pupil’s chronic health condition, including but not limited to asthma or anaphylaxis if:

(1) A licensed physician prescribed or ordered such medication for use by the pupil and

instructed such pupil in the correct and responsible use of such medication;

(2) The pupil has demonstrated to the pupil’s licensed physician or the licensed physician’s designee, and the school nurse, if available, the skill level necessary to use the medication and any device necessary to administer such medication prescribed or ordered;

(3) The pupil’s physician has approved and signed a written treatment plan for managing the pupil’s chronic health condition, including asthma or anaphylaxis episodes and for medication for use by the pupil. Such plan shall include a statement that the pupil is capable of self-administering the medication under the treatment plan;

(4) The pupil’s parent or guardian has completed and submitted to the school any written

documentation required by the school, including the treatment plan required under subdivision (3) of this subsection and the liability statement required under subdivision (5) of this subsection; and (5) The pupil’s parent or guardian has signed a statement acknowledging that the school district and its employees or agents shall incur no liability as a result of any injury arising from the self-administration of medication by the pupil or the administration of such medication by school staff. Such statement shall not be construed to release the school district and its employees or agents from liability for negligence.

3. An authorization granted under subsection 2 of this section shall:

(1) Permit such pupil to possess and self-administer such pupil’s medication while in school, at a school-sponsored activity, and in transit to or from school or school-sponsored activity; and

(2) Be effective only for the same school and school year for which it is granted. Such

authorization shall be renewed by the pupil’s parent or guardian each subsequent school year in accordance with this section.

4. Any current duplicate prescription medication, if provided by a pupil’s parent or guardian or by the school, shall be kept at a pupil’s school in a location at which the pupil or school staff has immediate access in the event of an asthma or anaphylaxis emergency.

5. The information described in subdivisions (3) and (4) of subsection 2 of this section shall be kept on file at the pupil’s school in a location easily accessible in the event of an emergency.

Considerations:

Attempt to provide the student with as much privacy as possible, given the urgency of the situation.
If appropriate, encourage parents to discuss with their physician the possibility of prescribing an inhaler with a valve holding chamber in place of the nebulizer since research shows that a properly used inhaler with valve holding chamber is as effective as a nebulized albuterol.
Nebulizer should be administered in a separate room away from other people, if possible.
The school nurse should develop a plan to systematically check the expiration date on the medication to ensure the medication has not expired.

Supplies:

Medication
Nebulizer machine (air compressor)
Connecting tubing
Facemask, or a mouthpiece held in the mouth
Asthma Action Plan/health care provider’s orders and student’s Individualized Health Care Plan (IHCP)
Parent/Guardian authorization form

Procedure:

Position student
Use a room separate from where other students are receiving care (if possible) or one that has limited other use
Explain the procedure to the student at their level of understanding
Encourage the student to assist in the procedure as much as the student is able to help the student learn self-care skills
Review IHP/Asthma Action Plan and/or health care provider’s orders
Ensure proper documentation of parent/guardian authorization to administer medication
Review the six rights of medication administration to be sure it is:
1. The right student
2. The right medication
3. The right dose
4. Being given at the right time
5. Being given by the right route
6. Being given for the right reason
Check medication expiration date
Review the student’s allergy status
Wash hands
Set up and plug in the nebulizer machine in a location where the power source is close to a comfortable location for the medication to be administered
Follow the directions for the specific brand of nebulizer machine, connection tubing and cup
Review the six rights of medication administration again to be sure that it is:
1. The right student
2. The right medication
3. The right dose
4. Being given at the right time
5. Being given by the right route
6. Being given for the right reason
Unscrew top of nebulizer cup
Add medication into the bottom half of the nebulizer cup
Screw the top of the cup back on
Attach the tubing from the nebulizer cup to the nebulizer machine
Attach the nebulizer cup onto the face mask or mouthpiece
Place either the facemask on the student or the mouthpiece in the student’s mouth, be sure their lips are sealed
Turn on the machine
1. A mist of medication should rapidly appear
Instruct the student to take relatively normal slow deep breaths
Keep the nebulizer cup in an upright position
The cup may require some tapping on the sides toward the end of the treatment to optimize the completion of the dose
The treatment is complete when there is no more mist from the cup (usually 10–15 minutes)
Turn off the machine
Remove the mask or mouthpiece
Rinse the nebulizer cup, mouthpiece or mask under warm water
Shake off excess water
Place on a paper towel to dry
Monitor student’s heart rate and respirations
Document medication administration in the student’s health record
Wash hands
Have the student rinse out their mouth with water and spit
Have student wash hands
Document the intervention and outcome in student’s health care record
Update parents/guardian and health care provider, if needed

Procedure for Cleaning and Storing (these are general guidelines, follow manufacturer’s directions:

Take the nebulizer apart
Set tubing aside
Do not soak, wash or rinse tubing
1. Replace it if it becomes cloudy, discolored or wet inside
Wash the medicine cup and mask with warm, soapy water
Rinse the medicine cup and mask in warm water
Let all pieces air dry on a paper towel
When dry, put pieces in a plastic bag or container

Procedure for Weekly Disinfection, if being used regularly:

Soak medicine cup and mask in half strength vinegar (1 part distilled white vinegar, 3 parts warm water solution) for 30-60 minutes
Rinse with water
Let all pieces air dry on a paper towel
When dry, put pieces in a plastic bag or container

Procedure for Care of the Machine:

Wipe with a damp cloth
Check the filter monthly
1. Change it every six months or sooner if discolored
The machine should be serviced every five years

References:

American Lung Association. (2023, March 27). How to use a nebulizer. . Retrieved May 24, 2023, from https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/resource-library/how-to-use-a-nebulizer

American Lung Association. (n.d.). The abc’s of using a nebulizer. Retrieved May 24, 2023, from https://www.lung.org/getmedia/3124fe1d-abc5-4741-8c17-bc8a449ea67b/ABCs-Nebulizer-V2-4-6-2020_new-branding.pdf?ext=.pdf

Asthma and Allergy Foundation. (n.d.). Quick asthma card. Nebulizers – Medicine in a mist. Retrieved August 4, 2023, from https://www.aafa.org/wp-content/uploads/2022/10/quick-asthma-nebulizers-card.pdf

Lynn, P. (2019). Administering medication via small-volume nebulizer In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 122-124).

Medline Plus. (2022, December 9). How to use a nebulizer. Retrieved May 24, 2023, from https://medlineplus.gov/ency/patientinstructions/000006.htm

Missouri Department of Health and Senior Services. (2022, October 17). Nebulizer guidance for school nurses. Retrieved May 24, 2023, from https://health.mo.gov/living/healthcondiseases/chronic/asthma/pdf/neb-guidance-20221017.pdf

Missouri Revised Statute: 167.627.1 RSMo. (2010). Possession and self-administration of medication in school—requirements. Retrieved June 202, 2023, from https://revisor.mo.gov/main/OneSection.aspx?section=167.627

National Heart, Lung, and Blood Institute. (2021, October). How to use a nebulizer. Retrieved May 24, 2023, from https://www.nhlbi.nih.gov/resources/how-use-nebulizer

Perry, A. G., Potter, P.A., Ostendorf, W., & Laplante, N. (2021). Nonparenteral medications. In Clinical nursing skills and techniques. (10th ed.). (pp. 642-645). St. Louis, MO: Elsevier.

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Acknowledgment of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Debra Funk, BSN, RN
Director of Practice
Missouri State Board of Nursing

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing
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Page last updated: February 20, 2024
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