Lesson 1, Topic 1
In Progress

Closing comments

April 11, 2024

Patient Coaching
Many patients who have chronic pulmonary conditions use MDIs as part of their treatments. It is important that patients learn how to clean their MDIs and spacers to prevent additional issues. A blocked or partially blocked MDI can prevent the patient from getting the proper dose of medication. To clean the MDI and spacer, do the following:
                • Take the spacer apart. Clean the spacer with mild soap and allow it to air dry.

                 • Remove the medication canister and the mouthpiece cover from the MDI. Let warm water flow over the top and bottom of the MDI inhaler for about 30 seconds. Shake off and let air dry overnight. When assembling the device, spray twice in the air before taking a dose. Clean the MDI weekly to prevent the medication from building up and blocking the sprayer.
Cleaning techniques can vary with medication products. Patients should be encouraged to check the product’s website for directions.


Legal and Ethical Issues
Many times, with pulmonary disorders and treatments, patients may become dizzy. This can affect their balance or even cause them to faint. If a patient has a recent history of fainting or passing out, it is important for the medical assistant to keep the patient safe in the ambulatory care environment. Here are some ways to assist patients and prevent falls:
                 • Assist the patient as needed when stepping on and off the scale.
                 • Assist the patient on and off the exam table.
                 • Do not leave the patient on the exam table unattended.
                 • Ask if the patient would like a wheelchair.
Many lawsuits have been brought forward involving situations in which patients were injured from falls in the ambulatory care environment. Several cases have involved medical assistants not helping patients on and off equipment such as scales or having patients wait unattended on exam tables. Remember, safety is one of the most important concerns when caring for patients.


Patient-Centered Care
To provide patient-centered care, medical assistants need to do the following:
                 • Provide patients with clear instructions on the pulmonary procedure being done.
                 • Perform the procedure correctly so the patient’s results are accurate.
                 • Be sensitive to patients’ concerns and feelings regarding pulmonary diseases.
                 • Be respectful and empathetic when encouraging patients to breathe for spirometry tests. Remember, if the patient is short of breath or coughing due to an illness, blowing for a spirometry test can be difficult. Allow the patient to tell you when he or she is ready to do the next test.


Professional Behaviors
Part of being professional is one’s appearance and grooming. When working with patients, it is essential that medical assistants have no odors on their bodies. Perfume, cologne, or scented lotions can trigger an allergic reaction in a patient. Patients with asthma can have flare-ups when they are around different scents, such as perfume, cologne, or scented lotions.
      Medical assistants who smoke cigarettes need to be especially concerned with the odor. Research has shown that tobacco smoke contains more than 7000 chemicals, of which 250 are harmful. When the olfactory (sense of smell) system is exposed to these chemicals, reversible or permanent injuries can occur. The injury relates to the length of time the person has smoked and the tobacco toxicity. Ultimately, smoking tobacco can lead to a decrease in odor sensibility and recognition. This means people who smoke may not be able to smell the cigarette smoke on their clothing or body, yet it may be noticeable to others.
      Many patients who have a chronic illness, such as cancer or chronic obstructive pulmonary disease (COPD), have quit smoking tobacco products. It is important that the healthcare professionals who care for these patients (and all other patients) do not smell of cigarette smoke.


Summary of Scenario

As Renee works with John, she realizes she has a lot more to learn. Pulmonary disease is common. Renee decides to research the diseases she encounters every week. She feels that to be professional, it is important to be up to date on the latest information. She likes to be confident in her skills and knowledge. This helps when patients have questions about diseases, procedures, or treatments.
Renee looks forward to her weekly pulmonary experiences. She is confident in rooming patients and performing oxygen saturation measurements. She is excited about learning how to do peak flow and spirometry tests in the coming weeks.


Summary of Learning Objectives

1. Differentiate among the structures of the upper respiratory tract.

The upper respiratory tract is composed of the nose, pharynx, and larynx. These organs are located outside of the chest cavity. The main functions of the upper respiratory tract include warming and cleaning the inspired air, serving as a passageway for air, and providing a sense of smell.

2. Differentiate among the structures of the lower respiratory tract.

The lower respiratory tract consists of the trachea, bronchial tubes, and lungs. The trachea (windpipe) lies in the space between the lungs, called the mediastinum. Air travels from the larynx through the trachea, and then the trachea branches into the right and left bronchi. The bronchi divide into smaller branches, called bronchioles. These bronchioles end in microscopic ducts capped by air sacs, called alveoli, which are involved with gas exchange.

3. Examine the physiology of the respiratory system.

The two primary functions of the respiratory system are to exchange O2 from the atmosphere for CO2 waste and to maintain the acid-base balance in the body. Both functions involve ventilation (breathing), which is the movement of gases between the lungs and the environment. Ventilation includes the process of inspiration (air moving into the lungs) and expiration (air moving out of the lungs). Two types of respiration occur during the ventilation process: external and internal respiration.

4. Examine the lifespan changes in the respiratory system.

An infant has a narrow airway with a shorter and softer trachea and tends to breathe through the nose. Infants are abdominal breathers and have immature respiratory muscles, meaning fatigue with breathing difficulties can set in quickly. As a person ages, the diaphragm grows weaker. The respiratory muscles become weaker, and there is a decrease in tissue elasticity. The alveoli lose their shape.

5. Differentiate between the signs and symptoms of respiratory diseases and disorders.

Respiratory diseases can cause dyspnea, shortness of breath, hemoptysis, epistaxis, and rhinorrhea. Breathing changes include apnea, bradypnea, Cheyne-Stokes respirations, hyperpnea, hyperventilation, orthopnea, and tachypnea. Oxygen changes include cyanosis, hypoxemia, and hypoxia. Abnormal lung sounds include pleural rub, rales, rhonchi, stridor, and wheezing.

6. Examine chronic respiratory diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

A chronic disease, disorder, or syndrome lasts longer than 6 months. Some chronic diseases last a lifetime. Chronic diseases discussed in this chapter include allergic rhinitis, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and sleep apnea. Refer to each disease to learn about the signs, symptoms, etiology, diagnostic procedures, and treatments.

This chapter discussed the hazards of using tobacco products. Cigarette smokers are more likely to develop heart disease, lung cancer, and strokes. Smoking impacts all body systems. Passive or secondhand smoke also causes health problems to others. Thirdhand smoke is the residue or chemicals from the smoke. This can be inhaled or ingested and can cause problems.

7. Examine respiratory system cancers, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

Respiratory system cancers discussed in this chapter include laryngeal cancer and lung cancer. Refer to each disease to learn about the signs, symptoms, etiology, diagnostic procedures, and treatments.

8. Examine acute respiratory diseases and disorders, including the signs, symptoms, etiology, diagnostic procedures, and treatments.

An acute disease has a severe, sudden onset. There are many acute respiratory diseases. Acute diseases discussed in this chapter include acute bronchitis, COVID-19, croup, epiglottis, influenza, laryngitis, pertussis, pneumonia, pulmonary embolism, pulmonary tuberculosis, respiratory syncytial virus, sinusitis, and strep throat. Refer to each disease to learn about the signs, symptoms, etiology, diagnostic procedures, and treatments.

9. Examine the medical assistant’s role in examinations, diagnostic procedures, and treatments for respiratory conditions.

Preparing a patient for a respiratory examination includes having the patient disrobe to the waist. The medical assistant is responsible for assisting the provider throughout the examination and providing privacy and support for the patient.

The peak flow meter measures the amount of air exhaled. A peak flow rate is measured using a peak flow meter in an ambulatory care or home setting. It is used to diagnose acute conditions and manage chronic diseases, such as asthma. Procedure 26.1 describes the steps that must be taken to measure a peak flow rate.

Spirometry is done to evaluate lung function as affected by respiratory, cardiac, and neuromuscular diseases. It can be ordered if the provider identifies abnormalities in the respiratory system. A spirometer can evaluate the amount of air inhaled and exhaled. Procedure 26.2 describes the spirometry procedure.

A metered-dose inhaler (MDI) provides aerosol medication that is breathed into the lungs. MDIs are typically ordered for conditions such as asthma and chronic obstructive pulmonary disease (COPD).

A nebulizer treatment can be done in the ambulatory care setting and in the home. A nebulizer is a small machine that turns liquid medication into a fine spray that can be inhaled. Typically, the medication used for nebulizers is much stronger than the same medication found in an MDI. Procedure 26.3 describes the steps for administering a nebulizer treatment.

When a patient comes to the ambulatory care facility with a cardiac or respiratory condition, the provider may order oxygen to be administered. Oxygen should be treated like a medication. The medical assistant must get the order from the provider for how much to administer and how to administer it. Procedure 26.4 presents the steps for administering oxygen.

Procedure 26.1  Measure a Peak Flow Rate
Tasks
Perform a peak flow measurement. Document the procedure in the patient’s health record.
Equipment and Supplies
                 • Peak flow meter
                 • Disposable mouthpiece
                 • Disinfection wipes
                 • Gloves
                 • Waste container
                 • Paper towel or denture cup (optional)
                 • Patient’s health record


Procedural Steps
1. Wash hands or use hand sanitizer.

PURPOSE: Hand sanitization is an important step for infection control.

2. Assemble the equipment and supplies needed for the peak flow procedure. Place the mouthpiece on the peak flow meter. Move the indicator to the bottom of the calibration scale (if not using a digital meter).

PURPOSE: Having the equipment ready reduces the patient’s wait time. The indicator needs to be at the bottom of the scale before the test to get an accurate reading.

3. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Make sure the patient’s information matches the order and the record. Explain the procedure in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient. Explaining the procedure can make the patient feel more comfortable and reduce anxiety.

4. Ask the patient to loosen any restrictive clothing. Have the patient remove any gum and loose dentures. Make sure to provide a paper towel or denture cup if needed.

PURPOSE: The patient needs to be able to take a large breath in before the test to get the most accurate results. Normally, dentures can be left in the mouth, but loose-fitting dentures may affect the results of the test and must be removed.

5. With patients in the seated position, ensure that their feet are flat on the floor and their legs are uncrossed. The patient should sit straight up and against the back of the chair.

PURPOSE: It is important for the patient to be in a position in which the lungs can fully expand.

6. Describe how the patient should do the test. “Take the deepest breath possible. Seal your lips around the mouthpiece. Blow as hard and as fast as you can.” Encourage patients to state when they are ready to start the test. Tell patients to seal their lips around the mouthpiece.

PURPOSE: Clear directions will help the patient to understand what to do.

7. Coach the patient during the test. After the patient has blown through the meter, read the number next to the indicator. Write the number down. Reset the indicator to the bottom of the scale (if it is not a digital meter).

PURPOSE: If the patient has breathing problems, it is important to allow the patient to indicate when he or she is ready.

8. Make any adjustments as needed. Repeat the test two additional times. Write down the last two numbers.

PURPOSE: Three acceptable readings are needed for the peak flow procedure.

9. Put on gloves and remove the mouthpiece. Discard the mouthpiece in the waste container. Disinfect the peak flow meter. Remove your gloves and dispose of them in the waste container. Wash your hands or use hand sanitizer.

PURPOSE: Wearing gloves and disinfecting the peak flow meter are important for infection control.

10. Notify the provider of the readings and document the readings in the patient’s health record. Indicate the name of the provider who ordered the test, the procedure done, the results of the test, and how the patient tolerated the test.

PURPOSE: Indicating who ordered the test and what was done is important for insurance reimbursement and legal reasons.

Documentation Example
08/07/20XX 1423 Per Dr. Angela Perez’s order, a peak flow was performed. Pt stated she was “a little short of breath” on the third test. Peak flow readings: 200, 230, and 260 L/min. Dr. Perez was notified of results and patient’s SOB complaint. ———————————————————————- Renee Thomas, CMA (AAMA)


Procedure 26.2  Perform Spirometry Testing
Tasks
Perform a spirometry test. Document the procedure in the patient’s health record.
Equipment and Supplies
                 • Spirometry machine with paper (and users’ guide if applicable)
                 • Disposable mouthpiece and tubing (if applicable)
                 • Nose clip
                 • Calibration equipment
                 • Disinfection wipes
                 • Gloves
                 • Waste container
                 • Paper towel or denture cup (optional)
                 • Patient’s health record
                 • Scale (if no height and weight measurements were taken earlier that day)


Procedural Steps
1. Wash hands or use hand sanitizer.

PURPOSE: Hand sanitization is an important step for infection control.

2. Assemble the equipment and supplies needed for the spirometry procedure. Calibrate the machine according to the users’ guide and the facility’s procedures.

PURPOSE: It is important to calibrate per the facility’s procedures. Calibration ensures that the results are accurate and reliable.

3. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Make sure the patient’s information matches the order and the record. Explain the procedure in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient. Explaining the procedure can make the patient feel more comfortable and reduces anxiety.

4. Enter the patient’s name, medical record number, age (or date of birth), race, sex, weight, and height into the machine. Enter any additional required information.

PURPOSE: The information used for the spirometry calculations is current weight, height, age, race, and sex.

5. Ask the patient to loosen any restrictive clothing. Have the patient remove gum and loose dentures (if applicable). Make sure to provide a paper towel or denture cup if needed.

PURPOSE: The patient needs to be able to take a large breath in before the test to get the most accurate results. Loose-fitting dentures can affect the results of the test.

6. With the patient in the seated position, ensure that the feet are flat on the floor and the legs are uncrossed. The patient should sit straight up and against the back of the chair.

PURPOSE: The patient may get dizzy during the test, so standing can be problematic. The seated position provides the maximum lung expansion for the test.

7. Describe how the patient should do the test. “Take the deepest breath possible. Seal your lips around the mouthpiece. Blow as hard and as fast as you can. Blow until you empty the air from your lungs.”

PURPOSE: Clear directions will help the patient understand what to do.

8. Attach the mouthpiece to the machine. Explain the purpose of the nose clip to the patient. Apply the nose clip to the patient (Figure 1). Have patients state when they are ready to start. Start the test as directed by the users’ guide.

PURPOSE: The nose clip prevents air from leaking out through the nose. It provides a more accurate reading.

9. During the test, encourage the patient to empty the lungs. Repeat until three acceptable tests have been done. Allow patients to rest between tests if needed and indicate when they are ready for the next test.

PURPOSE: Usually, three test results are needed for comparison. If the patient is struggling and having difficulty breathing, ask the provider if three tests need to be done.

10. Put on gloves and remove the mouthpiece. Discard the mouthpiece in the waste container. Disinfect the spirometer as indicated in the users’ guide. Remove your gloves and dispose of them in the waste container. Wash your hands or use hand sanitizer.

PURPOSE: Wearing gloves and disinfecting the equipment are important for infection control.

11. Document that the test was performed. Indicate the name of the provider who ordered the test, the name of the test, how the patient tolerated the test, and what you did with the test results. Any patient instructions regarding follow-up can also be documented.

PURPOSE: Indicating who ordered the test and what was done is important for insurance reimbursement and legal reasons.

Documentation Example
08/08/20XX 1423 Per Dr. James Martin’s order, a spirometry test was performed. Pt stated she felt dizzy during the third attempt. The dizziness cleared within 5 minutes, and she stated she felt better. Pt was instructed to call the clinic tomorrow for the spirometry results. The spirometry results were given to Dr. Martin. ———————————————————————– Renee Thomas, CMA (AAMA)


Procedure 26.3  Administer a Nebulizer Treatment
Tasks
Administer a nebulizer treatment. Document the medication administration in the patient’s health record.
Order
Levalbuterol 0.63 mg by nebulization

Equipment and Supplies
                 • Nebulizer machine
                 • Disposable nebulizer patient kit (tubing, medication cup, mouthpiece or mask, flexible tube, and tee)
                 • Medication as ordered
                 • Provider’s order
                 • Normal saline (as ordered or according to the facility’s protocol)
                 • Disinfection wipes
                 • Gloves
                 • Waste container
                 • Patient’s health record


Procedural Steps
1. Wash hands or use hand sanitizer. Using the drug reference information and the order, review the information on the medication if needed. Clarify any questions you have with the provider.

PURPOSE: Hand sanitization is an important step for infection control. It is important to be knowledgeable about the medication you are giving.

2. Select the right medication from the storage area. Check to see if the medication is concentrated and requires normal saline to dilute it. Check the medication label (and normal saline label, if used) against the order. Check for the right name, form, and route. Check the expiration date to make sure the drug has not expired. Verify that it is the right dose and time.

PURPOSE: A provider’s order is required for the nebulizer treatment. The medication needs to be verified three times before it is given. The nine rights of medication administration also need to be followed.

3. Assemble the equipment and supplies needed for the nebulizer treatment.

PURPOSE: Having the equipment ready reduces the patient’s wait time.

4. Perform the second medication check. Check the medication and normal saline label(s) against the order. Check for the right name, form, and route.

PURPOSE: It is important to check the label(s) a second time before pouring the medication into the medication cup.

5. Add the medication and, if required, the normal saline to the medication cup (Figure 1). Secure the cover on the cup.

PURPOSE: The medication cup holds the medication during the treatment.

 

6. Perform the third medication check. Check the medication label and normal saline label (if used) against the order. Check for the right name, form, and route. Verify that the amount of medication in the cup is correct according to the order. Clean up the area.

PURPOSE: It is important to check the label a third time before giving the medication.

7. Prior to entering the exam room, provide a courtesy knock on the door. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Make sure the patient’s information matches the order and the record.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient. Explaining the procedure can make the patient feel more comfortable and reduce anxiety.

8. Provide the right education to the patient. Explain the medication ordered, the desired effect, and common side effects; also identify the provider who ordered it. Explain the procedure in a manner that the patient understands. Answer any questions the patient may have about the procedure. Ask if the patient has any allergies. If the patient refuses the medication, notify the provider.

PURPOSE: The patient needs to be aware of what you are giving, the action and side effects, and who ordered it. It is also important to double-check the patient’s allergies before administering the medication.

9. Attach the mouthpiece (or mask). Attach the tubing to the medication cup and the machine.

PURPOSE: Use a mask if ordered by the provider.

10. Perform the right technique. The patient should be sitting upright on a chair. Instruct the patient to hold the mouthpiece between the teeth and seal the lips around the mouthpiece. Encourage the patient to take slow, deep breaths through the mouth. The patient should hold each breath for 2 to 3 seconds before exhaling.

PURPOSE: Sitting upright allows for total lung expansion. If patients breathe too deeply and too fast, they will become dizzy and may hyperventilate. Holding the breath in allows the medication to disperse through the lungs.

11. Turn on the nebulizer and give the medicine cup and mouthpiece to the patient to start the treatment. Instruct patients to put it into their mouths. If using a mask, position it securely and comfortably over the patient’s nose and mouth.

PURPOSE: It is important to make sure the mask is comfortable over the patient’s face. If it is not comfortable, the patient may not tolerate the treatment.

12. Continue the treatment until the mist has stopped (approximately 10 minutes) (Figure 2). Turn off the nebulizer. Encourage the patient to take several deep breaths and cough.

Note: After the treatment, it is common that patients will need to cough. Ensure that tissue is available if the patient needs it.

 

13. Put on gloves and dispose of the used supplies. Disinfect the nebulizer machine. Remove your gloves and dispose of them in the waste container. Wash your hands or use hand sanitizer.

PURPOSE: To ensure infection control.

14. Document in the patient’s health record. Include the name of the provider ordering the treatment, what was administered, how the patient tolerated the medication, and any follow-up assessments (e.g., vital signs).

PURPOSE: Documentation is the last of the nine rights of medication administration.

Documentation Example
08/06/20XX 1120 P: 76 regular, 1+ ; R: 26 regular, shallow. Per Dr. Angela Perez’s order, Levalbuterol 0.63 mg was administered by nebulizer. Pt stated she felt a little shaky after the treatment and her lungs felt less tight. Pt is resting on the exam table. P: 86 regular, 1+; R: 20 regular, normal. Dr. Perez was notified. ————————————————————————————– Renee Thomas, CMA (AAMA)


Procedure 26.4  Administer Oxygen Using a Nasal Cannula or Mask
Tasks
Administer oxygen using a nasal cannula or mask. Document the oxygen administration in the patient’s health record.
Order 1
Administer 2 LPM of oxygen using a nasal cannula.

Order 2
Administer 6 LPM of oxygen using a simple mask.

Equipment and Supplies
                 • Oxygen cylinder with oxygen regulator or oxygen flow meter (wall unit)
                 • Adult nasal cannula or simple mask
                 • Provider’s order
                 • Patient’s health record
                 • Mannequin (optional)


Procedural Steps
1. Wash hands or use hand sanitizer.

PURPOSE: Hand sanitization is an important step for infection control.

2. Assemble the equipment and supplies needed for the provider’s order. If an oxygen cylinder is used, identify the amount of oxygen left in the cylinder.

PURPOSE: The order will include the amount to give and the device (e.g., cannula) to use for the administration. It is important to make sure the cylinder has enough oxygen for the patient.

3. Verify the order if you have any questions.

PURPOSE: A provider’s order is required for oxygen administration.

4. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Make sure the patient’s information matches the order and the record. Explain the procedure in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient. Explaining the procedure can make the patient feel more comfortable and reduce anxiety.

5. Connect the nasal cannula or mask to the regulator or flow meter. Turn on the oxygen and adjust the flow rate to the correct amount per the provider’s order. The ball should be centered on the number of liters ordered.

PURPOSE: Oxygen needs to be flowing through the tubing before the cannula is applied to the patient.

6. Apply the mask or nasal cannula.

a. Place the mask over the patient’s nose, mouth, and chin. Place the elastic over the head. Adjust the elastic strap to tighten the mask on the face. Adjust the metal nasal bridge clamp, making sure it fits without obstructing the nose. Ensure that the mask fits tightly on the face.

PURPOSE: A poorly fitting mask can cause oxygen to be directed into the eyes, causing additional problems.

b. Insert the tips of the cannula into the nostrils. If the tips are curved, the curves face downward toward the bottom of the nose (Figure 1). Adjust the tubing around the back of the ears and then under the chin. Encourage the patient to breathe through the nose with the mouth closed.

PURPOSE: The cannula needs to be inserted correctly into the nostrils. The cannula tips may be blocked by the top of the nostrils if they are inserted incorrectly. Breathing through the mouth when using a cannula is not as beneficial as breathing through the nose.

7. Make sure the patient is comfortable. Answer any questions the patient may have. Sanitize your hands.

PURPOSE: Unanswered questions can cause anxiety. With breathing problems, it is important for the patient to be comfortable and calm.

8. Document the procedure. Include the name of the ordering provider, the number of liters of oxygen administered, the device used for administering the oxygen, and the patient’s condition.

PURPOSE: Indicating who ordered the oxygen and what was administered is important for insurance reimbursement and legal reasons.

Documentation Example
08/07/20XX 1541 R: 28 regular, shallow. Per Dr. Angela Perez’s order, 2 L/min of oxygen administered via nasal cannula. Pt resting on exam table. —————————————————————————————— Renee Thomas, CMA (AAMA)
08/07/20XX 1555 R: 20 regular, normal. Pt stated she is “feeling better” with the oxygen and has less SOB. Dr. Angela Perez was notified. —————————————————————————————– Renee Thomas, CMA (AAMA)