Med. J. Cairo Univ., Vol. 81, No. 2, September: 81-94, 2013 www.medicaliournalofcairouniversitv.

net

Knowledge and Performance of Critical Care Nurses Toward

Nebulizer Therapy in the Intensive Care Unit at Assiut University
Hospital
FARES A.A. KHODISH, B.Sc.N*; MONA A. MOHAMMED, D.N.Sc.*;
MERVAT ANWAR ABD EL-AZIZ, D.N.Sc.* and HANY AHMED IBRAHEM, M.D.**
The Departments of Critical Nursing* and Anesthesiology**, Faculties of Nursing* and Medicine**, Assiut University

Abstract Correspondence to: Dr. Mona A. Mohammed, The

Background: A nebulizer is an important device used to Department of Critical Nursing, Faculty of Nursing, Assiut
inhalant the drugs to treat some pulmonary diseases. The University delivered pi. A nebulizer is an electrically
examination of nurse's knowledge and performance powered machine that turns liquid medication into a mist
regarding the nebulizer therapy has not been conducted so that it can be breathed directly into the lungs through a
before at Assiut University Hospital. face mask or mouthpiece [21. It is generally believed that
nebulizers are superior to MDIs during mechanical
Aim of Study: Asses critical care nurse's knowledge and ventilation. The delivery of bronchodilators with MDI in
performance related to nebulizer therapy. mechanically ventilated patients has received considerable
Methods: Descriptive design was adapted for this interest in recent years. This is because the use of metered
study. The sample of this study consisted of 80 nurses dose inhalation (MDI) has several advantages over the
working in three intensive care units (38 nurses in nebulizer, such as reduced cost, ease of administration,
traumatic ICU, 20 nurses in postoperative ICU and 22 in less personnel time, reliability of dosing and a lower risk
general ICU). Two tools were used to collect the required of contamination. The use of nebulizers under certain
data; nurses' knowledge assessment questionnaire and circumstances may lead to patient/ventilator
skills observation checklist related to nebulizer therapy. dyssynchrony. Finally, nebulizers may damage the
expiratory transducer of some ventilators, rendering the
Results: The findings revealed that (56.2%) of nurses
have knowledge about nebulizer therapy at unsatisfactory expiratory volume measurement unreliable [31.
level (MeanSD=27.4412.09) also the findings revealed Bronchodilators are frequently used in ICU patients
that (88.8%) of nurses had performance about nebulizer receiving invasive mechanical ventilation (IMV) and
therapy at unsatisfactory level (MeanSD=29.2515.97). commonly delivered through the inhalation route [4].
There was a positive strong relationship between Medication that is inhaled in the form of small droplets is
knowledge and performance regarding nebulizer therapy absorbed immediately into the mucosa and blood stream
(r=0.277, p=0.013). and is available to the body within minutes. This method
of medication delivery is one of the fastest, noninvasive
Conclusions: Nurse's knowledge and performance methods of medications designed to ease respiratory
about nebulizer therapy were unsatisfactory so that the distress symptoms such as those seen with asthma [51.
nurses should be trained enough to give effective and safe Some studies reflect that, there are advantages of
care to such patients.
nebulizertreatment including: Patient coordination
Key Words: Nursing knowledge Nursing performance required, effective with tidal breathing, high dose possible,
Nebulizer therapy. dose medication possible, can be used with supplemental
oxygen, systemic side effects are less frequent and severe
Introduction with inhalation compared to systemic delivery (injection,
AEROSOLIZED medications can greatly benefit oral); e.g., less muscle tremor, tachycardia, Can deliver
critically ill patients with respiratory disorders. However, combination therapies if compatible and Ultrasonic
for an aerosol to be clinically useful, it must be delivered nebulizer is quiet, and has faster delivery are smaller and
more portable
effectively to the airways as well as produce a desired
therapeutic effect once
[6] . Aerosolized medication if not performed with [7] . Aerosolized medication must be performed
appropriate technique, will lead to several according to right standards and codes in order
consequences and perils such as mucosa to reduce its side effects [8]. Diggory & Vallone
irritation, bron- chospasm, dyspnea, airway [9],
burns (when heating elements are used), demonstrated in a study that performing
headaches, coughing, tachycardia, palpitations, aerosolized
nausea and precipitation of bronchoconstriction medication by well-educated nurses and after
most common in asthmatic and COPD patients checking patient's need has better effect and
and may result in hypoxemia fewer side effects than performing it routinely
[10]. Also revealed in a study that performing

1
 2 Knowledge & Performance of Critical Care Nurses
aerosolisolized medication by themselves
according to the codified protocol will minimize its
side effects. Despite the existence of several
studies, manual on the basis of evidences about
aerosolized medication by nebulizer is not
available in most units. There for performing
aerosolized medication by nebulizer with the
observance of such experimental evidences by
nurses is on question 1111. Day et al., [12] in two
separate studies in intensive and acute care units,
realized nurses lacking knowledge which was
reflected in their performance Nurses are one of
the major components of manpower in the field of
healthcare. The skills and knowledge of nursing
personnel may be directed towards health promo-
tion, crisis intervention, maintenance,
rehabilitation/ restoration or palliation in care of
critically ill patient [13] . Nursing rolebefore using
Nebulizer; assess the patients respiratory status.
Note if the patient is using accessory muscles for
respiration or if there is flaring of the nares.
Auscultate the clients chest for wheezes and
crackles. Respiratory distress is the primary reason
to administer nebulized treatment, the nurse must
Place the patient in an upright position (40 to 90
degrees), which allows deep ventilation and
maximal diaphragmatic movement Put the
mouthpiece in the mouth, between teeth, and close
the lips (if using a mask, cover mouth and nose
with the mask). Assess the breath sound, pulse rate,
respiratory status, oxygen saturation; assess the
heart rate during the treatment. In pregnant patient,
the fetal heart rate should also be assessed, instruct
the patients to take slow deep breaths for 10
seconds through the mouth and hold at end
inspiration and wash face if using a mask to
prevent rash [1 4] . The nurse must follow the
following steps when preparing a medication by a
nebulizer machine; if you have the multiple dose
vial be; Squeeze the dropper to fill it to the line
that matches your prescribed dose, squeeze the
medicine into the medicine cup, most medicines
that comes in multiple dose vials needs to be
diluted with normal saline [5] . The nurse instructs
the patient to do breathing exercise for two or three
seconds to give the medication time to fully enter
the airways of The lungs. After this first breath
continue this cycle of exhalation and inhalation
until the dose of medication is finished. Typically,
treatment will take roughly five to 10 minutes [15].
During the nebulizing; therapy it may be necessary
for the nurse to suction the patients tracheostomy
to enable removal of secretions. This should only
be carried out if necessary and if the patient is
unable to cough the secretions out of the tube
themselves. It should be remembered that suction-
ing is an invasive procedure, which may be
uncomfortable and frightening for the patient. It
should only be carried out following careful
assessment of the need for suctioning and should
only be undertaken by practitioners who are
competent. Patient indications for suctioning may
include: Visible or audible secretions that patient
are unable to clear, patient distress, clammy skin or
sweating, increased heart rate/respiratory rate
reduced oxygen saturation [1 6] . The role of the
nurse toward the patient with nebulizer therapy for
promoting respiratory care based. The nurse
instructs the patient to breathe through the mouth,
taking slow, deep breaths, and then to hold the
breath for a few seconds at the end of inspiration
for increasing the intrapleural pressure and reopen
collapsed alveoli, therapy increasing function
residual capacity, the nurse encourage the patient
to cough and to monitor the effectiveness of the
therapy [17]. So, the significance of the study from
an organizational perspective, the large and
increasing number of noninvasive procedures at
intensive care unit may result in capacity problems
such as respiratory infection. A possible solution
for these problems might be a reduction in length
hospital stay. The number of nebulizer therapy
performed at Assiut University ICU units in 2010-
2011 more than 450 intervention procedures
Observation of nebulizer therapy at ICU showed
that most patient who performed nebulizer therapy.
Therefore the aim of this study is to investigate
Knowledge and practices levels of nurses in ICU at
Assiut University Hospital. This study could be
beneficial in many ways; first, it will provide data-
base that can be utilized by health team members
to raise nurses awareness, and initiate more active
nurses roles at intensive care unit. Second, Health
professionals can utilize such information in the
care plan for such group of nurses in the future.
Third, proper nursing assessment and monitoring
can improve patients outcome.
Subjects and Methods
Research design: Descriptive design was adapt-
ed for this study.
Studyaim: Investigate critical care nurses
knowledge and performance related to nebulizer
therapy.
Research questions: What are nurses
knowledge and performance of toward nebulizer
therapy in the intensive care unit at Assiut
University Hospital.
Material:
Setting:
This study was conducted in three intensive
care units (general intensive care units, postoper-
ative intensive care units & traumatic intensive
care units) at Assiut University Hospital.
 Fares A.A. Khodish, et al. 3

Subjects: nebulizer therapy. Second section was concerned

A sample of convenience included all the avail- with the preparation of equipment and patient.
able nursing staff working at the general intensive Third section was for the application of the
care units (22 nurses), postoperative intensive care nebulizer therapy including practices such as,
units (20 nurses) & traumatic intensive care units breathexercises, vital- singes, suction, mechanical
I.C.0 (38 nurses) at Assiut University Hospital ventilation, pulse oximetry, oxygen therapy and
(Total 80 nurses). arterial blood gas. Section four involves post care
practices such as; washing hands and regular care
Tools: while the nebulizer therapy was maintained.
Two tools were used to collect the required Finally, section five was; documentation of the
data; nurses knowledge assessment questionnaire type of nebulizer, medications, time, indications
and skills observation checklist related to nebulizer and unexpected outcomes for nebulizer therapy.
therapy. Satisfactory levelof performance equal or more
Tool (1): Nurses knowledge assessment Question- than 60% of the maximum score. Unsatisfactory
naire: level of performance less than 60% of the
Arabic interview questionnaire sheet was con- maximum score.
structed after reviewing the relevant literature to Methods:
assess nurses knowledge about a nebulizer ma-
chine. It was developed and translated into Arabic
language. Thequestionnaire was included three
parts. Part (1): Is for nurses characteristics such
asage, marital status, years of experience, depart-
ment, qualifications and their attendance of related
course training about a nebulizer machine. Part (2):
Thispartassesses nurses knowledge related to
nebulizer machine in general such as type, indica-
tions for applications, and complications of nebu-
lizer machine. Part (3): Assess nurses knowledge
concerning nebulizer therapy related practices
including knowledge regarding assessment, prep-
aration, application, post nursing care, and docu-
mentation of nebulizer therapy.
The total score for this questioner tool was 24
points, the correct response answer was scored as
"1" and incorrect response or do not know as "o".
The Satisfactory level of knowledge equal or more
than 60% of the maximum score. Unsatisfactory
level of knowledge less than 60% of the maximum
Tool (2): Skills observation checklist tool:
This tool was adapted from Potter et al., it was
used to assess nursing performance while applying
and providing maintenance care of nebulizer ther-
apy. The check list items included 71 items. It
consists of three parts. Part (1): Includes type of
the ICU and the shift (morning, evening or night)
when the observation checklist was taken. Part (2):
Involves patients characteristics, such as; age,
medical diagnosis and past history. Part (3): Was
used to observe nurses practices while applying
and maintaining the nebulizer therapy. It contains
five main section covering the main steps of neb-
ulizer use and care; assessment, preparation, post-
care, maintenance and documentation. First section
was for assessment which involves items to be
assessed before the application of nebulizer
therapy, such as indication of nebulizertherapy,
physician s order and medications which used by
 4 Knowledge & Performance of Critical Care Nurses

Permission was obtained from the hospital
administrative authority to collect the necessary
data. Validation of the study tools was assessed by
presenting them to five experts from the critical
care nursing field. A pilot study was carried out in
march-July 2012 to test the tool. A pilot study was
conducted for purpose of testing clarity, complete-
ness, and validity, practicability of the study tools
of (5) nurses to determine the time involvement.
Also it was done to show the possibility and effec-
tiveness of using the observation checklist. Neces-
sary modification was done. Testing the questions
ware done to see if they are relevant and if they
elicit the type of information, which are thought
according to the answers and comments made by
nurse. Some details not required were omitted,
either to advance or reduce the tool lengthy test.
Also to show the possibility and the effectiveness of
using the observation checklist regarding the policy of hospital
performance
The observation checklist was carried out while the nurses
were working during their shifts in these units. Each
observation lasted for 20 minutes by using the direct
observation technique. At initial interview the researcher
explain the nature & purpose of the study, prior to answering
the questions to gain their oral consent & cooperation, and fill
out the questionnaire sheet by nurses were on duty during
morning,afternoon and night shifts. Nurses were observed two
hours for each nurse, while they were performance nursing
intervention for their patient during this period. The whole
period for implementation of study was morning shift.
Statistical analysis:
Data entry was done using compatible personal computer
by the investigator. The statistical analysis was done using
SPSS-16 statistical software package. The content of each tool
was analyzed, categorized and then coded by the investigator.
Data were presented using descriptive statistics in the form of
frequencies and percentages for qualitative variables,
Quantitative continuous data were compared using student t-
test in case of comparisons between three groups. Pearson
correlation analysis was used for assessment of the inter-
relationships among quantitative variables. Statistical signifi-
cance was considered at p-value<0.05.
Results

Table (1): Presentation of study group at three units in intensive care units.
Postoperative I.C.0 (n=20) General I.C.0 (n=22)
DF=2
Characteristics I.C.0 trauma (n=38)
No. % No. % No. % X2 p-value
Age in years:

<25 years 10 26.3 6 30.0 9 40.9 3.187

25-30 years 21 55.2 9 45.0 7 31.8
>30 years 7 18.4 5 25.0 6 27.2 0.527

Qualification:
Nursing Bachelor 10 26.3 4 20.0 2 9.0
Nursing Technical Institute 7 18.42 5 25.0 6 27.2 2.825 0.588
Nursing Diploma 21 55.2 11 55.0 14 63.6

Years of experience:
<5 years 4 10.5 7 35.0 4 18.1
5-10 years 25 65.7 5 25.5 7 31.8 13.219 0.010*
10 years and more 9 23.6 8 40.0 11 50.0

Training course:
Attended 0 00.0 0 00.0 0 00.0
Not attended. 38 10.0 20 10.0 22 10.0
(*) Statistical significant difference (p<0.05).

Table (1) showed that the total number of nurses are (80) (65.7%) were between 5-10 years in
nurses from different of intensive care units, (38) nurses from trauma ICU.
trauma intensive care unit, (20) from post operative & (22) L,
from general intensive care unit. The majority of nurses Unsatisfactory
(55.2%) were between 25-30 years old in traumatic ICU, The 56.2%
majority of the nurses were nursing diploma (63.6%) in
general ICU, and all nurses had no previous training IN Fig. (1):
courseabout nebulizer (100%). Illustrate nurses' knowledge
about nebulizer.
There was statistical significant difference related to years
of experience (p-value=0.010) and the majority of nurses
 Fares A.A. Khodish, et al. 5

This figure shows that (56.2%) of nurses at unsatisfactory

level of knowledge.
Table (2): Description of nurses' knowledge related to nebulizer therapy at three units.

Units
Postoperati p-
I.C.0 General value
Nurses' knowledge v
Unsatisf. Satisfact. Unsatisf. Satisfact. Unsatisf. Satisfact.
No. % No % No. % No. % No. % N %
. o.
Define the nebulizer 20 52.6 18 47.4 10 50.0 10 50.0 17 77.3 5 22.7 0.115
Indications of nebulizer 3 7.9 35 92.1 1 5.0 19 95.0 2 9.1 20 90.9 0.874
Assessment:
Sings of hypoxemia 12 31.6 26 68.4 8 40.0 12 60.0 16 72.7 6 27.3 0.007*
The lung sound. 16 42.1 22 57.9 9 45.0 11 55.0 16 72.7 6 27.3 0.059
Chest secretions 34 89.4 4 10.5 18 90.0 2 10.0 21 95.4 1 4.5 0.542
The arterial blood gases 12 31.5 28 73.6 5 25.0 15 75.0 10 45.4 12 54.5 0.214
Pulse oximetry 7 18.4 31 81.6 5 25.0 15 75.0 12 54.5 10 45.5 0.011*
Pulmonary function test 7 18.4 31 81.6 3 15.0 17 85.0 10 45.5 12 54.5 0.033*
Prepare:
The equipment 12 31.5 26 68.4 9 45.0 11 55.0 17 77.2 5 22.7 0.003*
The medication 4 10.5 34 89.5 1 5.0 19 95.0 4 18.2 18 81.8 0.394
Checkthe connections 14 36.8 24 63.1 14 70.0 6 30.0 13 59.0 9 40.9 0.039*
Explain breathing exercises 22 57.9 16 42.1 10 50.0 10 50.0 17 77.3 5 22.7 0.163
Complications of nebulizer 28 73.6 10 26.3 16 80.0 4 20.0 19 86.3 3 13.6 0.048*
(*) Statistical significant difference (p<0.05).

Table (2) shows that there were significant difference in 1. 003) and the majority of nurses in general ICU were at
nurses' knowledge about Sings of hypoxemia patient (p- Unsatisfactory level (77.2%).
value=0.007), and the majority of nurses in General I.C.0
There was significant difference in nurses' knowledge
were at unsatisfactory level (72.7%). Also, there was
about Check all connections of nebulizer (p-value=0.039) and
significant difference in nurses' knowledge about pulse
the majority of nurses in postoperative I.C.0 were at
oxime- tery (p-value=0.011) and the majority of nurses in
Unsatisfactory level (70%).
I.C.0 trauma were at satisfactory level (81.6%).

Shows there were significant difference in nurses'
knowledge aboutpulmonary function test (p-value=0.033) and
the majority of nurses in postoperative I.C.0 were at
satisfactory level (85.0%). There was significant difference in 2.
nurses' knowledge about prepare theequipment (p-value=
There was significant difference in nurses' knowledge
about complications of nebulizer (p- value=0.048) and the
majority of nurses in general
C.0 were at unsatisfactory level (86.3%).

Table (3):Difference between nurses' knowledge related to nebulizer therapy according to qualification.

Qualification
Nursing Bachelor (n=l6) Technical Institute (n=18) Nursing Diploma (n=46)
Nurses' knowledge p-value
Unsatis Satis Unsatis- Satisfactory
factory factory Unsatis- Satisfactory factory factory
No. % No. % No. % No. % No. % No. %
Define of nebulizer 13 81.3 36 78.3 10 21.7 4 8.7 42 0.000*
Indications nebulizer 3 18.8 2 12.5 14 87.5 12 66.7 6 33.3 4 22.2 14 77.8 91.3 0.194
Assessment:
Signs of hypoxemia 7 43.8 9 56.3 4 22.2 14 77.8 11. 54.3
25 10 45.7
21 0.067
The lung sound. 13 81.2 3 18.7 0. 16 88.8 2 1 46 0.0 0 0.0 0.026*
0 16 88.9 2 11.1 44 95.7 2 0 0.317
Thechest secretions. 16 100.0 0 30.432 30 4.3
Arterial blood gases 5 31.3 11 68.8 950.1 22 9 50.0 14 0.317
Pulse oximetry 4 25.0 12 75.0 4 .2 14 77.8 34.8
16 28. 33 69. 0.546
Pulmonary function test 4 25.0 12 75.0 3 16. 15 83.3 13 3 6 0.629
40 65.2
1 7 17 94.4 613.1 77. 5 0.685
Prepare medication 2 12.5 14 87.5 71.7
Cleans the equipments 12 31.5 26 9 5.6 11 55.0 17 0.003*
68.4 2 87.0
Explain: 45.0 42 22.7
Breathing exercises. 3 81.8 13 2 14 12 4 8.7 17
18.2 611.1 33 29
Procedures of neubilizer 5 31.2 11 68.7 88.9 63.0 0.548
Complications of nebulizer 12 75.0 3 .3 91.3
25.0 66.6 37.0 0.024*.
14 77.7 4 22.2 42 91.3 4 0.872
Fares A.A. Khodish, et al. 7

Qualification
Nursing Technical
Nursing Bachelor Institute (n=18) Nursing Diploma
Nurses' knowledge (n=16) (n=46) p-value
No. No. No.

Hand washing:
Satisfactory 4 25.0 2 11.1 6 13.0
Unsatisfactory 12 75.0 16 89.0 40 87.0 0.019*

Flow rate of 02:

Satisfactory 13 81.3 15 83.3 40 87.0
Unsatisfactory 3 3 16.7 13.0 0.838
18.8 6
Arterial blood gases:
Satisfactory 13 81.3 13 72.2 22 47.8
Unsatisfactory 3 18.8 5 27.7 24 52.2 0.007*

Reassess lung sounds, pulse:

Satisfactory 3 18.8 7 38.9 5 10.9
Unsatisfactory 13 81.3 41 89.1 0.036*
11 61.1
Clean of equipment:
Satisfactory 7 43.7 12 66.6 8 17.3
Unsatisfactory 9 56.2 6 33.3 38 82.6 0.001**

Table (3) shows there were significant difference in nurses' knowledge aboutdefine of nebulizer (p- value=0.000) and the
majority of nurses in Nursing Bachelorwere at satisfactory level (81.3%), there were significant difference in nurses' knowledge
aboutdefine of lung sound (p-value=0.026) and the majority of nurses in Nursing Bachelorwere at unsatisfactory level (81.2%),
there were significant

Table (4): Differences nurses' knowledge and nurses' characteristics according to department, education, and experience.
Level of Knowledge Nurses' l
characteristics Unsatisfactory Satisfactory P-value
No. % No. %
Department:
I.C.0 trauma 20 52.6 18 47.4 47.4
I.C.0 postoperative 10 50.0 10 50.0 50.0
General I.C.0 15 68.2 7 31.8 31.8
Education:
Nursing Bachelor 4 25.0 12 75.0 75.0
Nursing Diploma 32 69.6 14 30.4 30.4
Nursing Technical 9 50.0 9 50.0 50.0
Institute
Experience:
12 80.0 3 20.0 20.0
<5 years 5-10 years 22 59.5 15 40.5 40.5
10 years 11 39.3 17 60.7 60.7
(*) Statistical significant difference (p<0.05).

Table (4) shows that there was significant differences regarding to

education (p-value=0.07) and experiences (p-value=0.32).
difference in nurses' knowledge aboutdefine of Cleans the equipment's (p-
value=0.003) and the majority of nurses in Nursing Bachelorwere at satisfactory level (68.4%), there were significant difference in
(*) Statistical significant difference (p<0.05).

Table (5): Relationship between nurses' performance and nurses' qualifications related to nebulizer therapy.
nurses' knowledge aboutexplained procedure of nebulizer (p-value=0.024) and the majority of nurses in Nursing Bachelorwere at
satisfactory level (68.7%).

100 90 80 70 60 50 40 30 20 10 0
ICU Trauma Post operation General ICU
ICU
Unsatisfactory Satisfactory

Fig. (2): Nurses' performance according to department.

 Fares A.A. Khodish, et al. 9

Table (5) shows significant difference in nurses' performance about washing hands (p-value =0.019) and the majority of nurses
innursing Technical Institute were at unsatisfactory level (89.0%).

There was significant difference in nurses' performance about Arterial blood gases (p-value=
1. 007) and the majority of nurses in nursing bachelor were at satisfactory level (81.3%).
There was significant difference in nurses' performance aboutreassessing breath sounds, pulse, oxygen saturation, respiratory
rate, (p-value=0.036) and the majority of nurses in nursing diploma were at unsatisfactory level (89.1%).

There was significant difference in nurses' performance aboutwashing all parts of the nebulizer (p-value=0.001) and the
majority of nurses in nursing diploma were at unsatisfactory level (82.6%).

Table (6): Nurses performance related to nebulizer of MV (mechanical ventilation) according to qualifications.

Qualification
N
Nurses' knowledge
&
ursmg B^for Nurnng T^hnical Nursmg Dmloma p-value
(n=16) Institute (n=18) (n=46) 1

No. No. No.

Prepare suction equipment:
Satisfactory 14 87.5 14 77.77 33 71.73
2 12.5 4 22.22 13 28.26 0.436
Unsatisfactory
Reassess vital signs: 11 68.7 11 61.11 22 47.82
Satisfactory 5 31.25 0.035*
7 38.88 24 52.17
Unsatisfactory
Cleans the equipment: 4
12 25.0 11 23.39
Satisfactory 75.0 633.33 35 76.08 0.950
Unsatisfactory 1266.66
Attach MV to endotracheal tube/tracheostomy tube: 14
2 87.5 17 00.0
Satisfactory Unsatisfactory 12.5 15
83.33 29 100.0
0.010*
Secure ventilator tabling: 12 3 16.66
Satisfactory 4 75.1 25. 00.0
0 100,0
Unsatisfactory Setup nebulizer 5 46
11 61.11 0.010*
12
which attached with MV: 4 7 38.88 69.56
Satisfactory 75.0 32 30.43
25.0 14
Unsatisfactory Document all finding 12 13 72.22 0.913
4 73.91
5 27.77
before & after therapy: 75.0 34 26.08
Satisfactory 25.0 12
Unsatisfactory 15 83.33
16.66 0.817
3

(*) Statistical significant difference (p<0.05).

(*) Statistical significant difference (p<0.05).

 Table (6) shows there were significant difference in
nurses' performance about Reassess vital signs (p-
value=0.035) and the majority of nurses in Nursing Technical
Institute were at satisfactory level (77.7%).
There was significant difference in nurses' performance
about Attach mechanical ventilator to endotracheal tube or
Table (7): Nurses' performance related to nebulizer of mechanical ventilation according to units.
tracheostomy tube (p-value =0.10) and the majority of nurses
in Nursing Bachelor were at satisfactory level (87.5%).
There was significant difference in nurses' performance
aboutsecure ventilator tabling (p- value=0.010) and the
majority of nurses in Nursing Bachelor were at satisfactory
level (75%).
Units

Nurses' performance I.C.0 trauma General I.C.0 p-value

(n=38) Postoperative I.C.0 (n=20) (n=22)
No. % No. % No. %
Prepared suction equipment: Satisfactory 78.9
Unsatisfactory 30 21. 15 68.2
8 1 14 70.0 6 30.0 7 31.8 0.598
7.9
3 92. 1 4.5
Lung sound: Satisfactory Unsatisfactory 35 1 2 10.0 18 90.0 21 95.5 0.792
21. 4.5
Reassess vital signs: Satisfactory Unsatisfactory 8 1 3 15.0 17 85.0 1 95.5
30 78.9 21 0.226
Cleans the equipment at least once daily: 28.9
Satisfactory Unsatisfactory 11 71. 4 18.1
27 1 6 30.0 14 70.0 18 81.8 0.012*

Attach MV to endotracheal tube or tracheostomy

tube: Satisfactory Unsatisfactory 33 86.8 0 0.0
5 13.2 16 30.0 4 70.0 22 100.0 0.000*
Secure ventilator tabling: Satisfactory
Unsatisfactory 28 73.7 0 0.0
10 26.3 17 85.0 3 15.0 22 100.0 0.000*
Documentation:
Satisfactory 33 86.8 18 81.8
Unsatisfactory 5 13.2 17 85.0 3 15.0 4 18.2 0.871

Table (7) shows that there was significant difference in

nurses' performance about Cleans the equipment at least once =0.000) and the majority of the nurses in general I.C.0 were at
daily (p-value=0.012) and the nurses of the majority in general unsatisfactory level (0.100%).
I.C.0 were at unsatisfactory level (81.8%).
There was significant difference in nurses' performance about
There was significant difference in nurses' performance Secure ventilator tabling to reduce pull on tracheostomy or
about Attach mechanical ventilator to endotracheal tube or endotracheal tube (p-value = 0.000) and the majority of nurses in
tracheostomy tube (p-value general I.C.0 were at unsatisfactory level (100%).

Table (8): Nurses performance related to nebulizer of mechanical ventilation (MV) according to experiences.
Year of experiences
Nurses' performance <5 p-value
(n years 5-10 years = 15) (n=37) >10 years (n=28)
No. % No. % No . %

Prepared suction equipment readily available: 12 18 64.28

Satisfactory Unsatisfactory 3 80 28 75.67 20 9 24.32 10 35.71 0.314
Fares A.A. Khodish, et al. 11

Reassess vital signs, breathing and lung sound:

Satisfactory Unsatisfactory 4 26.6 10 27.0 73.3 27 73.0 39.28
11 11 60.71
17 0.048*
Cleans the equipment: Satisfactory Unsatisfactory
5 33.33 10 27.0 66.66 27 73.0 57.14
10 16 42.85
12 0.042*
Attach MV to endotracheal /tracheostomy tube:
Satisfactory Unsatisfactory 13 86.66 33 89.18 13.33 4 10.81 27 96.42
2 1 3.57
0.465

Secure MV tabling: Satisfactory Unsatisfactory

7 46.66 29 78.37 53.33 8 21.62 71.42
8 20 28.57
8 0.076
Setup nebulizer which attached with MV:
Satisfactory Unsatisfactory 9 60.1 30 81.08 22 78.57
6 40.1 7 18.91 6 13.04 0.253
Documentation:
Satisfactory 13 86.6 29 78.37 13.33 8 21.62 19 67.85
Unsatisfactory 0.353
2 9 3.57

Table (8) shows there were significant difference in Institute

nurses' performance about Reassess vital signs (p- Experience:
value=0.048) and the majority of the nurses at the age less <5 years 13 86.7 2 13.3
than 5 years old were at satisfactory level (73.3%). 5-10 years 32 86.5 5 13.5
10 years 26 92.9 2 7.1 0.695
There was significant difference in nurses' performance Nurses' performance
about Cleans the equipments at least once daily (p- Nurses' Unsati Satis p-value
value=0.042) and the majority of the nurses at the age characteristics s factor
between 5 to 10 years old (30.0%). factory y

Table (9) shows that significant differences in nursing

performance regarding to department (p- v alue=0 .027) and
education (p-value=0.001).
Discussion
Nebulisers are commonly used in the management of
acute exacerbation airways disease. A study was therefore
conducted to ascertain what nurses knew about this form of
therapy. Several areas of deficient knowledge were revealed,
including how to clean the equipment properly, what the flow
rate of gas should be and what type of gas to use. And nursing
care for nebuliser therapy is included [17] .
5.00 10.00 15.00 20.00 25.00 30.00 35.00
(*) Statistical significant difference (p<0.05).
(*) Statistical significant difference
Fig. (3): Correlation between nurses' (p<0.05).
knowledge and performance.
There was a significant positive correlation between The results of the present study showed that the majority
score of knowledge and score of performances (p- of nurses (55.2%) were between 25 -30 years old in traumatic
value=0.013). ICU. the majority of nurses were having nursing diploma
(63.6%) in general ICU, and all nurses had no previous
Table (9): Relationship between nurses' performance and training about nebulizer (100%).
nurses' characteristicsaccording to department,
education, and experience This study indicated that there was statistical a significant
No. % No. % difference related to years of experience and the majority of
nurses were between 510 years in trauma ICU. These findings
Department: are congruent with those of who [18] reported that; years of
I.C.0 trauma 30 78.9 8 21.1
Postoperative I.C.0 19 95.0 5.0 experience in the hospital significantly correlated to increased
1
General I.C.0 22 100.0 0 0.0 0.027* knowledge, attitudes and practices among the various
categories of staff but this did not translate into good clinical
Education:
62.5 practice in the ward and stated that the education and training
Nursing Bachelor 10 6 37.5
Nursing Diploma 45 97.8 1 2.2 are two components of staff development that occur after
Nursing Technical 16 88.9 2 11.1 0.001* employee indoctrination (which refers to planned, guided
adjustment of employees' organization and work
(*) Statistical significant difference (p<0.05).
environment). The staff knowledge level and capabilities are a
major factor in determining the number of staff required to It was found in the present study that there was
carry out unit goals. The better trained and more competent significant difference in nurses' knowledge about
the staff, the fewer staff required, which in turn saves the cleaning the equipments at least once daily These
organization money and rise reproductively. results are in agreement with the study of Canadian
Committee on Antibiotic Resistance, [23], they
The findings revealed that total knowledge was at an
found that reusable medical equipment must be
unsatisfactory level. The reasons might be due to education
thoroughly cleaned before disinfection or steriliza-
and training of the nurses, all nurses (100%) had not attended
tion, factors that affect the ability to effectively
training courses about nebulizer. The majority of the nurses in
clean medical equipment must be considered prior
the three units (intensive care unit of trauma, postoperative
to cleaning, instruments should be cleaned as soon
intensive care unit and general intensive care unit) had gained
as possible after use to prevent organic material
a diploma in nursing), Therefore, these factors may affect the
drying on instruments, place the instrument in a
unsatisfactory level of knowledge of nurses [19] . Stated that
pre-soak of water or an enzymatic solution, this
many medical personnel responsible for monitoring and
will prevent drying of organic material, organic
instructing patients in optimal inhaler use. Nurses seldom
material must be removed before disinfection or
receive formal training in the use of inhaling devices, and
sterilization procedures are initiated and the
newer inhaling devices designed to obviate problems of
process for cleaning should include written
technique are at present less likely to be used well by medical
protocols for disassembly, sorting and soaking,
personnel soon after their introduction [20] . In another
physical removal of organic material, rinsing,
study also discovered that knowledge is acquired primarily
drying physical inspection and wrapping. In this
through experience, usually observation of and
regard Labrague, et al., [24] found that age, gender,
working withmentors and continuing education.
length of clinical experience, and number of
Tacit knowledge may also be described as practical
trainings attended are not determinants of the
that is, derived from experience or practice [21].
Recommended that lack of knowledgeable nurses knowledge on the principles of sterile technique.
leads to increased risks to patients and may influ- This implies that nurses regardless of their age,
ence patient's outcomes. Nursing shortage also gender, length of clinical experience, and numbers
leads to increased workload as the nurse: Patient of trainings attended do not differ in knowledge on
ratio decreases and one nurse has to provide care sterile technique.
for more than one critically ill patient. Shift leaders The present study of revealed that nurses'
in both public and private sectors are working knowledge about checking all connections of neb-
under great pressure and a large number of them ulizer and the majority of nurses in postoperative
are also not trained, but simply have the
I. C.0 were at unsatisfactory level. McNeal, [25]
experience of working in an ICU for a number of
presented that There are lots of models of
years.
nebulizer out there, and each one is a little
The current study revealed that the majority of different from the others. This general guide to
the study sample (81.6%) werehaving satisfactory nebulizer parts will give a basic idea of what
in nurses' knowledge about pulse oximetery. These makes a nebulizer system function.
finding is in accordance with the results of the
The current study revealed that of nurses'
study conducted by [22] whomentioned that a
knowledge about pulmonary function test were at
pulse oximetry (Sp02) knowledge survey was
satisfactory level (85%). In this respect,
conducted with 551 experienced critical care
(Encyclopedia of Nursing) [26], reported that when
nurses at the 2002 American Association of
the results of pulmonary function testing are
Critical Care Two hundred and seven
accurate, the most frequent reason is adequate
questionnaires were completed (a response rate of
patient education and/or technician training. It is
74.5%). Mean pulse oximetry knowledge, with
recommended that personnel conducting
ICU nurses having significantly higher scores than
pulmonary function testing have one of the
anesthesia department nurses and those with more
following credentials: Certified respiratory therapy
than 10 years of experience having significantly
technician (CRTT); registered respiratory therapist
higher scores. Correct responses did not exceed
(RRT); certified pulmonary function technologist
50% for six questionnaire items, five of which
(CPFT); or registered pulmonary function
covered principles of pulse oximetry function. ICU
technologist (RPFT).
nurses had significantly more correct responses in
five items compared to nurses, and in two of them The results of the present study showed that the
compared to anesthesia department nurses. majority of studied sample were having unsat-
isfactory level of knowledge about complications
 Fares A.A. Khodish, et al.
of the nebulizer. according to (Hoyle, 2012) [27]
stated that nurses should have knowledge about
any complications that may occur during nebulizer
therapy, the patient may become dizzy,complainse
of headache or may become disoriented during the
course of treatment. If this happens, have patient
take off his or her mask or remove his mouthpiece
and take a break for a few minutes. Once his head
is clear, have him continue the treatment and focus
on breathing more slowly than before. In some
cases, slower breathing may not resolve dizziness
or disorientation. Kulas, [28] who also found that
the act of inhaling the medication through a nebu-
lizer can cause dry mouth, sore throat, a bad taste
in the mouth or hoarseness? Sometimes, nebulizers
can cause thrush, which is a yeast infection in the
mouth. Symptoms of thrush include white spots in
the mouth, bleeding and pain.
The current study results denoted that the ma-
jority of the studied nurse's were having a satisfac-
tory level of knowledge about the definition of the
nebulizer. The present study also showed that there
was significant difference in nurses' knowledge
about explaining procedures and the majority of
nurses in nursing Bachelor were at satisfactory
level of knowledge (68.7%). According to Ethan,
[29] the patient should be in a comfortable
position throughout the procedure. Once the
patient puts the face mask on, he or she can start
taking slow, deep breaths. He or she should
continue to breathe slowly and deeply until there is
no medication left in the Nebulizer cup. This
generally takes anywhere from ten to thirty
minutes, depending on the prescribed quantity of
medication.
The current study revealed the majority of
nurses in nursing diploma were unsatisfactory
knowledge regarding hearing the lung sound
(0.00%). This result agrees with Layman, et al.,
[30] who emphasized that the assessment of the
breath sound, pulse rate, respiratory status, oxygen
saturation and assess the heart rate during the
treatment. In pregnant patient, the fetal heart rate
should also be assessed, instruct the patient to take
slow deep breaths for 10 seconds through the
mouth and hold at end inspiration and wash face if
using a mask to prevent rash.
For performance regarding nebulizer, the find-
ings showed that total practice was at an unsatis-
factory level. The reasons may be due to lack of
equipments, ignorance and the activities not in the
duties of nurses Plaza, et al., [31] found that a
shortage of equipment was identified as obstacle to
the facilitation of the nurses' performance in
(*) Statistical significant difference (p<0.05).
clinical areas.
13
The present study showed that There was a
significant positive correlation between score of
knowledge and score of performances (p-value
=0.013). This result agreed with Whyte, [32] who
have reported that selection of a group of nurses
participants was classified as either novice or
experienced nurses on the basis of their years of
experience. There were 12 experienced nurses and
10 novice nurses. Using an experimental research
design based on the expert performance approach,
a simulated task environment was developed for
the study using a patient simulator and a fully
equipped true-to-life intensive care unit suite.
Nurses were required to control the physiologic
deterioration of the patient with respiratory com-
promise in 4 scenarios and were also tested on
their knowledge of the constructs present in the
scenarios.
The present study revealed significant differ-
ences in nursing knowledge regarding to
department (p-value=0.027) and education (p-
value=0.001) & there was no significant
differences regarding to experiences. Hassan &
Aboulazm, [32] stated that the highest mean scores
of knowledge was found among nurses' who have
bachelor of Science in nursing, and also found
there were improvement of nurses' knowledge
related to nebulizer.
In the present study we found significant dif-
ference in nurses' performance of arterial blood
gases (p-value=0.007). Nurses having Bachelor of
Sciences in nursing had significantly higher scores
than those having technical institute of nursing and
those having nursing diploma. Coombs, [33] found
that the ABG analysis provides useful monitoring,
especially for carbon dioxide. In most wards,
taking arterial samples has traditionally been a
medical role, but some specialist nurses are now
taking samples and so need to be able to interpret
measurements. Nurses who are not taking samples
may be able to initiate earlier intervention if they
are able to interpret results. Understanding results
can help nurses to understand treatments and
interventions, so making nursing more interesting.
The present study revealed a significant differ-
ence in nurses' performance about reassessing
breath sounds, pulse rate, oxygen saturation, res-
piratory rate, and peak (p-value=0.036) and the
majority of nurses in nursing diploma were at
unsatisfactory level (89.1%).
A report by Creed & Spiers, [34] entailed that
professional nurse must perform by assessing
patient status from breath sounds, respiratory
status, pulse rate and other significant respiratory
functions needed. Compare, record significant
changes and improvement. Refer if necessary and
perform other significant respiratory functions.
The current study revealed a great lack of
performance as regarding of hands washing as all
nurses were having an unsatisfactory performance
score level and had statistical significant (p-
value=0.019). Hand hygiene is the most important
single infection control measure used in nursing
[35] .
Pratt, et al., [36] presented that hand contami-
nation is one of the main contributing factors in
the current infection threat; contaminated hands
are responsible for transmitting infection.
Effective hand cleaning can significantly reduce
infection rates in high risk area. Unfortunately, the
result of the present study revealed that the
majority of nurses didn't carry out certain
procedures in relation to infection control
precautions such as hands washing, wearing
gloves and cleaning equipments. Lam, et al., [37]
presented that hand hygiene has been singled out as
the most important measures in preventing hospital acquired
infection Ahmed, [38] has found lack of knowledge related
universal precautions and infection control among nurses.
The current study revealed a great lack of performance as
regards to washing all parts of the nebulizer. Scores of nurses'
performance (p-value =0.001) and the majority of nurses in
nursing diploma were at unsatisfactory level (82.6%).
According to Ahmed, [39] who found that the majority of
nurses practices related to cleaning instruments mechanical
ventilation inadequately performed by nurses having diploma
of Science. Robert, et al., [40] mentioned that ineffectual dis-
infection of inhalation equipment between therapy sessions of
different patients has been reported to produce serious
outbreaks of infection. The role of properly disinfected
equipment that becomes colonized during use was assessed.
In the Vancouver General Hospital gram-negative bacilli in
the nebulizer water were demonstrated in 10.5% of nebulizers
being used for periods of 24 to 72 hours. In at least 15% of
patients exposed to contaminate nebulizers the organism was
recovered from the respiratory tract 48 hours after removal of
the equipment. Only one out of 85 patients exposed to
contaminated nebulizers developed pneumonia, and in this
instance a clear history of aspiration of vomitus was present.
The low incidence of pneumonia may be related to the high
percentage of nebulizers contaminated by organisms of low
virulence and might be much greater in hospitals where more
highly pathogenic organisms are commonly found as
nebulizer contaminants.
The present study revealed that there was significant
difference in nurses' performance about reassessing vital
signs (p-value=0.035) and the majority of nurses in Nursing
Bachelor Were at satisfactory level (68.7%). in this regard,
Quino, [41] reported that vital signs are necessary reassessing
patients status; breath sounds, respiratory status, pulse rate
and other significant respiratory functions needed. Compare
and record significant changes and improvement. Refer if
necessary after inhalation therapy. Gamal, [42] found that
highest mean scores of knowledge and performance among
younger nurses' those who have least experience and who
have Bachelor of Science in nursing.
The current study revealed a great highof performance as
regards toattach mechanical ventilator to endotracheal tube or
tracheostomy tube (p-value =0.10).
British Thoracic Society, [43] found that nebulizers
should not be connected directly to a cuffed endotracheal or
tracheostomy tube. This could result in a pneumothorax,
which occurs when there is no expiratory route for exhaled
gases When nebulizing with endotracheal or tracheostomy
tubes check compatibility with the nebulizer machine.
In thepresent there was significant difference in nurses'
performance about flow rate of 02 determined by the patient's
condition (p-value=0.021) this result agreed with
Nationallnstitute for Health & Clinical Excellence, [44] who
reported that driving gas, either an air compressor or
piped/cylinder oxygen at 6-8Lt/min flow rate for most
efficient nebulization. And the patients with chronic obstruc-
tive pulmonary disease (COPD) should not routinely use
oxygen driven nebulizers due to the risk of carbon dioxide
retention.
The current study showed that there was significant
differences nurses' knowledge regarding to education (p-
value=0.07) and experiences (p-value =0.32). The findings of
the present study are in accordance with Abolwafa, [45] who
found that the majority of score of nurses' knowledge who
have bachelor of Science in nursing had significant higher
score than those who have technical institute and nursing
diploma, scores of nurses' who have work experience ranged
from 5 to 10 years were higher than those who have work
experience less than 5 years.
Conclusion:
Nurses' knowledge and performance about nebulizer
therapy were unsatisfactory with slightly higher level of
knowledge and this could explain that the nurses acquired
experience during their nebulizer therapy.
Recommendations:
The nursingstaff in critical careunits are responsible for
giving care to the patients connected to nebulizer machine
should be trained enough to give effective and safe care to
such patients.
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