Nebulized Bronchodilator Treatment Procedure Note

Date/Time: [Treatment start time] to [Treatment end time]

Location: [Clinic/Unit/Room]

Clinician: [Name, credentials]

(Omit sections that do not apply rather than using placeholders. If a clinically expected datum is unavailable, briefly document why. Do not assert findings that were not assessed. Use safe dose formatting: leading zeros for decimals, no trailing zeros, units written in full.)

Indication

[Clinical reason for treatment] (Document as signs/symptoms rather than asserting a diagnosis unless established. Include baseline severity context if relevant, such as speech tolerance, work of breathing, and room air SpO₂.)

Pre-treatment Assessment

[Safety check and order source] (State that allergies were reviewed. Specify whether treatment was per patient-specific order or standing protocol; include ordering clinician if applicable.)

• Vitals: HR [value] bpm; RR [value]/min; BP [value] mmHg; SpO₂ [value]% [on room air / on supplemental O₂ at specified flow and device]
• Respiratory exam:
  • Work of breathing: [none / mild / moderate / severe] (If present, note observable signs such as retractions, accessory muscle use, nasal flaring, or tachypnea.)
  • Speech tolerance: [full sentences / short phrases / single words]
  • Breath sounds: [location, quality, and distribution]
  • Air movement: [good / fair / poor]
• PEF: [value] L/min ([percent predicted or percent personal best]) (If not obtained, briefly state why.)

Treatment Administered

• Medication: [Drug name, dose, units] via nebulizer; diluent [volume] mL normal saline (if used)
• Delivery interface: [mouthpiece / mask]
• Number of treatments: [number]; Total nebulization time: [minutes]
• Administering staff: [Name, role] (Include only if different from author.)
• Supplemental O₂ during treatment: [none / flow and device] (Include only if applicable.)

Tolerance and Monitoring

Tolerance: [good / fair / poor] (Briefly describe comfort, cooperation, or need to pause. State whether treatment was completed.)

Adverse effects: [effects observed / none observed] (If present, note tremor, palpitations, notable tachycardia, anxiety, or other symptoms.)

SpO₂ monitoring: [continuous / intermittent] (Include any notable SpO₂ or HR changes during treatment.)

Post-treatment Assessment

Assessed at [minutes] after treatment completion.

• Vitals: HR [value] bpm; RR [value]/min; SpO₂ [value]% [on room air / on supplemental O₂ at specified flow and device]
• Respiratory exam:
  • Work of breathing: [none / mild / moderate / severe]
  • Speech tolerance: [full sentences / short phrases / single words]
  • Breath sounds: [location, quality, and distribution; note changes vs. baseline]
  • Air movement: [good / fair / poor]
• PEF: [value] L/min ([percent predicted or percent personal best]) (If not obtained, briefly state why.)

Response

Subjective: [Patient-reported change] (Use quotes when helpful.)

Objective: [Observed response] (Describe objective findings such as improved air movement, decreased wheeze, reduced RR/HR, improved SpO₂ on room air, or improved PEF vs. baseline. Do not state improvement without supporting objective data.)

Complications/Escalation

(Include this section only if applicable; otherwise omit entirely.)

[Complication or escalation event and management] (Document additional bronchodilator treatments, anticholinergic addition, systemic steroids, EMS activation, ED transfer, or other escalation and the management provided.)

Disposition

[Discharged home / Continued observation in clinic / Transfer to higher level of care]

• Discharge readiness: [Symptoms improved], SpO₂ [value]% on room air and stable, [lung function improved if measured] (Include only when discharging.)
• Medications prescribed/changed: [Name, dose, route, frequency, duration]
• Follow-up: [Clinician/service] in [timeframe]
• Return precautions: Worsening shortness of breath, wheeze not relieved by rescue inhaler, increasing work of breathing, chest pain, confusion or drowsiness, cyanosis, or other concerning symptoms