Goal: The patient receives the medication via an inhaler using the correct technique.
1. Gather equipment. Check each medication order against the original order in the medical record, according to facility policy. Clarify any inconsistencies. Check the patient’s chart for allergies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.
3. Perform hand hygiene.
4. Move the medication cart to the outside of the patient’s room or prepare for administration in the medication area.
5. Unlock the medication cart or drawer. Enter pass code and scan employee identification, if required.
6. Prepare medications for one patient at a time.
7. Read the CMAR/MAR and select the proper medication from the patient’s medication drawer or unit stock.
8. Compare the label with the CMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.
9. When all medications for one patient have been prepared, recheck the label with the MAR before taking them to the patient.
10. Lock the medication cart before leaving it.
11. Transport medications to the patient’s bedside carefully, and keep the medications in sight at all times.
12. Ensure that the patient receives the medications at the correct time.
13. Perform hand hygiene and put on PPE, if indicated.
14. Identify the patient. Usually, the patient should be identified using two methods. Compare information with the CMAR/MAR.
a. Check the name and identification number on the patient’s identification band.
b. Ask the patient to state his or her name and birth date, based on facility policy.
c. If the patient cannot identify him- or herself, verify the patient’s identification with a staff member who knows the patient for the second source.
15. Complete necessary assessments before administering medications. Check the patient’s allergy bracelet or ask the patient about allergies. Explain what you are going to do and the reason to the patient.
16. Scan the patient’s bar code on the identification band, if required.
17. Remove the mouthpiece cover from the MDI and the spacer. Attach the MDI to the spacer. (See the Skill Variation in your skills book for using an MDI without a spacer.)
18. Shake the inhaler and spacer well.
19. Have patient place the spacer’s mouthpiece into mouth, grasping securely with teeth and lips. Have patient breathe normally through the spacer.
20. Patient should depress the canister, releasing one puff into the spacer, then inhale slowly and deeply through the mouth.
21. Instruct patient to hold his or her breath for 5 to 10 seconds, or as long as possible, and then to exhale slowly through pursed lips.
22. Wait 1 to 5 minutes, as prescribed, before administering the next puff.
23. After the prescribed amount of puffs has been administered, have patient remove the MDI from the spacer and replace the caps on both.
24. Have the patient gargle and rinse with tap water after using an MDI, as necessary. Clean the MDI according to the manufacturer’s directions.
25. Remove gloves and additional PPE, if used. Perform hand hygiene.
26. Document the administration of the medication immediately after administration.
27. Evaluate the patient’s response to medication within appropriate time frame. Reassess lung sounds, oxygenation saturation if ordered, and respirations.
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