Safety

• Ensure that the Six Rights of Medication Administration are observed: right medication, right dose, right patient, right route, right time, and right documentation.
• Be aware that medication delivered by metered-dose inhaler (MDI) can be absorbed rapidly through the pulmonary circulation and create systemic side effects (e.g., albuterol may cause palpitations, tremors, and tachycardia).
• If the patient is receiving beta-adrenergic agonists and has a cardiac dysrhythmia characterized by lightheadedness or syncope, withhold additional doses of the medication and notify the health care provider. Evaluate his or her vital signs and respiratory status. Notify the health care provider if the patient has rapid, shallow breathing, wheezing, or paroxysmal coughing.
• If the patient has trouble coordinating breath and/or hand control when using an MDI, the use of a spacer device may improve accuracy of administration.
• If you are using a new MDI or one that has not been used for several days, push a test spray into the air to prime the device before using it.
• If more than one MDI medication is to be given at the same time, administer bronchodilators before steroids, because bronchodilators can open the airways. Administer short-acting medications before giving long-acting medications.
• Instruct any patient receiving a steroid preparation to rinse out his or her mouth with warm water about 2 minutes after using the inhaler to prevent the development of a fungal infection.

Equipment

(Roll cursor over items to see labels)

Spacer device (optional)

Metered-dose inhaler (MDI)

Medication canister

Stethoscope

Pulse oximeter

Alcohol swabs

Facial tissues

Delegation

Medication administration by means of a metered-dose inhaler cannot be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following:

• The expected therapeutic effects of the medication, and to report to you any potential side effects (e.g., anxiety, tremors, and lightheadedness)
• To report to you immediately any wheezing or paroxysmal coughing, or if the patient reports being short of breath or having difficulty breathing

Preparation

• Check the accuracy and completeness of each medication administration record (MAR) against the health care provider’s medication orders. Confirm the patient’s name, the drug and dosage and number of puffs, the route of administration, and the time of administration. Note if the health care provider’s orders indicate the use of a spacer changer. Clarify incomplete or unclear orders with the health care provider.
• Note the patient’s allergies.
• Read the manufacturer’s application/administration directions carefully.
• Observe the Six Rights of Medication Administration: right medication, right dose, right patient, right route, right time, and right documentation. (For details, see the Video Skill “Ensuring the Six Rights of Medication Administration.”)
• Check the label on the metered-dose inhaler (MDI) against the MAR two times. Note the expiration date on the medication canister. If the MDI is new or has not been used for several days, push a test spray into the air to prime the device before using it, to ensure that the inhaler is patent and that the metal canister is positioned properly.
• Assess the patient’s respiratory pattern, and auscultate breath sounds. Obtain an oxygen saturation level if indicated.
• Assess the patient’s ability to hold, manipulate, and activate the MDI.

Follow-up

• Observe the patient’s response to the inhaled medication, noting changes in oxygen saturation level, rate of respiration, and/or breath sounds. Ask if symptoms have been relieved, and note any side effects. Assess peak flow measurement if ordered.
• Confirm the patient’s understanding of the medication’s purpose, action, possible side effects, and administration technique.
• Ensure that the patient rinses his or her mouth with warm water and spits it out after using the metered-dose inhaler (MDI), to reduce the risk of throat irritation and oral fungal infection.
• Review with the patient the procedure for cleaning and storage of the MDI.
• Notify the health care provider for reassessment of respiratory status if the patient uses the MDI more than once every 4 hours.
• Document and report side effects, the patient’s response, and/or withheld doses to the health care provider.

Documentation

• Document the medication administered by metered-dose inhaler (MDI), its concentration, the dosage or strength, the number of puffs given, and the time of administration. This documentation must be made on the medication administration record (MAR) immediately after administration, not before.
• Document patient teaching and validation of the patient’s understanding.
• Document objective data related to the respiratory system (e.g., respiration rate, oxygen saturation, and breath sounds), any subjective data (e.g., shortness of breath), and the patient’s response to the medication, including side effects such as anxiety, tremors, palpitations, lightheadedness, or arrhythmia.
• Report to the health care provider if the patient had an adverse response and/or if any drug was withheld.