NUR 232: SKILL 21-6 Using Metered-Dose Inhalers

1. NUR 232: SKILL 21-6 Using Metered-Dose Inhalers

2. SKILL 21-6: INTRODUCTION Medications administered with handheld inhalers are dispersed through an aerosol spray, mist, or powder that penetrates the airways.Pressurized metered-dose inhalers, breath-actuated metered-dose inhalers, and dry powder inhalers deliver medications that produce local effects such as broncho-dilation.Some of these medications are absorbed rapidly through the pulmonary circulation and create systemic side effects may cause palpitations, tremors, and tachycardia.An MDI (Metered-dose inhaler) is a small, handheld device that disperses medication into the airways through an aerosol spray or mist by activation of a propellant. Dosage is usually achieved with 1 or 2 puffs.

3. COMMON PROBLEMS IN USING AN INHALER • Not taking the medication as prescribed: Taking either too much or too little. • Incorrect activation: This usually occurs through pressing the canister before taking a breath.These actions should be done simultaneously so the drug can be carried down to the lungs with the breath. • Forgetting to shake the inhaler: The drug is in a suspension; therefore particles may settle. If the inhaler is not shaken, it man not deliver the correct dose of the drug.

4. COMMON PROBLEMS IN USING AN INHALER • Not waiting long enough between puffs: A delay between puffs is needed before taking a second puff; otherwise an incorrect dose may be delivered, or the drug may not penetrate into the lungs. • Failure to clean the valve: particles may jam the valve in the mouthpiece unless it is cleaned occasionally. This is a frequent cause of failure to get 200 puffs from one inhaler. • Failure to observe whether the inhaler is actually releasing a spray; if it is not, this should be checked with the pharmacist. • Failure to recognize when the canister is empty: this occurs when the metered-dose inhaler has no built-in dose counter or instructions in dose counting. • Picture to the right: How can you check to see how much medicine you have left in an inhaler?

5. ASSESSMENT 1. Check accuracy and completeness of each medication administration record (MAR) with health care provider’s medication order. Check patient’s name, drug name and dosage, route, and time for administration. Clarify incomplete or unclear orders with health care provider before administration.2. Review pertinent information related to medication, including action, purpose, normal dose and route, side effects, time of onset and peak action, and nursing implications.

6. ASSESSMENT – CONT’D 3. Assess patient’s medical history, history of allergies, and medication history.4. Assess respiratory pattern and auscultate breath sounds.5. Assess patient’s ability to hold, manipulate, and depress canister and inhaler.6. Assess patient’s readiness and ability to learn: asks questions about medication; is alert; participates in own care; is not fatigued, in pain, or in respiratory distress.7. Assess patient’s knowledge and understanding of disease and purpose and action of prescribed medications.

7. PLANNING 1. Expected outcomes following completion of the procedure:Patient correctly self-administers metered dose.Patient describes proper time during respiratory cycle to inhale and spray and number of inhalations for each administration.Patient’s breathing pattern improves, and lung sounds indicate airways are less restrictive.2. Explain procedure to the patient. Be specific if patient wishes to self-administer drug. Explain where and how to set up at home.

8. IMPLEMENTATION 1. Prepare medications for inhalation. Check label of medication against MAR 2 times (see Skill 22-1). Preparation usually involves taking inhaler device out of storage and into patient room. Check expiration date on the container.2. Take medication (s) to patient at correct time (see agency policy). Medications that require exact timing include state, first-time or loading doses, and one time doses.3. Identify patient using two identifiers.4. Compare MAR with medication labels at the patient’s bedside, asked patient if they have any allergies.

9. IMPLEMENTATION – CONT’D 5. Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions about the drugs. Explain what a metered-dose is and how to administer it. Warn about overuse of inhaler and side effects.6. Allow adequate time for patient to manipulate inhaler, canister, and spacer device (if provided). Explain and demonstrate how canister fits into the inhaler.7. Explain steps for administering MDI without spacer (demonstrate when possible).A. Remove mouthpiece cover from inhaler after inserting MDI canister into holder.

10. IMPLEMENTATION – CONT’D 7. Explain steps for administering MDI without spacer (demonstrate when possible). (Cont’d from pervious page)B. Shake inhaler well for 2 to 5 seconds (five or six shakes).C. Hold inhaler in dominant hand.D. Instruct patient to position inhaler in one or two ways:1. Place mouthpiece in mouth with opening toward back of throat, closing lips tightly around it.2. Position mouthpiece 2 to 4 cm (1 to 2 inches) in front of widely opened mouth, with opening of inhaler toward back of throat. Lips should not touch inhaler.

11. IMPLEMENTATION – CONT’D 7. Explain steps for administering MDI without spacer (demonstrate when possible). (Cont’d from pervious page)E. Have patient take a deep breath and exhale completely.F.With inhaler positioned, have patient hold it with thumb at mouthpiece and index and middle fingers at top. This is a three-point or bilateral hand position.G. Instruct patient to tilt head back slightly and inhale slowly and deeply through mouth for 3 to 5 seconds while depressing canister fully.H. Have patient hold their breath for about 10 seconds.I. Remove MDI from mouth before exhaling and exhale slowly through nose or pursed lips.

12. IMPLEMENTATION – CONT’D 8. Explain steps to administer MDI using spacer device (demonstrate when possible).A. Remove mouthpiece cover from MDI and mouthpiece of spacer device.B. Shake inhaler well for 2 to 5 seconds (five or six shakes).C. Insert MDI into end of spacer device.D. Instruct patient to place spacer device mouthpiece in mouth and close lips. Do not insert beyond raised lip on mouthpiece. Avoid covering small exhalation slots with the lips.

13. IMPLEMENTATION – CONT’D E. Have patient breathe normally through spacer device mouthpiece.F. Instruct patient to depress medication canister, spraying one puff into spacer device.G. Patient breathes in slowly and fully (for 5 seconds).H. Instruct patient to hold full breath for 10 seconds.9. Instruct patient to wait 20 to 30 seconds between inhalations (if same medication) or 2 to 5 minutes between inhalations (if different medications).10. Instruct patient to not repeat inhalations before next scheduled.11. Warn patients that they may feel gagging sensation in throat caused by droplets of medication on pharynx or tongue.

14. IMPLEMENTATION – CONT’D 12. About 2 minutes after last dose, instruct patient to rinse mouth with warm water and spit the water out.13. For daily cleaning, instruct patient to remove medication canister, rinse inhaler and cap with warm running water, and be sure that the inhaler is completely dry before reuse. Do not get valve mechanism of canister wet.14. Ask if the patient has any questions.15. Help the patient to a comfortable position and perform hand hygiene.

15. EVALUATION 1. Have patient explain and demonstrate steps in use and cleaning of inhaler.2. Ask patient to explain drug schedule and dose of medication.3. Ask patient to describe side effects of medication and criteria for calling health care provider.4. After medication administration, assess patient’s respirations, breath sounds, and peak flow measures if ordered.

16. UNEXPECTED OUTCOMES 1. Patient’s respirations are rapid and shallow; breath sounds indicate wheezingEvaluate Vital signs and respiratory status.Notify health care provider.Reassess type of medication and / or delivery method.2. Patient experiences paroxysms of coughing.Reassess patient’s delivery method.3. Patient needs bronchodilator more than every 4 hours (may indicate respiratory problem).

17. UNEXPECTED OUTCOMES 4. Patient experiences cardiac dysrhythmias (light-headedness, syncope), especially if receiving beta-adrenergics.Withhold all further doses of medication.Evaluate cardiac and pulmonary status.5. Patient is not able to self-administer medication properly.6. Patient is unable to explain technique and risks of drug therapy.

18. RECORDING AND REPORTING Record drug administered, dose or strength, route, number of inhalations, and actual time administered on MAR immediately after administration, not before. Include initials or signature. Record patient teaching and validation of understanding in nurses’ notes and Electronic Health Records (EHR).Record in nurses’ notes and EHR the patient’s response to MDI (e.g., breath sounds), evidence of side effects (e.g., arrhythmia, feelings of anxiety), and patient’s ability to use MDI.Report adverse effects / patient response and / or with-held drugs to nurse in charge of health care provider.

19. END OF SKILL This is the end of the skillYour book has not provided a video for this skill, but if you practice in the lab, you should not have any problem passing it.Remember to teach your patients that inhalers are easy to lose and they should always keep it in on them, in case they have an asthma attack.