1. General medication administration considerations (review in the room, with the patient).

1. Upon first entering the patient's room, wash hands with soap and warm water, applying vigorous friction for at least 20 s. Hand sanitizers may be used if the hands are not visibly soiled, but vigorous friction should also be applied.
2. At the bedside computer, log into the patient's electronic health record and review the patient's medical history and previous administration times. Verify with the patient any medication allergies and discuss his/her physical allergic responses and reactions.
3. At the bedside computer, pull up the Medication Administration Record (MAR).
   1. Review the inhaled medications that are due to be administered, and clarify with the patient whether he/she has a preference or concerns prior to acquiring and preparing the medication.
   2. Assess the patient's respiratory rate and auscultate breath sounds in all respiratory fields to determine medication appropriateness and to serve as a reference for evaluating medication effectiveness. If the patient demonstrates shallow respirations or increased work of breathing, this delivery method may be inappropriate, and the care provider should be notified.
4. Review the medication administration process with the patient and ensure that the patient has sufficient knowledge, understanding, and ability to follow the instructions and effectively carry out the procedure. Provide additional education as needed.
5. Leave the patient's room, washing hands as described above (step 1.1)

2. Go to the medication preparation area and complete the first safety check using the five "rights" of medication administration. Refer to the "Safety Checks for Acquiring Medications from a Medication Dispensing Device" video.

1. Upon acquiring the medication from the medication dispensing device, verify the expiration date.

3. In the medication preparation area, complete the second safety check using the five "rights" of medication administration. Refer to the "Safety Checks for Acquiring Medications from a Medication Dispensing Device" video.

4. Gather the necessary supplies, including a cup of water, a basin, and a spacer (if required). Take the supplies into the patient's room.

Administration

5. Wash hands when entering the patient's room.

6. In the patient's room, complete the third and final medication safety check, adhering to the five "rights" of medication administration.

7. As with any medication administration, remind the patient of the medication purpose, any adverse reactions, and the administration procedure.

8. Assist the patient into an upright position to facilitate lung expansion.

9. Administer the inhaled medication using the mouthpiece.

1. Shake the inhaler vigorously and then remove the mouthpiece cover.
2. Ask the patient to hold the lower portion of the inhaler between his/her thumb and middle finger, with the index finger at the top of the canister, and place the mouthpiece of the inhaler between the upper and lower lips.
3. Instruct the patient to take a deep breath and to exhale fully.
4. Ask the patient to close his/her lips tightly around the mouthpiece and to inhale deeply and fully while depressing the canister with his/her index finger to release the medication.
5. At the top of the patient's inhalation, ask him/her to hold his/her breath for 10 s, or as long as it is comfortable, and to release his/her index finger from the top of the canister.
6. If a second inhaled dose is ordered, have the patient wait for approximately 1 min prior to administering the second dose. For the second inhaled dose, instruct the patient to repeat steps 9.1-9.5.

10. Variation: Administer the inhaled medication using a spacer.

1. Shake the inhaler vigorously and remove the mouthpiece cover.
2. Holding the inhaler near the bottom, between your thumb and middle finger of your non-dominant hand, and the spacer between the thumb and index finger of your dominant hand, insert the mouthpiece of the inhaler into the spacer end.
3. Ask patient to hold the lower portion of the inhaler between his/her thumb and middle finger, with the index finger at the top of the canister. Have the patient support the spacer between the index finger and thumb of his/her non-dominant hand.
4. Instruct the patient to place the mouthpiece of the spacer between the upper and lower lips, to close his/her lips tightly around the mouthpiece, and to breathe normally.
5. Ask the patient to depress the canister with his/her index finger, to release the medication, and to take in a slow, deep breath.
6. At the top of the patient's inhalation, ask him/her to hold his/her breath for 10 s, or as long as it is comfortable, and then to release the index finger from the top of the canister and to remove the spacer from his/her mouth before slowly exhaling.
7. If a second inhaled dose is ordered, have the patient wait for approximately 1 min prior to administering the second dose. For the second inhaled dose, instruct the patient to repeat steps 10.1-10.6.

11. If the patient received an inhaled corticosteroid, or if he/she requests it, hand the patient the cup of water and ask him/her to swish the water in his/her mouth and spit it in the basin.

12. As with any medication, document the medication administration date, time, and location of administration in the electronic MAR.

13. Prior to leaving the room, remind the patient about any side effects/adverse effects or considerations for which he/she should notify the nurse.

14. Leave the patient room and wash hands with soap and water for at least 20 s, applying vigorous friction