Skill 5-22

Administering Medication via a Metered-Dose Inhaler (MDI)

Skill Variation: Administering Medication via a Metered-Dose Inhaler Without a Spacer

Drugs for inhalation may be administered via a metered-dose inhaler (MDI). An MDI is a handheld inhaler that uses an aerosol spray or mist to deliver a controlled dose of medication with each compression of the canister that is then breathed in by the patient. The medication is then absorbed rapidly through the lung tissue, resulting in local and systemic effects. There are two methods for using an MDI; the preferred method is with a device called a valved holding chamber or spacer and is outlined in the steps in this skill (Center for Disease Control, 2018; Quaranta, 2018). An MDI can also be used without a chamber. Refer to the accompanying Skill Variation at the end of this skill. Patients should discuss which method is most appropriate for use with their health care provider. There are a number of different medication inhaler devices, which increases the risk of administration error (Quaranta, 2018). As a result, using the proper technique for the prescribed inhaler is imperative, or therapy will not be effective (Price et al., 2017; Quaranta, 2018).

Delegation Considerations

The administration of medication via a metered-dose inhaler is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, administration of a metered-dose inhaler may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Stethoscope
Prescribed medication in an MDI
Spacer or holding chamber
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)
PPE, as indicated

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Assess respiratory rate, rhythm, effort, and depth to establish a baseline. Assess lung sounds before and after use to establish a baseline and determine the effectiveness of the medication. Assess the peak flow before and after administration to establish a baseline and determine the effectiveness of the medication. If appropriate and/or prescribed, assess oxygen saturation level before and after medication administration. The oxygenation level usually increases after the medication is administered. Assess the patient's ability to manage an MDI; young and older adults may have dexterity problems. Assess the patient's knowledge and understanding of the medication's purpose and action. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Activity intolerance
Impaired gas exchange
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve when using an MDI are that the medication is administered and breathed in by the patient, and the patient experiences the intended effect of the medication. Other outcomes that may be appropriate include the following: the patient verbalizes an understanding of and engages in the medication regimen, and the patient demonstrates correct use of the MDI.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
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.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the computer system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the patient's medication drawer or medication supply system.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
10. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
11. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
12. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
13. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
14. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
15. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
16. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain what you are going to do and the reason for doing it to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, promotes patient engagement, and reduces anxiety.
17. Scan the bar code on the patient's identification band, if required (The Joint Commission, 2021) (Figure 1).	This provides an additional check to ensure that the medication is given to the right patient.
18. Based on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
19. Remove the MDI mouthpiece cover. Shake the inhaler, if necessary; refer to the details for the individual drug and inhaler in use (Allergy & Asthma Network, 2020a).	Shaking requirements and amount of shaking differ based on type of medication and inhaler (Allergy & Asthma Network, 2020a). The medication and propellant may separate when the canister is not in use. Shaking well ensures that the patient is receiving the correct dosage of medication.
20. If the MDI is new or has not been used recently (several days or weeks), the device should be primed (Asthma Initiative of Michigan, n.d.; Hess et al., 2021); priming refers to actuating the device several times before use. Refer to specific details for the individual drug in use.	Priming the metering chamber is required to ensure accurate delivery of the medication (Hess et al., 2021).
21. Remove the cover from each end of the spacer. Attach the MDI to the spacer by inserting in the open end of the spacer, opposite the mouthpiece. (Refer to the accompanying Skill Variation for using an MDI without a spacer.)	The use of a spacer or valved holding chamber is preferred because it traps the medication and aids in delivery of the correct dose.
22. The patient should take a deep breath in, then breathe out completely, and place the spacer's mouthpiece into their mouth, grasping it securely with their teeth and above the tongue, and sealing the lips tightly around the mouthpiece (Figure 2).	The tongue should be kept under the mouthpiece so it does not block the opening of the mouthpiece (Gerald & Dhand, 2020). Medication should not leak out around the mouthpiece.
23. The patient should then depress the canister once, releasing one puff into the spacer, then inhale slowly and deeply through the mouth, until their lungs are full (Allergy & Asthma Network, 2020a).	The spacer will hold the medication in suspension for a short period so that the patient can receive more of the prescribed medication than if it had been projected into the air. Breathing slowly and deeply distributes the medication deep into the airways.
24. Instruct the patient to hold their breath for 5 to 10 seconds, or as long as possible; the patient should remove the spacer from their mouth and then exhale slowly through pursed lips (Allergy & Asthma Network, 2020a; American Lung Association, 2021).	This allows better distribution of the medication to the airways and longer absorption time for the medication.
25. Wait 1 to 5 minutes, as prescribed, before administering the next puff, if prescribed.	This ensures that both puffs are absorbed as much as possible. Bronchodilation after the first puff allows for deeper penetration by subsequent puffs.
26. After the prescribed number of puffs has been administered, have the patient remove the MDI from the spacer and replace the caps on both MDI and spacer.	By replacing the caps, the patient is preventing any dust or dirt from entering and being propelled into the bronchioles with later doses.
27. Have the patient gargle and rinse with tap water after using an MDI, as necessary. Clean the MDI according to the manufacturer's directions.	Rinsing removes medication residue from the mouth. Rinsing is necessary when using inhaled steroids because oral fungal infections can occur. The buildup of medication in the device can attract bacteria and affect how the medication is delivered.
28. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
29. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
30. Evaluate the patient's response to the medication within an appropriate time frame. Reassess lung sounds, oxygen saturation level, peak flow, and respirations, as indicated.	The patient needs to be evaluated for therapeutic and adverse effects from the medication.

Evaluation

The expected outcomes have been met when the medication was administered and breathed in by the patient, the patient has experienced the intended effect of the medication, the patient has verbalized an understanding of and engaged with the medication regimen, and the patient has demonstrated correct use of the MDI.

Documentation

Guidelines

Document the administration of the medication immediately after administration, including date, time, dose, route of administration and any teaching done with the patient on the eMAR/MAR or record using the required format. If using a bar-code system, medication administration is recorded automatically when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. Document respiratory rate, oxygen saturation, if applicable, peak flow measurements and lung assessment, and the patient's response to the treatment, if appropriate. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team. This verifies the reason medication was omitted and ensures that health care personnel providing care for the patient are aware of the occurrence.

Sample Documentation

9/29/25

0820 Wheezes noted bilaterally, during expiration in all lung fields, O₂ saturation 92%, respiratory rate 24 breaths per minute, patient reports shortness of breath and cough. After albuterol MDI administration, lung sounds are clear to auscultation bilaterally in all lung fields, O₂ saturation 97%, respiratory rate 18 breaths per minute with no cough or report of shortness of breath. Patient able to demonstrate accurately the use of an MDI and spacer and verbalizes understanding of medication purpose and action.

—C. Bausler, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient uses MDI, but symptoms are not relieved: Check to make sure that the inhaler still contains medication. The patient may have received only propellant, without medication. If necessary, obtain a new medication inhaler and administer dose as prescribed. If the inhaler is not empty and symptoms persist, contact the health care team to discuss appropriate interventions.
Patient is unable to use MDI: Many companies have adaptive devices that assist patients to use MDIs.
Patient reports that relief of symptoms has decreased, even with increased number of puffs: Have the patient demonstrate the technique they are using. Because it is common for patients to have knowledge gaps regarding the correct use of an MDI, it is imperative to review the technique with each patient (Frandsen & Pennington, 2021; Quaranta, 2018). Poor administration technique can lead to a decrease in effectiveness and a need for an increased dosage of medication.

Special Considerations

General Considerations

Effective use of the MDI depends on proper technique (Hess et al., 2021). Education on correct use of inhaler is critical to reduce errors in use and improve efficacy of medication and patient outcomes (Hess et al., 2021; Price et al., 2017). Education should include brief, repeated MDI practice for motor learning to promote mastery (Gao et al., 2020; Schmitz et al., 2019).
The plastic holder and cap provided with the inhaler should be cleaned at least weekly. Remove the medication canister and clean with warm running water. Shake the holder and allow it to air dry.
Some medication canisters cannot be removed from the plastic holder. Wipe the mouthpiece with a cloth or dry cotton swab and/or refer to the manufacturer's directions for cleaning (Cleveland Clinic, 2014).
Store the MDI in a location that is not exposed to heat (Frandsen & Pennington, 2021).
Clean the spacer (valved holding chamber) once a week by soaking in warm water with a mild detergent for 15 minutes. Rinse well and shake off excess water. Allow it to air dry (Allergy & Asthma Network, 2020c; Cleveland Clinic, 2014).
Do not store the spacer (valved holding chamber) in a plastic bag to prevent moisture retention and possible resulting microorganism growth.
If the medication being administered is a steroid, the patient should rinse their mouth with water after administration to prevent throat irritation and secondary infection to the oral mucosa (MFMER, 2021f).
Ongoing assessment is an important part of nursing care to evaluate patient response to administered medications and early detection of adverse reactions. If an adverse effect is suspected, withhold further medication doses and notify the patient's health care team. Additional intervention is based on type of reaction and patient assessment.

Infant and Child Considerations

Young children usually require a spacer to use an MDI. A spacer is recommended for any child who has difficulty squeezing the canister and inhaling at the right time, particularly children younger than ages 5 to 6 years (Moore, 2020). Spacers with masks are available for young children. The mask must fit securely over both the nose and the mouth to ensure a good seal and prevent medication from escaping.
Children must be able to seal their lips around the mouthpiece in order to use a spacer without a mask.
Many medications can also be administered as a nebulizer (see Skill 5-24).

Community-Based Care Considerations

It is important for patients to know how to tell when MDI medication levels are getting low. The most reliable method is to look on the canister and see how many puffs the canister contains. Divide this number by the number of puffs used daily to ascertain how many days the MDI will last. For instance, if the MDI contains 200 puffs and the patient takes 6 puffs per day, the MDI should last for 33 days. Keep a diary or record of inhaler use and discard the inhaler on reaching the labeled number of doses. This method may be cumbersome and impractical for some patients, but it is a reliable way to determine how much medication remains in an MDI. Another accurate way to know when the canister is depleted is to use a dose counter, which counts down each time the canister is activated (Gerald & Dhand, 2020). Floating the canister in water is not reliable and is no longer recommended (Gerald & Dhand, 2020; MedlinePlus, 2020).

Administering Medication via a Metered-Dose Inhaler Without a Spacer

There is inconsistency in the evidence for practice related to use of an MDI without a spacer. Some sources identify that the mouthpiece should be held in the mouth, with lips sealed around the inhaler, and other sources identify that the mouthpiece should be held two finger breadths from the mouth for use (CDC, 2018; Cleveland Clinic, 2014; Hess et al., 2021; MedlinePlus, 2020). Patients should refer to the specific instructions provided with the MDI or from their health care provider.

Prepare medication as outlined in Steps 1-20 above (Skill 5-22).

Remove the cap from the MDI.
Have the patient take a deep breath and exhale.
Have the patient hold the inhaler 1 to 2 inches away from the mouth (about the width of two fingers [Quaranta, 2018]) (Figure A). Alternatively, have the patient place the inhaler mouthpiece in their mouth, grasping it securely with teeth and above the tongue, and sealing the lips tightly around the mouthpiece.
Have the patient begin to inhale slowly and deeply, depress the medication canister, and continue to inhale until their lungs are full.
Instruct the patient to hold their breath for 5 to 10 seconds, or as long as possible, and then remove the spacer from their mouth and exhale slowly through pursed lips.
Wait 1 to 5 minutes, as prescribed, before administering the next puff.
After the prescribed number of puffs has been administered, have the patient replace the cap on the MDI.
Remove PPE, if used. Perform hand hygiene.
Document administration of the medication on the eMAR/MAR immediately after administering the medication.
Evaluate the patient's response to the medication within an appropriate time frame. Reassess lung sounds, oxygen saturation level, peak flow, and respirations, as indicated.

EVIDENCE FOR PRACTICE

Patient Education and Inhaled Medications

Correct use of an inhaler is critical to ensure accurate dosing of medication. Nurses play a key role in educating patients and their family/caregivers and validating mastery of knowledge to improve patient outcomes.

Related Research

Gao, G., Liao, Y., Mo, L., Gong, Y., Shao, X., & Li, J. (2020). A randomized controlled trial of a nurse-led education pathway for asthmatic children from outpatient to home. International Journal of Nursing Practice, 26(3), e12823. https://doi.org/10.1111/ijn.12823

The purpose of this randomized controlled trial was to evaluate the efficacy of a nurse-led pathway, a standard education program, on children with asthma. A convenience sample of children with asthma was recruited from an outpatient department of a hospital in China. Participants experienced asthma symptoms during the day or night, experienced limitation in daily activities or sports because of asthma, had a need for rescue medication or unscheduled visits to their health care provider, and had a need emergency department visits because of exacerbations in the 3 months prior to initiation of study. The 125 participants were randomly assigned to either the control group or the intervention group. The intervention group (n = 73) received predetermined step-by-step education sessions based on a self-designed education pathway, including four visits by a clinical nurse with expertise in pediatric asthma management (two outpatient sessions, one home visit, and one telephone visit). Each visit had specific education items and addressed tailored interventions for problems identified by the patient during the visit. Visits focused on education about asthma management, trigger avoidance, peak flow measurement and asthma diary use, inhaler training, medication adherence, and management of asthma attacks. The control group (n = 52) received usual care, consisting of one routine education session. Asthma control, health-related quality of life, and health care utilization measures were taken at baseline and at follow-up visits (3 months and 6 months). Results indicated significantly higher scores in the intervention group for health-related quality of life (P = .026) and inhaler technique (P = .002) at the 3-month visit and asthma control test (P = .002) at the 6-month visit. The numbers of unscheduled physician visits and school absences were lower in the intervention group than in the control group within 6 months. There were no significant differences observed in emergency department visits and hospitalizations. The researchers concluded a nurse-led education pathway was more effective than usual care to provide information and support in asthma self-management from the outpatient clinic to home to improve asthma control, health-related quality of life, inhaler technique, and health care utilization. The authors suggest a nurse-led education pathway is an effective intervention for children with asthma.

Relevance to Nursing Practice

EVIDENCE FOR PRACTICE

Inhaled Medications

Correct use of a metered-dose inhaler is critical to ensure accurate dosing of medication. Patients who are prescribed medications delivered with an MDI must have accurate knowledge and demonstrate appropriate technique regarding use to ensure accurate medication delivery. Nurses play a key role in patient education and must have adequate knowledge to provide appropriate educational intervention.

Related Research

De Tratto, K., Gomez, C., Ryan, C. J., Bracken, N., Steffen, A., & Corbridge, S. J. (2014). Nurses' knowledge of inhaler technique in the inpatient hospital setting. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 28(3), 156-160. https://doi.org/10.1097/NUR.0000000000000047

The purpose of this study was to examine inpatient staff nurses' self-perceptions of their inhaler technique knowledge, frequency of providing patient education, and responsibility for providing education. The study also assessed the nurses demonstrated inhaler technique using both a metered-dose inhaler (MDI) and diskus (a dry powder inhaler). A total of 100 nurses at a large urban academic medical center working on inpatient medical units agreed to participate. Participants completed a Likert-scale written survey to measure self-perceptions of inhaler technique and frequency and responsibility of patient education regarding MDI and diskus inhaler discharge teaching. Participating nurses then demonstrated inhaler-use technique to a data collector who utilized a detailed, validated checklist outlining the steps for use of both types of inhalers to evaluate the nurses' performance. Misuse of both MDI and diskus technique was defined for the study as having less than 75% of the steps correct (;9 of 12 steps for MDI and ;8 steps for diskus). Overall misuse rates for both MDI (82%) and diskus (92%) devices were high, with poor correlation between perceived ability and investigator-measured level of performance of inhaler technique. Key steps missed in use of the devices included breathing out fully prior to inhaling with both devices. Ninety percent of participants missed keeping the device horizontal, and 78% did not breathe in quickly during use of the diskus. Frequency of teaching for the diskus device by nurses was correlated with higher scores on the validated checklist, but this was not the case with the MDI. The researchers concluded that although nurses are a key component of patient education, nursing staff lack adequate knowledge of inhaler technique.

Relevance to Nursing Practice

Nurses play a large role in patient education and in designing interventions to positively impact patient outcomes. Accurate dosing of inhaled medications, and therefore control of symptoms and disease treatment, depends on correct use of the delivery device. Providing patient education related to self-administration of medications, leading to accurate medication dosing, is a very important nursing intervention. Nurses must take responsibility for acquiring and maintaining accurate knowledge with regard to use of these devices in order to provide accurate patient teaching. Nurses may advocate for education regarding inhaler technique as part of facility-wide professional development interventions.

section name header

Skill 5-22

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE