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Student _______________________________________________________ Date __________________________

Instructor _____________________________________________________ Date __________________________

PERFORMANCE CHECKLIST SKILL 21-6 USING METERED-DOSE INHALERS

S U NP Comments

ASSESSMENT1. Checked accuracy and completeness of each

MAR against medication order, clarified incom-plete or unclear orders with health care pro-vider. ____ ____ ____ ___________________________

2. Reviewed pertinent information related to medication. ____ ____ ____ ___________________________

3. Assessed patients medical history, history of allergies, and medication history. ____ ____ ____ ___________________________

4. Assessed respiratory pattern, auscultated breath sounds. ____ ____ ____ ___________________________

5. Assessed patients ability to hold, manipulate, and depress canister and inhaler. ____ ____ ____ ___________________________

6. Assessed patients readiness and ability to learn. ____ ____ ____ ___________________________

7. Assessed patients knowledge and understand-ing of disease and purpose and action of medi-cations. ____ ____ ____ ___________________________

PLANNING1. Identified expected outcomes. ____ ____ ____ ___________________________

2. Explained procedure to patient, explained spe-cifics if patient wished to self-administer drug. ____ ____ ____ ___________________________

IMPLEMENTATION1. Prepared medications for inhalation, checked

label of medication against MAR twice, checked expiration date. ____ ____ ____ ___________________________

2. Took medication(s) to patient at correct time, applied the six rights of medication adminis-tration. ____ ____ ____ ___________________________

3. Identified patient using two identifiers. ____ ____ ____ ___________________________

4. Compared MAR with medication labels at patients bedside, asked patient if he or she had allergies. ____ ____ ____ ___________________________

5. Discussed purpose of each medication, action, and possible adverse effects; allowed patient to ask any questions; explained what a metered-dose is and how to administer it, warned about overuse and side effects. ____ ____ ____ ___________________________

Copyright 2014, 2010 by Mosby, an imprint of Elsevier Inc.

272 Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

6. Allowed adequate time for patient to manipu-late equipment, explained and demonstrated how canister fits into inhaler. ____ ____ ____ ___________________________

7. Explained steps for administering MDI without spacer:

a. Removed mouthpiece cover from inhaler after inserting MDI canister into holder. ____ ____ ____ ___________________________

b. Shook inhaler well for 2 to 5 seconds. ____ ____ ____ ___________________________

c. Held inhaler in dominant hand. ____ ____ ____ ___________________________

d. Instructed patient to position inhaler prop-erly. ____ ____ ____ ___________________________

e. Had patient take deep breath and exhale completely. ____ ____ ____ ___________________________

f. Had patient hold inhaler in three-point or bilateral hand position when positioned properly. ____ ____ ____ ___________________________

g. Instructed patient to tilt head back and inhale slowly and deeply through mouth for 3 to 5 seconds while depressing canister fully. ____ ____ ____ ___________________________

h. Had patient hold breath for about 10 seconds. ____ ____ ____ ___________________________

i. Removed MDI from mouth before exhaling. ____ ____ ____ ___________________________

8. Explained steps to administer MDI using a spacer.

a. Removed mouthpiece cover from MDI and mouthpiece of spacer device. ____ ____ ____ ___________________________

b. Shook inhaler well for 2 to 5 seconds. ____ ____ ____ ___________________________

c. Inserted MDI into end of spacer device. ____ ____ ____ ___________________________

d. Instructed patient to place spacer mouthpiece in mouth and close lips, avoided covering exhalation slots with lips. ____ ____ ____ ___________________________

e. Had patient breathe normally through mouthpiece. ____ ____ ____ ___________________________

f. Instructed patient to spray one puff into spacer device. ____ ____ ____ ___________________________

g. Had patient breathe in slowly and fully. ____ ____ ____ ___________________________

h. Instructed patient to hold breath for 10 seconds. ____ ____ ____ ___________________________

9. Instructed patient to wait appropriate length between inhalations. ____ ____ ____ ___________________________

S U NP Comments

Copyright 2014, 2010 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved. 273

10. Instructed patient to not repeat inhalation before next scheduled. ____ ____ ____ ___________________________

11. Warned patient they may feel gagging sensa-tion. ____ ____ ____ ___________________________

12. Instructed patient to rinse and spit with warm water 2 minutes after dose. ____ ____ ____ ___________________________

13. Instructed patient in daily cleaning of inhaler. ____ ____ ____ ___________________________

14. Asked if patient had any questions. ____ ____ ____ ___________________________

15. Assisted patient to comfortable position, per-formed hand hygiene. ____ ____ ____ ___________________________

EVALUATION1. Had patient explain and demonstrate steps in

use and cleaning of inhaler. ____ ____ ____ ___________________________

2. Asked patient to explain drug schedule and dose or medication. ____ ____ ____ ___________________________

3. Asked patient to describe side effects of medica-tion and criteria for calling health care provider. ____ ____ ____ ___________________________

4. Assessed patients respirations, breath sounds, and peak flow measures after medication administration if ordered. ____ ____ ____ ___________________________

5. Identified unexpected outcomes. ____ ____ ____ ___________________________

RECORDING AND REPORTING1. Recorded drug, dose, route, number of inhala-

tions, and time on MAR; included initials or signature; recorded patient teaching and valida-tion of understanding in nurses notes. ____ ____ ____ _________________________

2. Recorded patients response to MDI, side effects, and patients ability to use MDI. ____ ____ ____ _________________________

3. Reported adverse effects/patient response/withheld drugs to nurse in charge or health care provider. ____ ____ ____ _________________________

S U NP Comments

Copyright 2014, 2010 by Mosby, an imprint of Elsevier Inc.

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