Which inhaler needs to be given first?

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Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.

I'm guessing that the OP is a student.

Let me give you some advice: NEVER give ANY patient ANY drug if you don't know what it is, what it's supposed to treat, and what the safe dosage amount is.

As a student or a new nurse, I wouldn't expect you to be familiar with all the common drugs, and that's where your Drug Handbook (or equivalent app on your phone or computer) comes in.

Doctors make mistakes, pharmacists make mistakes, poop happens. YOU are the last line of defense for your patient.... YOU are expected to catch those mistakes before the patient is put in danger.

If you don't know what the drug is or how it is given or how much is normally given, LOOK IT UP and/or ASK FOR HELP.

Even after you're a seasoned nurse, you'll still come across new meds from time to time. Don't take your patient's word for it -- look it up before administering it. That's your responsibility as a nurse.

4xJG

6 Posts

I read this thread earlier today and agreed w PP since we were taught in school/clinical that bronchodilators were always given before steroids or other meds. Just came across this in reading my med-surg textbook:

"Historically it has been recommended that [sABAs] should be used first to open up the airway and improve the delivery of subsequent medications. However, this is no longer recommended because there is no evidence demonstrating that it is beneficial, and it is a potential source of confusion to patients" (Lewis et al., 2011. p601-02).

Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
Hi.

Last week I had a chance to give medications to one patient who was metal disorder...OMG...although he was with mental condition, he has been on these inhalers for many years so I think he is probably right....I

I just want to give you a cyber hug! You have now been told by the experienced nurses on AN about how and why the different inhalers work and why they should be given in a certain order.

Good for you for asking and learning. I'll bet you'll never forget now, lol!

I'm a new grad nurse, I've worked in dementia care as well as in acute psychiatric care. I've learned that when a pt questions their meds, it's best for me to double (or triple or quadruple) check then because sometimes, they are right. For that reason if a pt questions me, I follow up on his concern, because sometimes they are correct!

Also, as a new grad, I still look up certain meds before I give them. Because I do this, I caught a med error last month. The other more experienced nurse had been giving the wrong inhaler. The correct one wasn't even in the cart (but shed signed it as given) It looked like she mixed up the names of the inhalers. (Pt was on several) Only because it looked them up did I realize the routine inhaler wasn't even available.

Your errors were.... putting the psych diagnosis first instead of the medical diagnosis/ reason for the medication.

When you have multiple meds to give via the same route , you MUST do your research BEFORE administering them.You can use your handbook or consult pharmacy.

I was a nurse for many years, my patient had several different eye drops ordered. I had NO clue what order to give them in. It took some time, I looked them up and deduced the correct order.

This is addressed in the six rights of medication administration.

amoLucia

7,736 Posts

Specializes in retired LTC.

To OP-this is a problem also with various eye drops, ie which gtt comes first.

To prevent further repeat error, could you somehow change some times on the MAR or somehow leave directions re correct sequence of administration?

GrannyRRT

188 Posts

I read this thread earlier today and agreed w PP since we were taught in school/clinical that bronchodilators were always given before steroids or other meds. Just came across this in reading my med-surg textbook:

"Historically it has been recommended that [sABAs] should be used first to open up the airway and improve the delivery of subsequent medications. However, this is no longer recommended because there is no evidence demonstrating that it is beneficial, and it is a potential source of confusion to patients" (Lewis et al., 2011. p601-02).

Do you have a citation for their reference?

While it might not make a difference for someone who is having a good breathing, it might matter in an exacerbation. Most of the delivery deves are flow dependent. Do PEFR pre and post will give you good info for the patient. You can also look at the patient's last PFT to see the bronchodilator response.

Part of the teaching should be to tell the patient to bronchodilate first if they are feeling their breathing is z little off from the norn. No need to have them waste time puffin the Flovent or a DPI.

As a nurse who has the responibility of giving inhalers it is your responsibility to inform the doctor if a patient is not able to achieve the appropriate inspiratory flow rate for the DPI. No need for the patient to waste over $700/ month on a med which will be ineffective due to delivery issues. For MDIs this is not that much of and issue as long as a spacer is used which should be stressed in the hospital setting. A recent study showed inhalers were an area where nurses needed more education. Patients will be confused about the meds and technique if you are not clear about it yourself.

Also, make sure you know the individual medications in the combo inhalers. If you have Symbicort and ProAir ordered, double check before giving since they look similar. If the patient is going home with them as scripts, give them tips on marking the containers. There have been incidents with the Symbicort left at the bedside as a rescue inhaler instead of the ProAir. Not good to takes 12 hits off of a LABA in a short time.

OCNRN63, RN

5,978 Posts

Specializes in Oncology; medical specialty website.
Yes that has been my experience too. I've told this story here before but it's something that I will not forget for the entirety of my career. I was working in the hospital, come onto a night shift, assigned to take care of a post-op teenager. This teenager happened to have a history of cutting. We did written report and in the day nurse's report, she had written "hx of cutting but so nice you would never know." This was probably 5 years ago and I remain horrified and dumbfounded at this comment. What on earth does being nice have to do with the inner turmoil that causes one to self-injure? People with mental illness can be nice, mean, black, white, knowledgeable about their medical conditions or not, employed, unemployed, your mother, your sister, your brother, your next door neighbor, you.

​Maybe she meant it as, "She's so nice you'd never know she was suffering from such internal turmoil."

4xJG

6 Posts

Do you have a citation for their reference?

Lewis, S. L., Dirksen, S. R.,Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Meical-surgical nursing: Assessment and management of clinical problems(8th ed.). St. Louis, MO: Elsevier Mosby.

Here's the full citation for the textbook and, as stated in my OP, the quotation referenced was on page 601-602. Clearly, the long-standing recommendations for inhaler administration order aren't going anywhere anytime soon; I just thought it was an interesting tidbit to add to the discussion.

​Maybe she meant it as, "She's so nice you'd never know she was suffering from such internal turmoil."

Quite possibly....I read it again and see how that could have been the meaning. That being said, that doesn't seem to be appropriate to put in a patient's chart.

Specializes in critical care, ER,ICU, CVSURG, CCU.

I am a Reg.Resp Therapist, besides a 42yr RN........ventolin is a bronchial dilator, and should be given first, then the ithers, but it is not the end of the world......some personalities do not have a good dat, without a little drama :)

GrannyRRT

188 Posts

Consistency is key.

Find out what others are teaching the patients throughout the hospital and stay on the same page. By now most hospitals should have certified asthma and COPD educators working with patients at least in the ER or with discharge planning. Community Paramedics will also be following these patients on discharge and should be consistent with the discharge instructions. Pulmonary Rehab nurses will also be repeating the meds over and over so patients know what, how and why. Pulmonologists will be doing the same. We want patients to not be getting mixed messages which can lead to confusion, noncompliance, hospital readmission, a ventilator and death.

All have a common goal of having the patients understand each medication or at least what a rescue inhaler is. If you give some answer like "it doesn't matter", the message about the rescue inhaler might be missed or they think you don't know your meds. In peds, many of the kids know their meds by 5 years old and their proper use and order.

3rdGenRN

105 Posts

Specializes in Emergency.

My 8 year old asthmatic daughter chewed me out for this mistake last week ;P

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