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Which inhaler needs to be given first?

solanim solanim (New) New

Hi.

Last week I had a chance to give medications to one patient who was metal disorder i kni knwith COPD.

At same time, he was on seretide, ventolin, and spiriva . I just had a brief idea of these inhalers that helps breathing by expanding lung capacity and relives COPD symptoms.

I gave him spiriva first then pt used it. Then he asked me " do you really know what you are doing? I mean what meds you are giving to me?"

So i told him that I know these medication helps your breathing by expanding your lung capacity..

The patient said. " no I don't think you know what you are doing. You are supposed to give me ventolin first which opens my airway and expand my lung capacity and then the one you gave me helps remaining expansion. Then you need to give me other.

OMG. I was so embarrassed and shamed myself. But I was wondering why he took spiriva first then pt said " because you gave it first!"

OMG...although he was with mental condition, he has been on these inhalers for many years so I think he is probably right. When I finished my work, I tried to find more info through internet regarding this issue , but I couldn't find good resources. Can anyone teach me about this?

I

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 48 years experience.

Pt. logically correct. Just because someone has a mental disorder doesn't mean they're unaware of anything.

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 10 years experience.

He's right. Ventolin then others. Usually steroid & spiriva at least 5 min after Ventolin

Student Mom to Three

Has 2 years experience.

I was taught to give the bronchodilator first....so that would be the Ventolin. The other important thing I remember about inhalers is to wait a full minute between "puffs" when using a bronchodilator. I had a short stint as a school nurse and administered a lot of albuterol. Was really difficult for the little ones to wait for the full minute so we ended up buying sand timers so they could watch it themselves.

On another note- I always find it interesting when pts tell you after the fact that you did something wrong. If he was going to mention it, why not do it before hand so it can be corrected?

Edited by Student Mom to Three
spelling

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

I'm not sure what the patient having a "mental disorder" has to do with anything. Do you think a patient with depression or anxiety or bipolar disorder is clueless about his or her own medical conditions/history? That is laughably untrue and a borderline offensive suggestion. The bronchodilator should be given first, the patient is correct.

T-Bird78

Has 6 years experience.

Is the ventolin supposed to given daily or just PRN? I have asthma pts who swear up and down their albuterol is daily and the others are PRN, and they are wrong in that assumption. If the ventolin is supposed to be daily for the administration of the other inhalers, that's one thing, but so many people misuse their albuterol with daily use when it's not needed.

You guys are totally right. But don't get me wrong. I was new to geriatric psychiatric unit and i was told some patients had their own delusional ideas about their medication so gave medication as charted. When he mentioned I was doing wrong , I briefly thought about what I was told at that time. But when he explained how to give meds I thought he was right and I apologised him . And when I gave him meds with inhalers, I used medication tray to show his meds first before taking it. so he could pick the right one to use. But pt didn't pick inhaler waited until i picked wrong one. Then told me he was testing me. Anyway this time I had a big lesson.

I'm not sure . But this patient was on daily ventolin, spiriva, and seretide in the morning.

klone, MSN, RN

Specializes in Women's Health/OB Leadership. Has 14 years experience.

Yes, as others have said, the bronchodilator is always given first, in order to open up the airway more so you can take in more of the steroid. I live in a houseful of asthmatics, so I know this routine well.

klone, MSN, RN

Specializes in Women's Health/OB Leadership. Has 14 years experience.

Is the ventolin supposed to given daily or just PRN? I have asthma pts who swear up and down their albuterol is daily and the others are PRN, and they are wrong in that assumption. If the ventolin is supposed to be daily for the administration of the other inhalers, that's one thing, but so many people misuse their albuterol with daily use when it's not needed.

Yes, I had a patient recently who was using the Ventolin BID, and Flovent PRN. NO NO NO! Other way around!

The patient is right. You give the SABA first then the LABA or steroid last. Remember they must wash out their mouth after the steroids. The SABA or Albuterol is what keeps them open and the other Meds are what maintain them. If he was having an attack, you'd give the emergency inhaler first which is his Ventolin.

Also Ventolin HFA is not given routinely. It is suppose to be ordered or given prn. If the patient is using that MDI more than twice a week then they need intervention. That means that their asthma or symptoms are not under control.

Also Ventolin HFA is not given routinely. It is suppose to be ordered or given prn. If the patient is using that MDI more than twice a week then they need intervention. That means that their asthma or symptoms are not under control.

For asthma, yes, but this patient had COPD, so his ventolin could be a scheduled med instead of PRN.

There are guidelines for COPD management. You can use a SABA prn for mild cases, for moderate you can do a combination inhaler such as Combivent, and for end-stage or severe we use the SABA routinely. If the order was followed as written then it really doesn't matter what the patient says but the SABA should be given first to open up the airways to allow the the steroids to work. Psych patients can be manipulative so be careful. I get them every day in the clinic asking to me to alter their meds. Go to goldcopd.org if you wanna know the management of said condition. 😊

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 10 years experience.

My grandmother has COPD after 65 years of smoking. Her pulmonologist explained that many times daily SABA is indicated. Some insurance doesn't cover combivent. But they cover Ventolin plus spiriva (spiriva is anticholinergenic similar to Atrovent. Atrovent plus Ventolin = combivent). Spiriva much more effective 5 minutes post Ventolin

Seretide is like advair (Flovent (steroid) plus serevent (laba).

In my experience it should be Ventolin, wait, spiriva wait then seretide/advair to have optimal effects

Meriwhen, ASN, BSN, RN

Specializes in Psych ICU, addictions.

Ventolin first. Spiriva won't do the patient any good if it has a hard time getting there.

You would be surprised how well psychiatric patients, even geriatric ones, know their medications. Do not fall into the trap of thinking otherwise.

As for delusions...well, if they give you some hare-brained story about how they take Haldol intranasally for their hemorrhoids, or whatever other idea that you know for a fact is false or doesn't sound right, then don't listen to it. If they want medication changes, remind them that you need to defer to their MD/prescriber.

Otherwise, consider what feedback the patient has to say...because it's likely that the patient knows what he or she is talking about.

I'm not sure what the patient having a "mental disorder" has to do with anything. Do you think a patient with depression or anxiety or bipolar disorder is clueless about his or her own medical conditions/history? That is laughably untrue and a borderline offensive suggestion. The bronchodilator should be given first, the patient is correct.

That's because patients with mental conditions are CRAZEEEEEEEEEEE and don't have a clue as to what is going on around them!

At least that's the impression I get from some medical professionals.

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

That's because patients with mental conditions are CRAZEEEEEEEEEEE and don't have a clue as to what is going on around them!

At least that's the impression I get from some medical professionals.

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.

, for moderate you can do a combination inhaler such as Combivent, and for end-stage or severe we use the SABA routinely. If the order was followed as written then it really doesn't matter what the patient says but2;

We have to remind the doctors of the order of the meds also especially during the month of July.

We also are constantly changing the times in the MAR since there is a conflict in timing the order with the BID, 4x_day and q 4 schedules. It really messes up the bronhiectasis, CF and some mixed CLD_ with pulmonary htn if you mix up the meds. It is up to you to know the specific policy or the how to and whys for pulmonary drugs to be effective. DPIs_ such as Spiriva_ are challenging to ensure the pt is able to achieve max inspiratory flow for adequate delivery. Also, for the MDIs_, almost every one had different priming puffs and schedule. As expensive as these meds are, you don't want to waste but delivery needs to be effective.

The hospital times also promotes noncompliance since it wants people to breathe around a computer generated schedule rather than their activity. No wonder people with COPD are in respiratory distress when they have a full set of early morning tests or PT but only can get a QID_ albuterol at 0900. Some COPD pts like their albuterol first thing in the morning with their coffee and cigarette.

Insurance isn't paying for Combivent because it is no longer available as an MDI since HFA_ replaced the CFC_ inhalers. It is now Respimat_, an atomizer type inhaler costing around $350.

*** Combivent is also a name for the liquid combo in Canada and a few other countries which in the US was known as DuoNeb, a brand name.

Look, I just gave examples of which meds to use and I'm sure epocrates, the GOLD guidelines, or MPR won't steer us wrong as far as reference goes. I always start the patient off on the cheapest SABA or LABA combination necessary then I refer out. I work for a community health center so believe me I know about cost. The ACA insurance plan barely covers Albuterol let alone the combination inhalers. It's a daily challenge managing chronic conditions but the guidelines will never steer you wrong. I always consult the Pharm-D where I work to keep up with what is affordable and what is covered.

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