You are a team leader RN working with a student nurse. The student nurse is to teach a patient how to use and MDI without a spacer. Put in correct order the steps that the student nurse should teach the patient.

Remove the inhaler cap and shake the inhaler
Open your mouth and place the mouthpiece 1 to 2 inches away
Tilt your head back and breathe out fully
Hold your breath for at least 10 seconds
Press down firmly on the canister and breathe deeply through your mouth
Wait at least 1 minute between puffs.

Before each use. the cap is removed and the inhaler is shaken according to the instructions in the package insert. Next the patient should tilt the head back and breathe out completely. As the patient begins to breathe in deeply through the mouth. the canister should be pressed down to release one puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow the medication to reach deep into the lungs. The patient should wait for at least 1 minute between puffs from the inhaler.