Suctioning is appropriate only when secretions are present in the upper airways as indicated by coarse crackles, diminished breath sounds, increased inspiratory pressure, increased respiratory rate, or decreased oxygen saturation (Tamburri, 2000). Oral and nasal suctioning can greatly relieve the dyspnea that accompanies excessive secretions, but the process is frightening and unpleasant for nearly all patients.
- Assess respiratory system
- Assess client’s ability to cough. Note amount and character of sputum.
- Assess vital signs. Compare to baseline vital signs. Note an elevation in temperature.
- Assess level of consciousness and ability to protect airway (eg., presence of cough reflex). Note any drainage from mouth.
- Verify the physician order and identify the client. Rationale: Prevents potential errors.
- Wash your hands. Rationale: Handwashing prevents transmission of microorganisms.
- Explain procedure and purpose to client. Rationale: Explanations reduce anxiety and encourage cooperation with procedure.
- Position the conscious client with an intact gag reflex in a semi-Fowler’s position. Position the unconscious client in a side-lying position facing you. Rationale: The semi-Fowler’s position helps prevent aspiration of secretions. A side-lying position facilitates drainage of secretions by gravity and prevents aspiration.
- Turn on suction device and adjust pressure: infants and children, 50 to 75 mmHg; adults, 100 to 120 mmHg. Rationale: Excessive negative pressure traumatizes mucosa and can induce hypoxia.
- Open and prepare sterile suction catheter kit. Pour sterile saline into cup.
- Preoxygenate client with 100% oxygen. Hyperinflate with manual resuscitation bag, Rationale: Preoxygenate helps prevent hypoxia; hyperinflation decreases atelectasis caused by suctioning.
- Don sterile or clean gloves. Rationale: Protect yourself from exposure to mucous membrane and sputum.
- Pick up the catheter with dominant hand. Pick up connecting tubing with nondominant hand. Attach catheter to suction tubing.
- Place catheter end into cup of saline. Test functionality of equipment by applying thumb from nondominant hand over open port to create suction. Return catheter to sterile field. Rationale: Lubrication makes catheter insertion easier and ensures proper functioning of suction equipment.
- Insert catheter into trachea through nostril, nasal trumpet, or artificial airway during inspiration. Rationale: Inspiration opens epiglottis and facilitates catheter movement into trachea.
- Advance catheter until you feel resistance. Retract catheter 1cm before applying suction. Client will usually cough when catheter enters trachea. Rationale: Retracting catheter slightly prevents mucosal damage.
- Apply suction by placing thumb of nondominant hand over open port. Rotate the catheter with your dominant hand as you withdraw the catheter. This should take 5 to 10 seconds. Rationale: Rotation of catheter prevents trauma to mucous membrane from prolonged suctioning of one area. Limiting the suction time to 10 seconds or less prevents hypoxia.
- Hyperoxygenate and hyperinflate using manual resuscitation bag for a full minute between subsequent suction passes. Encourage deep breathing. Rationale: Prolonged suctioning can induce hypoxia.
- Rinse catheter thoroughly with saline. Rationale: Rinsing clears secretions from catheter.
- Repeat steps 10 to 14 until airway is clear.
- Without applying suction, insert the catheter gently along one side of the mouth. Advance to the oropharynx. Rationale: Suction the oropharynx after trachea because the mouth is less clean than the trachea. Directing the catheter along the side of the mouth prevents stimulation of the gag reflex.
- Apply suction for 50 to 10 seconds as you rotate and withdraw catheter. Rationale: Rotation of the catheter prevents trauma to the mucous membrane. Be sure to remove secretions that pool beneath the tongue and in the vestibule of the mouth.
- Allow 1 to 2 minutes between passes for the client to ventilate. Encourage deep breathing. Replace oxygen if applicable.
- Repeat steps 16 and 17 as necessary to clear oropharynx.
- Rinse catheter and tubing by suctioning saline through.
- Remove gloves by holding catheter with dominant hand and pulling glove off inside-out. Catheter will remain coiled inside the glove. Pull other glove off inside-out. Dispose of in trash receptacle. Rationale: Contain client secretions inside gloves to reduce transmission of microorganisms.
- Turn off suction device.
- Assist client to comfortable position. Offer assistance with oral and nasal hygiene. Replace oxygen device if used. Rationale: Accumulated respiratory secretions irritate the mucous membranes and are unpleasant for the client.
- Dispose of disposable supplies.
- Wash your hands.
- Document procedure and observations. Rationale: Maintains legal record and communicates with other healthcare team members.
Info source: Fundamentals of Nursing – Lippincott
Video Source: Youtube, NurseCentral
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