[Oxy] Med-Surg Checklist With Rationale

8/4/2019 [Oxy] Med-Surg Checklist With Rationale

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ADMINISTERING OXYGEN BY CANNULA, FACE MASK, OR FACE TENT

Overview:

Oxygen is a basic need; it is required for life. Adequate oxygenation is essential for cerebral functioning. The cerebral cortex can tolerate

hypoxia for only 3-5 minutes before permanent damage occurs. Nurses frequently assists clients in meeting oxygen needs.

Indication:

When a client has inadequate ventilation or impaired pulmonary gas exchange, oxygen (O2) therapy may be needed to prevent hypoxia. The

primary care provider prescribes O2 therapy, the method of delivery, and the liter flow per minute. In hospitals and long-term care facilities, O2 is usuallypiped into wall outlets at the clients bedside. In other facilities, pressurized tanks or cylinders of O2 are used. Small, portable cylinders of O2 are

available for clients who require oxygen therapy at home. O2 is a dry gas, so humidifying devices are essential to add water vapour to the inspired air,

especially if the liter flow is >2 L/min.

Oxygen Delivery Devices:

Cannula The cannula is disposable plastic tube with two prongs for insertion into the nostrils. It fits around the head or loops over the ears

to hold it in place and is connected by tubing to the O2 source. It is easy to apply, relatively comfortable, and allows the client to eat and talk. It is

adequate for rates of 2-6 L/min. Above 6 L/min it is not effective.

Face MaskMasks cover the clients nose and mouth. They have exhalation ports on the sides to allow exhaled carbon dioxide to escape. It

is important that the mask be of appropriate size for the client. Simple face mask - Delivers O2 concentration of 40%-60% at flows of 5-8 L/min, respectively

Partial rebreather mask Delivers O2 concentrations of 60-90% at flows of 6-10 L/min, respectively.

Nonrebreather mask Delivers the highest possible of O2 concentration (95%-100%), except for intubation or mechanical ventilation, at

flows of 10-15 L/min.

Face Tent Some clients do not tolerate masks well; they may respond with anxiety or even panic. A face tent is similar to a mask, but

larger and open at the top. It fits snugly around the clients jaw line, but is open at the top over the nose. It delivers a concentration of 30%-50% at 4-8

L/min.

Transtracheal catheter is placed through a surgically created tract in the lower neck directly into the trachea. Once the trach has matured,

the client removes and cleans the catheter two or four times per day. Oxygen applied to the catheter at less than 1 L/min need not be humidified, andrates above 5 L/min can be administered.

Safety Precautions:

Place cautionary sings reading No Smoking: Oxygen is in Use on the clients door, at the foot or head of bed, and on the oxygen

equipment.

Instruct the client and visitors about the hazard of smoking with oxygen in use.

Make sure that electrical equipment (e.g. razors, hearing aids, radios, televisions, and heating pads) is in good working order to prevent

occurrence of short-circuit sparks.

Avoid materials that generate static electricity, such as woollen blankets and synthetic fabrics. Cotton blankets are used, and nurses are

advised to wear cotton fabrics.

Avoid, the use of volatile, flammable materials, such as oils, greases, alcohol, and ether, near clients receiving oxygen. Avoid alcohol

back rubs, and take nail polish removers and the like away form the immediate vicinity.

Ground electric monitoring equipment, suction machines, and portable diagnostic machines

Make known location of fire extinguishers, and make sure personnel are trained in their used.

Assessment:

Signs of hypoxia: tachycardia, tachypnea, dyspnea, pallor, cyanosis

Signs of hypercabia: restlessness, hypertension, headache

Signs of oxygen toxicity: tracheal irritation, cough, decreased pulmonary ventilation

Special Considerations:

Older adults are prone to dehydration that causes dry mucous membranes.

Ciliary action decreases with age, causing decreased clearing of the airways.

Muscular structures of the pharynx and larynx atrophy with age.

Less ventilation in the lower lobes of the older adult causes secretions to pool or predispose to pneumonia.

Equipment:

Cannula

Oxygen supply with a flow meter and adapter

Humidifier with distilled water or tap water according to agency protocol

Nasal cannula and tubing


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Tape

Padding for the elastic band

Face Mask



Prescribed face mask of the appropriate size

Padding for the elastic band

Face Tent



Face tent of the appropriate size

PROCEDURE RATIONALEPreparation

1. Determine the need for oxygen therapy, verify the order for the therapy. To develop a baseline data if not

already available

2. Prepare the client and support people.

Assist the client to a semi-Fowlers position if possible.

Explain that oxygen is not dangerous when safety precautions are observed. Inform the client and

support people about the safety precautions connected with oxygen use.

This position permits easier chest

expansion and hence easierbreathing

Performance

1. Explain to the client what you are going to do, why is it necessary, and how he or she can cooperate.

Discuss how the effects of the oxygen therapy will be used in planning further care or treatments.

By explaining the procedure the

nurse can help to allay anxiety.

2. Wash hands and observe appropriate infection control procedures. To prevent transfer of

micoorganisms

3. Set up oxygen equipment and the humidifier.

Attach flow meter to the wall outlet or tank. The flow meter should be in the OFF position.

If needed, fill the humidifier bottle (This can be done before coming to the bedside).

Attach humidifier bottle to the base of the meter.

Attach the prescribed oxygen tubing and delivery device to the humidifier.

Dry gasses dehydrate the

respiratory mucous membrane.

PROCEDURE RATIONALE4. Turn on the oxygen at the prescribed rate, and ensure proper functioning.

Check that the oxygen is flowing freely through the tubing. There should be no kinks in the tubing,

and the connections should be airtight. There should be no kinks in the tubing, and the connections

should be airtight. There should be bubbles in the humidifier as the oxygen flows through. You

should feel the oxygen at the outlets of the cannula, mask or tent.

Set the oxygen at the flow rate ordered, for example.

Kinks of the tubes obstruct the

flow of air to the client

Bubbles in the water indicate that

oxygen flow is satisfactory

5. Apply the appropriate oxygen delivery device.

Cannula

Put the cannula over the clients face, with the outlet prongs fitting into the nares and the elastic band

around the head.

If the cannula will not stay in place, tape it at the sides of the face.

Pad the tubing and band over the ears and cheekbones as needed.

Face Mask

Guide the mask toward the clients face, and apply it from the nose downward.

Fit the mask to the contours of the clients face.

Correct placement of the prongs

facilitate oxygen administration.

To reduce irritation and pressure

on the cheek or behind the ears.

The mask should mold to the

face so that very little oxygen

escapes into the eyes or around

the cheek and chin


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Secure the elastic band around the clients head so that the mask is comfortable but snug.

Mask that fits snugly to clients

face minimizes the loss of

oxygen.

Padding will prevent irritation

from the mask.

PROCEDURE RATIONALE

Pad the band behind the ears and over bony prominences.

Face Tent

Place the tent over the clients face, and secure the ties around the head

7. Assess client regularly.

Assess the clients vital signs, level of anxiety, color, and ease of respirations, and provide support

while the client adjusts to the device.

Assess the client in 15-30 minutes, depending on the clients condition, and regularly thereafter

Assess the client regularly for clinical signs of hypoxia, tachycardia, confusion, dyspnea,

restlessness, and cyanosis. Review arterial blood gas if they are available.

Nasal Cannula

Assess the clients nares for encrustations and irritation. Apply a water-soluble lubricant as required

to soothe the mucous membranes.

Face Mask or Tent

Inspect the facial skin frequently for dampness or chafing, and dry and treat it as needed.

Continuous assessment provides

information if the client is

tolerating the oxygen therapy well

or not and prevents possible

complications.

PROCEDURE RATIONALE8. Inspect the equipment on a regular basis

Check the liter flow and the level of water in the humidifier in 30 minutes and whenever providing care to the

client.

Make sure safety precautions are being followed

9. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate.

TEACHING DEEP BREATHING EXERCISES

Definition:

Lung inflation techniques include diaphragmatic breathing exercises, apical and basal lung expansion exercises, and use of blow bottles,

sustained maximal inspiration (SMI) devices , or intermittent positive pressure breathing (IPPB) apparatuses.

Apical Expansion exercises are often required for clients who restrict their upper chest movement because of pain from severe respiratory

disease or surgery eg, lobectomy.

Purpose:

To promote the exchange of gases in the lungs and strengthen the muscles used for breathing.

Indication:

For clients with restricted chest expansion such as people with chronic obstructive pulmonary disease (COPD) or people recovering from

thoracic surgery.

PROCEDURE RATIONALE

1. Assess the clients condition and identify anything that may affect the success

of the procedure.

Factors like clients anxiety may affect the clients ability to

follow the procedure. In addition, pain on the part of the client

may alter clients learning capability.

Abdominal (diaphragmatic ) and Pursed-Lip Breathing

2. Explain to the client that diaphragmatic breathing can help the person breath

A person who understands and accepts the importance of

deep breathing is more likely to cooperate and participate in


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PROCEDURE RATIONALE11. Instruct the client to inhale through the nose and to concentrate on

pushing the upper chest upward and forward against the fingers.

This helps aerate the apical areas of the upper lung lobes.

12. Have the client hold the inhalation for a few seconds. This promotes aeration of the alveoli.

13. Have the client exhale through the mouth or nose slowly, quietly and

passively while concentrating on moving the upper chest inward and

downward

This allows for more comfortable elveolar expansion. Slow

movement usually creates less discomfort than rapid movement

does.

14. Instruct the client to perform the exercise for at least five respirations four

times a day.

Repeating the exercise helps to reexpand lung tissue, eliminate

secretions, and minimize flattening of the upper chest wall.

BASAL EXPANSION EXERCISES

14. Place the palms of your hands in the area of the lower ribs along the

midaxillary lines, and exert moderate pressure, or have the client place his

or her hands over the same areas.

This hand position enables evaluation and comparison of the depth

of bilateral basal inspiration.

15. Instruct the client to inhale through the nose and to concentrate on moving

the lower chest outward against the hands.

To encourage complete lung expansion.

more deeply and with less effort. the exercise.

3. Have the client assume either a comfortable semi-Fowlers position with knees

flexed, back supported, and with one head pillow or a supine position with one

head pillow and knees flexed. After learning, the client can practice.

The semi-Fowlers and supine position with knees flexed help

relax the abdominal muscles.

4. Have the client place one or both hands on the abdomen just below the ribs. This position will aid in the accurate observation of the

patients chest expansion.

PROCEDURE RATIONALE

5. Instruct the client to breath in deeply through the nose with the mouth

closed, to stay relaxed, not to arch the back, and to concentrate on

feeling the abdomen rise as far as possible.

When a person breaths in, the diaphragm contracts (drops), the lungs

fill with air and the abdomen rises or protrudes.

6. If the client has difficulty raising the abdomen, instruct the person to

take a quick, forceful inhalation through the nose.

With a quick sniff, the client will feel the abdomen rise.

7. Instruct the client to purse the lips as if about to whistle; to breath out

slowly and gently, making a slow whooshing sound; to avoid puffing

out the cheeks; to concentrate on feeling the abdomen fall or sink; and

to tighten the abdominal muscles while breathing out.

Pursing the lips creates a resistance to air flowing out of the lungs ,

increases pressure within the bronchi, and minimizes the collapse of

smaller bronchioles , a common problem for clients with COPD. While

the client breaths out, the diaphragm relaxes (rises) and the abdomen

sinks. Tightening the abdominal muscles helps a person to exhale more

effectively.

8. If the client has COPD, teach the double cough technique. Have the

client

a. Breath in through the nose and inflate the lungs to the mid

inspiration point, rather than to the full deep inspiration point.

b. Simultaneously exhale and cough two or more abrupt, sharp

coughs in rapid succession.

A very forceful cough by a client with COPD can case small airway

collapse. With two or more abrupt coughs, the first one loosens

secretions; while subsequent facilitate movement of secretions toward

the upper airways.

9. Instruct the client to use this exercise whenever feeling short of breath

to increase it gradually 5-10 minutes four times a day.

Regular practice enables a person eventually to do this type of

breathing without conscious effort.

APICAL EXPANSION EXERCISES

10. Place your fingers below the clients clavicles and exert moderate

pressure, or have the client place his or her fingers over the same

area.

This hand position enables evaluation of the depth of apical inhalation.


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16. Have the client hold the inhalation for a few seconds.

17. Have the client exhale through the nose or mouth slowly, quietly and

passively. If the person has COPD, observe the rate and character of the

exhalation. Normal exhalation is slow, and the upper chest appears

relaxed. If the exhalation appears difficult or there is in drawing of the

upper chest, encourage pursed-lip exhalation.

This allows for more comfortable elveolar expansion. Slow

movement usually creates less discomfort than rapid movement

does.

ASSISTING CLIENTS TO USE INCENTIVE SPIROMETRY

Definition:

Incentive spirometry is a method of encouraging voluntary deep breathing by providing visual feedback to clients about inspiratory volume.

Purpose:

It is used to promote deep breathing to prevent or treat atelectasis in the postoperative client.

Equipment:

Incentive spirometer

PROCEDURE RATIONALE

1. Wash hands. Reduces transmission of microorganisms.

2. Instruct client to assume semi-Fowlers or high Fowlers position. Promotes optimal lung expansion.

3. Either aet or indicate to client on the device scale, the volume level to be

attained with each breath.

Establishes goal to volume level necessary for lung expansion.

4. Demonstarte to client how to place mouthpiece of spirometer so that lips

completely cover mouthpiece.

Demonstration is reliable technique for teaching psychomototr

skills and enables client to ask questions.

5. Instruct client to inhale slowly and maintain constant flow through unit.

When maximal inspiration is reached, client should hold breath for 2 to 3

seconds and then exhale slowly.

Maintains maximal inspiration and reduces risk of progressive

collapse of individual alveoli. Slow breath prevents or minimizes

pain from sudden pressure changes in chest.

6. Instruct client to breath normally for short period. Prevents hyperventilation and fatigue.

7. Have client repeat maneuver until volume goals are achieved. Ensures correct use of spirometer.

8. Wash hands. Reduces transmission of microorganisms.

9. Record the procedure done and clients ability to perform it. Documents clients education and provides data for instructional

follow-up.

ADMINISTERING PERCUSSION, VIBRATION,

AND POSTURAL DRAINAGE TO ADULTS

Definition:

Percussion sometimes called clapping or cupping, is forcefully striking the skin with cupped hands.

Vibration is a series of vigorous quivering produced through hands that are placed flat against chest wall.

Postural drainage is the drainage, by gravity, of secretions from various lung segments.

Indication:

For clients who produce greater than 30cc of sputum per day or have evidence of atelectasis by chest x-ray examination.

PROCEDURE RATIONALE18. Instruct the client to perform this exercise at least five respirations four

times a day.

Repetition helps to reexpand lung tissue and eliminates secretions.

19. Correct the patients breathing technique as necessary. To encourage complete lung expansion.


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Contraindication:

1. 1.Percussion is contraindicated in clients with bleeding disorders, osteoporosis, or fractured ribs.

Considerations:

Postural drainage, percussion and vibration is best tolerated if done between meals , at least two hours after the patient has eaten, to

decrease the possibility of vomiting.

Purpose:1. To mechanically dislodge and loosen mucous secretions.

2. Facilitate drainage of mucous secretions by gravity.

Equipment:

1. A bed that can be placed in Trendelenburg position.

2. Towel

PROCEDURE RATIONALE1. Provide visual and auditory privacy. Coughing and expectorating secretions can embarrass

the client and disturb others.

2. Assist the client to the appropriate position for postural drainage. To provide the appropriate position for postural drainage.

Drainage of the upper lobe

3. Have the client lie back at a 30o angle. Percuss and vibrate between the clavicles

and above the scapulae.

To drain the apical segments of the upper lobes.

PROCEDURE RATIONALE4. Have the client sit upright in a chair or in bed with the head bent slightly forward.

Percuss and vibrate the area between the clavicles and scapulae.

To drain the posterior segments of the upper lobes.

5. Have the client lie on a flat bed with pillows under the knees to flex them.Percuss and

vibrate the upper chest below the clavicles down to the nipple line, except for women.

The breasts of women are not percussed, because percussion may cause pain.

To drain the anterior segments of the upper lobes.

Drainage of the right middle lobe and lower division of the left upper lobe

6. Elevate the foot of the bed about 15o or 40cm and have the client lie on the left side.

Help the client to lean back slightly against pillows extending at the back from the

shoulder to the hip. A pillow may be placed between the knees for comfort. For a male,

percuss and vibrate over the right side of the chest at the level of the nipple between the

4rth and 6th

ribs For a female, position the heel of your hand toward the axilla and your

cupped fingers extending forward beneath the breast to percuss and vibrate beneath the

breast.

To drain the right lateral and medial segments.

7. Elevate the foot of the bed as in step 6, and have the client lie as in step 6 except on the

right side.Percuss and vibrate the right side of the chest as in step7.

To drain the left lingular segments.

Drainage of the lower lobes

8. Have the client lie on the abdomen on a flat bed, and place two pillows under the hips.

Percuss and vibrate the middle area of the back on both sides of the spine.

To drain the superior segment

PROCEDURE RATIONALE

9. Have the client lie on the unaffected side, with the upper arm over the head. Elevate the foot of

the bed about 30o or 45 cm , or to the height tolerated by the client. Place one pillow between

the knees. Another under the head is optional.Percuss and vibrate the affected side of the chest

over the lower ribs, inferior to the axilla.

To drain the anterior basal segment.

10. Have the client lie partly on the unaffected side and partly on the abdomen. Elevate the foot of

the bed about 30o or 45cm (18in.), or to the height tolerated by the client. As an alternative,

elevate the hips with pillows. Percuss and vibrate the uppermost side of the lower ribs.

To drain the lateral basal segments.

11. Have the client lie prone. Elevate the foot of the bed about 30o or 45cm (18in.), or to the height To drain the posterior basal segments.


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tolerated by the client. Elevate the hips on two or three pillows to produce a jackknife position

from the knees to the shoulders.Percuss and vibrate over the lower ribs on both sides close to

the spine, but not directly over the spine or the kidneys.

PERCUSSION

12. Ensure that the area to be percussed is covered. Percussing skin directly can cause discomfort.

13. Ask the client to breath slowly and deeply. Slow deep breathing promotes relaxation.

14. Cup your hands,ie, old your fingers and thumb together , and flex them slightly to form a cup, as

you would to scoop up water.

Cupped hands trap the air against the chest.

The trapped air sets up vibrations through the

chest wall to the secretions , helping to loosen

them.

PROCEDURE RATIONALE15. Relax your wrists, and flex your elbows. Relaxed wrists, and flexed elbows help obtain

a rapid ,hollow, popping action.

16. With both hands cupped, alternately flex and extend the wrists rapidly to slap the chest. The

hands must remain cupped so that air cushions the impact, to avoid injuring the c lient.

These blows are transmitted through the

tissue and help loosen secretions in the lung

segment immediately below the area struck.

17. Percuss each affected lung segments for 1-2 minutes. The percussing action should produce a

hollow, popping sound when done correctly.

VIBRATION

18. Place your flattened hands, one over the other (or side by side) against the affected chest area.

19. Ask the client to inhale deeply through the mouth and exhale slowly through pursed lips or the

nose.

This preserves the normal inspiratory-

expiratory ratio and encourages maximum

filling and emptying of the alveoli.

20. During the exhalation, straighten your elbows, and lean slightly against the clients chest while

tensing your arm and shoulder muscles in isometric contractions.

Isometric contractions will transmit fine

vibrations through the clients chest wall.

21. Vibrate during five exhalations over one affected lung segment. Vibrating over a specific five times will loosen

the secretion.

22. Encourage the client to cough and expectorate secretions into the sputum container. Offer the

client mouthwash.

To remove unpalatable taste of the mucus

secretions from the mouth.

23. Auscultate the clients lungs, and compare the findings to the baseline data. To check for the effectiveness of the

intervention.

24. Document the percussion, vibration, and postural drainage and assessments. Note the amount,

color, and character of expectorated secretions.

Anything done to a client undocumented is

considered not done.

STEAM INHALATION

Definition:

A treatment to provide warm, moist air for the patient to breath.

Indication:

1. Irritation (tickling or pain in throat) by moistening mucous membranes.

2. Acute or chronic inflammation and congestion of mucous membranes of nose and throat due to colds and bronchitis.

3. Coughing (relaxes muscles).

4. Dry or thick secretions.

Purposes:

1. To relieve swelling, inflammation, congestion and pain in the nose and throat in upper respiratory infections.

2. To stimulate expectoration.

3. To reduce dryness of mucous membrane.

4. To relieve spasmodic breathing.


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Equipment:

Pitcher

Basin

Boiling water

Paper cone

Bath towel and face towel (patients gown)

Drug ordered (optional)

NOTE: If an electric inhaler/ vaporizer is used, please study operation manual/ package.

PROCEDURE RATIONALE1. Check doctors order. Steam inhalation may be initiated by a doctors order.

2. Explain procedure to client. To ensure client operation.

3. Wash hands. Hand washing deter the spread of infection.

4. Place boiling water about 1/3 to full in a pitcher. Boiling water provides moist heat for inhalation.

5. Add ordered medication, if any. In some instance, drug may be administered via steaminhalation.

6. Bring pitcher on a basin to the bedside. Place on a firm surface. To enable the health worker to safely bring equipment

to bedside.


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PROCEDURE RATIONALE7. Assist client to assume convenient position. May sit at edge of bed. Provide privacy

PRN.

To provide comfort during procedure.

8. Place paper cone on mouth of pitcher. Paper cone directssteam to clients nose.

9. Place bath towel over clients chest. Provide face towel over clients forehead and

eyes as necessary. At about one foot away from the paper cone, have the client

inhale steam.

To provide a safe distance from the stream. A towel may

be provided to protect clients eyes if the steam is

perceived to be too hot for the clients eyes.

10. Remove pitcher at the end of prescribed period. Wipe clients face and make him

comfortable. Protect from cold air.

To provide to client protection from cold air prevents

chilling caused by marked change in air temperature. This

may counteract the benefits of inhalation.

11. Wash used article with soap and water (except cone). Rinse and dry and return to

proper place. Wash hands.

To prevent spread of infection.

12. Record clients response to therapy. For proper documentation of procedure.

OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING

Definition:

Suctioning is the aspiration of secretions, often through a rubber or polyethylene catheter connected to a suction machine or outlet.

Oropharyngeal or nasopharyngeal suctioning removes secretions from the upper respiratory tract.

Suctioning is the aspiration of secretions by a rubber catheter connected to a suction machine with an application of a negative pressure to

create a vacuum to enable secretions to move from an area of higher pressure (the airway) to an area of lower pressure (the suction bottle).

Indications:

This procedure is indicated when the client:

1. Is unable to cough and expectorate secretions effectively (e.g., infants and comatose patients);2. Is unable to swallow;

3. Makes light bubbling or rattling breath sounds that indicate the accumulation of secretions in the respiratory tract; and

4. Is dyspneic or appears cyanotic.

Purposes:

1. To remove secretions that obstruct the airway;

2. To facilitate respiratory ventilation;

3. To obtain secretions for diagnostic purposes; and

4. To prevent infection that may result from accumulated secretions in the respiratory tract.

Special Considerations:

1. Perform suctioning several minutes before mealtime.

2. Suction client immediately if he is cyanotic.

3. Report to the nurse or physician significant changes observed in the clients condition after suctioning.

4. Have standby oxygen at bedside.

Equipments:

1. Towels or pads

2. Emesis basin lined with paper

3. Portable or wall suction machine: includes a collection bottle, a tubing system connected to the suction catheter, and a gauge that

registers the degree of suction

4. Sterile disposable container for sterile fluids

5. Sterile normal saline or water

6. Sterile gloves


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7. Sterile suction catheter

a. For adults - #12 to # 18

b. For children - # 8 to # 10

c. For infants - # 5 to # 8

Note: If both oropharynx and nasopharynx are to be suctioned, one sterile catheter is required for each.

Types of Suction Catheter

1. Open-tipped catheter has an opening at the end and several openings along the sides. It is effective for thick mucus plugs,

but it can irritate the tissue.

2. Whistle-tipped catheter has a slanted opening at the tip.Most catheters have a thumb port on the side, which is used to control the suction. Several openings along the sides of the tip

of the suction catheter ensures distribution of negative pressure of the suction over a wide area, thus preventing excessive

irritation of any area of the respiratory mucous membrane.

8. Water-soluble lubricant or glass of sterile water

9. Y-connector

10. Sterile gauzes

11. Moisture-resistant disposable bag

12. Sputum trap or cup, if specimen is to be collected

13. Sterile forceps (in cases where institution practices such or in absence of gloves)

14. Resuscitation bag (Ambu bag) connected to 100% oxygen

PROCEDURE RATIONALE

A. Prepare the client.

1. Wash hands and observe other appropriate infection control procedures (e.g.,

gloves, goggles.

For infection control.

2. Gather necessary equipment and supplies. Knowing that the procedure will relive breathing

problems is often reassuring and enlists client

cooperation.

3. Explain to the client, regardless of level of consciousness, the purpose and

rationale of the procedure. Provide information that suctioning will relieve

breathing difficulty and the procedure is painless but may stimulate the cough,

gag, or sneeze reflex.

PROCEDURE RATIONALE

4. Assess for signs and symptoms indicating upper airway secretions: gurgling

respirations, restlessness, vomitus in the mouth, and drooling. Monitor HR, RR,

color, and ease of respirations.

5. Position the client correctly.

For oropharyngeal and nasopharyngeal suctioning:a. Position a conscious person who has a functional gag reflex in the semi-

Fowlers position with the head turned to one side for oral suctioning or with

the neck hyperextended for nasal suctioning.

b. Position an unconscious client in the lateral position facing you.

This position facilitates the insertion of the catheter

and helps prevent aspiration of pulmonary secretions

and gastrointestinal (GI) contents.

This position allows the tongue to fall forward, so that

it will not obstruct the catheter on insertion. Lateral

position also facilitates drainage of secretions fromthe pharynx and prevents the possibility of aspiration.

6. Place the towel or pad over the pillow or under the chin. Provide emesis basin

under the chin or side of the face.

To protect the clients gown and pillow from soiling.

B. Prepare the equipment.

7. Set the pressure on the suction gauge and turn on the suction. Many suction

devices are calibrated to three pressure ranges:

Wall unit

Suction should be ready to save time and effort when

performing the procedure.


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Adult: 100-120 mmHg

Child: 95-110 mmHg

Infant: 50-95 mmHg

Portable unit

Adult: 10-15 mmHg

Child: 5-10 mmHg

Infant: 2-5 mmHg

Calibrated pressure ranges provides safe but effective

negative pressure according to the clients age and

decreases possibility of hypoxemia damage to

mucous membranes.

PROCEDURE RATIONALE8. Hyperoxygenate client before inserting catheter and suctioning. To provide sufficient amount of oxygen necessary before

10-15 seconds of suctioning.

9. Open the sterile suction package.

10. Set up the cup or container, touching only its outside.

11. Pour sterile water or saline into the sterile container.

12. Don the sterile gloves, or don a nonsterile glove on the non-dominant handand sterile glove on the dominant hand.

The sterile gloved hand maintains the sterility of the suctioncatheter, and the unsterile glove prevents the transmission

of the microorganisms to the nurse.

13. With you sterile gloved hand, pick up the catheter, and attach it to the

suction unit.

14. Open the lubricant if performing nasopharyngeal suctioning.

C. Make an approximate measure of the depth for the insertion of the catheter and

test the equipment.

For oropharyngeal and nasopharyngeal suctioning:15. Measure the distance between the tip of the clients nose and the earlobe

or about 13cm (5in) for an adult. The appropriate distance for an infant or

small child is 4 to 8 cm (1.6 to 3.2 in) or 8 to 12 cm (3.2 to 4.8 in) for an

older child.

For nasal tracheal suctioning, measure the distance between the tip

of the clients nose to the earlobe and then along the side of the

neck to the thyroid cartilage (Adams apple). For oral tracheal

suctioning, measure from the mouth to the midsternum.

Appropriate length ensures the catheter remains inpharyngeal region. Insertion past this point places catheter

in trachea.

Premeasuring the correct length for catheter insertion prior

to suctioning prevents unnecessary trauma to the tracheal

mucosa.

PROCEDURE RATIONALE

16. Mark the position on the tube with the fingers of the sterile gloved hand.

17. Test the pressure of the suction and the patency of the catheter by

applying your sterile gloved finger or thumb to the port or open branch

of the Y connector (the suction control) to create suction.

Ensures that equipment is functioning prior to insertion.

D. Lubricate and introduce the catheter.

For nasopharyngeal suction:

a. Lubricate the catheter tip with water-soluble lubricant.

b. Without applying suction, insert the catheter the premeasured or

recommended distance into either nares, and advance it along the

floor of the nasal cavity.

c. Never force the catheter against an obstruction. If one nostril is

obstructed, try the other.

For an orpharyngeal suction:

a. Moisten tip with sterile water or saline.

b. Pull the tongue forward, if necessary, using gauze.

This reduces friction and eases insertion.

Gentle insertion without applying suction prevents trayma to the

mucous membranes. Directing the catheter along the floor of

the nasal cavity avoids the nasal turbinates.

This reduces friction and eases insertion.

Doing so causes trauma to the mucous membranes.


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c. Do not apply suction during insertion.

d. Gently advance the catheter about 4 to 6 inches along one side of

the mouth into the oropharynx.

Directing the catheter along the side prevents gagging.

PROCEDURE RATIONALEE. Perform suctioning.

18. Apply your finger to the suction control port to start suction, and gently

rotate the catheter. Suction intermittently as catheter is withdrawn.

Occlusion of control port activates suction pressure. Gentle

rotation of the catheter ensures that all surfaces are reached and

prevents trauma to any one area of the respiratory mucosa due

to prolonged suction.

19. Apply suction for 5 to 10 seconds; then remove your finger form the

control, and remove the catheter. A suction attempt should last only 10

to 15 seconds. During this time, the catheter is inserted, the suction

applied and discontinued, and the catheter removed.

It may be necessary during oropharyngeal suctioning to apply

suction to secretions that collect in the vestibule of the mouth and

beneath the tongue.

Suctioning longer than 10-15 seconds robs the respiratory tract of

oxygen which may result to hypoxia, hypoxemia, and other

cardiopulmonary complications.

F. Clean the catheter, and repeat suctioning as above.

20. Wipe off the catheter with sterile gauze if it is thickly coated with

secretions. Dispose of the gauze in a moisture-resistant bag.

21. Flush the catheter with sterile water or saline. Rinsing the catheter helps remove secretions from the tubing and

lubricates it for next suctioning.

22. Relubricate the catheter, and repeat suctioning until the air passage is

clear.

Note: Allow 20- to 30-second intervals between each suction, and

limit suction to 5 minutes in total.

Applying suction for too long may cause secretions to increase or

decrease the clients oxygen supply.

23. Alternate nares for repeat suctioning.

PROCEDURE RATIONALE

24. Encourage client to breathe deeply and to cough between suctions. Coughing and deep breathing help carry secretions from the

trachea and bronchi into the pharynx, where they can be reached

with the suction catheter.

G. Obtain a specimen if required.a. Attach the suction catheter to the rubber tubing of the sputum trap.

b. Attach the suction tubing to the sputum trap air vent.

c. Suction the clients nasopharynx or oropharynx. The sputum trap

will collect the mucus during suctioning.

d. Remove the catheter from the client. Disconnect the sputum trap

rubber tubing from the trap air vent.

e. Connect the rubber tubing of the sputum trap to the air vent.

f. Flush the catheter to remove secretions from the tubing.

This retains any microorganisms in the sputum trap.

H. Promote client comfort.

25. Offer to assist the client with oral or nasal hygiene. Respiratory secretions that are allowed to accumulate in the

mouth are irritating to the mucous membranes and unpleasant to

the taste.

I. Dispose of equipment and ensure availability for the next suction.


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26. Dispose of the catheter, gloves, water and waste container. Wrap the

catheter around your sterile glove and roll it inside the glove for

disposal.

Reduces spread of bacteria from suction equipment.

PROCEDURE RATIONALE

27. To ensure that equipment is available for the next suctioning, change suction collection bottles

and tubing daily or more frequently as necessary.

J. Assess the effectiveness of suctioning.

28. Auscultate the clients breathing sounds to ensure they are clear secretions. Observe for

restlessness or presence of oral secretions.

K. Wash hands.

L. Document relevant data.

a. Record the procedure: the amount, consistency, color, and odor of sputum (e.g., foamy, white

mucus: thick, green-tinged mucus; or blood-flecked mucus), clients breathing status before

and after the procedure and the clients reaction to the procedure.

b. If the technique is carried out frequently, e.g., q1h, it may be appropriate to record only once,

at the end of the shift; however, the frequency of the suctioning must be recorded.