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CLINICAL GUIDANCE
PERFORMING ORAL AND NASAL SUCTION IN THE COMMUNITY
For use in: Paediatric and Adult Community Health Services
Target Audience: All Trust Clinical Staff caring for patients and children requiring oral and nasal suction
Purpose Safe Delivery of Care
Document Author: Alison Sutch
Approved by: Clinical Guidelines Group or Equivalent
Ratified by: Policy Sub-Committee (PSC)
Policy Index No: HStHCL277
Version Number: 2.0
Effective From: February 2011
Review Date: February 2014
Statutory and legal requirements Policy based on recommendations from the NHS Litigation Authority
Implementation Lead Alison Sutch
Implementation Process Refer to attached dissemination plan
The Trust is committed to creating an environment that promotes equality and embraces diversity, both within our workforce and in service delivery. This document should be implemented with due regard to this commitment.
This document seeks to uphold the duties and principles contained within the Human Rights Act. All Staff within the PCT should be aware of its implications.
If clinical activity takes place i.e. examination, hand decontamination should take place before and after the procedure by following February 2014. After this date, this guidance and associated process documents may become invalid. All users should ensure that they are consulting the current version of this document.
Page 2 of 22
Key individuals involved in developing the document (Internal Staff Only)
Name(s)
Designation
Alison Sutch Specialist Nurse Children with Disabilities
Sally Adams Community Matron
Annette Dunning Children’s Community Nurse
Distributed to the following for approvals and comments
Committee(s)
Members of the Policy Sub Committee (PSC)
Members of the Clinical Policies Guidelines Group (CPG)
Individual(s) (Include email address of external individuals (NON NHS))
Designation
Carol Kerry Manager Physio /OT Services
Eleanor Marsh Manager Therapy Services
Denise Hogg Community Children’s Nurse Manager
Karen Twamley School Health Nurse Inclusion Lead
Sally Adams Community Matron
Sue Gray Special School Nurse (Halton)
Viv Dunmore Special School Nurse Lead (St Helen’s)
Lorraine Hodson Clinical services manager
Sue Davison Clinical services manager
Revision History and Version Control
Revision Date
Reason for Change
Version No.
By Who
Version No.
10/02/2010 Reference update old Policy out of date review of procedures
1.0 A Sutch 2.0
Page 3 of 22
Table of Contents
Introduction ..................................................................................................................................4
Rationale......................................................................................................................................4
Audit.............................................................................................................................................4
Glossary of Terms........................................................................................................................4
Equipment Required ....................................................................................................................4
Catheter Sizes .............................................................................................................................5
Suction Pressures........................................................................................................................5
Any other relevant information .....................................................................................................5
Assessing the need - for children/young people and adults not already receiving suction.........5
Indication for Suction....................................................................................................................6
Training ........................................................................................................................................6
Consent........................................................................................................................................6
Equipment....................................................................................................................................7
Oral Suction-Yankuer Catheters ..................................................................................................8
Oral Suction - Catheters...............................................................................................................9
Procedure Naso-Pharyngeal Suction.........................................................................................10
Disposal/ reuse of equipment.....................................................................................................12
References.................................................................................................................................13
Appendix 1 .................................................................................................................................14
Appendix 2 .................................................................................................................................15
Appendix 3 .................................................................................................................................16
Appendix 4 .................................................................................................................................18
Appendix 5 .................................................................................................................................19
Appendix 6 .................................................................................................................................20
Appendix 7 .................................................................................................................................21
Page 4 of 22
INTRODUCTION These guidelines have been devised to ensure that children/young people (aged 0-19 years) and adults who require suction are cared for safely within the provision of a holistic care package. These guidelines will provide clinicians with standardized, up to date, evidence based guidance on care of patients requiring suction.
Normally people keep their airways clear by coughing, sneezing and blowing their noses. If a child, young person or adult is able to clear their airway independently by repositioning or encouraging the child to cough, this is always more pleasant. Suction can be traumatic and therefore should only be used where less invasive treatments are ineffective. Consideration should be given to alternatives such as medication to reduce secretions via a consultation with a paediatrician, consultant or General Practitioner. Suction is a method of removing excessive secretions and vomit from the airway, when the child, young person or adult is unable to do so themselves, preventing choking and aspiration and maintaining a clear airway.
RATIONALE The rationale of this protocol is to promote good practice in performing oral and nasal pharyngeal suction within the community. The guidelines aim to ensure safe procedure by professionals working within the children/young people and adults services within Halton and St Helens undertaking this role.
Suction is a skilled procedure that requires appropriate training and competence
AUDIT This policy will be audited annually using audit tool (appendix 2)
Monitoring of near misses/clinical incidents in line with PCT policy using form IR1 (available from service manager)
Review of training to update skills annually (appendix 3)
GLOSSARY OF TERMS Refer to Appendix 1. Glossary of terms.
EQUIPMENT REQUIRED Suction Machine
Suction Catheters/Yankeurs
Connection Tubing
Cool Previously Boiled Water (stored in a clean container with a lid)
Gloves (clean or sterile)
Hand gel
Leaflet/information for correct cleaning of suction machine
All equipment should be used and discarded according to the manufactures guidelines.
Page 5 of 22
All catheters and equipment should be checked for size and expiry date
Catheter Sizes
The catheter size should be recorded in the clients care plan
AGE CATHETER SIZE
Premature baby 6 fr
Baby to 1 yr 8fr
Toddler 10 fr
Preschooler 10fr
School age 10-12 fr (normally 10)
Adolescent/ Adult 12-14 fr
Suction Pressures
The suction pressure to be used should be recorded in the clients care plan
AGE SUCTION PRESSURES
Premature baby 80-100mmhg
Baby to 1 yr 80-100mmhg
toddler 100-120mmhg
preschooler 100-120mmhg
School age 100-120mmhg
Adolescent/adult 120-150mmhg
ANY OTHER RELEVANT INFORMATION
Assessing the need - for children/young people and adults not already receiving suction
a. It is the responsibility of the multi-disciplinary team to assess the need for suction. This should be completed in collaboration with the patient’s consultant, G.P. physiotherapist and fully discussed with the child parents/guardian.
Page 6 of 22
b. Careful consideration needs to made when considering long term suction in the community. Where possible alternatives such as medication to dry secretions, postural drainage and positioning should be contemplated in the first instance.
c. Children young people and adults who have difficulty clearing their airways must also be assessed for the correct equipment such as seating and sleep systems
Indication for Suction
A child, young person or adult may need suction when:
a. They are having difficulty dealing with their own secretions, or have excessive secretions.
b. To prevent recurrent chest infections.
c. They are unable to expectorate secretions adequately due to reduced function, such as Duchennes Muscular Dystrophy or COPD.
d. To be used when necessary with other equipment such as “Cough Assists” to prevent infections and maintain clear airways
e. Nasopharyngeal suction may only be considered for extreme life threatening incidents due to the invasive nature of this suction
Training
a. Staff will be trained and assessed as competent to administer suction by the Registered Community Nurse on an individual named child basis in children’s services. In adult services staff must be trained and competent to undertake this procedure.
b. It is the responsibility of the trainee to keep their training up-to-date
c. Nurses are responsible for maintaining and developing their competency and performance in line with NMC.
ACTION RATIONALE
1. Consent
Page 7 of 22
a. Consent should be obtained prior to each episode of suction verbally from the client where possible
b. Consent should be obtained by
the patient or the child / young person’s guardian before under-taking the procedure and recorded in the health record.
c. The consent should include; type of suction, size, correct pressure and type of suction catheter. (Appendix 5)
d. Each client should also have a care plan written out lining their specific needs
In line with Halton & St Helen’s PCT (2009) Consent to Examination or Treatment Policy
To ensure there is an agreed care plan.
2. Equipment
a. Halton and St Helen’s PCT should supply a suction machine for the use of the individual client
b. Staff must ensure that the
machine has been serviced and is working, with full instructions
c. Please refer to suction pressure chart to ascertain the pressure for nasal suction on page 5.
d. All the equipment for performing suction at home will be supplied by the child’s General Practitioner, Health Visitor, District Nurse or the Community Children’s Nurses this includes:-
i. Suction catheters of the correct size and type for the individual. Choose smallest size possible. See chart on page 5 for
To ensure that safety is maintained.
To reduce the degree of trauma caused to the mucosal wall.
Page 8 of 22
catheter sizes.
ii. The connection tubing
(change used tubing at home every day)
iii. Gloves
3. Oral Suction-Yankuer Catheters
i. Assess the need for suction by assessing the client’s respiratory system, observing for increased effort of breathing, changes in colour and/ or increased pulmonary secretions.
ii. Reassure the client. Explain procedure. Put client in appropriate position
iii. Wash and dry hands according to infection control policy.
iv. Assemble the equipment: v. Turn suction machine on and
check that it is working. vi. Open yankaur and attach to
suction tubing without removing cover completely.
vii. Put glove on your dominant hand.
viii. Hold the yankaur in the gloved hand and the vent in the non-gloved hand without letting the yankaur touch anything. If the yankaur is unvented bend the connection tube in the ungloved hand to prevent sucking.
ix. With the thumb over the vent but not covering, insert the catheter gently into the mouth, clear secretions from buccal spaces and the back of the mouth. Put the thumb over the vent to suck secretions
x. Do NOT pass the yankaur past the back of the teeth/buccal space
xi. Discard yankaur inside the glove
To ensure that a base line assessment has taken place so that the client can be continually assessed throughout the procedure for any complications and to ensure that suction is required.
To gain co-operation of client. To reduce the risk of aspiration
To reduce risk of infection in accordance with PCT policy.
To maintain hygiene
Avoid over stimulating the gag reflex. To avoid vomiting
To ensure early detection of any
Page 9 of 22
without touching the catheter. Yankaurs will be changed according to need and client’s specific care plan
xii. Assess the need for further suction. Allow client to rest for 3-5 breaths before repeating the procedure-if required
xiii. Monitor type and amount of secretions obtained, observing for changes in colour and consistency.
xiv. Monitor client during and immediately after suction procedure, observing for any changes in respiratory status such as changes in colour and breathing pattern.
xv. If the client deteriorates during the suction procedure. Stop suction and call for help. Initiate resuscitation measures until child’s baseline observations are normal.
xvi. Flush suction tubing with cooled boiled water/sterile water and switch off suction machine.
complications of suction that may require intervention.
To prevent further deterioration and promote full recovery
In order to maintain good hygiene and maintenance of the machine. To discourage growth of micro organisms
4. Oral Suction - Catheters
i. Assess the need for suction by assessing the client’s respiratory system, observing for increased effort of breathing, changes in colour and/ or increased pulmonary secretions.
ii. Wash and dry hands according to infection control policy.
iii. Assemble the equipment: iv. Position client, explain that they
are going to have suction. v. Turn suction machine on and
check that it is working. vi. Open suction catheter and attach
to suction machine without removing cover completely.
vii. Put glove on your dominant hand. Remove cover from suction catheter
To ensure that a base line assessment has taken place so that the client can be continually assessed throughout the procedure for any complications and to ensure that suction is required. To maintain safe hygiene
To reduce the client’s distress
To maintain hygiene
Page 10 of 22
viii. Hold the catheter in the gloved hand and the vent in the non-gloved hand without letting the catheter touch anything.
ix. With the thumb over the vent but not covering, insert the catheter gently into the mouth, clear secretions from buccal spaces and the back of the mouth.
xvii. Do NOT pass the suction catheter past the back of the teeth/buccal space. Avoid over stimulating the gag reflex
x. Discard suction catheter inside the glove without touching the catheter.
xviii. Assess the need for further suction. Allow client to rest for 3-5 breaths before repeating the procedure-if required
xix. Monitor type and amount of secretions obtained, observing for changes in colour and consistency.
xx. Monitor client during and immediately after suction procedure, observing for any changes in respiratory status such as changes in colour and breathing pattern.
xxi. If the client deteriorates during the suction procedure. Stop suction and call for help. Initiate resuscitation measures until client’s baseline observations are normal.
xxii. Flush suction tubing with cooled boiled water/sterile water and switch off suction machine.
To avoid vomiting
To ensure early detection of complications such as infection
To ensure early detection of any complications of suction that may require intervention.
To prevent further deterioration and promote full recovery
In order to maintain good hygiene and maintenance of the machine. To discourage growth of micro organisms
5. Procedure Naso-Pharyngeal Suction
i. Assess the need for suction by assessing the client’s respiratory system, observing for increased effort of breathing, changes in colour and/ or increased pulmonary secretions.
ii. Wash and dry hands according
To ensure that a base line assessment has taken place so that the client can be continually assessed throughout the procedure for any complications and to ensure that suction is required. To maintain safe hygiene
In order to maintain good hygiene and
Page 11 of 22
to infection control policy. iii. Assemble the equipment: iv. Position client, explain that they
are going to have suction. v. Turn suction machine on and
check that it is working. vi. Open suction catheter and attach
to suction tubing without removing cover completely.
vii. Put glove on your dominant hand. Gently withdraw the catheter from the packaging ensuring the part of the catheter that will enter the nose does NOT touch anything
viii. Hold the catheter in the gloved hand and the vent in the non-gloved hand without letting the catheter touch anything.
ix. With the thumb over the vent but not covering pass the suction catheter into the nostril along the top of the nose as this allows the catheter to follow the angle of the nostril
x. Pass catheter only till a cough is solicited
xi. Cover the vent hole with the non-gloved hand and withdraw the catheter. Gently rotate catheter between thumb and index finger while suctioning and withdrawing. DO NOT SUCTION FOR MORE THAN 10 SECONDS AT A TIME AND ALLOW RESTS BETWEEN SUCTION PERIODS
xii. Repeat in second nostril. xiii. Check the client’s mouth; if
secretions appear then gently suction the back and sides of mouth with a new suction catheter.
xiv. Avoid over stimulating the gag reflex
xv. Discard suction catheter inside the glove without touching the catheter.
xvi. Wash hands. xvii. Assess the need for further
suction. Only repeat the process if necessary. Allow client to rest
maintenance of the machine. To discourage growth of micro organisms
To maintain safe hygiene
Too prevent stimulation of vagus nerve
Prolonged suction can produce contraction of the laryngeal muscle, slow pulse and irregular heartbeats due to vagal nerve stimulation and loss of oxygen. During suction the client receives less oxygen than normal therefore the process should not be prolonged.
Too frequent suction leads to over stimulation of secretions.
To ensure early detection of complications
Page 12 of 22
for 3-5 breaths before repeating the procedure-if required
xxiii. Monitor type and amount of secretions obtained, observing for changes in colour and consistency.
xxiv. Monitor client during and immediately after suction procedure, observing for any changes in respiratory status such as changes in colour and breathing pattern.
xxv. If the client deteriorates during the suction procedure. Stop suction and call for help. Initiate resuscitation measures until client’s baseline observations are normal.
xxvi. Flush suction tubing with cooled boiled water/sterile water and switch off suction machine.
xviii. Observe breathing rate and effort, and the sound of the breathing
such as infection
To ensure early detection of any complications of suction that may require intervention.
To prevent further deterioration and promote full recovery
In order to maintain good hygiene and maintenance of the machine. To discourage growth of micro organisms
6. Disposal/ reuse of equipment
a. The suction catheters are single use only. They may be used on a single occasion of suction.
b. The suction tubing is changed daily or assessed on an individual bases in line with infection control policy.
c. The suction bottle is washed with warm soapy water everyday. The outside may be cleaned with alcohol. The suction bottles are for single patient use only.
To maintain safe hygiene in line with the PCT Waste Management Policy and Infection Prevention & Control Policy No1 Standard Precautions.
Page 13 of 22
REFERENCES Reference
Relevance (whole document or section, please state)
Evidence Grade
Birmingham East And North (2009) Oral and Tracheostomy Suction Policy
Whole E
Halton & St Helen’s PCT (2009) Infection Prevention & Control Policy No 1 Standard Precautions
Whole E
Halton & St Helen’s PCT (2009) Infection Prevention and Control Policy No 24 Waste Management
Whole E
Halton & St Helen’s PCT (2009) Consent to Examination or Treatment Policy
Whole E
Herd. L. (2006) Information For Carers and Young People Who Require. Oral Suction. The Coventry and Warwickshire's Children's and Young People's Teaching and Assessment Framework
Whole E
Herd, L., (2007) Information for Young Peoples Who Require Nasopharngeal Suction. The Coventry and Warwickshire's Children's and Young People's Teaching and Assessment Framework
Whole E
Huband Sand Trigg E (2000) Practices in Children’s Nursing Guidelines for Hospital and Community. Churchhill Livingstone, Edinburgh
Whole 2
Moore T (2003) Suction techniques for the removal of respiratory secretions, Nursing Standard, 18,9,47-53
Whole 2
Page 14 of 22
APPENDIX 1
Glossary of Terms
Buccal Space The buccal space is the area between the cheek and gums, or between the teeth and the buccal mucosa or buccal membrane
Yankauer suction catheter A rigid hollow plastic tube with a curve at the distal end to facilitate the removal of thick pharyngeal secretions during oral pharyngeal suctioning
Non-registered staff Staff not registered with Nursing and Midwifery Council.
Community setting Any setting within the community, such as home, school, nursery.
Named carers Staff specifically trained for a named individual.
Child/young person A person aged between 0-19 years.
APPENDIX 2
CLINICAL GUIELINES FOR THE CLIENT REQUIRING ORAL OR NASAL SUCTION IN THE COMMUNITY AUDIT TOOL
Date……………………………………………….
ACTION NURSE’S SIGNATURE
A consent form has been signed (appendix 8) or record held of verbal consent.
Client has an up to date care plan.
Update training has been carried out or arranged
Date equipment has been serviced.
It is the responsibility of the Registered Nurse to ensure that annual audit of practice is carried out on all children/young people and adults requiring oral or nasal suction in the community setting.
Page 15 of 22
APPENDIX 3
TRAINING CHECKLIST FOR ORAL/NASOPHARYNGEAL SUCTION OF CLIENTS IN THE COMMUNITY CHECKLIST
NAME OF TRAINEE …………………… DATE OF TRAINING ………
Knowledge & Technique Date/Trainers Signature
Date/ Trainee Signature
Understanding the reasons for suctioning a
client.
Able to recognise when suction is
necessary.
Be familiar with the mechanics and
equipment.
Understand the adverse effects of
nasopharyngeal suction.
Observe and Demonstrate
Approach and explain procedure at the
client’s level of understanding.
Wash hands, wear gloves when handling
sterile catheter.
Correct entry with catheter (no suction) to
correct depth.
Correct withdrawal of catheter, applying
Page 16 of 22
Page 17 of 22
suction whilst rotating catheter between
finger and thumb
Correct disposal of catheter and rinsing of
tube
Comfort and reassure the client
Observe effect of suction and respiratory
rate
Document event and effect.
Maintain cleaning routine of machine and
equipment
REMEMBER: If the client’s condition deteriorates and causes concern summon medical assistance or call 999
APPENDIX 4
Oral and Nasal Suction
Authorisation for designated carer to undertake the task of Oral Suction / and or Nasal Suction when appropriate. (Delete where appropriate)
Name of carer ………………………………………………………
The above carer has received training and is competent to undertake the technique of Oral Suction / Nasal Suction (Delete where appropriate)
Trainer ………………………………………
Signature………………………………………
Date …………………………………………..
Agreement by carer
I ……………………… Agree that I have received training and feel confident to undertake the technique of Oral / Nasal Suction
Carers signature …………………
Date ……………………………
Page 18 of 22
APPENDIX 5
INDIVIDUAL CONSENT FORM
Please tick where appropriate
1. Administration of oral suction using a yankuer suction catheter as required by trained carers
2. Administration of oral suction using a size……….suction catheter as required by trained carers
3. Administration of nasal suction using a size………suction catheter as required by trained carers
The pressure setting on the suction machine should not exceed …………………. mmhg
I/we hereby give consent for my/our child………………………………..to receive suction /
I give consent to receive suction as indicated above whilst in community setting or whilst transported to and from community setting.
Signature…………………………………………………………………….
Print…………………………………………………………………………..
Relationship to child…………………………………………………………
Date…………………………………………………………………………..
Page 19 of 22
Page 20 of 22
APPENDIX 6
EQUALITY IMPACT ASSESSMENT TOOL To be completed with the corporate document when submitted to the appropriate committee for consideration, approval and ratification.
Yes/No Comments
1. Does the corporate document affect one group less or more favourably than another on the basis of:
Race No
Ethnic origins (including gypsies and travellers) No
Nationality No
Gender No
Culture No
Religion or belief No
Sexual orientation including lesbian, gay and bisexual people
No
Age No
Disability - learning disabilities, physical disability, sensory impairment and mental health problems
yes Each person would need to be assessed on an individual basis
2. Is there any evidence that some groups are affected differently?
No
3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?
No
4. Is the impact of the policy/guidance likely to be negative?
No
5. If so can the impact be avoided?
6. What alternative are there to achieving the policy/guidance without the impact?
7. Can we reduce the impact by taking different action?
Page 21 of 22
APPENDIX 7
DISSEMINATION AND TRAINING PLAN To be completed with the corporate document when submitted to the appropriate committee for consideration, approval and ratification.
The status column must be given a Red, Amber or Green rating with evidence to demonstrate an action has been completed.
DISSEMINATION PLAN
Title of document: PERFORMING ORAL AND NASAL SUCTION IN THE COMMUNITY
Date finalised: 10/02/2010
Dissemination Lead: Alison Sutch
Lorraine Hodson
Previous document already being used? Yes
If yes, in what format and where? Paper
Proposed action to retrieve out-of-date copies of the document:
Withdraw from the internet/intranet/portal
To be disseminated to: Childrens community services
District Nurses
Disseminated by whom?
Timescale (Date)
Status
R A G
Paper or
Electronic
Comments
Trust Times
Team Brief
Training sessions (Give Details Below)
Other (Give Details Below)
Alison Sutch
Lorraine Hodson
Feb 2011 Electronic To be place on the Document Portal on the intranet
IMPLEMENTATION PLAN
Training Timescale Owner Status R A G
Training Event (Please provide details of available training venues/dates to educate staff about this document)
Training will be provided on an individual basis
Training Plan Lead (Please provide details of staff who will be responsible for overseeing this training)
Compliance Monitoring Timescale Owner Status R A G
Methodology to be used for monitoring/audit (please include PCT Audit Proposal Form)
Audit tool with appendices
Practitioners
Responsibilities for conducting monitoring/audit 12 months Practitioners
Page 22 of 22
Frequency of monitoring/audit (e.g. annually, 6 monthly etc) Annually
Process for reviewing/reporting results Within Clinical Supervision, peer review
Denotes: Action not yet taken or deadline for action not met. Action plan to address this must be provided.
Denotes: Action partially implemented.
Denotes: Action complete.