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Skill

Suctioning: Oral and Nasal

Prerequisite Skills

Respiratory assessment, sterile technique

Critical Element Criteria

Students must meet criteria of Critical Elements to safely perform the skill based on evidence-based practice. Score can be pass/fail, letter grade, or point assignment. Only acceptable score for Critical Elements is 100%

Critical Elements

  • Maintain sterile technique throughout.
  • Perform hand hygiene before and after procedure.
  • Educate patient of the procedure.
  • Apply suction no longer than 15 seconds.
  • Perform procedure safely for patient.

Procedure

Prior to Treatment: (Critical Thinking)

  • Assess patients need for treatment.
  • Confirm order.
  • Gather equipment: face shield or goggles and gown, wall suction or portable suction, gloves, suction catheter, sterile saline.

Patient Interaction: (Safety)

  • Patient identifiers.
  • Provide for privacy.
  • Explain procedure.
  • Wash hands.

Steps of the Procedure (Patient Centered Care; Safety, Infection Control)

  1. Place patient in a semi-fowler"s position with head turned facing the nurse.
  2. Place linen saver pad or towel on patient"s chest.
  3. Apply personal protective equipment.
  4. Turn on suction and adjust pressure according to agency policy.
  5. Apply procedure glove and test the suction by occluding the connection tubing, discard glove, and wash hands.
  6. Open the suction catheter kit.
  7. Apply sterile gloves, keeping dominant hand sterile.
  8. Pour sterile saline into containers with nondominant hand.
  9. Grab sterile catheter with sterile hand and place onto suction tubing without contaminating.
  10. Place catheter in sterile water, moistening.
  11. Use nondominant hand, removing oxygen, if present.
  12. Insert the suctions catheter along the side of the patient"s mouth into the oropharynx or through the nose to the nasopharynx area.
  13. Advance the suction catheter with inspiration, do not force the catheter.
  14. Place a thumb over the suction control port of the catheter, apply suction while withdrawing the catheter, using a continuous motion.
  15. Apply suction no longer than 15 seconds.
  16. Withdraw the catheter, placing the tip in the sterile water and clearing the tubing.
  17. Repeat as needed.
  18. Clear the tubing by suctioning the remaining water.
  19. Dispose of equipment properly.
  20. Assess respiratory status.

After Procedure (Patient Centered Care, Safety)

  • Straighten room making patient comfortable, replace call light.
  • Wash hands before leaving room.

Documentation (Informatics, Communication)

  • Amount and color of sputum.
  • Patient"s response to procedure including respiratory assessment.