Nursing Procedure 6.8
- Suctioning an Oral Airway
- Clears oral airway of secretions
- Facilitates breathing
- Decreases halitosis and anorexia by removing excess pooling of secretions on the mouth
Nursing Procedure 6.8
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
If a client, adult or child, is capable and wishes to manage suctioning independently, provide instruction in the use of the suction catheter or Yankauer catheter.
Suctioning of infants may require two people. Enlist the help of parents in assisting and in soothing the infant.
Remove dentures before suctioning.
Clients and caregivers may use a bulb syringe for oral suctioning at home. These can be purchased at a pharmacy. Oral Yankauer suction catheters may be reused after being cleaned with soap and water.
Oral Yankauer suction catheters can be reused after being cleaned with soap and water.
Unlicensed assistive personnel may perform oral suctioning.
| Action | Rationale | |
|---|---|---|
| 1 | Explain procedure to client. | Reduces anxiety; promotes cooperation |
| 2 | Perform hand hygiene and organize equipment. | Reduces microorganism transfer; promotes efficiency |
| 3 | Check suction apparatus for appropriate functioning. | Maintains safety |
| 4 | Lower side rails and position client in semi-Fowler’s or Fowler’s position. | Promotes forward draining of secretions in mouth |
| 5 | Turn suction source on and place finger over end of attached tubing. Use 50–120 mm Hg pressure. | Tests suction apparatus |
| 6 | Open sterile irrigation solution and pour into cup. | Allows for sterile rinsing of catheter |
| 7 | Open mouthwash and dilute with water (optional). | Freshens mouth and decreases oral microorganisms |
| 8 | Open suction catheter package. | Provides access to equipment |
| 9 | Place towel under client’s chin. | Prevents soiling of clothing |
| 10 | Don gloves. | Prevents contamination of hands; reduces risk of infection transmission |
| 11 | Attach suction control port of suction catheter to tubing of suction source. | Promotes suction through catheter |
| 12 | Lubricate 3–4 in. of catheter tip with irrigating solution. | Prevents mucosal trauma when catheter is inserted |
| 13 | Ask client to push secretions to front of mouth. | Makes secretion removal easier |
| 14 | Insert catheter into mouth along jawline and slide to oropharynx until client coughs or resistance is felt. BE SURE FINGER IS NOT COVERING OPENING OF SUCTION PORT. | Promotes removal of pooled secretions |
| 15 | Withdraw catheter slowly while applying suction by covering suction port. | Removes secretions from oropharynx |
| 16 | AVOID DIRECT CONTACT OF CATHETER WITH IRRITATED OR TORN MUCOUS MEMBRANES. | Prevents additional trauma to oral tissue |
| 17 | Place tip of suction catheter in sterile solution and apply suction for 1–2 s. | Clears secretions from tubing |
| 18 | Ask client to take three or four breaths while you auscultate for bronchial breath sounds and assess status of secretions. | Permits reoxygenation; determines need for repeat suctioning |
| 19 | Repeat Steps 13–18 once or twice if secretions are still present. | Promotes clearing of airway |
| 20 | When secretions are removed, irrigate mouth with 5–10 mL mouthwash and ask client to rinse out mouth. | Removes microorganisms and thick secretions; freshens breath and improves taste sensation |
| 21 | Suction mouth; repeat irrigation and suctioning. | Removes secretions and residual mouthwash |
| 22 | Disconnect suction catheter from machine tubing, turn off suction source, and discard catheter. | |
| 23 | Apply petroleum jelly to lips and mouth, moistener to inner lips and tongue, if desired. | Prevents cracking of lips and maintains moist membranes |
| 24 | Restore or discard all equipment appropriately. | Reduces transfer of microorganisms among clients; prepares equipment for future use |
| 25 | Remove gloves and discard with soiled materials. | Reduces microorganism transfer |
| 26 | Perform hand hygiene | Reduces microorganism transfer |
| 27 | Position client for comfort with head of bed elevated 45 degrees. | Lowers diaphragm and promotes lung expansion |
| 28 | Raise side rails and place call light within reach. | Promotes safety; facilitates communication |
Were desired outcomes achieved? Examples of evaluation include
The following should be noted on the client's record:
Cost-Cutting Tip