Nursing Procedure 6.9
- Performing Nasopharyngeal/Nasotracheal Suctioning
- Clears airway of secretions
- Makes breathing easier
Nursing Procedure 6.9
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
In clients sensitive to decreased oxygen levels (e.g., with head injury or with possibly increased intracranial pressure), suction for shorter durations but more frequently to ensure adequate airway clearance without hypoxia. Whenever possible, secure the help of another person to minimize tube manipulation and to perform bagging with less risk of contamination. Suction only when necessary: Question any routine order for suctioning at regular intervals. Regular suctioning is appropriate if the client has excessive secretions, but suctioning causes trauma to the mucosa and should be performed only as needed.
Two people may be required to suction infants and children to minimize trauma. Measure from the tip of the child's nose to the ear lobe, then to the midsternum to determine the proper length for insertion of suction catheter. That length should be used to prevent tracheal trauma.
Dying clients often experience pulmonary congestion and hypoxia and need suctioning.
Teach caregivers how to suction using clean, not sterile, technique. Advise caregivers that suction catheters may be cleaned and reused.
If possible, use prepackaged suction catheter kits. Depending on the brand used, these kits usually are less expensive than the items gathered individually.
This skill can be delegated to specially trained and certified personnel.
| Action | Rationale | |
|---|---|---|
| 1 | Explain procedure to client. | Reduces anxiety; promotes cooperation |
| 2 | Perform hand hygiene and organize equipment. | Reduces microorganism transfer; promotes efficiency |
| 3 | Lower rails and position client in semi-Fowler’s position. | Allows maximal breathing during procedure |
| 4 | Turn suction machine on and place finger over end of tubing attached to suction machine. Use 60 mm Hg for children and up to 120 mm Hg for adults for normal secretions. | Tests suction pressure |
| 5 | Open sterile irrigation solution and pour into sterile cup. | Allows for sterile rinsing of catheter |
| 6 | Open sterile gloves and suction catheter package. | Maintains aseptic procedure |
| 7 | Place towel under client’s chin. | Prevents soiling of clothing |
| 8 | Don nonsterile gloves. | Prevents contamination of hands; reduces risk of infection transmission |
| 9 | Ask client to breathe through one naris while the other is occluded; repeat with the other naris. | Determines patency of nasal passage |
| 10 | Have client blow nose with both nares open (if client cannot assist, proceed to next step). | Removes excess mucus and dried secretions |
| 11 | Clean mucus and dried secretions from nares with wet tissue or cottontipped swab. | Clears nasal passage; promotes skin integrity |
| 12 | Don sterile glove on dominant hand (on top of nonsterile glove). | Maintains sterile technique |
| 13 | Wrap suction tubing partially around dominant hand. Holding suction catheter control port in sterile hand and tubing for suction source in nondominant hand, attach suction catheter port to tubing of suction source. | Maintains sterility while establishing suction; ensures correct attachment of catheter |
| 14 | Slide sterile hand from control port to suction catheter tubing. | Facilitates control of tubing |
| 15 | Lubricate 3–4 in. of catheter tip with irrigating solution. | Prevents mucosal trauma when catheter is inserted |
| 16 | Ask client to take several deep breaths (make sure there is an oxygen source nearby). | Provides additional oxygen to body tissues before suctioning |
| 17 | Insert catheter into an unobstructed naris, using slanted downward motion. | Allows unrestricted insertion of catheter |
| BE SURE FINGER IS NOT COVERING OPENING OF SUCTION PORT. | Prevents trauma to membranes due to suction from catheter | |
| 18 | As catheter is being inserted, ask client to open mouth. | Allows nurse to see tip of catheter once inserted |
| 19 | Apply suction: | |
| For nasopharyngeal suctioning | ||
| Applies suction | |
| Promotes cleaning of large area and sides of lumen | |
| DO NOT APPLY SUCTION FOR MORE THAN 10 S. | Prevents hypoxia | |
| Clears secretions from tubing | |
| Permits reoxygenation; determines need for repeat suctioning | |
| Promotes adequate clearing of airway | |
| For nasotracheal suctioning | ||
| Opens trachea and facilitates entrance into trachea | |
| Decreases resistance to catheter insertion | |
| Initiates suction | |
| Promotes loosening and removal of secretions | |
| Minimizes adherence of catheter to sides of airway | |
| DO NOT APPLY SUCTION FOR MORE THAN 10 S. | Prevents hypoxia | |
| Clears secretions from tubing | |
| Permits reoxygenation; determines need for repeat suctioning | |
| Promotes adequate clearing of airway | |
| 20 | Complete the suctioning procedure: | |
| Clears secretions from oral airway | |
| ||
| Prevents spread of microorganisms | |
| 21 | Assess incisions and wounds for drainage and approximation. | Detects complications, such as bleeding or weakened incisions, from coughing and straining |
| 22 | Position client for comfort. | Promotes slow, deep breathing |
| 23 | Raise side rails and place call light within reach. | Promotes safety; facilitates communication |
| 24 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include
The following should be noted on the client's record:
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