Oral and Nasal Suctioning Procedure Guidelines

Suctioning is appropriate only when secretions are present in the upper airways as
indicated by coarse crackles, diminished breath sounds, increased inspiratory pressure,
increased respiratory rate, or decreased oxygen saturation (Tamburri, 2000). Oral and
nasal suctioning can greatly relieve the dyspnea that accompanies excessive
secretions, but the process is frightening and unpleasant for nearly all patients.
Assessment
Assess respiratory system

Assess clients ability to cough. Note amount and character of sputum.

Assess vital signs. Compare to baseline vital signs. Note an elevation in

temperature.
Assess level of consciousness and ability to protect airway (eg., presence of
cough reflex). Note any drainage from mouth.

Equipment

Wall suction or portable suction unit

Connecting tubing

Sterile normal saline solution

Disposable sterile container

Sterile suction catheter (#10 to #16 French for an adult)

Sterile gloves

Clean gloves

Goggles

Oropharyngeal airway (optional for frequent suctioning)

Overbed table

Waterproof trash bag

Towel

Suctioning Procedure
1. Verify the physician order and identify the client. Rationale: Prevents potential
errors.
2. Wash your hands. Rationale: Handwashing prevents transmission of
microorganisms.
3. Explain procedure and purpose to client. Rationale: Explanations reduce anxiety
and encourage cooperation with procedure.
4. Position the conscious client with an intact gag reflex in a semi-Fowlers position.
Position the unconscious client in a side-lying position facing you. Rationale: The
semi-Fowlers position helps prevent aspiration of secretions. A sidelying position facilitates drainage of secretions by gravity and prevents aspiration.
5. Turn on suction device and adjust pressure: infants and children, 50 to 75 mmHg;
adults, 100 to 120 mmHg. Rationale: Excessive negative pressure traumatizes
mucosa and can induce hypoxia.
6. Open and prepare sterile suction catheter kit. Pour sterile saline into cup.
7. Pre oxygenate client with 100% oxygen. Hyper inflate with manual resuscitation
bag, Rationale: Pre oxygenate helps prevent hypoxia; hyperinflation
decreases atelectasis caused by suctioning.
8. Don sterile or clean gloves. Rationale: Protect yourself from exposure to mucous
membrane and sputum.
9. Pick up the catheter with dominant hand. Pick up connecting tubing with
nondominant hand. Attach catheter to suction tubing.
10. Place catheter end into cup of saline. Test functionality of equipment by applying
thumb from nondominant hand over open port to create suction. Return catheter
to sterile field. Rationale: Lubrication makes catheter insertion easier and
ensures proper functioning of suction equipment.
11. Insert catheter into trachea through nostril, nasal trumpet, or artificial airway
during inspiration. Rationale: Inspiration opens epiglottis and facilitates catheter
movement into trachea.
12. Advance catheter until you feel resistance. Retract catheter 1cm before applying
suction. Client will usually cough when catheter enters trachea. Rationale:
Retracting catheter slightly prevents mucosal damage.

13. Apply suction by placing thumb of nondominant hand over open port. Rotate the
catheter with your dominant hand as you withdraw the catheter. This should take
5 to 10 seconds. Rationale: Rotation of catheter prevents trauma to mucous
membrane from prolonged suctioning of one area. Limiting the suction time to 10
seconds or less prevents hypoxia.
14. Hyperoxygenate and hyperinflate using manual resuscitation bag for a full minute
between subsequent suction passes. Encourage deep breathing. Rationale:
Prolonged suctioning can induce hypoxia.
15. Rinse catheter thoroughly with saline. Rationale: Rinsing clears secretions from
catheter.
16. Repeat steps 10 to 14 until airway is clear.
17. Without applying suction, insert the catheter gently along one side of the mouth.
Advance to the oropharynx. Rationale: Suction the oropharynx after trachea
because the mouth is less clean than the trachea. Directing the catheter along
the side of the mouth prevents stimulation of the gag reflex.
18. Apply suction for 50 to 10 seconds as you rotate and withdraw
catheter. Rationale: Rotation of the catheter prevents trauma to the mucous
membrane. Be sure to remove secretions that pool beneath the tongue and in
the vestibule of the mouth.
19. Allow 1 to 2 minutes between passes for the client to ventilate. Encourage deep
breathing. Replace oxygen if applicable.
20. Repeat steps 16 and 17 as necessary to clear oropharynx.
21. Rinse catheter and tubing by suctioning saline through.
22. Remove gloves by holding catheter with dominant hand and pulling glove off
inside-out. Catheter will remain coiled inside the glove. Pull other glove off insideout. Dispose of in trash receptacle. Rationale: Contain client secretions inside
gloves to reduce transmission of microorganisms.
23. Turn off suction device.
24. Assist client to comfortable position. Offer assistance with oral and nasal
hygiene. Replace oxygen device if used. Rationale: Accumulated respiratory
secretions irritate the mucous membranes and are unpleasant for the client.
25. Dispose of disposable supplies.
26. Wash your hands.

27. Document procedure and observations. Rationale: Maintains legal record and
communicates with other healthcare team members.
Info source: Fundamentals of Nursing Lippincott