SUCTIONING

Oropharyngeal, tracheal, and endotracheal suction are methods of clearing secretions by the application of negative pressure via either a yankauer sucker (oropharyngeal) or an appropriately sized tracheal suction catheter (tracheal/endotracheal).

PURPOSE:
1.The purpose of performing oral suction is to maintain oral hygiene and comfort for the patient or to remove blood and vomit in an emergency situation. 2. The purpose of tracheal/endotracheal suction is to remove pulmonary secretions in patients who are unable to cough and clear their own secretions effectively. The patient may be fully conscious or have an impaired conscious level. 3. Secretions are cleared from these patients airways in order to maintain airway patency, to prevent atelectasis secondary to blockage of smaller airways and to ensure that adequate gas exchange (particularly oxygenation) occurs.

INDICATIONS: 1. Visible presence of secretions in tube orifice 2. Coarse tubular breath sounds on auscultation in patient unable to cough or without artificial airway in place. 3. Patient with an artificial airway. NURSING CONSIDERATIONS :

1. Review the patient's chart for physician order, and note any indications, contraindications, or potential side effects of therapy ordered. Review the patient's history, physical diagnosis, progress notes, CXR, lab reports (including PFT's and ABG'S) and medications before performing the procedure. 2. Identify patient by comparing hospital and billing numbers on the armband to those on the physicians orders for therapy. 3. Examine and auscultate patient. 4. Assemble Equipment: Attach connective tubing to suction regulator/equipment and inlet of suction container. Connect suction machine to vacuum wall outlet. Turn vacuum on, and occlude tip of connective tubing. If no suction is demonstrated on gauge, tighten all connections. If still no suction occurs increase vacuum. If still suction occurs, label machine "defective" obtain another suction machine, reassemble and retest. 5. Identify patient by verification of name on armband and by verbal questioning. 6. Identify yourself and your department. 7. Inform the patient/family of the procedure and its purpose. Be prepared to answer any questions about the procedure that the patient may have.

EQUIPMENT: Sub-micron mask Suction Regulator/Equipment Suction cannister Connective tubing 02 flow meter Resuscitation bag Sterile suction catheter Sterile gloves Sterile cup (if needed) Sterile H20 Stethoscope Metered vials of normal saline (for tenacious secretions) or other irrigant Water soluble lubricant (for N-T auctioning) Personal Protective Equipment (gown, goggles, gloves

PROCEDURE

Nasopharyngeal and Oropharyngeal Suctioning

PROCEDURE
1. Assess the clients need for suctioning: inability to effectively clear the airway by coughing and expectoration; coarse bubbling or gurgling noises with respiration. 2. Choose the most appropriate route (nasopharyngeal or oropharyngeal) for your client. If nasopharyngeal approach is considered, inspect the nares with a penlight to determine patency. Alternatively, you may assess patency by occluding each nare in turn with finger pressure while asking the client to breathe through the remaining nare.
3.

RATIONALE
1. Suctioning is an uncomfortable and traumatic procedure and should be used only when needed.

2. The oropharyngeal approach is easier but

3. Explain the procedure to the client. Advise that

suctioning may cause coughing or gagging but emphasize the importance of clearing the airway. 4. Wash your hands. 5. Position the client in a high Fowlers or semiFowlers position. 6. If the client is unconscious or otherwise unable to protect his or her airway, place in a side-lying position. 7. Connect extension tubing to suction device if not already in place, and adjust suction control to between 110 and 120 mm Hg. 8. Put on gown and mask and goggles or face shield if indicated. 9. Using sterile technique , open the suction kit. Consider the inside wrapper of the kit to be sterile, and spread the wrapper out carefully to create a small sterile field.

requires that the client cooperate; it may also produce gagging more readily in some persons. The nasopharyngeal route is more effective for reaching the posterior oropharynx but is contraindicated in clients with a deviated nasal septum, nasal polyps, or any tendency toward excessive bleeding (low platelet count, use of anticoagulants, r 3. Promotes cooperation and reduces anxiety.

4. Reduces the transmission of pathogens.

Maximizes lung expansion and effective coughing 6. Protects the client from aspiration in the event of vomiting. 7. Excessive negative pressure can cause tissue trauma, whereas insufficient pressure will be ineffective. 8. Protects you from splattering with body fluids.
5. 9. Produces an area in which to place sterile

items without contaminating them.

10. Open a packet of sterile water-soluble lubricant

and squeeze out the contents of the packet onto the sterile field. 11. If sterile solution (water or saline) is not included in the kit, pour about 100 ml of solution into the sterile container provided in the kit. 12. Carefully lift the wrapped gloves from the kit without touching the inside of the kit or the gloves themselves. Lay the wrapped gloves down next to the suction kit, and open the wrapper. Put on the gloves using sterile gloving technique
13. If a cup of sterile solution is included in the

10. Lubricant will be used to further lubricate

the catheter tip if the nasopharyngeal route is used. 11. This solution will be used to lubricate the catheter and to rinse the inside of the catheter to clear secretions.
12. The gloves should be kept sterile for handling

the sterile suction catheter to avoid introducing pathogens into the clients airway.

suction kit, open it. 14. Designate one hand as sterile (able to touch only sterile items) and the other as clean (able to touch only nonsterile items).
15. Using your sterile hand, pick up the suction

13. This solution will be used to lubricate the

catheter. Grasp the plastic connector end between your thumb and forefinger and coil the tip around your remaining fingers.

catheter and to rinse the inside of the catheter to clear secretions. 14. Usually, the dominant hand is the sterile hand, while the nondominant hand is clean. This prevents contamination of sterile supplies while allowing you to handle unsterile items. 15. Prevents accidental contamination of the catheter tip.

16. Pick up the extension tubing with your clean

16. The extension tubing is not sterile.

hand. Connect the suction catheter to the extension tubing, taking care not to contaminate the catheter (Figure 32-24).
17. Position your clean hand with the thumb over

the catheters suction port.

17. Suction is activated by occluding this port

with the thumb. Releasing the port deactivates the suction.

18. Dip the catheter tip into the sterile solution,

and activate the suction. Observe as the solution is drawn into the catheter.
19. For oropharyngeal suctioning, ask the client to

18. Tests the suction device as well as lubricates

open his or her mouth. Without activating the suction, gently insert the catheter and advance it until you reach the pool of secretions or until the client coughs. 20. For nasopharyngeal suctioning, estimate the distance from the tip of the clients nose to the earlobe and grasp the catheter between your thumb and forefinger at a point equal to this distance from the catheters tip. 21. Dip the tip of the suction catheter into the watersoluble lubricant to coat catheter tip liberally. suction control port uncovered. Advance the catheter gently with a slight downward slant. Slight rotation of the catheter may be used to ease insertion. Advance the catheter to the point marked by your thumb and forefinger

the interior of the catheter to enhance clearance of secretions. ( 19. To minimize trauma, do not apply suction while the catheter is being advanced.
20. Ensures placement of the catheter tip in the

oropharynx and not in the trachea.

21. Promotes the clients comfort and minimizes

trauma to nasal mucosa.

22. Guides the catheter toward the posterior

22. Insert the catheter tip into the nare with the

oropharynx along the floor of the nasal cavity.

23. If resistance is met, do not force the catheter.

Withdraw it and attempt insertion via the opposite nare.

23. Forceful insertion may cause tissue damage

and bleeding

24. Apply suction intermittently by occluding the

suction control port with your thumb; at the same time, slowly rotate the catheter by rolling it between your thumb and fingers while slowly withdrawing it. Apply suction for no longer than 15 seconds at a time.
25. Repeat step 24 until all secretions have been

24. Prolonged suction applied to a single area of

tissue can cause tissue damage

cleared, allowing brief rest periods between suctioning episodes.

25. Promotes complete clearance of the airway.

26. Withdraw the catheter by looping it around

26. Allows you to maintain control over the

your fingers as you pull it out.

27. Dip the catheter tip into the sterile solution and

catheter tip as it is withdrawn.

27. Clears the extension tubing of secretions that

apply suction.

28. Disconnect the catheter from the extension

tubing. Holding the coiled catheter in your gloved hand, remove the glove by pulling it over the catheter. Discard catheter and gloves in an appropriate container. container.
30. Wash your hands. 31. Provide the client with oral hygiene if indicated

would promote bacterial growth. 28. Contains the catheter and secretions in the glove for disposal.

29. Discard remaining supplies in the appropriate

29. Follow institutional policy regarding the

disposal of patient care supplies.

.30 Prevents the transmission of pathogens. 31. Suctioning and coughing may produce an

or desired.
32. Document the procedure, noting the amount,

unpleasant taste.
32. Changes in the amount, color, or odor of

color, and odor of secretions and the clients response to the procedure.

pulmonary secretions may indicate infection

Performing Tracheostomy Suctioning

PROCEDURE
1. Assess the clients need for suctioning: inability

RATIONALE
1. Suctioning is an uncomfortable and traumatic

to effectively clear the airway by coughing and expectoration; coarse rales auscultated over the upper airways. suctioning may cause coughing; emphasize the importance of clearing the airway.
3. Wash your hands 4. Position the client in a high Fowlers or semi-

procedure and should be used only when needed. .

2. Explain the procedure to the client. Advise that

2. Promotes cooperation and reduces anxiety.

3. Reduces the transmission of pathogens. 4. Maximizes lung expansion and effective

Fowlers position.
5. Connect extension tubing to suction device if

coughing
5. Excessive negative pressure can cause tissue

not already in place, and adjust suction control to between 80 and 100 mm Hg.
6. Put on gown and mask and goggles or face

trauma, hypoxemia, and atelectasis, whereas insufficient pressure will be ineffective.

shield if indicated.
7. Using sterile technique (see Figure 32-23), open

6. Protects you from splattering with body fluids.

the suction kit. Consider the inside wrapper of the kit to be sterile, and spread the wrapper out carefully to create a small sterile field. .
8. If sterile solution (water or saline) is not

7. Produces an area in which to place sterile items

without contaminating them

8. This solution will be used to lubricate the

included in the kit, pour about 100 ml of solution into the sterile container provided in the kit.
9. Carefully lift the wrapped gloves from the kit

catheter and to rinse the inside of the catheter to clear secretions.

without touching the inside of the kit or the gloves themselves. Lay the wrapped gloves down next to the suction kit, and open the wrapper. Put on the gloves using sterile gloving technique.

9. The gloves should be kept sterile for handling

the sterile suction catheter to avoid introducing pathogens into the clients airway.

10. If a cup of sterile solution is included in the

10. This solution will be used to lubricate the

suction kit, open it.

11. Designate one hand as sterile (able to touch

catheter and to rinse the inside of the catheter to clear secretions.

11. Usually, the dominant hand is the sterile hand,

only sterile items) and the other as clean (able to touch only nonsterile items)
12. Using your sterile hand, pick up the suction

while the nondominant hand is clean. Prevents contamination of sterile supplies while allowing you to handle unsterile items.
12. Prevents accidental contamination of the

catheter. Grasp the plastic connector end between your thumb and forefinger and coil the tip around your remaining fingers.
13. Pick up the extension tubing with your clean

catheter tip.

13. The extension tubing is not sterile.

hand. Connect the suction catheter to the extension tubing, taking care not to contaminate the catheter (see Figure 32-24)
14. Instruct the patient to take several slow, deep

breaths.

14. Promotes optimal opening of airways and

reduces suction-induced hypoxemia. Note: Clients who are especially prone to suctioninduced hypoxemia may be preoxygenated by taking several deep breaths with supplemental oxygen set at 100% or by delivery of 100% oxygen via manual resuscitation bag. Always return oxygen flow to the prescribed rate after the suctioning procedure is completed.
15. Permits access to the tracheostomy tube.

15. Using your clean hand, remove the oxygen

delivery device from the tracheostomy tube and place it on a clean surface.

Placing the oxygen device on a clean surface reduces contamination (the sterile glove wrapper may be used for this purpose).
16. Suction is activated by occluding this port with

16. Position your clean hand with the thumb over

the catheters suction port.

17. Dip the catheter tip into the sterile solution,

the thumb. Releasing the port deactivates the suction.

17. Tests the suction device as well as lubricating

and activate the suction. Observe as the solution is drawn into the catheter.
18. Without occluding the suction control port,

the interior of the catheter to enhance clearance of secretions.

18. To minimize trauma, do not apply suction

insert the catheter tip into the tracheostomy tube and advance it until the patient coughs

while the catheter is being advanced

19. If extremely strong coughing occurs, withdraw

the catheter slightly.

19. The tracheal tissue at the point of bifurcation

(the carina) is extremely sensitive to touch and produces a vigorous cough. . .

20. Prolonged suction can cause tissue damage,

20. Apply suction intermittently by occluding the

suction control port with your thumb; at the same time, slowly rotate the catheter by rolling it between your thumb and fingers while slowly withdrawing it. Apply suction for no longer than 15 seconds at a time.

atelectasis, and hypoxemia.

21. Repeat step 20 until all secretions have been

21. Promotes complete clearance of the airway.

cleared, allowing brief rest periods between suctioning episodes. Encourage client to breathe deeply between suctioning episodes.
22. Withdraw the catheter by looping it around

your fingers as you pull it out.

22. Allows you to maintain control over the

23. Ask the client to open his or her mouth. Insert

the catheter and advance it along the oropharynx until resistance is felt. Apply suction and slowly withdraw the catheter.

catheter tip as it is withdrawn 23. Removes pooled secretions above the cuff of the tracheostomy, which may provide a source of infection if aspirated. Note: At this point the catheter is contaminated. If another suctioning pass into the tracheostomy is needed, a new sterile catheter must be used.
24. Clears the extension tubing of secretions,

24. Dip the catheter tip into the sterile solution

and apply suction.

25. Disconnect the catheter from the extension

which would promote bacterial growth.

25. Contains the catheter and secretions in the

tubing. Holding the coiled catheter in your gloved hand, remove the glove by pulling it over the catheter. Discard catheter and gloves in an appropriate container.
26. Reapply oxygen delivery device. 27. Discard remaining supplies in the appropriate

glove for disposal.

26. Restores supplemental oxygen and

container.
28. Wash your hands.

humidification 27. Follow institutional policy regarding the disposal of patient care supplies.
28. Prevents the transmission of pathogens. 29. Suctioning and coughing may produce an

.
29. Provide the client with oral hygiene if

indicated/ desired 30. Document the procedure, noting the amount, color, and odor of secretions and the clients response to the procedure.

unpleasant taste.
30. Changes in the amount, color, or odor of

pulmonary secretions may indicate infection