Suctioning Procedure PDF

SUCTIONING  LEARNING OUTCOMES ❑ To understand suctioning ❑ To know the indication, purpose and the type of suctioning ❑ Recognize when it is appropriate to assign aspects of suctioning care to assistive personnel. ❑ Verbalize the steps used in: a. Oropharyngeal, nasopharyngeal, and...

SUCTIONING  LEARNING OUTCOMES ❑ To understand suctioning ❑ To know the indication, purpose and the type of suctioning ❑ Recognize when it is appropriate to assign aspects of suctioning care to assistive personnel. ❑ Verbalize the steps used in: a. Oropharyngeal, nasopharyngeal, and nasotracheal suctioning b. Suctioning a tracheostomy or endotracheal tube ❑ Demonstrate appropriate documentation and reporting of suctioning.  OVERVIEW: SUCTIONING Suctioning ❑is the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet.  OVERVIEW: SUCTIONING Oropharyngeal and nasopharyngeal ❑suctioning removes secretions from the upper respiratory tract. Nasotracheal suctioning provides closer access to the trachea and requires sterile technique.  OVERVIEW: SUCTIONING ► Suction catheters are flexible, made of plastic, and may be either open tipped or whistle tipped.  OVERVIEW: SUCTIONING An oral suction tube, or Yankauer suction tube, is used to suction the oral cavity. Alert clients can be taught how to use this method of oral suctioning themselves.  OVERVIEW: SUCTIONING The catheter is connected to suction tubing, which in turn is connected to a collection chamber and suction control gauge.  SUCTIONING SIZE OF WALL UNIT PORTABLE UNIT CATHETER Fr. 12-18 100-120 mmhg 10-15 mmhg ADULTS Fr. 8-10 95-110 mmhg 5-10 mmhg CHILDS Fr. 5-8 50-95 mmhg 2-5 mmhg INFANT  OVERVIEW: SUCTIONING The nurse decides when suctioning is needed by assessing the client for signs of respiratory distress or evidence that the client is unable to cough up and expectorate secretions.  CLINICAL JUDGEMENT Suctioning irritates mucous membranes, can increase secretions if performed too frequently, and can cause the client’s oxygen saturation to drop further, put the client in bronchospasm, and if the client has a head injury, cause the intracranial pressure to increase.  INDICATION OF SUCTIONING ► Remove retained secretion ► To maintain airway patency ► To treat atelectasis ► Visible secretion ► Audible gurgling noise while breathing ► To obtain of a sputum specimen RISK AND COMPLICATION OF SUCTION  RISK AND COMPLICATION OF SUCTION TRAUMA ❑ Mucosal hemorrhage and erosion frequently occur in the patient who has been suctioned, leading eventually to the formation of granulation tissue. ❑ The amount of trauma depend upon the frequently of suction, the amount of negative pressure applied, the size and type of catheter used and the vigour of insertion.  RISK AND COMPLICATION OF SUCTION HYPOXIA ► This can occur following suction. ► To avoid this the suctioning time should be kept to a minimum, particularly those patient who are dependent on a ventilator, and the inspired oxygen and ventilation may be increased prior to suction providing there are no contraindication.  RISK AND COMPLICATION OF SUCTION CARDIOVASCULAR EFFECT ❑ Cardiac arrhythmias and hypotension can occur during suction due to hypoxia and vagal stimulation from direct pharyngeal and tracheal irritation. ❑ Particular care should be taken with neonates as bradycardia and apnea can follow nasopharyngeal suction in these patient.  RISK AND COMPLICATION OF SUCTION ATELECTASIS ❑ To large a suction catheter in too small an airway will prevent room air from entering around the catheter during suctioning and atelectasis, in varying degrees, may occur. ❑ Too high negative pressure may also cause atelectasis and airway collapse.  RISK AND COMPLICATION OF SUCTION PNEUMOTHORAX ❑ This can occur primarily in premature infants with severe underlying lung disease due to perforation of segmental bronchi by a suction catheter.  TYPES OF SUCTION Depending on the site of suction A. Nasotracheal Suctioning B. Oropharyngeal Suctioning C. Tracheostomy suctioning D. Endotracheal Suctioning Depending upon Circuit ❑ Open Circuit ❑ Closed Circuit  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. PURPOSES To remove secretions that obstruct the airway To facilitate ventilation To obtain secretions for diagnostic purposes To prevent infection that may result from accumulated secretions  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. ASSESSMENT Assess for clinical signs indicating the need for suctioning: Restlessness, anxiety, Noisy respirations Adventitious (abnormal) breath sounds when the chest is auscultated Change in mental status, Skin color, Rate and pattern of respirations Pulse rate and rhythm ,Decreased oxygen saturation  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. PLANNING Assignment Oral suctioning using a Yankauer suction tube can be assigned to AP and to the client or family, if appropriate, since this is not a sterile procedure. The nurse needs to review the procedure and important points such as not applying suction during insertion of the tube to avoid trauma to the mucous membrane. Oropharyngeal suctioning uses a suction catheter and, although not a sterile procedure, should be performed by a nurse or respiratory therapist. Suctioning can stimulate the gag reflex, hypoxia, and dysrhythmias that may require problem-solving. In contrast, nasopharyngeal and nasotracheal suctioning use sterile technique and require application of knowledge and problem-solving and should be performed by the nurse or respiratory therapist  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. EQUIPMENT Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning (Using Sterile Technique) Towel or moisture-resistant pad Portable or wall suction machine with tubing, collection receptacle, and suction pressure gauge, Sterile disposable container for fluids ,Sterile normal saline or water. Goggles or face shield, if appropriate ,Moisture-resistant disposal bag ,Sterile gloves  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. EQUIPMENT Sterile suction catheter kit (#12 to #18 Fr for adults, #8 to #10 Fr for children, and #5 to #8 Fr for infants) Water-soluble lubricant Y-connector Sputum trap, if specimen is to be collected  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. EQUIPMENT Oral and Oropharyngeal Suctioning (Using Clean Technique) Yankauer suction catheter or suction catheter kit Clean gloves  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 4. Prepare the client. Position a conscious client who has a functional gag reflex in the semi-Fowler’s position with the head turned to one side for oral suctioning or with the neck hyperextended for nasal suctioning. Position an unconscious client in the lateral position, facing you. Place the towel or moisture-resistant pad over the pillow or under the chin.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 5. Prepare the equipment. Turn the suction device on and set to appropriate negative pressure on the suction gauge. The amount of negative pressure should be high enough to clear secretion but not too high.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. For Oral and Oropharyngeal Suction Apply clean gloves. Moisten the tip of the Yankauer or suction catheter with sterile water or saline. Pull the tongue forward, if necessary, using gauze. Do not apply suction (that is, leave your finger off the port) during insertion Advance the catheter about 10 to 15 cm (4 to 6 in.) along one side of the mouth into the oropharynx It may be necessary during oropharyngeal suctioning to apply suction to secretions that collect in the mouth and beneath the tongue. Remove and discard gloves. Perform hand hygiene.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. For Nasopharyngeal and Nasotracheal Suction Open the lubricant. Open the sterile suction package. a. Set up the cup or container, touching only the outside. b. Pour sterile water or saline into the container c. Apply the sterile gloves, or apply an unsterile glove on the nondominant hand and then a sterile glove on the dominant hand. With your sterile gloved hand, pick up the catheter and attach it to the suction unit.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 6. Test the pressure of the suction and the patency of the catheter by applying your sterile gloved finger or thumb to the port or open branch of the Y-connector (the suction control) to create suction. If needed, apply or increase supplemental oxygen  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 7. Lubricate and introduce the catheter. Lubricate the catheter tip with sterile water, saline, or water- soluble lubricant. Remove oxygen with the nondominant hand, if appropriate. Without applying suction, insert the catheter into either naris and advance it along the floor of the nasal cavity. Never force the catheter against an obstruction. If one nostril is obstructed, try the other.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 8. Perform suctioning. Apply your finger to the suction control port to start suction, and gently rotate the catheter.. Apply suction for 5 to 10 seconds while slowly withdrawing the catheter, then remove your finger from the control and remove the catheter. A suction attempt should last only 10 to 15 seconds. During this time, the catheter is inserted, the suction applied and discontinued, and the catheter removed.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 9. Rinse the catheter and repeat suctioning as above if necessary. Rinse and flush the catheter and tubing with sterile water or saline. Relubrication the catheter, and repeat suctioning until the air passage is clear. Allow sufficient time between each suction for ventilation and oxygenation. Limit suctioning to 5 minutes in total. Encourage the client to breathe deeply and to cough between suctions. Use supplemental oxygen, if appropriate.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 10. Obtain a specimen if required. Use a sputum trap as follows: a. Attach the suction catheter to the tubing of the sputum trap. b. Attach the suction tubing to the sputum trap air vent. c. Suction the client. The sputum trap will collect the mucus during suctioning. d. Remove the catheter from the client. e. Connect the tubing of the sputum trap to the air vent. Connect the suction catheter to the tubing. Flush the catheter to remove secretions from the tubing.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 11. Promote client comfort. Offer to assist the client with oral or nasal hygiene. Assist the client to a position that facilitates breathing.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 12. Dispose of equipment and ensure availability for the next suction. Dispose of the catheter, gloves, water, and waste container. a. Rinse the suction tubing as needed by inserting the end of the tubing into the used water container. b. Wrap the catheter around your sterile gloved hand and hold the catheter as the glove is removed over it for disposal. Perform hand hygiene  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 13. Assess the effectiveness of suctioning. Auscultate the client’s breath sounds to ensure they are clear of secretions. Observe skin color, dyspnea, level of anxiety, and oxygen saturation levels  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. 14. Document relevant data. Record the procedure: the amount, consistency, color, and odor of sputum (e.g., foamy, white mucus; thick, green-tinged mucus; or blood-flecked mucus) and the client’s respiratory status before and after the procedure. This may include lung sounds, rate and character of breathing, and oxygen saturation. If the procedure is carried out frequently (e.g., every hour), it may be appropriate to record only once, at the end of the shift; however, the frequency of the suctioning must be recorded.  Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning. EVALUATION Conduct appropriate follow-up, such as appearance of secretions suctioned; breath sounds; respiratory rate, rhythm, and depth; pulse rate and rhythm; and skin color. Compare findings to previous assessment data if available. Report significant deviations from normal to the primary care provider  NURSING CONSIDERATION: SUCTION INFANTS A bulb syringe is used to remove secretions from an infant’s nose or mouth. Care needs to be taken to avoid stimulating the gag reflex CHILDREN A catheter is used to remove secretions from an older child’s mouth or nose. OLDER ADULTS Older adults often have cardiac or pulmonary disease, thus increasing their susceptibility to hypoxemia related to suctioning. Watch closely for signs of hypoxemia. If noted, stop suctioning and hyperoxygenation. Patient-Centered Care: Suctioning Patient-Centered Care: Suctioning Teach clients and families that the most important aspect of infection control is frequent hand washing. Patient-Centered Care: Suctioning Suction only as needed. ❑ Because suctioning the client with an ETT or tracheostomy is uncomfortable for the client and potentially hazardous because of hypoxemia, it should be performed only when indicated and not on a fixed schedule. Patient-Centered Care: Suctioning Sterile technique. ❑ Infection of the lower respiratory tract can occur during tracheal suctioning. The nurse using sterile technique during the suctioning process can prevent this complication. Patient-Centered Care: Suctioning No saline instillation. ❑ Instilling normal saline into the airway has been a common practice and a routine part of the suctioning procedure. It was thought that the saline would facilitate removal of secretions and improve the client’s oxygenation status. Patient-Centered Care: Suctioning Hyperinflation. ❑ This involves giving the client breaths that are greater than the tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag. Three to five breaths are delivered before and after each pass of the suction catheter. Patient-Centered Care: Suctioning Hyperventilation. This involves increasing the number of breaths the client is receiving Patient-Centered Care: Suctioning Hyperoxygenation. ❑ This can be done with a manual resuscitation bag or through the ventilator and is performed by increasing the oxygen flow (usually to 100%) before suctioning and between suction attempts. This is the best technique to avoid suction-related hypoxemia. Patient-Centered Care: Suctioning Safe catheter size. ❑ To prevent hypoxia when tracheostomy and endotracheal suctioning are administered, the outer diameter of the suction catheter should not exceed one-half the internal diameter of the artificial airway. For example, an artificial airway (e.g., tracheostomy) diameter of 8 mm * 2 = 16. A size 16 French suction catheter would be safe to use. Patient-Centered Care: Suctioning Depending upon Circuit ❑Open Circuit ❑Closed Circuit Closed-circuit  Suctioning a Tracheostomy or Endotracheal Tube Suctioning a Tracheostomy or Endotracheal Tube PURPOSES To maintain a patent airway and prevent airway obstructions. To promote respiratory function (optimal exchange of oxygen and carbon dioxide into and out of the lungs). To prevent pneumonia that may result from accumulated secretions. Suctioning a Tracheostomy or Endotracheal Tube ASSESSMENT ❑ Assess the client for the presence of adventitious (abnormal) breath sounds. Assess the client’s cough reflex and note the client’s ability or inability to remove the secretions by coughing. Suctioning a Tracheostomy or Endotracheal Tube PLANNING Assignment Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique requiring application of scientific knowledge and problem- solving. This skill is performed by a nurse or respiratory therapist and is not assigned to AP. Suctioning a Tracheostomy or Endotracheal Tube Equipment Resuscitation bag (bag valve mask) connected to 100% oxygen Sterile towel (optional) Equipment for suctioning. Goggles and mask (if necessary) Gown (if necessary) Sterile gloves Moisture-resistant bag Suctioning a Tracheostomy or Endotracheal Tube IMPLEMENTATION Preparation Determine if the client has been suctioned previously and, if so, review the documentation of the procedure. Performance 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy Suctioning a Tracheostomy or Endotracheal Tube 4. Prepare the client. If not contraindicated, place the client in the semi-Fowler’s position to promote deep breathing, maximum lung expansion, and productive coughing. Suctioning a Tracheostomy or Endotracheal Tube 5. Prepare the equipment for an open suction system—see Variation section for a closed suction system. Attach the resuscitation apparatus to the oxygen source. Adjust the oxygen flow to 100% Attaching the resuscitation apparatus to the oxygen source. Open the sterile supplies: a. Suction kit or catheter b. Sterile basin or container. Suctioning a Tracheostomy or Endotracheal Tube Pour sterile normal saline or water into sterile basin or container. Place the sterile towel, if used, across the client’s chest below the tracheostomy or on a workspace. Turn on the suction, and set the pressure in accordance with agency policy. Suctioning a Tracheostomy or Endotracheal Tube Apply goggles, mask, and gown if necessary. Apply sterile gloves. Some agencies recommend putting a sterile glove on the dominant hand and an unsterile glove on the nondominant hand. Holding the catheter in the dominant hand and the connector in the nondominant hand, attach the suction catheter to the suction tubing. Suctioning a Tracheostomy or Endotracheal Tube 6. Flush and lubricate the catheter. Using the dominant hand, place the catheter tip in the sterile saline solution. Using the thumb of the nondominant hand, occlude the thumb control and suction a small amount of the sterile solution through the catheter. Suctioning a Tracheostomy or Endotracheal Tube 7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning. Summon an assistant, if one is available, for this step. Using your nondominant hand, turn on the oxygen to 12 to 15 L/min. If the client is receiving oxygen, disconnect the oxygen source from the tracheostomy tube using your nondominant hand. Suctioning a Tracheostomy or Endotracheal Tube Attach the resuscitator to the tracheostomy or ETT. Compress the resuscitation bag three to five times, as the client inhales. Observe the rise and fall of the client’s chest to assess the adequacy of each ventilation. Remove the resuscitation device and place it on the bed or the client’s chest with the connector facing up Suctioning a Tracheostomy or Endotracheal Tube Variation: Using a Ventilator to Provide Hyperventilation ❑ If the client is on a ventilator, use the ventilator for hyperventilation and hyperoxygenation. Newer models have a mode that provides 100% oxygen for 2 minutes and then switches back to the previous oxygen setting as well as a manual breath or sigh button. Suctioning a Tracheostomy or Endotracheal Tube 8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead: Keep the regular oxygen delivery device on and increase the liter flow or adjust the FiO2 to 100% for several breaths before suctioning. Suctioning a Tracheostomy or Endotracheal Tube 9. Quickly but gently insert the catheter without applying any suction. With your nondominant thumb off the suction port, quickly but gently insert the catheter into the trachea through the tracheostomy tube. Insert the catheter about 1 to 2 cm (1/2 to 1 in.) past the distal end of the tube until resistance is felt, even if the client coughs. Suctioning a Tracheostomy or Endotracheal Tube 10. Perform suctioning. Apply suction for 5 to 10 seconds by placing the nondominant thumb over the thumb port. Rotate the catheter by rolling it between your thumb and forefinger while slowly withdrawing it Withdraw the catheter completely, and release the suction. Hyperventilate the client. Suction again, if needed Suctioning a Tracheostomy or Endotracheal Tube 11. Reassess the client’s oxygenation status and repeat suctioning. Observe the client’s respirations and skin color. Encourage the client to breathe deeply and to cough between suctions. Allow 2 to 3 minutes with oxygen Flush the catheter and repeat suctioning until the air passage is clear and the breathing is relatively effortless and quiet. After each suction, pick up the resuscitation bag with your nondominant hand and ventilate the client with no more than three breaths. Suctioning a Tracheostomy or Endotracheal Tube 12. Dispose of equipment and ensure availability for the next suction. Flush the catheter and suction tubing. Turn off the suction and disconnect the catheter from the suction tubing. Wrap the catheter around your sterile hand and peel the glove off so that it turns inside out over the catheter. Remove the other glove. Discard the gloves and the catheter in the moisture resistant bag. Suctioning a Tracheostomy or Endotracheal Tube Perform hand hygiene. Replenish the sterile fluid and supplies so that the suction is ready for use again. Be sure that the ventilator and oxygen settings are returned to pre-suctioning settings. Suctioning a Tracheostomy or Endotracheal Tube 13. Provide for client comfort and safety. Assist the client to a comfortable, safe position that aids breathing. If the client is conscious, a semi-Fowler’s position is frequently indicated. If the client is unconscious, Sims’ position aids in the drainage of secretions from the mouth. Suctioning a Tracheostomy or Endotracheal Tube 14. Document relevant data. Record the suctioning, including the amount and description of suction returns and any other relevant assessments. Suctioning a Tracheostomy or Endotracheal Tube Variation: Closed Suction System Aseptically Attach one end of the suction connecting tubing. Turn suction on. Use the ventilator to hyper oxygenate and hyperinflate the client’s lungs. Unlock the suction control mechanism if required by the manufacturer. Advance the suction catheter enclosed in its plastic sheath with the dominant hand. Suctioning a Tracheostomy or Endotracheal Tube Depress the suction control valve and apply continuous suction for no more than 10 seconds and gently withdraw the catheter. Repeat as needed remembering to provide hyperoxygenation and hyperinflation as needed. When suctioning is completed, withdraw the catheter into its sleeve and close the access valve, if appropriate. Flush the catheter by instilling normal saline into the irrigation port and applying suction Close the irrigation port and close the suction valve. Remove and discard gloves. Perform hand hygiene. Suctioning a Tracheostomy or Endotracheal Tube EVALUATION Perform a follow-up examination of the client to determine the effectiveness of the suctioning (e.g., respiratory rate, depth, and character; breath sounds; color of skin and nail beds; character and amount of secretions suctioned; changes in vital signs [e.g., heart rate, oxygen saturation]). Compare findings to previous assessment data if available. Report significant deviations from normal to the primary care provider.  Book reference: Fundamentals of Nursing 11 edition Kozier and Erbs th Page. 1330-1332