Nursing Care That Needs Improvement

In the hospital and home-health setting I have observed a variation in the criteria
nurses use to do endotracheal suctioning. There is a discrepancy between the assessment
measures nurses use to indicate a patient requires endotracheal suctioning and what is the
recommended best practice. In the past when dealing with patients who have an artificial
airway, I routinely assessed their need for suctioning by auscultation of their lung sounds
or observation of secretions. Evidence-based research has indicated these are not the
most effective methods.
QSEN Competencies
Cronewett et al (2007) defines evidence-based practice as integrate best current
evidence with clinical expertise and patient/family preferences and values for delivery of
optimal health care (p. 126). An outline of the evidence-based competencies includes
the use of the strength and availability of evidence to determine the best clinical practice
for provision of patient-centered care (Cronewett et al, 2007). Healthcare providers
follow well-designed protocols to optimize the effectiveness and efficiency of treatments,
however, there remains a gap between best practice based on evidence and actual practice
(Ledddy & Wilkinson, 2015). Because suctioning a patient can result in hypoxemia,
dysrhythmias or damage of the tracheal mucosa (Sole, Barnett, & Ashworth, 2015),
nurses should be aware of the best evidence practices to ensure no harm is done to a
patient. The QSEN competencies on Evidence-based Practice describes the need for
nurses to participate in integrating new evidence into standards of practice, question the
use of routine approach with less than desired outcomes, and value improved clinical
practice based on new evidence (Cronewett et al, 2007). The importance of exploring

this concern is best described as suctioning of an artificial airway is not a benign

procedure and as such, health care providers must be aware of the potential complications
and side effects (Leddy & Wilkinson, 2015, p.63). Guidelines for endotracheal
suctioning remains an issue because of adherence among nurses to traditional guidelines
instead of current evidence-based practice.
Best Practices
Endotracheal suctioning is done effectively when a nurse utilizes the best
evidence-based practices for the best patient outcomes. The cornerstone for
implementing evidence-based practice is based on a thorough respiratory assessment.
Schriber (2015) notes a thorough respiratory assessment includes: patients respiratory
rate, signs of labored breathing, adventitious lung sounds, quality of cough to clear
secretions, quantity and characteristics of secretions, any signs & symptoms of infection,
pulse oximeter reading, and if supportive equipment is working properly. Sole, Bennett,
& Ashworth (2015) study on patients in critical care units requiring mechanical
ventilation indicated the auscultation over the trachea and ventilator waveforms were the
best indicators of a patient needing endotracheal suctioning. Even though its a common
practice among nurses, lung auscultation was not the best method to indicate suctioning.
Tracheal auscultation was shown to be the most accurate indication for endotracheal
suctioning, because endotracheal suctioning only removes secretions from the upper part
of the airway.
Strategies
Strategies to improve the suctioning procedure and reduce potential
complications can be implemented by training nurses and changing the standard practice

guidelines in the organizations manual. Nurses can be trained with the most recent
scientific based evidence on endotracheal suctioning. Evaluation on the correct
assessment indicators for endotracheal suctioning should be done after training. It is
important for the healthcare system to develop and implement standard practice
guidelines on endotracheal suctioning throughout. To improve quality of care,
development of standard practice guidelines and monitoring of nursing compliance to
standards are important requirements (Ozden & Gorgulu, 2012).

References
Cronenwett, L.,Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P.,
Sullivan, D.T., Warren, J. (2007). Quality and safety education for nurses.
Nursing Outlook, 55(3) 122-131. doi:10.1016/j.outlook.2007.02.006
Leddy, R., & Wilkinson, J.M. (2015). Endotracheal suctioning practice of nurses
and respiratory therapists: How well do they align with clinical practice
guidelines? Canadian Journal of Respiratory Therapy 51(3), 60-64.
Ozden, D., & Gorgwa, R.S. (2012). Development of standard practice guidelines
For open and closed system suctioning. Journal of Clinical Nursing
9/10, 1327-1338. doi: 10.1111/j.1365.2702.2011.03997.x
Schreiber, M.L. (2015). Clinical how to tracheostomy: site care, suctioning and
readiness. MEDSURG Nursing 124(2), 121-124.
Sole, M.L., Bennett, M., & Ashworth, S. (2015). Clinical indicators for endotracheal
Suctioning in adult patients receiving mechanical ventilation. American Journal
Of Critical Care 24(4), 31-324. doi: http://dx.doi.org/10.4037/ajcc2015794