OROPHARYNGEAL, TRACHEAL AND ENDOTRACHEAL SUCTIONING DEFINITION These are methods of clearing foreign matter such as secretions or mucus,

fluids or blood from the upper airway that cannot be expectorated by the patient spontaneously. This is through application of negative pressure via either vankauer sucker (oropharyngeal), or an appropriately sized tracheal suction catheter (tracheal/endotracheal). METHODS OF SUCTIONING Oral suctioning (suctioning through the mouth) Nasal suctioning (suctioning through the nose) Tracheal suctioning (suctioning through a tracheostomy tube or laryngectomy stoma) SUCTIONING DEVICES

MANUAL SUCTIONING UNITS o These are operated by the hand. o Do not require an energy source. o They avoid some problems that may be associated with mechanical units. MECHANICAL SUCTIONING UNITS o These are electronically powered that produces a vacuum that is enough to suction substances from the throat. Wall unit Portable unit

EQUIPMENT: 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: Preparation 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. Check heart rate before, during and after procedure. If tachycardia or bradycardia occurs discontinue the procedure until it resolves. 4. Assemble Equipment: i. 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 no 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. Implementation 1. Perform hand hygiene. 2. Adjust bed to comfortable working position. Lower side rail closet to you. Place patient in a semi-Fowlers position if he or she is conscious. An unconscious patient should be placed in the lateral position facing you. 3. Position the patient by extending the neck slightly to facilitate entrance into the trachea (especially for nasotracheal auctioning). 4. Place towel or waterproof pad across patients chest. 5. Turn suction to appropriate pressure. a. Wall unit

o o o

Adult: 100 to 120 cm Hg Child: 95 to 110 cm Hg Infant: 50 to 95 cm Hg

b. Portable unit o Adult: 10 to 15 cm Hg o Child: 5 to 10 cm Hg o Infant: 2 to 5 cm Hg 8. Open sterile suction package. Set up sterile container, touching only the outside surface, and pour sterile saline into it. 9. Don sterile gloves. The dominant hand that will handle catheter must remain sterile, whereas the nondominant hand is considered clean rather than sterile. 10. With sterile gloves. The dominant hand, pick up sterile catheter and connect to suction tubing held with unsterile hand. 11. Moisten catheter by dipping it into container of sterile saline. Occlude Y-tube to check suction. 12. Estimate the distance form earlobe to nostril and place thumb and forefinger of gloved hand at that point on catheter. 13. Gently insert catheter with suction off by leaving the vent on the Y-connector open. Slip catheter gently along the floor of an unobstructed nostril toward trachea to suction the nasopharynx. Or insert catheter along side of mouth toward trachea to suction the oropharynx. Never apply suction as catheter is introduced. 14. Apply suction by according suctioning port with your thumb. Gently rotate catheter as it is being withdraw. Do not allow suctioning to continue for more than 10 to 15 seconds at a time. 15. Flush the catheter with saline and repeat suctioning as needed and according to patients toleration of the procedure. 16. Allow at least a 20- to 30-second interval if additional suctioning is needed. The nares should be alternated when repeated suctioning required. Do not force the catheter through the nares. Encourage patient to cough and breathe deeply between suctioning. 17. When suctioning is completed, remove gloves inside out and dispose of gloves, catheter, and container with solution in proper receptacle. Perform hand hygiene. 18. Use auscultation to listen to chest and breath sounds to assess effectiveness of suctioning. 19. Record time of suctioning and nature and amount of secretions. Also note the character of the patients respirations before and after suctioning. 20. Offer oral hygiene after suctioning.

Follow Up 1. Discard gloves and catheters in an aseptic manner, clear connective tubing with remaining sterile H20 and turn off suction. 2. Return the patient to comfortable position. 3. Discard personal protective equipment and wash hands. 4. Document procedure as per department guidelines. 5. Inform nurse and/or physician of any pertinent request, complaints or reactions to the therapy. SUCTION MACHINE CLEANING PROCEDURE The collection bottle should be emptied when it becomes half full. At least once a day the collection bottle, lid, and tubing should be cleaned and disinfected using the following procedure: 1. Empty the collection bottle contents into the toilet very slowly to avoid splashing. Rinse the collection bottle thoroughly with water, and again slowly empty all rinse water into the toilet and flush. Pour cup of bleach into the bottle and fill the bottle to the top with water. Allow to stand for 30 minutes. Again slowly empty the contents of the bottle into the toilet and rinse thoroughly always avoiding splashing. 2. Wash the lid and tubing in warm soapy water. In a small container, soak these parts for 30 to 40 minutes in a solution of one cup of white vinegar and three cups of water. If this does not provide enough solution to completely cover the parts, double the mixture. 3. With the suction machine unplugged from the electrical outlet, the outside surface of the machine may be cleaned by wiping with a soft cloth dampened with water. 4. When reassembling the machine, place the lid back on the bottle securely. Make sure all tubing connections are tight. A loose connection anywhere in the system will greatly reduce the suction. INFECTION CONTROL 1. If you have disposable gloves available, it is advisable that they be worn when emptying the collection bottle. 2. Always wash your hands after handling the suction equipment and after emptying the collection bottle. 3. Always wash your hands after removing either sterile or unsterile gloves. Precautions/Complications 1. Hypoxia 2. Vagal stimulation: Cardiac arrhythmia 3. Tracheitis 4 Damage to mucus membranes

5: Airway occlusions 6. Sudden death 7. Bleeding disorders ADMINISTERING ORAL MEDICATIONS DEFINITION Oral medication is defined as the administration of medication by mouth. Is preferred over parenteral administration if the patient can tolerate medication by mouth because it is EASY and NON-INVASIVE PURPOSE 1. To prevent the disease and take supplement in order to maintain health 2. To cure the disease 3. To promote the health 4. To give palliative treatment 5. To give as a symptomatic treatment EQUIPMENTS physicians order for the medication medication administration record medication cart medication tray disposable medication cups glass of water, juice or liquid drinking straw mortar, pestle if needed paper towels kidney tray PROCEDURE 1. Review the patient's chart for physician order, and note any indications, contraindications, or potential side effects of drug ordered. Review the patient's history, physical diagnosis, progress notes, CXR, lab reports (including PFT's and ABG'S) and other medications given. 2. Check the Kardex and clients record for allergies. 3. Check the name, dosage, type, time of medication with the clients kardex. 4. If you are going to give more than one medication, make sure they are compatible 5. Know actions, special nursing consideration, and adverse effects of medications to be administered. 6. Perform proper hand hygiene.

7. Move medication cart outside patients room or prepare for administration in medication area. 8. Unlock medication cart or drawer. 9. Set up medication following the 10 rights of medication administration Right client Right drug Right dose Right time Right route Right history and assessment Right documentation Right to education Right drug to drug interaction and evaluation Right to refuse Plus two rights: Right expiration Right reason 10. Prepare medications for one patient at a time. 11. Select proper medication from drawer or stock and compare with Kardex or order. Check expiration dates and perform calculations if necessary. a. Place unit dose-package medications in a disposable cup. Do not open wrapper until at bedside. Keep narcotics and medications that require special nursing assessments in a separate container. b. When removing tablets or capsules from a bottle, pour the necessary number into bottle cap and then place tablets in a medications cup. Break only scored tablets, if necessary, to obtain proper dose. c. Hold liquid medication bottles with the label against palm. Use appropriate measuring device when pouring liquids and read the amount of medication at the bottom of the meniscus at eye level. Wipe bottle lip with a paper towel. 12. Recheck each medication package or preparation with the order as it is poured. 13. When all medications for one patient have been prepared, recheck once again with the medication order before taking them to patient. 14. Carefully transport medications to patients bedside. Keep medications in sight at all times. 15. See that patient receives medications at the correct time. 16. Identify the patient carefully. There are three correct ways to do this. a. Check name on patients identification bracelet. b. Ask patient his or her name.

c. Verify patients identification with a staff member who knows patient. 17. Complete necessary assessments before administration of medications. Check allergy bracelet or ask patient about allergies. Explain purpose and action of each medication to patient. 18. Assist patient to an upright or lateral position. 19. Administer medications. o Offer water or other permitted fluids with pills, capsules, tablets, and some liquid medications. o Ask patients preference regarding medications to be taken by hand or in cup and one at a time or all at once. o If capsule or tablet falls to the floor, discard it and administer a new one. o Record and fluid intake I-O measurement is ordered. 20. Remain with patient until each medication is swallowed unless nurse has been patient swallow drug, she or he cannot record drug as having been administered. 21. Perform hand hygiene. 22. Record each medication given on medication chart or record using required format. a. If drug was refused or omitted, record this in appropriate area on medication record. b. Recording of administration of a narcotic may require additional documentation on a narcotic record stating drug count and other specific information. 23. Check on patient within 30 minutes of drug administration to verify response to medication.