College of Mount St.

Joseph NUR 460

Division of Health Sciences, Departent of Nursing S! "0#0$"0##
SUCTIONING
Purpose
Reove respirator% secretions &hen patient is una'le to (o so &ith coughing an($or
e)pectoration.
Types
*rophar%ngeal
*rotracheal
Nasotracheal
Suctioning of artificial air&a%
When to Perform
+hen secretions are i(entifie( (uring assessent an( the patient is una'le to clear secretions
on his$her o&n.
Common Conditions which often result in Increased Secretions or Problems with
Cough!"pectoration
,lui( status
o ,lui( overloa( -increase(.
o Deh%(ration -thic/.
0ac/ of hui(it%
!nfections -pneuonia etc..
1nato% changes -a'noralities, e(ea, tuors etc..
Misc. con(itions -neurological 2stro/e etc3, paral%sis etc..
#elegation
Ma% 'e (elegate( to 14 onl% in special situations such as
sta'le patient &ith esta'lishe( tracheosto% or hoe ventilation
Ma% onl% 'e (elegate( if allo&e( per agenc% polic%, inclu(e( in the 5o' (escription of the 14,
an( the 14 has ha( appropriate training an( (eonstrate( copetence in perforing the s/ill
RN ust follo& all the appropriate steps of the (elegation process, inclu(ing a/ing sure it is
the right tas/, right circustance, right person, right counication$(irection, an( right
supervision$evaluation
$e%uired !%uipment
Suction catheter -sallest (iaeter that &ill effectivel% reove secretions. *R 6an/auer
catheter -for oral secretions.
7o&el or (rape
Sterile or clean gloves -(epen(s on t%pe of suctioning.
Suction e8uipent -&all or porta'le.
4ersonnel protective e8uipent for nurse -as/ 9 e%e protection or face shiel(.
Sterile saline apoules -controversial: not al&a%s use(.
Connecting tu'e
Physical SignsSymptoms of Need to Suction
Respirator% rate changes -usuall% increase(.
1(ventitious 'reath soun(s
Nasal secretions
;urgling
Drooling
Restlessness
;astric secretion or voitus in outh
Coughing &ithout clearing secretions
Others &associated with hypo"ia or hypercapnia'
Decrease( Sp*"
1pprehension, an)iet%
Decrease( a'ilit% to concentrate
0etharg%
Decrease( 0*C
!ncrease( fatigue
Di<<iness
=ehavioral changes especiall% increase( irrita'ilit%
!ncrease( HR, =4, RR
Decrease( (epth of 'reathing
Car(iac (%srh%thias
4allor
C%anosis
D%spnea
Techni%ue O(er(iew
+ill 'e either clean or sterile techni8ue (epen(ing on area suctione(
o Clean > orophar%n)
o Sterile > orotracheal, nasotracheal, suctioning of artificial air&a%
Ma% re8uire pre?o)%genation an($or (eep 'reathing
Re8uires 44@ -as/, face shiel(, goggles.
)ey Steps
1ssess clientAs respirator% status
;ather supplies
*and hygiene
Identify client
@)plain proce(ure
4osition client -H*= elevate( 'est.
$emo(e salinewater basin without contaminating other materials
4our saline$&ater into 'asin
+pply sterile glo(es, #ominant hand will remain sterile,
+ttach suction catheter to suction tubing and turn on suction &while
maintaining sterility of catheter,'
7est suction &ith saline$&ater.
0u'ricate catheter &ith saline$&ater or &ater solu'le lu'ricant.
o ,or trach onl% use saline to lu'ricate
Nares
Insert catheter into nares to appropriate distance without applying
suction,
+pply suction to remo(e secretions &-. /-0 second ma"imum'
+s suction catheter is remo(ed use twisting motion, 1ay also intermittently
apply suction,
7racheosto%
o Bpreo)%genateC 'efore suctioning
o ,or patients that can cough onl% insert as far as o'turator
o ,or patients &ho cannot cough a% nee( to insert (eeper 'ut N*7 as far as carinaDD
#o NOT apply suction during insertion
+pply suction to remo(e secretions &-. /-0 second ma"imum'
+s suction catheter is remo(ed use twisting motion,
Reassess clientAs respirator% status.
4rovi(e cofort care -&ipe outh, oral care prn.
#isposes of materials without contamination,
Perform hand hygiene,
2ea(e client in a safe and appropriate conditionposition,
$ecording and $eporting
4resuction > patientAs car(iopulonar% status
1fter suction / 1ount, consistenc%, color, o(or, patient response, an( patientAs
car(iopulonar% status
Docuentation @)aple > (presuction) Diffuse inspiratory and expiratory wheezes all fields,
frequent productive cough of thick yellow secretions, increased WOB, ! "#, !! $#, O% &"'(
(after suction) )opious thick yellow secretions, no odor, client coughed vigorously with
procedure, no *radycardia, decreased inspiratory wheezes all fields, respirations full and
unla*ored, ! &#, !! %#, O% "+'( ,atient ver*alized, -.ow / can *reathe0(
Une"pected Outcomes and Inter(entions
+orsening respirator% con(ition
o 0iit length of suctioning
o Deterine nee( for ore fre8uent &ith shorter (uration
o Notif% MD
=loo(% secretions
o Chec/ suction pressure
o @valuate fre8uenc%
o 4rovi(e ore fre8uent oral h%giene
Una'le to pass catheter through #
st
nares
o 7r% other naris or oral route
o !nsert nasal air&a%
o ;ui(e catheter along floor of naris
o !f ucus o'struction suction ucus: if clot notif% MD
o !ncrease lu'rication of catheter
Cough spass
o 1(inister o)%gen
o 1llo& rest 'et&een passes
o Consult MD for nee( for 'roncho(ilators or inhale( anesthetics
No secretions
o @valuate flui( status
o 1ssess for infection
o Deterine nee( for chest ph%siotherap%
o 1ssess hui(ification on o)%gen (eliver% (evice