Oxy Skills

ADMINISTERING OXYGEN BY CANNULA, FACE MASK, OR FACE TENT Overview: Oxygen is a basic need; it is required for life. Adequate oxygenation is essential for cerebral functioning. The cerebral cortex can tolerate hypoxia for only 3-5 minutes before permanent damage occurs. Nurses frequently assists clients in meeting oxygen needs. Indication: When a client has inadequate ventilation or impaired pulmonary gas exchange, oxygen (O2) therapy may be needed to prevent hypoxia.

The primary care provider

prescribes O2 therapy, the method of delivery, and the liter flow per minute. In hospitals and long-term care facilities, O2 is usually piped into wall outlets at the client’s bedside. In other facilities, pressurized tanks or cylinders of O2 are used. Small, portable cylinders of O2 are available for clients who require oxygen therapy at home.

O2 is a dry gas, so

humidifying devices are essential to add water vapour to the inspired air, especially if the liter flow is >2 L/min. Oxygen Delivery Devices: Cannula – The cannula is disposable plastic tube with two prongs for insertion into the nostrils.

It fits around the head or loops over the ears to hold it in place and is

connected by tubing to the O2 source. It is easy to apply, relatively comfortable, and allows the client to eat and talk. It is adequate for rates of 2-6 L/min. Above 6 L/min it is not effective. Face Mask – Masks cover the client’s nose and mouth. They have exhalation ports on the sides to allow exhaled carbon dioxide to escape. It is important that the mask be of appropriate size for the client. •

Simple face mask

- Delivers O2 concentration of 40%-60% at flows of 5-8

L/min, respectively •

Partial rebreather mask – Delivers O2 concentrations of 60-90% at flows of 6-10 L/min, respectively.

•

Nonrebreather mask – Delivers the highest possible of O2 concentration (95%100%), except for intubation or mechanical ventilation, at flows of 10-15 L/min.

Face Tent – Some clients do not tolerate masks well;

they may respond with

anxiety or even panic. A face tent is similar to a mask, but larger and open at the top. It fits snugly around the client’s jaw line, but is open at the top over the nose. It delivers a concentration of 30%-50% at 4-8 L/min. Transtracheal catheter – is placed through a surgically created tract in the lower neck directly into the trachea. Once the trach has matured, the client removes and cleans the catheter two or four times per day. Oxygen applied to the catheter at less than 1 L/min need not be humidified, and rates above 5 L/min can be administered.

Safety Precautions: •

Place cautionary sings reading “No Smoking: Oxygen is in Use” on the client’s door, at the foot or head of bed, and on the oxygen equipment.

•

Instruct the client and visitors about the hazard of smoking with oxygen in use.

•

Make sure that electrical equipment (e.g. razors, hearing aids, radios, televisions, and heating pads) is in good working order to prevent occurrence of short-circuit sparks.

•

Avoid materials that generate static electricity, such as woollen blankets and synthetic fabrics.

Cotton blankets are used, and nurses are advised to wear

cotton fabrics. •

Avoid, the use of volatile, flammable materials, such as oils, greases, alcohol, and ether, near clients receiving oxygen. Avoid alcohol back rubs, and take nail polish removers and the like away form the immediate vicinity.

•

Ground electric monitoring equipment, suction machines, and portable diagnostic machines

•

Make known location of fire extinguishers, and make sure personnel are trained in their used.

Assessment: •

Signs of hypoxia: tachycardia, tachypnea, dyspnea, pallor, cyanosis

•

Signs of hypercabia: restlessness, hypertension, headache

•

Signs of oxygen toxicity:

tracheal irritation, cough,

decreased pulmonary

ventilation Special Considerations: •

Older adults are prone to dehydration that causes dry mucous membranes.

•

Ciliary action decreases with age, causing decreased clearing of the airways.

•

Muscular structures of the pharynx and larynx atrophy with age.

•

Less ventilation in the lower lobes of the older adult causes secretions to pool or predispose to pneumonia.

Equipment: Cannula •

Oxygen supply with a flow meter and adapter

•

Humidifier with distilled water or tap water according to agency protocol

•

Nasal cannula and tubing

•

Tape

•

Padding for the elastic band

Face Mask •

Oxygen supply with a flow meter and adapter

•

Humidifier with distilled water or tap water according to agency protocol

•

Prescribed face mask of the appropriate size

•

Padding for the elastic band

Face Tent •

Oxygen supply with a flow meter and adapter

•

Humidifier with distilled water or tap water according to agency protocol

•

Face tent of the appropriate size PROCEDURE

RATIONALE

Preparation 1.

2.

Determine the need for oxygen therapy,

To develop a baseline data if not already

verify the order for the therapy.

available

Prepare the client and support people.

This position permits easier chest expansion

•

and hence easier breathing

Assist the client to a semi-Fowler’s position if possible.

•

Explain that oxygen is not dangerous when safety precautions are observed. Inform the client and support people about the safety precautions connected with oxygen use.

Performance 1.

Explain to the client what you are going

By explaining the procedure the nurse can

to do, why is it necessary, and how he

help to allay anxiety.

or she can cooperate. Discuss how the effects of the oxygen therapy will be used in planning further care or treatments. 2.

Wash hands and observe appropriate

To prevent transfer of micoorganisms

infection control procedures. 3.

Set up oxygen equipment and the

Dry gasses dehydrate the respiratory

humidifier.

mucous membrane.

•

Attach flow meter to the wall outlet or tank. The flow meter should be in the OFF position.

•

If needed, fill the humidifier bottle (This can be done before coming to the bedside).

•

Attach humidifier bottle to the base of the meter.

•

Attach the prescribed oxygen tubing and delivery device to the humidifier.

4.

PROCEDURE Turn on the oxygen at the prescribed

RATIONALE

rate, and ensure proper functioning. •

Check that the oxygen is flowing

Kinks of the tubes obstruct the flow of air to

freely through the tubing. There

the client

should be no kinks in the tubing, and the connections should be airtight. There should be no kinks in the tubing, and the connections should be airtight. There should be bubbles in the humidifier as the oxygen flows through. You should feel the oxygen at the outlets of the cannula, mask or tent. •

5.

Set the oxygen at the flow rate

Bubbles in the water indicate that oxygen

ordered, for example.

flow is satisfactory

Apply the appropriate oxygen delivery device.

Cannula •

Put the cannula over the client’s face,

Correct placement of the prongs facilitate

with the outlet prongs fitting into the

oxygen administration.

nares and the elastic band around the head. •

If the cannula will not stay in place, tape it at the sides of the face.

•

Pad the tubing and band over the

To reduce irritation and pressure on the

ears and cheekbones as needed.

cheek or behind the ears.

Face Mask •

Guide the mask toward the client’s

The mask should mold to the face so that

face, and apply it from the nose

very little oxygen escapes into the eyes or

downward. •

around the cheek and chin

Fit the mask to the contours of the client’s face.

•

Secure the elastic band around the

Mask that fits snugly to clients face

client’s head so that the mask is

minimizes the loss of oxygen.

comfortable but snug.

Padding will prevent irritation from the mask.

•

PROCEDURE Pad the band behind the ears and

RATIONALE

over bony prominences. Face Tent •

Place the tent over the client’s face, and secure the ties around the head

7.

Assess client regularly. •

•

Assess the client’s vital signs, level of

Continuous assessment provides information

anxiety, color, and ease of

if the client is tolerating the oxygen therapy

respirations, and provide support

well or not and prevents possible

while the client adjusts to the device.

complications.

Assess the client in 15-30 minutes, depending on the client’s condition, and regularly thereafter

•

Assess the client regularly for clinical signs of hypoxia, tachycardia, confusion, dyspnea, restlessness, and cyanosis. Review arterial blood gas if they are available.

Nasal Cannula •

Assess the client’s nares for encrustations and irritation. Apply a water-soluble lubricant as required to soothe the mucous membranes.

Face Mask or Tent •

Inspect the facial skin frequently for dampness or chafing, and dry and treat it as needed.

8.

PROCEDURE Inspect the equipment on a regular basis •

Check the liter flow and the level of water in the humidifier in 30 minutes and whenever providing care to the client.

•

Make sure safety precautions are being followed

9.

Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate.

RATIONALE

TEACHING DEEP – BREATHING EXERCISES Definition: Lung inflation techniques include diaphragmatic breathing exercises, apical and basal lung expansion exercises, and use of blow bottles, sustained maximal inspiration (SMI) devices , or intermittent positive pressure breathing (IPPB) apparatuses. Apical Expansion exercises are often required for clients who restrict their upper chest movement because of pain from severe respiratory disease or surgery eg, lobectomy. Purpose: To promote the exchange of gases in the lungs and strengthen the muscles used for breathing. Indication: For clients with restricted chest expansion such as people with chronic obstructive pulmonary disease (COPD) or people recovering from thoracic surgery.

PROCEDURE 1. Assess the client’s condition and identify

RATIONALE Factors like client’s anxiety may affect the

anything that may affect the success of

client’s ability to follow the procedure. In

the procedure.

addition, pain on the part of the client may alter client’s learning capability.

Abdominal (diaphragmatic ) and Pursed-Lip

A person who understands and accepts the

Breathing

importance of deep breathing is more likely

2. Explain to the client that diaphragmatic

to cooperate and participate in the exercise.

breathing can help the person breath more deeply and with less effort. 3. Have

the

client

assume

either

a

The semi-Fowler’s and supine position with

comfortable semi-Fowler’s position with

knees

flexed

knees flexed, back supported, and with

muscles.

help

relax

will

aid

the

abdominal

one head pillow or a supine position with one head pillow and knees flexed. After learning, the client can practice. 4. Have the client place one or both hands on the abdomen just below the ribs.

This

position

in

the

accurate

observation of the patient’s chest expansion.

PROCEDURE 5. Instruct the client to breath in deeply

RATIONALE When a person breaths in, the diaphragm

through the nose with the mouth closed,

contracts (drops), the lungs fill with air and

to stay relaxed, not to arch the back, and

the abdomen rises or protrudes.

to concentrate on feeling the abdomen rise as far as possible. 6. If the client has difficulty raising the abdomen, instruct the person to take a

With a quick sniff, the client will feel the abdomen rise.

quick, forceful inhalation through the nose. 7. Instruct the client to purse the lips as if

Pursing the lips creates a resistance to air

about to whistle; to breath out slowly and

flowing out of the lungs , increases pressure

gently, making a slow “ whooshing “

within

sound; to avoid puffing out the cheeks;

collapse of smaller bronchioles , a common

to concentrate on feeling the abdomen

problem for clients with COPD. While the

fall or sink; and to tighten the abdominal

client breaths out, the diaphragm relaxes

muscles while breathing out.

(rises) and the abdomen sinks. Tightening

the

bronchi,

and

minimizes

the

the abdominal muscles helps a person to exhale more effectively. 8. If the client has COPD, teach the “double

A very forceful cough by a client with COPD

cough” technique. Have the client

can case small airway collapse. With two or

a. Breath in through the nose and inflate

more abrupt coughs, the first one loosens

the lungs to the mid inspiration point,

secretions;

while

subsequent

facilitate

rather than to the full deep inspiration

movement of secretions toward the upper

point.

airways.

b. Simultaneously exhale and cough two or more abrupt, sharp coughs in rapid succession. 9. Instruct the client to use this exercise whenever

feeling

short

of

breath

to

increase it gradually 5-10 minutes four

Regular practice enables a person eventually to

do

this

type

of

breathing

without

conscious effort.

times a day. APICAL EXPANSION EXERCISES 10. Place your fingers below the client’s clavicles and exert moderate pressure, or have the client place his or her fingers over the same area.

This hand position enables evaluation of the depth of apical inhalation.

PROCEDURE 11. Instruct the client to inhale through the nose and to concentrate on pushing the

RATIONALE This helps aerate the apical areas of the upper lung lobes.

upper chest upward and forward against the fingers. 12. Have the client hold the inhalation for a

This promotes aeration of the alveoli.

few seconds. 13. Have

the

client

exhale

through

the

This allows for more comfortable alveolar

or

nose

slowly,

quietly

and

expansion. Slow movement usually creates

mouth

passively while concentrating on moving

less discomfort than rapid movement does.

the upper chest inward and downward. 14.

Instruct

the

client

to

perform

the

Repeating the exercise helps to reexpand

exercise for at least five respirations four

lung

tissue,

eliminate

secretions,

and

times a day.

minimize flattening of the upper chest wall.

BASAL EXPANSION EXERCISES 14. Place the palms of your hands in the area

of

the

lower

ribs

along

the

midaxillary lines, and exert moderate

This hand position enables evaluation and comparison of the depth of bilateral basal inspiration.

pressure, or have the client place his or her hands over the same areas. 15. Instruct the client to inhale through the

To encourage complete lung expansion.

nose and to concentrate on moving the lower chest outward against the hands. 16. Have the client hold the inhalation for a few seconds. 17. Have the client exhale through the nose

This allows for more comfortable elveolar

or mouth slowly, quietly and passively. If

expansion. Slow movement usually creates

the person has COPD, observe the rate

less discomfort than rapid movement does.

and character of the exhalation. Normal exhalation is slow, and the upper chest appears

relaxed.

If

the

exhalation

appears difficult or there is in drawing of the upper chest, encourage pursed-lip exhalation.

18. Instruct

PROCEDURE the client to perform

this

exercise at least five respirations four

RATIONALE Repetition helps to reexpand lung tissue and eliminates secretions.

times a day. 19. Correct the patient’s breathing technique as necessary.

To encourage complete lung expansion.

ASSISTING CLIENTS TO USE INCENTIVE SPIROMETRY Definition: Incentive spirometry is a method of encouraging voluntary deep breathing by providing visual feedback to clients about inspiratory volume. Purpose: It is used to promote deep breathing to prevent or treat atelectasis in the postoperative client. Equipment: •

Incentive spirometer

PROCEDURE 1. Wash hands.

RATIONALE Reduces transmission of microorganisms.

2. Instruct client to assume semi-Fowler’s

Promotes optimal lung expansion.

or high Fowler’s position. 3. Either aet or indicate to client on the device scale, the volume level to be

Establishes goal to volume level necessary for lung expansion.

attained with each breath. 4. Demonstarte

to

client

how

to

place

Demonstration

is

reliable

technique

for

mouthpiece of spirometer so that lips

teaching psychomotor skills and enables

completely cover mouthpiece.

client to ask questions.

5. Instruct

and

Maintains maximal inspiration and reduces

unit.

risk of progressive collapse of individual

When maximal inspiration is reached,

alveoli. Slow breath prevents or minimizes

client should hold breath for 2 to 3

pain from sudden pressure changes in chest.

maintain

client

to

constant

inhale flow

slowly

through

seconds and then exhale slowly. 6. Instruct client to breath normally for

Prevents hyperventilation and fatigue.

short period. 7. Have

client

repeat

maneuver

until

Ensures correct use of spirometer.

volume goals are achieved. 8. Wash hands.

Reduces transmission of microorganisms.

9. Record the procedure done and client’s

Documents client’s education and provides

ability to perform it.

data for instructional follow-up.

ADMINISTERING PERCUSSION, VIBRATION, AND POSTURAL DRAINAGE TO ADULTS Definition: Percussion sometimes called clapping or cupping, is forcefully striking the skin with cupped hands. Vibration is a series of vigorous quivering produced through hands that are placed flat against chest wall. Postural drainage is the drainage, by gravity, of secretions from various lung segments. Indication: For clients who produce greater than 30cc of sputum per day or have evidence of atelectasis by chest x-ray examination. Contraindication: 1. 1.Percussion is contraindicated in clients with bleeding disorders, osteoporosis, or fractured ribs. Considerations: Postural drainage, percussion and vibration is best tolerated if done between meals , at least two hours after the patient has eaten, to decrease the possibility of vomiting. Purpose: 1. To mechanically dislodge and loosen mucous secretions. 2. Facilitate drainage of mucous secretions by gravity. Equipment: 1. A bed that can be placed in Trendelenburg position. 2. Towel PROCEDURE 1. Provide visual and auditory privacy.

RATIONALE Coughing and expectorating secretions can embarrass the client and disturb others.

2. Assist

the

client

to

the

appropriate

To provide the appropriate position for

position for postural drainage.

postural drainage.

Drainage of the upper lobe

To drain the apical segments of the upper

3. Have the client lie back at a 30o angle.

lobes.

Percuss

and

vibrate

between

clavicles and above the scapulae.

the

PROCEDURE 4. Have the client sit upright in a chair or in bed with the head bent slightly forward.

RATIONALE To drain the posterior segments of the upper lobes.

Percuss and vibrate the area between the clavicles and scapulae. 5. Have the client lie on a flat bed with pillows

under

them.Percuss

the and

knees

vibrate

to the

flex

To drain the anterior segments of the upper lobes.

upper

chest below the clavicles down to the nipple

line,

except

for

women.

The

breasts of women are not percussed, because percussion may cause pain. Drainage of the right middle lobe and lower division of the left upper lobe

6. Elevate the foot of the bed about 15o or To drain the right lateral and medial 40cm and have the client lie on the left

segments.

side. Help the client to lean back slightly against pillows extending at the back from the shoulder to the hip. A pillow may be placed between the knees for comfort. For a male, percuss and vibrate over the right side of the chest at the level of the nipple between the 4rth and 6th ribs For a female, position the heel of your hand toward the axilla and your cupped

fingers

beneath

the

extending

breast

to

forward

percuss

and

vibrate beneath the breast.

7. Elevate the foot of the bed as in step 6, and have the client lie as in step 6 except on the right side.Percuss and vibrate the right side of the chest as in

To drain the left lingular segments.

step7. Drainage of the lower lobes 8. Have the client lie on the abdomen on a flat bed, and place two pillows under the hips. Percuss and vibrate the middle area of the back on both sides of the spine.

To drain the superior segment

PROCEDURE 9. Have the client lie on the unaffected

RATIONALE To drain the anterior basal segment.

side, with the upper arm over the head. Elevate the foot of the bed about 30o or 45 cm , or to the height tolerated by the client. Place one pillow between the knees.

Another

under

the

head

is

optional.Percuss and vibrate the affected side of the chest over the lower ribs, inferior to the axilla. 10. Have

the

unaffected

client side

lie

partly

on

the

and

partly

on

the

To drain the lateral basal segments.

abdomen. Elevate the foot of the bed about 30o or 45cm (18in.), or to the height tolerated by the client. As an alternative, elevate the hips with pillows. Percuss and vibrate the uppermost side of the lower ribs. 11. Have the client lie prone. Elevate the

To drain the posterior basal segments.

foot of the bed about 30o or 45cm (18in.), or to the height tolerated by the client. Elevate the hips on two or three pillows to produce a jackknife position from the knees to the shoulders.Percuss and vibrate over the lower ribs on both sides close to the spine, but not directly over the spine or the kidneys. PERCUSSION 12. Ensure that the area to be percussed is covered. 13. Ask the client to breath slowly and deeply.

Percussing

skin

directly

can

cause

discomfort. Slow deep breathing promotes relaxation.

14. Cup your hands,ie, old your fingers and

Cupped hands trap the air against the chest.

thumb together , and flex them slightly

The trapped air sets up vibrations through

to form a cup, as you would to scoop up

the chest wall to the secretions , helping to

water.

loosen them.

PROCEDURE 15. Relax your wrists, and flex your elbows.

RATIONALE Relaxed wrists, and flexed elbows help obtain a rapid ,hollow, popping action.

16. With both hands cupped, alternately flex

These blows are transmitted through the

and extend the wrists rapidly to slap the

tissue and help loosen secretions in the lung

chest. The hands must remain cupped so

segment immediately below the area struck.

that air cushions the impact, to avoid injuring the client. 17. Percuss each affected lung segments for 1-2 minutes.

The percussing action should produce a hollow, popping sound when done correctly.

VIBRATION 18. Place your flattened hands, one over the other (or side by side) against the affected chest area. 19. Ask the client to inhale deeply through

This

preserves

the

normal

inspiratory-

the mouth and exhale slowly through

expiratory ratio and encourages maximum

pursed lips or the nose.

filling and emptying of the alveoli.

20. During the exhalation, straighten your elbows, and lean slightly against the

Isometric contractions

will transmit

fine

vibrations through the client’s chest wall.

client’s chest while tensing your arm and shoulder

muscles

in

isometric

contractions.

21. Vibrate during five exhalations over one affected lung segment. 22. Encourage

the

client

Vibrating over a specific five times will loosen the secretion.

to

cough

and

expectorate secretions into the sputum

To remove unpalatable taste of the mucus secretions from the mouth.

container. Offer the client mouthwash. 23. Auscultate

the

client’s

lungs,

and

compare the findings to the baseline

To

check

for

intervention.

the

effectiveness

of

the

data. 24. Document the percussion, vibration, and postural

drainage

and

assessments.

Note the amount, color, and character of expectorated secretions.

Anything done to a client undocumented is considered not done.

STEAM INHALATION Definition: A treatment to provide warm, moist air for the patient to breath. Indication: 1. Irritation (tickling or pain in throat) by moistening mucous membranes. 2. Acute or chronic inflammation and congestion of mucous membranes of nose and throat due to colds and bronchitis. 3. Coughing (relaxes muscles). 4. Dry or thick secretions. Purposes: 1. To relieve swelling, inflammation, congestion and pain in the nose and throat in upper respiratory infections. 2. To stimulate expectoration. 3. To reduce dryness of mucous membrane. 4. To relieve spasmodic breathing. Equipment: •

Pitcher

•

Basin

•

Boiling water

•

Paper cone

•

Bath towel and face towel (patient’s gown)

•

Drug ordered (optional)

NOTE: If an electric inhaler/ vaporizer is used, please study operation manual/ package. PROCEDURE 1. Check doctor’s order.

RATIONALE Steam inhalation may be initiated by a doctor’s order.

2. Explain procedure to client.

To ensure client operation.

3. Wash hands.

Hand washing deter the spread of infection.

4. Place boiling water about 1/3 to ½ full in a pitcher. 5. Add ordered medication, if any.

Boiling

water

provides

moist

heat

for

inhalation. In some instance, drug may be administered via steam inhalation.

6. Bring pitcher on a basin to the bedside. Place on a firm surface.

To enable the health worker to safely bring equipment to bedside.

7. Assist

PROCEDURE client to assume

convenient

RATIONALE To provide comfort during procedure.

position. May sit at edge of bed. Provide privacy PRN. 8. Place paper cone on mouth of pitcher.

Paper cone directs steam to client’s nose.

9. Place bath towel over client’s chest.

To provide a safe distance from the stream.

Provide face towel over client’s forehead

A towel may be provided to protect client’s

and eyes as necessary. At about one foot

eyes if the steam is perceived to be too hot

away from the paper cone, have the

for the client’s eyes.

client inhale steam. 10. Remove pitcher at the end of prescribed

To provide to client protection from cold air

period. Wipe client’s face and make him

prevents chilling caused by marked change

comfortable. Protect from cold air.

in air temperature. This may counteract the benefits of inhalation.

11. Wash used article with soap and water

To prevent spread of infection.

(except cone). Rinse and dry and return to proper place. Wash hands. 12. Record client’s response to therapy.

For proper documentation of procedure.

OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING Definition: Suctioning is the aspiration of secretions, often through a rubber or polyethylene catheter connected to a suction machine or outlet. Oropharyngeal or nasopharyngeal suctioning removes secretions from the upper respiratory tract. Suctioning is the aspiration of secretions by a rubber catheter connected to a suction machine with an application of a negative pressure to create a vacuum to enable secretions to move from an area of higher pressure (the airway) to an area of lower pressure (the suction bottle). Indications: This procedure is indicated when the client: 1. Is unable to cough and expectorate secretions effectively (e.g., infants and comatose patients); 2. Is unable to swallow; 3. Makes light bubbling or rattling breath sounds that indicate the accumulation of secretions in the respiratory tract; and 4. Is dyspneic or appears cyanotic. Purposes: 1. To remove secretions that obstruct the airway; 2. To facilitate respiratory ventilation; 3. To obtain secretions for diagnostic purposes; and 4. To prevent infection that may result from accumulated secretions in the respiratory tract. Special Considerations: 1. Perform suctioning several minutes before mealtime. 2. Suction client immediately if he is cyanotic. 3. Report to the nurse or physician significant changes observed in the client’s condition after suctioning. 4. Have standby oxygen at bedside. Equipments:

1. Towels or pads 2. Emesis basin lined with paper 3. Portable or wall suction machine: includes a collection bottle, a tubing system connected to the suction catheter, and a gauge that registers the degree of suction 4. Sterile disposable container for sterile fluids 5. Sterile normal saline or water 6. Sterile gloves

7. Sterile suction catheter a. For adults - #12 to # 18 b. For children - # 8 to # 10 c. For infants - # 5 to # 8 Note: If both oropharynx and nasopharynx are to be suctioned, one sterile catheter is required for each. Types of Suction Catheter 1. Open-tipped catheter – has an opening at the end and several openings along the sides. It is effective for thick mucus plugs, but it can irritate the tissue. 2. Whistle-tipped catheter – has a slanted opening at the tip. Most catheters have a thumb port on the side, which is used to control the suction. Several openings along the sides of the tip of the suction catheter ensures distribution of negative pressure of the suction over a wide area, thus preventing excessive irritation of any area of the respiratory mucous membrane. 2. Water-soluble lubricant or glass of sterile water 3. Y-connector 4. Sterile gauzes 5. Moisture-resistant disposable bag 6. Sputum trap or cup, if specimen is to be collected 7. Sterile forceps (in cases where institution practices such or in absence of gloves) 8. Resuscitation bag (Ambu bag) connected to 100% oxygen

PROCEDURE A. Prepare the client. 1. Wash hands and observe other

RATIONALE For infection control.

appropriate infection control procedures (e.g., gloves, goggles. 2.

Gather necessary equipment and

supplies.

Knowing that the procedure will relive breathing problems is often reassuring and enlists client cooperation.

3.

Explain to the client, regardless

of level of consciousness, the purpose and rationale of the procedure. Provide information that suctioning will relieve breathing difficulty and the procedure is painless but may stimulate the cough, gag, or sneeze reflex.

4.

PROCEDURE Assess for signs and symptoms

RATIONALE

indicating upper airway secretions: gurgling respirations, restlessness, vomitus in the mouth, and drooling. Monitor HR, RR, color, and ease of respirations. 5.

Position the client correctly.

For oropharyngeal and nasopharyngeal suctioning: a. Position a conscious person who

This position facilitates the insertion of the

has a functional gag reflex in the

catheter and helps prevent aspiration of

semi-Fowler’s position with the

pulmonary secretions and gastrointestinal (GI)

head turned to one side for oral

contents.

suctioning or with the neck hyperextended for nasal suctioning. b. Position an unconscious client in the lateral position facing you.

This position allows the tongue to fall forward, so that it will not obstruct the catheter on insertion. Lateral position also facilitates drainage of secretions from the pharynx and prevents the possibility of aspiration.

6.

Place the towel or pad over the

pillow or under the chin. Provide

To protect the client’s gown and pillow from soiling.

emesis basin under the chin or side of the face. B. Prepare the equipment. 7.

Set the pressure on the suction

gauge and turn on the suction. Many

Suction should be ready to save time and effort when performing the procedure.

suction devices are calibrated to three pressure ranges: •

Wall unit

Calibrated pressure ranges provides safe but

•

Adult: 100-120 mmHg

effective negative pressure according to the

•

Child: 95-110 mmHg

client’s age and decreases possibility of

•

Infant: 50-95 mmHg

hypoxemia damage to mucous membranes.

•

Portable unit

•

Adult: 10-15 mmHg

•

Child: 5-10 mmHg

•

Infant: 2-5 mmHg

8.

PROCEDURE Hyperoxygenate client before

inserting catheter and suctioning. 9.

RATIONALE To provide sufficient amount of oxygen necessary before 10-15 seconds of suctioning.

Open the sterile suction

package. 10.

Set up the cup or container,

touching only its outside. 11.

Pour sterile water or saline into

the sterile container. 12.

Don the sterile gloves, or don a

The sterile gloved hand maintains the sterility

nonsterile glove on the non-dominant

of the suction catheter, and the unsterile glove

hand and sterile glove on the

prevents the transmission of the

dominant hand.

microorganisms to the nurse.

13.

With you sterile gloved hand,

pick up the catheter, and attach it to the suction unit. 14.

Open the lubricant if performing

nasopharyngeal suctioning. C. Make an approximate measure of the depth for the insertion of the catheter and test the equipment. For oropharyngeal and nasopharyngeal suctioning: 15.

Measure the distance between

Appropriate length ensures the catheter

the tip of the client’s nose and the

remains in pharyngeal region. Insertion past

earlobe or about 13cm (5in) for an

this point places catheter in trachea.

adult. The appropriate distance for an infant or small child is 4 to 8 cm (1.6 to 3.2 in) or 8 to 12 cm (3.2 to 4.8 in) for an older child.

For nasal tracheal suctioning,

Premeasuring the correct length for catheter

measure the distance between

insertion prior to suctioning prevents

the tip of the client’s nose to the

unnecessary trauma to the tracheal mucosa.

earlobe and then along the side of the neck to the thyroid cartilage (Adam’s apple). For oral tracheal suctioning, measure from the mouth to the midsternum.

16.

PROCEDURE Mark the position on the tube

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with the fingers of the sterile gloved hand. 17.

Test the pressure of the suction

and the patency of the catheter by

Ensures that equipment is functioning prior to insertion.

applying your sterile gloved finger or thumb to the port or open branch of the Y connector (the suction control) to create suction. D. Lubricate and introduce the catheter. For nasopharyngeal suction: a. Lubricate the catheter tip with

This reduces friction and eases insertion.

water-soluble lubricant. b. Without applying suction, insert

Gentle insertion without applying suction

the catheter the premeasured or

prevents trayma to the mucous membranes.

recommended distance into either

Directing the catheter along the floor of the

nares, and advance it along the

nasal cavity avoids the nasal turbinates.

floor of the nasal cavity. c. Never force the catheter against an obstruction. If one nostril is obstructed, try the other. For an orpharyngeal suction: a. Moisten tip with sterile water or

This reduces friction and eases insertion.

saline. b. Pull the tongue forward, if necessary, using gauze. c. Do not apply suction during insertion.

Doing so causes trauma to the mucous membranes.

d. Gently advance the catheter about 4 to 6 inches along one side of the mouth into the oropharynx.

Directing the catheter along the side prevents gagging.

PROCEDURE B. Perform suctioning. 18.

Apply your finger to the suction

RATIONALE Occlusion of control port activates suction

control port to start suction, and

pressure. Gentle rotation of the catheter

gently rotate the catheter. Suction

ensures that all surfaces are reached and

intermittently as catheter is

prevents trauma to any one area of the

withdrawn.

respiratory mucosa due to prolonged suction.

19.

Suctioning longer than 10-15 seconds robs the

Apply suction for 5 to 10

seconds; then remove your finger

respiratory tract of oxygen which may result to

form the control, and remove the

hypoxia, hypoxemia, and other

catheter. A suction attempt should last

cardiopulmonary complications.

only 10 to 15 seconds. During this time, the catheter is inserted, the suction applied and discontinued, and the catheter removed. It may be necessary during oropharyngeal suctioning to apply suction to secretions that collect in the vestibule of the mouth and beneath the tongue. C. Clean the catheter, and repeat suctioning as above. 20.

Wipe off the catheter with sterile

gauze if it is thickly coated with secretions. Dispose of the gauze in a moisture-resistant bag. 21.

Flush the catheter with sterile

water or saline.

Rinsing the catheter helps remove secretions from the tubing and lubricates it for next suctioning.

22.

Relubricate the catheter, and

Applying suction for too long may cause

repeat suctioning until the air passage

secretions to increase or decrease the client’s

is clear.

oxygen supply.

Note: Allow 20- to 30-second intervals between each suction, and limit suction to 5 minutes in total. 23.

Alternate nares for repeat

suctioning.

24.

PROCEDURE Encourage client to breathe

deeply and to cough between suctions.

RATIONALE Coughing and deep breathing help carry secretions from the trachea and bronchi into the pharynx, where they can be reached with the suction catheter.

D. Obtain a specimen if required. a. Attach the suction catheter to the rubber tubing of the sputum trap. b. Attach the suction tubing to the sputum trap air vent. c. Suction the client’s nasopharynx or oropharynx. The sputum trap will

This retains any microorganisms in the sputum trap.

collect the mucus during suctioning. d. Remove the catheter from the client. Disconnect the sputum trap rubber tubing from the trap air vent. e. Connect the rubber tubing of the sputum trap to the air vent. f.

Flush the catheter to remove secretions from the tubing.

E. Promote client comfort. 25.

Offer to assist the client with

oral or nasal hygiene.

Respiratory secretions that are allowed to accumulate in the mouth are irritating to the mucous membranes and unpleasant to the taste.

F. Dispose of equipment and ensure

availability for the next suction. 26.

Dispose of the catheter, gloves,

water and waste container. Wrap the catheter around your sterile glove and roll it inside the glove for disposal.

Reduces spread of bacteria from suction equipment.

27.

PROCEDURE To ensure that equipment is

available for the next suctioning, change suction collection bottles and tubing daily or more frequently as necessary. G. Assess the effectiveness of suctioning. 28.

Auscultate the client’s breathing

sounds to ensure they are clear secretions. Observe for restlessness or presence of oral secretions. H. Wash hands. I.

Document relevant data. a. Record the procedure: the amount, consistency, color, and odor of sputum (e.g., foamy, white mucus: thick, green-tinged mucus; or blood-flecked mucus), client’s breathing status before and after the procedure and the client’s reaction to the procedure. b. If the technique is carried out frequently, e.g., q1h, it may be appropriate to record only once, at the end of the shift; however, the frequency of the suctioning must be recorded.

RATIONALE