PROCEDURE GUIDELINES 10-9Nasotracheal Suctioning

EQUIPMENTAssemble the following equipment or obtain a prepackaged tracheostomy care kit:

Disposable suction catheter (preferably soft rubber)Sterile towel

Sterile disposable glovesSterile water

Anesthetic water-soluble lubricant jellySuction source at -80 to -120 mm Hg

Resuscitation bag with face mask. Connect 100% O2 source with flow of 10 L/minuteOximeter

PROCEDURENursing Action Rationale

Preparatory phase1. Monitor heart rate, respiratory rate, color, ease of respirations. If the patient is on monitor,

continue monitoring heart rate or arterial blood pressure. Discontinue the suctioning and apply oxygen if heart rate decreases by 20 beats per minute or increases by 40 beats per minute, if blood pressure increases, or if cardiac dysrhythmia is noted.

1. Suctioning may cause the occurrence of: a. Hypoxemia—Initially resulting in tachycardia and increased blood pressure, and later

causing cardiac ectopy, bradycardia, hypotension, and cyanosis. b. Vagal stimulation resulting in bradycardia.

Performance phase1. Make sure that the suction apparatus is functional. Place suction tubing within easy reach. 1. The procedure must be done aseptically because the catheter will be entering the trachea

below the level of the vocal cords, and introduction of bacteria is contraindicated.2. Inform and instruct the patient about the procedure. 2. A thorough explanation will decrease patient anxiety and promote patient cooperation. a. At a certain interval, the patient will be requested to cough to open the lung passage so

the catheter will go into the lungs and not into the stomach. The patient will also be encouraged to try not to swallow because this will also cause the catheter to enter the stomach.

b. The postoperative patient can splint the wound to make the coughing produced by nasotracheal (NT) suctioning less painful.

3. Place the patient in a semi-Fowler's or sitting position if possible. 3. NT suctioning should follow chest physical therapy, postural drainage, or ultrasonic nebulization therapy. The patient should not be suctioned after eating or after a tube feeding is given (unless absolutely necessary) to decrease the possibility of emesis and aspiration.

4. Monitor oxygen saturation via oximetry and heart rate during suctioning. 5. Place a sterile towel across the patient's chest. Squeeze a small amount of sterile anesthetic

water-soluble lubricant jelly onto the towel.

6. Open the sterile pack containing curved-tipped suction catheter. 7. Aseptically glove both hands. Designate one hand (usually the dominant one) as “sterile†�

and the other hand as “contaminated.†�7. The “contaminated†� hand must also be gloved to ensure that organisms in the sputum

do not come in contact with the nurse's hand, possibly resulting in infection of the nurse.8. Grasp the sterile catheter with the sterile hand. 9. Lubricate catheter with the anesthetic jelly and pass the catheter into the nostril and back into

the pharynx.9. If obstruction is met, do not force the catheter. Remove it and try the other nostril.

10. Pass the catheter into the trachea. To do this, ask the patient to cough or say “ahh.†� If the patient is incapable of either, try to advance the catheter on inspiration. Asking the patient to stick out tongue, or hold tongue extended with a gauze pad, may also help to open the airway. If a protracted amount of time is needed to position the catheter in the trachea, stop and oxygenate the patient with face mask or the resuscitation bag-mask unit at intervals. If three attempts to place the catheter are unsuccessful, request assistance.

10. These maneuvers may aid in opening the glottis and allowing passage of the catheter into the trachea. To evaluate proper placement, listen at the catheter end for air, or feel for air movement against the cheek. An increase in intensity of breath sounds or more air movement against cheek indicates nearness to the larynx. Gagging or sudden lessening of sound means the catheter is in the hypopharynx. Draw back and advance again. The presence of the catheter in the trachea is indicated by:

a. Sudden paroxysms of coughing. b. Movement of air through the catheter. c. Vigorous bubbling of air when the distal end of the suction catheter is placed in a cup

of sterile water. d. Inability of the patient to speak.

11. Specific positioning of catheter for deep bronchial suctioning: 11. Turning the patient's head to one side elevates the bronchial passage on the opposite side, making catheter insertion easier. Suctioning of a particular lung segment may be of value in patients with unilateral pneumonia, atelectasis, or collapse.

a. For left bronchial suctioning, turn the patient's head to the extreme right, chin up. b. For right bronchial suctioning, turn the patient's head to the extreme left, chin up. Note: The value of turning the head as an aid to entering the right or left mainstem bronchi is

not accepted by all clinicians.12. Never apply suction until catheter is in the trachea. Once the correct position is ascertained,

apply suction and gently rotate catheter while pulling it slightly upward. Do not remove catheter from the trachea.

12. Because entry into the trachea is often difficult, less change in arterial oxygen may be caused by leaving the catheter in the trachea than by repeated insertion attempts.

13. Disconnect the catheter from the suctioning source after 5-10 seconds. Apply oxygen by placing a face mask over the patient's nose, mouth, and catheter, and instruct the patient to breathe deeply.

13. Be sure adequate time is allowed to reoxygenate the patient as oxygen is removed, as well as secretions, during suctioning.

14. Reconnect the suction source. Repeat as necessary. 14. No more than three to four suction passes should be made per suction episode.15. During the last suction pass, remove the catheter completely while applying suction and

rotating the catheter gently. Apply oxygen when the catheter is removed.15. Never leave the catheter in the trachea after the suction procedure is concluded, because the

epiglottis is splinted open and aspiration may occur.Follow-up phase1. Dispose of disposable equipment. 2. Measure heart rate, blood pressure, respiratory rate, and oxygen saturation. Record the patient's tolerance of procedure, type and amount

of secretions removed, and complications.2. To assess for hypoxemia, trauma, or other

complications.3. Report any patient intolerance of procedure (changes in vital signs, bleeding, laryngospasm, upper airway noise).

PROCEDURE GUIDELINES 10-13Administering Nebulizer Therapy (Sidestream Jet Nebulizer)

EQUIPMENTAir compressor

Connection tubingNebulizer

Medication and saline solutionPROCEDURE

Nursing Action RationalePreparatory phase1. Monitor the heart rate before and after the treatment for patients using

bronchodilator drugs.1. Bronchodilators may cause tachycardia, palpitations, dizziness, nausea, or nervousness.

Performance phase 1. Explain the procedure to the patient. This therapy depends on patient effort. 1. Proper explanation of the procedure helps to ensure the patient's cooperation and effectiveness of the

treatment.2. Place the patient in a comfortable sitting or a semi-Fowler's position. 2. Diaphragmatic excursion and lung compliance are greater in this position. This ensures maximal distribution

and deposition of aerosolized particles to basilar areas of the lungs.3. Add the prescribed amount of medication and saline to the nebulizer. Connect the

tubing to the compressor and set the flow at 6-8 L/minute.3. A fine mist from the device should be visible.

4. Instruct the patient to exhale. 5. Tell the patient to take in a deep breath from the mouthpiece, hold breath briefly,

then exhale.5. This encourages optimal dispersion of the medication.

6. Nose clips are sometimes used if the patient has difficulty breathing only through the mouth.

7. Observe expansion of chest to ascertain that patient is taking deep breaths. 7. This will ensure that medication is deposited below the level of the oropharynx.8. Instruct the patient to breathe slowly and deeply until all the medication is

nebulized.8. Medication will usually be nebulized within 15 minutes at a flow of 6-8 L/minute.

9. On completion of the treatment, encourage the patient to cough after several deep breaths.

9. The medication may dilate airways, facilitating expectoration of secretions.

Follow-up phase 1. Record medication used and description of secretions. 2. Disassemble and clean nebulizer after each use. Keep this equipment in the

patient's room. The equipment is changed according to facility policy.2. Each patient has own breathing circuit (nebulizer, tubing, and mouthpiece). Through proper cleaning,

sterilization, and storage of equipment, organisms can be prevented from entering the lungs.