PROCEDURE GUIDELINES 10-9

Nasotracheal Suctioning
EQUIPMENT
Assemble the following equipment or obtain a prepackaged tracheostomy care kit:
Disposable suction catheter (preferably soft rubber)
Sterile towel
Sterile disposable gloves
Sterile water
Anesthetic water-soluble lubricant jelly
Suction source at -80 to -120 mm Hg
Resuscitation bag with face mask. Connect 100% O2 source with flow of 10 L/minute
Oximeter
PROCEDURE
Nursing Action Rationale
Preparatory phase
1. Monitor heart rate, respiratory rate, color, ease of respirations. If the patient 1. Suctioning may cause the occurrence of:
is on monitor, continue monitoring heart rate or arterial blood pressure. a. Hypoxemia—Initially resulting in tachycardia and increased blood
Discontinue the suctioning and apply oxygen if heart rate decreases by 20 pressure, and later causing cardiac ectopy, bradycardia, hypotension,
beats per minute or increases by 40 beats per minute, if blood pressure and cyanosis.
increases, or if cardiac dysrhythmia is noted. b. Vagal stimulation resulting in bradycardia.

Performance phase
1. Make sure that the suction apparatus is functional. Place suction tubing 1. The procedure must be done aseptically because the catheter will be
within easy reach. 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
a. At a certain interval, the patient will be requested to cough to open the cooperation.
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) 7. The “contaminated” hand must also be gloved to ensure that
as “sterile” and the other hand as “contaminated.” 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 9. If obstruction is met, do not force the catheter. Remove it and try the other
nostril and back into the pharynx. nostril.
1 Pass the catheter into the trachea. To do this, ask the patient to cough or say 1 These maneuvers may aid in opening the glottis and allowing passage of
0. “ahh.” If the patient is incapable of either, try to advance the catheter 0. the catheter into the trachea. To evaluate proper placement, listen at the
on inspiration. Asking the patient to stick out tongue, or hold tongue catheter end for air, or feel for air movement against the cheek. An
extended with a gauze pad, may also help to open the airway. If a protracted increase in intensity of breath sounds or more air movement against cheek
amount of time is needed to position the catheter in the trachea, stop and indicates nearness to the larynx. Gagging or sudden lessening of sound
oxygenate the patient with face mask or the resuscitation bag-mask unit at means the catheter is in the hypopharynx. Draw back and advance again.
intervals. If three attempts to place the catheter are unsuccessful, request The presence of the catheter in the trachea is indicated by:
assistance. 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.

1 Specific positioning of catheter for deep bronchial suctioning: 1 Turning the patient's head to one side elevates the bronchial passage on
1. 1. the opposite side, making catheter insertion easier. Suctioning of a
a. For left bronchial suctioning, turn the patient's head to the extreme particular lung segment may be of value in patients with unilateral
right, chin up. pneumonia, atelectasis, or collapse.
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.

1 Never apply suction until catheter is in the trachea. Once the correct position 1 Because entry into the trachea is often difficult, less change in arterial
2. is ascertained, apply suction and gently rotate catheter while pulling it 2. oxygen may be caused by leaving the catheter in the trachea than by
slightly upward. Do not remove catheter from the trachea. repeated insertion attempts.
1 Disconnect the catheter from the suctioning source after 5-10 seconds. Apply 1 Be sure adequate time is allowed to reoxygenate the patient as oxygen is
3. oxygen by placing a face mask over the patient's nose, mouth, and catheter, 3. removed, as well as secretions, during suctioning.
and instruct the patient to breathe deeply.
1 Reconnect the suction source. Repeat as necessary. 1 No more than three to four suction passes should be made per suction
4. 4. episode.
1 During the last suction pass, remove the catheter completely while applying 1 Never leave the catheter in the trachea after the suction procedure is
5. suction and rotating the catheter gently. Apply oxygen when the catheter is 5. concluded, because the epiglottis is splinted open and aspiration may
removed. occur.

Follow-up phase
1. Dispose of disposable equipment.
2. Measure heart rate, blood pressure, respiratory rate, and oxygen saturation. Record the patient's tolerance of 2. To assess for hypoxemia, trauma, or
procedure, type and amount of secretions removed, and complications. other complications.
3. Report any patient intolerance of procedure (changes in vital signs, bleeding, laryngospasm, upper airway noise).
PROCEDURE GUIDELINES 10-13
Administering Nebulizer Therapy (Sidestream Jet Nebulizer)
EQUIPMENT
Air compressor
Connection tubing
Nebulizer
Medication and saline solution
PROCEDURE
Nursing Action Rationale
Preparatory phase
1 Monitor the heart rate before and after the treatment for patients 1 Bronchodilators may cause tachycardia, palpitations, dizziness, nausea, or nervousness.
. using bronchodilator drugs. .
Performance phase
1 Explain the procedure to the patient. This therapy depends on 1 Proper explanation of the procedure helps to ensure the patient's cooperation and
. patient effort. . effectiveness of the treatment.
2 Place the patient in a comfortable sitting or a semi-Fowler's 2 Diaphragmatic excursion and lung compliance are greater in this position. This ensures
. position. . maximal distribution and deposition of aerosolized particles to basilar areas of the
lungs.
3 Add the prescribed amount of medication and saline to the 3 A fine mist from the device should be visible.
. nebulizer. Connect the tubing to the compressor and set the flow .
at 6-8 L/minute.
4 Instruct the patient to exhale.
.
5 Tell the patient to take in a deep breath from the mouthpiece, hold 5 This encourages optimal dispersion of the medication.
. breath briefly, then exhale. .
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 7 This will ensure that medication is deposited below the level of the oropharynx.
. breaths. .
8 Instruct the patient to breathe slowly and deeply until all the 8 Medication will usually be nebulized within 15 minutes at a flow of 6-8 L/minute.
. medication is nebulized. .
9 On completion of the treatment, encourage the patient to cough 9 The medication may dilate airways, facilitating expectoration of secretions.
. after several deep breaths. .
Follow-up phase
1 Record medication used and description of secretions.
.
2 Disassemble and clean nebulizer after each use. Keep this 2 Each patient has own breathing circuit (nebulizer, tubing, and mouthpiece). Through
. equipment in the patient's room. The equipment is changed . proper cleaning, sterilization, and storage of equipment, organisms can be prevented
according to facility policy. from entering the lungs.