In this assignment, I reflected on one nursing skill in clinical practice upon

a specific client group. The skill was selected to underpin the appropriate
therapeutic interventions within the patients. The tracheostomy suction would be
reflected within this assignment by using a reflective model based on the
previous practice on the tracheostomy patients. The skill was focused on the
management of airway due to the blocked of the patients’ respiratory. As Siviter
(2004, p.165) explains the important of reflection is about gaining self-
confidence, identify when to improve, learning from own mistakes and behaviour,
looking at other people perspectives, being self-aware and improving the future
by learning from the past. I select to reflect and discuss this skill for my reflection
based on the past incidents because I want to improve my suctioning skill for
tracheostomy patients in managing airway for future practice. In order to achieve
the goal, the adequate knowledge underpins regarding the skill was essential to
be explored to offer the safe practice. Therefore within this assignment, the
knowledge that contributes to the way in performing the skill also been identified.

In this reflection, I would use Gibbs (1988) Reflective Cycle. This model
was a recognised framework for reflection. The essential of using model in the
reflection was supported by Brooker and Nicol (2003, p16) because it provided
the conceptual frameworks in structuring the nursing practice. As Gibbs (1988)
model consists of six stages to complete one cycle which is able to improve my
nursing practice continuously and learning from the experience for better practice
in the future. The cycle starts with a description of the situation, analysis of the
feelings, evaluation of the experience, analysis to make sense of the experience,
a conclusion of what else could I have done and final stage is an action plan to
prepare if the situation arose again (NHS, 2006). Baird and Winter (2005, p156)
state that a reflect is to generate the practice knowledge, assist an ability to
adapt new situations, develop self-esteem and satisfaction as well as to value,
develop and professionalizing practice.
 Generally, tracheostomy is a preferable intervention to the patients which
involved in long term mechanical ventilation especially in the critical care
settings. McPhee et al (2008, p200) indicates the tracheostomy is done due to
the respiratory failure and the obstruction above the larynx. Therefore in order to
enhance the patients’ airway, the patients underwent the intubation procedure
under the surgical intervention. According to Barnett (2005, p4) tracheostomy is a
surgical opening in the anterior wall of trachea. The tracheostomy provided more
comfort to the patients by clearing secretions which could reduce the resistance
of respiration (Marino and Sutin, 2006, p495). Once the surgical intervention
done, the suctioning via the tracheostomy tube would be performed to assist in
clearing the blockage of the respiration airway. Furthermore, the tracheostomy
tube suction is a vital skill in a way to promote better and effective respiration for
the patients. Barnett (2008, p26) supports that the suction technique allow the
secretions out from the patients’ chest via the tracheostomy and consequently
provide the patent airway.

During clinical practice, I observed, assisted and performed the

tracheostomy suctioning. The skill was quite challenging and it required the good
understanding and competency. According to the local guideline, the suction
should be performed when necessary (Kaur, 2008, p1). This indicated that the
frequency of suction performed would depend on the patients’ condition. The
most important part to ensure that whether the patients required the suction was
to assess the patients’ condition either the oxygen saturation, percentage of
oxygen supply, chest movement or the level of cyanosis. Higgins (2005, p36)
outlines few assessment which is a comprehensive patient assessment included
the respiratory characteristics, chest movement, palpation and auscultation is
more important thing to look for rather than the regimented frequencies.
Fortunately I got chance to perform the skill on patients during my practical in the
ward as the patients were struggle for adequate breathing. I noticed the
saturation of oxygen decreased and skin changes from pink to blue even though
the supplemental oxygen was still administered. There were also changes in
breathing sound among the patients. I realized that the conditions of the patients
might be due to compensate of air to breathe in. Therefore I notified my clinical
instructor to perform the suction. I gained consent from patients, provided safety,
maintained their privacy, prepared equipments and performed the procedure. I
did suction via tracheostomy tube under the supervision of the clinical instructor.
Even I learnt the skill at the clinical lab in college, the clinical instructor still
guided me from the beginning until the procedure completed as I was not
competent enough to conduct the procedure on my own. I encountered the
objective in performed this skill as the patients’ respiration gradually improved
after the procedure.

I felt anxious during performing the procedure compared with my feelings

during practicing the skill in clinical lab at college. Performing encompassed more
strength and confidence. However, I was able to precede the skill until it
completed. During the procedure, I worried of my actions even though my clinical
instructor was next to me to support and guide my performances. My feelings
were mixed up especially regarding the pressure that I had to put on in order to
suction the patients. 80 to 120 mmHg was the pressure recommended by Smith
et al (2004, p912) because higher pressure provide a risk of mucosal damage.
Apart from that, I was taught by the clinical instructor to count until 10 seconds to
insert the catheter, do rotation and remove the suction catheter. Tollefson (2005,
p1073) mention the advantage of doing the rotation of catheter enhances the
removal of mucous. During the insertion of the catheter, no pressure applied yet
until one third of the catheter was inserted. Perruzzi and Candido (2007, p493)
explain no application of vacuum for the catheter should be placed until the
catheter beyond the tip of the tube. In the meantime I was scared that my
suctioning could do excessively make the patients worst. However Smith et al
(2004, p913) restrict the duration of suction should not be more than 10 seconds
to minimize loss of oxygen that could lead to hypoxia. Event though I did the
suction in 10 seconds but fortunately the patients did not turn to hypoxia. These
feelings lead me to the responsibility in duty of care to the patients. According to
Code of Conduct (Nursing & Midwifery Council, 2008, p1), a professional must
accountable for the actions in practice. I would be responsible of my actions
towards patients which eligible to receive the safe care. Therefore, even though I
was a not a register nurse yet but I reminded myself to be a responsible towards
the consequences of my actions in practicing the skill.

I evaluated my experience in performing the skill during clinical practice as

the significant and important part to develop the skill. Suctioning via
tracheostomy tube is an advanced skill in nursing practice. The skill required me
to understand the underpinning knowledge which relies on the procedure in
delivering the care to the patients. The experience provided me with the new
exposure to practice on real patients and I learnt to put the theory into practice.
As I learnt in college, I practiced on the mannequin who did not display the signs
and symptoms of the real conditions such as the skin changes, chest movement
and level of oxygen saturation. These conditions were very essential to evaluate
the patients in order to recognize the problem that encountered the patients. As
soon as the problem had been identified, the action was taken to overcome the
problem. Therefore according to Price (2008, p49) a combination of knowledge,
experience, decisions and actions construct the beneficial effects for patients
within the skills in practice. This was much related to my experience in clinical
practice to perform suctioning. I identified what decreased the saturation of
oxygen level, changes in skin colour and breathing sound. As a result I decided
to notify my clinical instructor and perform the suctioning. These experience
acquired knowledge to decide my actions towards patients.

I analysed that experience in clinical practice required more knowledge to

evaluate the incidents with the patients. Moreover assess, plan, intervention and
evaluate of the patients aided in delivering the care to the patients. The
procedure encompassed the knowledge and attitude in performing the skill on
the tracheostomy patients. The most important part I really had to have the
knowledge about the tracheostomy patients. The assessment on the patients
breathing could indicate the respiratory problems occur. Audible bilaterally is the
breath sounds signify that the air is flowing freely through the tracheostomy tube
(Astle, 2003, p35). The indication of sound explain by McConnell (2002, p17) are
the coarse breath sounds, noisy breathing, and prolonged expiratory sounds
showed that the patients needed to be suctioned.

Therefore if the patients could not breathe through the tracheostomy tube
that indicated that there was blockage occurs in the tube. Since patients were not
able to cough or secrete by themselves, I performed the suctioning procedure to
assist in secreting the mucous. Barnett (2006, p6) identify the cough reflex had
been impaired because of the tracheostomy tube which prevents to clear the
secretions through coughing. Buglass (1999, p500) state that the patients could
not have the sufficient intra-abdominal pressure to cough due to the
tracheostomy. According to Barnett (2008, p25) mention that suctioning would
be perform due to inability of the patients to secrete the mucous on their own in
order to maintain the patent airway .The reason of performing the procedure was
related to the patients’ conditions which occur due to the respiratory problems.

The tracheostomy tube should provide the patent airway for tracheostomy
patients in breathing process. However as the patients need more oxygen, the
administration of supplemental oxygen was provided to improve the breathing
process. Therefore the continuous monitoring of saturation oxygen of the patients
via pulse oximetry was applied to show the reading of the oxygen level in the
body. The purpose of the tool is to measure the arterial oxygen saturation of
haemoglobin by continuously monitoring the patients’ oxygenation status (Editors
of Nursing2008, 2008, p42). The decrease of the saturation oxygen indicated that
patients were consumed the less oxygen even the administration of oxygen was
provided. This situation specified that the airway was blocked. During performing
the suctioning, the saturation oxygen was continuously monitored. Instead of
that, the figure could determine and note the differences of the oxygen level of
the patients before and after the suctioning. The purpose is to indicate whether
the patients responding to the therapy or deteriorate because the normal range is
between 98%–100% (Higginsons and Jones, 2009, p458). The suction catheter
was inserted intermittently to allow the patients consumed oxygen. However after
the suctioning performed, the saturation oxygen increased. This situation showed
that the tube was patent and patients did not require suction.

Another consideration point was the positioning. I positioned the patients

based on their conditions before performed suctioning. The correct position was
very important to consider in suctioning. Edgtton-Winn and Wright (2005, p3)
specify the different position for the different conditions of the patients such as
the upright position suitable for the conscious patients compared to unconscious
patients on the semi Fowler’s position assist in clearing the secretions. The
positioning of patients to perform suctioning was varied because it depends on
their conditions.

Apart from that, I could clearly observe the colour of the nail beds patients
changed. The normal colour of the nail beds’ patients were pink but gradually
changed to slightly blue. I analyzed that the patients had the peripheral cyanosis.
Hadaway (2009, p 50) determine the cause of cyanosis is due to impair venous
return in the lower extremity. Apart from that according to Martin (2009, p1)
cyanosis occurs when approximately 5g/dL of deoxygenated haemoglobin in the
capillaries produce the dark blue colour which also indicate of hypoxemia. Moore
(2003, p52) suggests that the size of the catheter should not be more than half of
the diameter of the tracheotomy tube in order to prevent hypoxemia. Therefore, it
shows that the correct size of catheter contributed to the effectiveness of
tracheostomy suction depend on the patients’ size of tracheostomy tube.

During the suctioning, the mucous were secreted out from the tube. I
noticed the colour of secretion during suctioning. Colourless, green and yellow
were the colour of secretion from the patients. According to Johnson et al (2008,
p452) those condition presented due to either viral or bacterial infection resulted
from the inflammatory cells or sloughed mucosal epithelial cell. The findings were
documented to the patients’ record and inform to the senior staff nurse. The
physician notified from the findings from the senior staff nurse and further
treatment was conducted.

Though, I did discuss with my clinical instructor after performing the

procedure regarding the doubt that encountered my thinking during suctioning. I
did ask about the rest duration to the next suction but no accurate answer given
for my question because of quite unsure about the accurate timing. However
Tollefson (2004, p198) suggest that patients should rest 30 seconds before next
suctioning. Yet, during the procedure I did not gap 30 seconds to perform the
next suction but waited for 60 seconds. The evidence was contraindicated with
my practice as I performed under the supervision and teaching of the clinical
instructor. I could analyze that my practice could be improved if I referred to the
evidence literature compared to the practice based from the unsure clinical
instructor.

I performed the further suction based on the same principle of actions but
using new gloves and catheter. This is recommended by Dougherty and Lister
(2004, p699) to repeat the same actions by using the new sterile gloves and
catheter. I disposed the used sterile gloves and catheter into the clinical waste.
Furthermore, Anderson (2006, p138) advises to use waterproof trash bag to
discard the gloves and catheter. Dougherty and Lister (2004, p699) explain that
the suction catheter should be used once in order to reduce the risk of infections
during suctioning. Moreover, Timby (2008, p854) suggest that the further suction
should be performed unless the saturation oxygen remained 95% and above.
Nazarko (2008, p121) explains that suction could enhance the droplet
transmission of infection. Therefore, the skill was performed in aseptic technique.
Evidence (Thompson, 2000, p6) showed that it is important to apply aseptic
technique when performing suctioning for tracheostomy patients in hospital. The
next consideration was the frequency of further suction could be performed. In
my experience, I did the further suction twice. According to evidence presented it
was recommended that the maximum of suctioning were twice (Thompson, 2000,
p5). However Nicol and Bevin (2004, p288) argue that the tracheostomy
suctioning should be repeated until the secretion and breathing sounds clear.
This situation leads to the ability of decision-making to apply the best practice
depend on the patients’ condition within the clinical practice.

The effective suctioning provides the clear airway to the respiration take
place. I felt glad because the skill I performed offered the patients more effective
in breathing. The patients’ saturation oxygen increased and patients were
evaluated after implementing the suction intervention. In performing the skill, the
patients’ priorities were fulfilled such as privacy and safety. Price (2008, p52)
state that the patients would feel valuable when the nurse concerned about their
situation by showing the sensitivity, responsively and adaptable in nursing care.
Based on my experiences about suctioning, I realized that the skill did not only
require the competency but the underpinning knowledge within the actions during
the procedure and the way I evaluated the situations. Price (2008, p50) mentions
that the underpinning knowledge is likely based on the clinical experience
research.

In future if I were given a chance to practice the skill, I would practice

better from my previous experience. Hence within my action plan, I would prefer
to do further literature search on the knowledge and practice of tracheostomy
tube suctioning. It could improve my understanding towards the care of patients
and also enable me to put evidence-based into practice in order to provide the
best care. I learnt to develop and enhance the skill under the supervision of the
clinical instructor. However, due to my lack of experience the clinical instructor
was fully guided me. In future, I must able to work with less supervision.
According to Code of Conduct (Nursing & Midwifery Council, 2008, p7) in order
to work without direct supervision, I must have the knowledge and skills to
promote the effective and safe practice. Therefore I have to upgrade myself with
sufficient knowledge related to the evidence-base practice. Bowers and Jinks
(2004, p159) stated that the practitioner feel confident in the development of
practice from the constructive support and guidance in the consensuses
literature. Even though the qualified clinical instructor experienced to handle in
such incidents but I could not totally depend on the experiences in practice
because the way of practice could be changed and improved within the time
frame. Price (2008, p50) suggest that experience could be insight compared and
shared. Therefore it could be better if the current evidence and practice applied
in clinical practice. Jenkins (2005, p69) conclude that the work improve
dynamically by the process of linking theory and practice and also sense of
experience.

In conclusion, it is beneficial to use a model to reflect and analyze the skill

because it enables me to explore and evaluate my previous experiences in
clinical practice. I managed to analyze within the stages of the model. Moreover,
the development of the skill by analytical evaluate through the reflection process
enhances my base knowledge regarding to the skill and professional
improvement in future practice. The reflection provides me the opportunity to
improve the area of weakness that has to be upgraded in performing the skill in
future. I concern the existence of current evidence-base practice which provides
the guidance to improve my professional practice development.