Suctioning Objectives: After 2 hours of varied teaching and learning activities, the Level II students will be able to:

1. Define the following terms: 1.1. Suctioning 1.2. Aspiration 1.3. Hypoxia 1.4. Hypoxemia 1.5. Cough reflex 1.6. Asphyxia 2. Review the normal anatomy and physiology of the respiratory system 3. Enumerate the following: 3.1. Types of Suction Catheter 3.2. Types of Suctioning According to Depth 4. Discuss suctioning as to its: 4.1. Purpose 4.2. Indications 4.3. Contraindications 4.4. Complications 5. Explain the following: 5.1. Principles involved in suctioning 5.2. Nursing responsibilities, before, during, and after suctioning 6. Demonstrate beginning skills in suctioning

DEFINITION OF TERMS: 1. SUCTIONING - is aspirating secretions through a catheter connected to a suction machine or wall suction outlet. 2. ASPIRATION - the withdrawal of fluid that has abnormally collected or to obtain a specimen. - the unintentional inhalation of oro pharyngeal or gastric contents into the trachea or the lung airways. 3. HYPOXIA - insufficient oxygen anywhere in the body specifically the body tissues

4.HYPOXEMIA - reduced or insufficient oxygenation of the blood in the blood vessels. 5. COUGH REFLEX - removal of inhaled foreign bodies and irritating material from the respiratory tract - is initiated with the sensory receptors that detect these substances and initiate action potentials that pass along the vagus nerves to the medulla oblongata, where the cough reflex is triggered. 6.ASPHYXIA - is a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally . Ex: choking

ANATOMY OF THE RESPIRATORY SYSTEM

UPPER RESPIRATORY SYSTEM NOSE PHARYNX LARYNX

LOWER RESPIRATORY SYSTEM TRACHEA LUNGS o BRONCHI o BRONCHIOLES o ALVEOLI o PULMONARY CAPILLARY NETWORK o PLEURAL MEMBRANES

TRACHEA Major function is to maintain and protect the air way. It is lined with mucus glands which is humidifying as the air passes through it and catches the small particles before they enter. Trachea is supplied by nerves that are part of the cough reflex that helps get rid of irritation.

PHYSIOLOGY OF RESPIRATION a. PULMONARY VENTILATION MOVING AIR IN AND OUT OF THE LUNGS b. EXTERNAL RESPIRATION GAS EXCHANGE BETWEEN BLOOD AND CHAMBERS OF LUNGS c. RESPIRATORY GAS TRANSPORT GAS TRANSPORT BETWEEN LUNGS AND TISSUE CELLS OF THE BODY d. INTERNAL RESPIRATION GAS EXCHANGES BETWEEN BLOOD AND TISSUE CELLS

MECHANICS OF BREATHING a. INHALATION the diaphragm & intercostal muscles contract

when the diaphragm contracts, is pulled downward toward the abdomen, gets flatten & enlarges the chest cavity when the intercostal muscles contract, chest rises and enlarges the chest cavity expansion of chest cavity causes the air pressure in the alveoli to decrease Air from the outside environment rushes in through the nose or mouth to equalize the pressure.

b. EXHALATION diaphragm & intercostal muscle relax when the diaphragm muscle relaxes, it moves upward when the intercostal muscles relax, moves down and inward Both actions cause the air pressure in the alveoli to increase and force air out of the lungs through the airways & out the nose or mouth. TYPES OF SUCTION CATHETER OPEN TIP

More effective in removing thick mucous plugs

WHISTLE TIP

- is designed to slide down the endotracheal tube easily and has holes on the side and molded ends that minimize trauma of the tracheal & bronchial walls YANKAUER SUCTION

- used to suction the oral cavity WALL SUCTION UNIT - a suction device which can be found mounted on a wall in a patients room

TYPES OF SUCTIONING ACCORDING TO DEPTH SHALLOW SUCTIONING - Suction secretions at the opening of the area to be suctioned. PRE- MEASURED SUCTIONING - Suction the length of the area, or the length of the tracheotomy tube DEEP SUCTIONING - it is inserting the catheter until resistance is felt - is usually not necessary - be cautious & avoid vigorous suctioning as this may injure the lining of the airway.

TYPES OF SUCTIONING ROUTES ORAL & PHARYNGEAL - Removes the secretions from the upper respiratory tract NASOPHARYNGEAL & NASOTRACHEAL - Provides closer access to the trachea and requires sterile techniques

Purpose: Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning: To remove secretions that obstruct the airway. To facilitate ventilation To obtain secretions for diagnostic purposes. To prevent infection that may result from accumulated secretions.

Suctioning a Tracheostomy or Endotracheal Tube: To maintain a patent airway and prevent airway obstructions. To promote respiratory function (optimal exchange of oxygen and carbon dioxide into and out of the lungs) To prevent pneumonia that may result from accumulated secretions

Indications: Patients who have signs and symptoms of respiratory distress.

o Ex: Poor Skin Color (Cyanosis) Patients who are unable to cough up and expectorate secretions. Patients with dyspnea o Decreased Oxygen Saturation levels Patients with bubbling or rattling breath sounds Patients with decreased oxygen saturation levels. Unconscious Patients with muscle weakness and paralysis Patients with a nasogastric feeding tube o To avoid feeding tube obstruction and accumulation of waste and filth. Patients with diminished cough/gag/sneezing reflexes.

Contraindications: Frequent suctioning. o This may disturb the normal mucosal lining of the area being suctioned.

Complications: Hypoxia o Due to the suctioning of the airway and oxygen being consumed. Trauma to the airway o From extensive suctioning. Nosocomial infection o From unsterile technique. Cardiac dysrhythmia which is related to hypoxemia o Due to the suctioning of oxygen along with secretions and the heart trying to compensate for the reduced oxygen saturation in the blood.

Principles involved in suctioning: Physics the negative pressure involved during suctioning. Also, the position of the patient plays a role in the effectiveness of suctioning. Proper positioning can promote optimum suctioning and promote breathing. Anatomy and Physiology the nurse must know how to properly insert the suction catheter. Also, the nurse must know the structure of the airway to promote proper suctioning technique. Microbiology sterile techniques must be observed to prevent infection because suctioning is an invasive procedure Psychology the nurse must be able to establish rapport with the patient in order for the patient to trust the nurse and for the procedure to be done. Patients might also feel embarrassed about having suctioning done, so patients privacy is important.

Safety proper suctioning technique must be performed to prevent further injury to the patient. During suctioning, secretions are removed, but also oxygen may be removed. The patient must be pre-oxygenated before the procedure is done and an oxygen source must be present at all time. This is done to prevent dysnea and hypoxia from occurring. Suctioning must also be applied only upon withdrawal of the catheter in a circular motion. This is done to maximize the suctioning of secretions. This motion must not be done very rapidly to avoid injuring the patient. Time and Energy In suctioning, the nurse should not constantly suction the patient. Suctioning should be done in intervals with a duration of 10 seconds each suctioning. This is to avoid suctioning the oxygen in the lungs of the patient. Suctioning must also be done as needed and during scheduled time to avoid accumulation of secretions and to avoid placing the patient at risk for dysnea. Chemistry When lubricating the suction catheter, an isotonic solution like Normal Saline Solution must be used. This is used because it does not affect the cells by shrinking them or swelling them.

Nursing responsibilities, before, during, and after suctioning Before: Transcribe the order on the yellow/blue ticket (depending on the hospital policies) Introduce yourself Verify the clients identity Explain the procedure to the client. o Inform the client that suctioning will relieve breathing difficulty. o Inform the client that suctioning is painless, but may be uncomfortable and stimulate the cough/gag/sneeze reflex. Perform medical handwashing. Provide privacy by performing the procedure in the patients room and also closing the blinds and curtains. Prepare the equipment. o Attach the resuscitation apparatus to the oxygen source. Adjust the oxygen flow to 100%. o Open the sterile supplies and arrange. Place the towel or moisture-resistant pad over the pillow or under the chin. Place the sterile towel across the clients chest below the tracheostomy. Hyperoxygenate the patient before starting the procedure. This is done by placing the patient on 100% oxygen inhalation for 30 seconds o Source: Lesson 25, Page 25, Intensive and Critical Care Nursing (2009) Published by Elsevier

o Authors: Pedersen, Rosendahl-Neilsen, Hjermind, and Egerod Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning: o Position a conscious person who has a functioning gag reflex in semiFowlers position with the head turned to one side for oral suctioning or with the neck hyperextended for nasal suctioning. o Position an unconscious patient in the lateral position, facing you. Suctioning a Tracheostomy or Endotracheal Tube: o Place the client in a semi-Fowlers position to promote deep breathing, maximum lung expansion, and productive coughing. o Provide analgesia before suctioning, if necessary. During: Oral and Oropharyngreal Suctioning: Moisten the tip of the Yankauer/Suction catheter with sterile water/saline. Pull the tongue forward, if necessary using a gauze. Do not apply suction during insertion. Advance the catheter about 10-15cm (4 to 6 in.) along one side of the mouth into the oropharynx, Apply suctioning, for 10 seconds upon withdrawal of the catheter in a circular manner, to secretions that collect in the vestibule of the mouth and beneath the tongue.

Nasopharyngeal and Nasotracheal Suctioning: Open the lubricant Open the sterile suction package o Set up the cup/container, only touching the outside. o Pour the sterile water/saline into the container. o Don sterile gloves, or a nonsterile glove on your nondominate hand and a sterile glove on your dominant hand. Pick up the catheter with your sterile hand and attach it to the suction unit. Approximately measure the depth for insertion of the catheter and test the equipment. o Measure the distance between the tip of the clients nose and the earlobe. About 13 cm (5 inches) for adults. o Position the tube with the fingers of the sterile gloved hand.

o Test the pressure of the suction and the patency of the catheter by applying your sterile gloved finger/thumb to the port/open branch of the Y-connector. Lubricate and introduce the catheter without applying suction. Never force the catheter against an obstruction. Perform Suctioning. o Apply your finger to the suction control port to start suction. o Gently rotate the catheter o Apply suction for 5-10 seconds while slowly withdrawing the catheter. Discontinue suctioning before removal of the catheter o Suction for 10-15 seconds only. Rinse the catheter and repeat if needed. Encourage the patient to breathe deeply and to cough between suctions. Obtain a specimen, if required. Promote patient comfort at all times.

Suctioning a Tracheostomy or Endotracheal Tube: o Turn on the suction and adjust the pressure (100-120 mm Hg for adults; 50 95 mm Hg for children and infants) o Don goggles, mask, and gown, if necessary. o Don sterile gloves. o Hold the catheter in the dominant hand and an unsterile glove on the nondominant hand to protect the nurse. o Flush and lubricate the catheter in normal saline solution. o Hyperventilate the patient if they do not have copious secretions. If copious secretions are present, do not hyperventilate with a resuscitator. o Quickly and gently insert the catheter without applying suction. o Insert the catheter about 12.5 cm (5 in) in adults. o Perform Suctioning o Reassess the patients oxygenation status and repeat suctioning, if necessary. After: Hyperoxygenate the patient after the procedure. This is done by placing the patient on 100% oxygen inhalation for 30 seconds. o Source: Lesson 25, Page 25, Intensive and Critical Care Nursing (2009) Dispose of the catheter, gloves, water, and waste container. o Wrap the catheter around your sterile gloved hand and hold the catheter as the glove is removed for disposal.

Rinse the suction tubing as needed. Change the suction tubing and container daily. Ensure that supplies are available for the next suctioning. Assess the effectiveness of suctioning by auscultating the clients breath sounds. Observe skin color, dyspnea, level of anxiety, and oxygen saturation levels. Document data. Perform after care.

Source(s): -Fundamentals of Nursing by Kozier & Erb, Chapter 50: Oxygenation -Merriam & Websters Medical Dictionary -University of Maryland Medical Center Online Medical Reference Encyclopedia - Lesson 25, Page 25, Intensive and Critical Care Nursing (2009) Published by Elsevier Authors: Pedersen, Rosendahl-Neilsen, Hjermind, and Egerod