307
Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition
Nome, Date,
Unit Position.
InsituctorfEveluator: Position
SKILL 14-11
Suctioning the Tracheostomy: Open System
:
i
Goal: the patient exhibitsimprovedoreath sounds onda
clea patent ciwey. Comments
Needs Practice
cellent
—— —_] i Bring necessary equipment tothe bedside stand or overbed
table.
—— | 2-Perform nand hygiene and put on PPE, ifindicated.
— —— | 3.tdentty the patient.
— | + Glose curtains around bed and close the door tothe room,
ifpossible
—— —— —_| 5 determine the need for suctioning. Verify the suction order
inthe patient's chart, Assess for pain or the potential to
cause pain, Administer paln medication, as prescribed,
before suctioning.
—— —— —| 6 kxptain to the patient whatyou are going to do and the
reason or doing it, even ifthe patient does not appear to
be alert. Reassure the patient you wil interrupt the proce-
dure ifhe or she indicates respiratory dificulty.
— — | 7-Aujust bed to comfortable working position, usually elbow
height ofthe caregiver (VISN 8 Patient Safety Center, 2009).
Lower side rai closest to you. if patient is conscious, place
‘him or her in a semi-Fowler's position. f patient is uncon-
scious, place him or her in the lateral position, facing you.
Move the overbed table close to your work area and raise to
‘waist height
—— —— —_| 8 Place towel or waterproof pad across patient's chest.
—— — —_| 9.1wn suction co appropriate pressure.
— — =| Forawail uniefor an adult: 100-120 mm Hg (Roman,
2005); neonates: 60-80 mm Hg: Infants: 80-100 mm Hg:
children: 80-100 mm Hg; adolescents: 80-120 mm Hg
(reton, 2007)
—— —| Fora portable unitfor an adult: 10-15 em Hg; neonates:
6-8 em Ng: nfants 8-10 cm Hg; children 8-10 cm Hg;
adolescents: 8-10 om Hg.
— — | Puronadisposable, clean glove and occlude the end of
the connecting tubing to check suction pressure. Place the
connecting tubing in a convenient location. if using, place
resuscitation bag connected to oxygen within convenient
reach,
(coy 20:1 Wouter Lge liek Wain Sicherheit
“nung Pcs pon ean ned een.Excellent
Satisfactory
Needs Practice
SKILL 14-11
Suct
ning the Tracheostomy: Open System (Continued)
Comments
10, Open sterile suction package using aseptic technique, The
‘open wrapper or container becomes a sterile field to hold
‘other supplies. Carefully remove the sterile container,
‘touching only the outside surface. Set it up on the work
surface and pour sterile saline nto I.
11. Put on face shield or goggles and mask, Puton sterile
gloves. The dominant hand will manipulate the catheter
‘and must remain sterile. The nondominant hand is consid
‘ered clean rather than sterile and will control the suction
valve (Y-port) on the catheter.
12, With dominant gloved hand, pick up sterile eatheter, Pick
‘up the connecting tubing with the nondominant hand and
connectthe tubing and suction catheter,
13, Moisten the catheter by dipping it into the container of
sterile saline, unless itis silicone catheter. Occlude ¥-tube
tocheck suction.
14, Using your nondominant hand and a manval resuscitation
bag, lyperventilate the patient, delivering three to six
breaths or use the sigh mechanism on a mechanical
ventilator.
15, Open the adapter on the mechanical ventilator tubing oF
remove oxygen delivery setup with your nondominant
hand,
16. Using your dominant hand, gently and quickly insert
catheter into trachea. Advance the catheter to the predeter-
‘mined length. Do not occlude Y-port when inserting
‘catheter.
117. Apply suction by intermittent occluding the Y-port on
‘the catheter withthe thumb of your nondominant hand,
and gently rotate the catheter as ti being withdrawn. Do
not suction for more than 10 to 15 seconds ata time.
16. Hlyperventilate the patient using your nondominant hand
‘and a manual resuscitation bag, delivering three to six
breaths. Replace the oxygen delivery device, I applicable,
using your nondominant hand and have the patient take sev:
eral deep breaths. IFthe patient is mechanically ventiated,
lose the adapter on the mechanical ventilator tubing and,
use the sigh mechanism on a mechanical ventilator.
19, Flush catheter with saline. Assess the effectiveness of,
suctioning and repeat, as needed, and according to
patient’ tolerance. Wrap the suction catheter around your
‘dominant hand between attempts.
‘og 2011by ewes Upp Win in Ces Cine se
‘Attra ats precede ams yn an lec,309
Excellent
Satisfactory
Needs Practice
SKILL 14-11
Suctioning the Tracheostomy: Open System (Continued)
Comments
20. Allow at least a 30-second to 4-minute interval if additional
‘suctioning is needed. No more than three suction passes
Should be made per suctioning episode. Encourage the
patient to cough and deep breathe between suctionings. Suc-
tion the oropharynx after suetioning the trachea. Do not
reinsert inthe tracheostomy after suctioning the mouth.
21, When suctioning is completed, remove gloves from domi-
nant hand over the oiled catheter, pulling t off inside out.
Remove glove from nondominant hand and dispose of
loves, catheter, and container with solution in the appro-
Driate receptacle. Assist patient toa comfortable position.
Raise bed rail and place bed inthe lowest position,
22. Turn off suction. Remove supplemental oxygen placed for
suctioning, if appropriate. Remove face shield or goggles
and maste Perform hand hygiene.
23. Offer oral hygiene ater suctioning,
24, Reassess patient's respleatory status including respiratory
rate, effort, oxygen saturation, and lung sounds,
25. Remove additional PPE, fused. Perform hand hygiene.
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‘ving es ochre Pc yma eon