DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

COLLEGE OF NURSING

PERFORMANCE EVALUATION CHECKLIST

Procedure: Nasopharyngal, Tracheal and Endotracheal Suctioning

Name: _________________________________________Year Level & Section: _____________

Date of Performance: ____________________

Procedure DONE NOT DONE Remarks

1.Prior to performing the procedure,
introduce self and verify the client’s identity
using agency protocol. Explain to to the client
what you are going to do, why it is necessary,
and how he or she can cooperate. Inform the
client that suctioning will relieve breathing
difficulty and that the procedure is painless,
but may be uncomfortable and stimulate the
cough,gag or sneeze reflex.
2.Perform hand hygiene and observe other
appropriate infection control procedures.
3.Provide for clirnt privacy
4.Prepare the client.
1)Position a conscious personwho has a
functional gag reflex in the semi-Fowler’s
position with the head turned to one side for
oral suctioning or with the the neck
hyperextended for nasal suctioning.
2)Position an unconscious client in the lateral
position,facing you
3)Place the towel or moisture-resistant pad
over the pillow or under the chin.
5.Prepare the equipment
1)Set the pressure on the suction gauge, and
turn on the suction. Many suction devices are
calibrated to three ranges.
2.Wall unit:
Adult: 100 to 120mm Hg
Child: 95 to 220 mm Hg
Infant: 50 to 95 mm Hg

Portable Unit:
Adult: 20 to 14 mm Hg
Child: 5 to 10 mm Hg
Infant: 2 to 5 mm Hg

Procedure: For Oral and Oropharyngal

suction
1.Moisten tip of the Yankauer or suction
catheter with sterile water or saline.
2.Do not apply suction(that is,leave your
finger off the port) during insertion.
3.Advance the catheter about 10 to 15 cm (4
to 6 in.), along one side of the mouth into the
oropharynx.

Procedure: For Nasopharyngeal and

Nasotracheal Suction
1.Open the lubricant if performing
nasopharyngeal/nasotracheal suctioning.
2.Open the sterile suction package.
a)Set up the cup or the container touching
only outside
3.Pour sterile water or saline into the
container.
4.Put on the sterile gloves or put on a
nonsterile glove on the nondominant hand.
5.With your sterile goved hand, pick up the
catheter and attach it to the suction unit.
6.Make the approximate measure of the
depth for the insertion of the catheter and
test the equipment.
a)Make sure the distance between the tip of
the client’s nose and the earlobe, or about
13cm (5in.) for an adult.
7.Mark the position on the tube with the
fingers of the sterile gloved hand.
8.Test the pressure of the suction and the
patency of the catheter by applying your
sterile gloved finger or thumb to the port or
open branch of the Y-connector (the suction
control) to create suction.
9.If needed, apply or increase supplemental
oxygen.
10.Lubricate and introduce the catheter.
a)Lubricate the catheter tip with sterile
water, saline or water soluble lubricant.
11.Remove oxygen with the nondominant
hand, if appropriate.
12.Without applying suction,insert the
catheter the premeasured or recommended
distance into either naris and advance it
along the floor of the nasal cavity.
13.Never force the catheter against the
obstruct. If one nostril is obstructed, thry the
other.
14.Perform suctioning.
15.Apply your finger to the suction control
port to start suction and gently rotate the
catheter.
16.Apply suction for 5 to 10 seconds while
slowly withdrawing the catheter, then
remove your finger from the control and
remove the catheter.
17.A suction attempt should last 10 to 15
seconds. During this time, the catheter is
inserted , the suction applied and
discontinued, and the catheter removed.
18.Rinse the catheter.
a)Rinse and flush the catheter and tubing
with sterile water or saline.
19.Relubricate the catheter and repeat
suctioning until the air passage is clear.
20.Allow the sufficient time between each
solution for ventilation and oxygenation.
Limit suctioning to 5 minutes in total.
21.Encourage the client to breathe deeply
and to cough between suctions. Use
supplemental oxygen, if appropriate.
22.Obtain specimen if required.
a)Use a sputum trap
b)Attach the suction catheter to the tubing
23.Remove the catheter from the client.
Disconnect the sputum trap tubing from the
suction tubing from the trap air vent.
24.Connect the tubing of the sputum trap to
the air vent.
25.Connect the suction catheter to the
tubing.
26.Flush the catheter to remove secretions
from the tubing.
27.Promote client comfort.
a)Assist the client with oral or nasal hygiene.
b)Assist the client to a position that facilitates
breathing.
28.Dispose of equipment, and ensure
availability for the next suction.
a)Dispose of the catheter, gloves, water, and
waste container. Wrap the catheter as the
glove is removed over it for disposal.
b)Rinse the suction tubing as needed by
inserting the end of the tubing into the used
water container. Empty and rinse the suction
collection container as needed or indicated
by protocol. Change the suction tubing and
container daily.
c)Ensure that supplies are available for the
next suctioning (suction kit,gloves,water or
normal saline)
29.Assess the effectiveness of suctioning.
a)Auscultate the client’s breath sounds to
ensure they are clear of secretions. Observe
skin color,dyspnea, and level of anxiety and
oxygen saturation levels.
30.Document relevant data.
a)Record the procedure: the
amount,consistency, color and odor of
sputum(e.g. foamy,white mucus, thick green
tinged mucus, or blood flecked mucus) and
the client’s respiratory status before and
after the procedure.This may include lung
sounds, rate and character of breathing and
oxygen saturation.
b)If the procedure is carried out frequently
(e.g.every hour) it may be appropriate to
record only once, at the end of the shift ;
however, the frequency of the suctioning
must be recorded.