Oropharyngeal-Nasopharyngeal Suctioning

Name: MACARAIG, MARIE KELSEY A, Date: OCTOBER 2, 2021

Course/ Year: BSN—III Score: __________________
Clinical Instructor: Mrs. Kathleen R. Parel RN, MAN
 

Purposes:
Copious secretions, which may obstruct the airway

Materials/Equipment needed:
Sterile bowls with sterile cover, sterile normal saline solution or sterile water, protective
eye gear (goggles), mask, face shield, disinfecting solution 1:1000 dilution, suction
machine, sterile packet container, suction tips (for oral and nasal), sterile forceps in
sterile bottle, sterile gauze, Yankauer tube (as an alternative to catheter suction)

STEPS
1. Assess respiratory status and
need for suctioning.
2. Wash hands.
3. Identify the client, provide privacy,
and explain procedure.
4. Don goggles, mask or face shield.
5. Place the client in semi-Fowler’s
position and drape a towel over his
chest.
6. Set the suction machine between
80-120 mmHg (60-100mmHg for
infants; 80-115 mmHg for a child).
7. Open all sterile packages, pour all
sterile solutions, and draw 5 to 10
mL of sterile normal saline solution
into the sterile syringe with sterile
gloves.
8. Ensure client oxygenation before
suctioning. If after IPPB treatment,
ventilate client 4-5 times in 100%
oxygen. Encourage client to do
keep breathing exercises 6-10
times. Increase oxygen flow,
unless contraindicated.
RATIONALE
Baseline respiratory assessment,
including an O2 saturation level, can alert
the health care provider to worsening
condition.
To prevent transmission of disease.
Ensure correct client, alleviate anxiety
and increase cooperation.
Protect the nurse from bodily secretions.
Promotes patient comfort and removal of
airway secretions.
Ensures that catheter tip reaches pharynx
for suctioning.
Normal saline is used to clean tubing
after each suction pass. To maintain
sterility.
Preoxygenation converts large proportion
of resident lung gas to 100% oxygen to
offset amount used in metabolic
consumption while ventilation or
oxygenation is interrupted and volume is
lost during suctioning
9. Put on sterile gloves, or use sterile Reduces transmission of microorganisms
forceps. protect nurse from bodily secretions.
10. Remove the suction tip from its Connects catheter to suction.
sterile container or from the sterile
packet container and attach one
end to the suction machine tubing.
11. Turn on the suction machine. To prevent irritation and discomfort to the
Moisten the suction tip in the bowl client while suctioning. Lubricating the
of sterile water or sterile normal catheter for easier insertion.
saline solution, or apply water-
soluble lubricant
12. Insert the catheter into the nostril. Application of suction pressure while
Do not apply suction while introducing catheter into nasal mucosa
inserting. increases risk for damage and increased
hypoxia.
13. Advance to posterior Oro-nasal To remove pharyngeal secretions.
pharynx.
14. Begin suctioning by placing thumb Intermittent suction removes pharyngeal
of your non-dominant hand over secretions and reduces trauma and
the catheter valve. Withdraw irritations.
catheter slowly could lessen
irritation/trauma by applying
intermittent suction at the catheter
valve with your non-dominant
thumb.
15. Suction no more than 10-15 Apply suction for only 10 to 15 seconds at
seconds at each insertion. a time to minimize tissue trauma and
hypoxia.
16. Dip the used suction tip in bowl of To clean and remove secretions in the
sterile water or sterile normal tubing.
saline solution, and place thumb of
your non-dominant hand over the
catheter valve, applying suction to
flush and rinse the suction tip.
17. Then, dip the rinsed solution tip in To disinfect the equipment.
bowl of disinfecting solution for a
few seconds.
18. Allow the client to rest as Applying rest phases reduces the risk of
necessary between catheter hypoxia.
insertions, and/or apply oxygen if
the client is oxygen-dependent.
19. Alternate between nostrils when
repeated suctioning is necessary.
20. Use a different suction tip for oral Using a different suction tip for oral and
suctioning. Insert the catheter nasal suctioning prevents cross
along the side of the mouth to the contamination.
 oral pharynx for oral suctioning,
and apply suction when
withdrawing, as described above.
Follow procedure numbers 14-17
21. When suctioning is completed, To clean and disinfect the equipment.
turn off the suction machine and
wipe the suction tip from the
disinfecting bowl with a sterile
gauze.
22. Return the suction tip in the sterile Returning the suction tip on the packet is
packet container for the next use, for immediate access for the next suction
or dispose after 24 hours per procedure. Disposing to prevent
institution’s policy. harboring of microorganism to the
equipment.
23. Provide oral hygiene after Promote hygiene and reduces oral
suctioning. infections.
24. Clean work area, ensure client’s Reduces transmission of microorganisms.
safety and comfort.
25. Remove gloves and wash hands. Reduces transmission of microorganisms.
26. Chart: Document the times, To provide accurate records.
reason for suctioning, Color and
characteristics of secretions, and
the client’s tolerance of the
procedure. Document oro-nasal
condition. Document the client’s
respiratory status before and after
suctioning, any complications, and
any nursing action taken.