URDANETA CITY

UNIVERSITY College of Health Sciences

Bachelor of Science in Nursing
Owned and operated by the City Government of Urdaneta

NCM 112- Care of Clients with Problems in Oxygenation, Fluid & Electrolytes, Infectious,
Inflammatory and Immunologic Response, Cellular Aberrations, Acute & Chronic
Skill: Oropharyngeal Suctioning

Name: _________________________________________ Date: ____________________

Year and Block: _______________________________ RLE Group: ______________

Directions: Please rate the student based on the competencies listed below. Indicate the rate on the
space provided for using the following as guide:

3 Excellent Student is able to do the task or demonstrate with full mastery,

indicating no errors and deficiency.
2 Satisfactory Student is able to do the task or demonstrate the skill with
some mastery, indicating major errors or deficiency.
1 Unsatisfactory Student is able to do the task with little mastery, indicating
major errors or deficiencies.
0 Needs Improvement Student is unable to demonstrate the skill.

PROCEDURE Rate
1. Identify patient using at least two identifiers (e.g., name and birthday or name
and medical record number) according to agency policy
2. Identify risk factors for airway obstruction: impaired cough or gag re ex,
weakened respiratory muscles, impaired swallowing, and decreased level of
consciousness.
3. Assess for signs and symptoms of hypoxia: anxiety, change in level of
consciousness, change in vital signs, decreased SpO2, adventitious sounds
4. Obtain patient’s oxygen saturation level via SpO2. Keep pulse oximeter in place.

5. Determine patient’s ability to hold or manipulate catheter and his or her

knowledge about use of suction catheter and procedure.
6. Assess for signs and symptoms of upper airway obstruction: gurgling on
inspiration or expiration, restlessness, obvious excessive oral secretions, drooling,
gastric secretions or vomitus in mouth, or coughing without clearing secretions
from upper airway.
7. Auscultate for presence of adventitious sounds

8. Expected outcomes following completion of procedure:

 No gurgling sounds are heard in patient’s pharynx on inspiration and
expiration.
 Drooling is diminished or absent.
 Vomitus or gastric secretions are absent from mouth.
 SpO2 improves or remains at patient’s normal baseline.
9. Perform hand hygiene. Gather equipment/supplies. Close room door or curtain.

10. Explain to patient how procedure helps clear airway secretions and relieves
some breathing problems. Explain that coughing, gagging, or (less commonly)
sneezing is normal and lasts only a few seconds. Encourage patient to cough
out secretions and show how to splint painful areas during procedure. Practice
coughing if able.
11. Position patient in semi-Fowler’s or sitting position. Place towel, cloth, or paper
drape across patient’s neck and chest.
12. Apply clean gloves. Apply mask or face shield if splashing is likely. Wear gown if
isolation precautions are indicated.
13. Fill cup or basin with approximately 100 mL of water or normal saline.

14. Connect one end of connecting tubing to suction machine and other to
Yankauer suction catheter. Turn on suction machine; set vacuum regulator to
appropriate setting (infants 80–100 mm Hg; children 100–120 mm Hg; adults
100–150 mm Hg) (AARC, 2004).
15. Check that suction machine is functioning properly by placing tip of catheter in
water or normal saline and suctioning small amount from cup or basin.
16. Remove patient’s oxygen mask if present. Nasal cannula may remain in place.
Keep oxygen mask near patient’s face.
17. Insert catheter into mouth along gum line to pharynx.
Move catheter around mouth until secretions have cleared.
Encourage patient to cough. Replace oxygen mask.
18. Rinse catheter with water or normal saline in cup or basin until connecting
tubing is cleared of secretions. Turn off suction. Place catheter in clean, dry area.
19. Wash face if secretions are present on patient’s skin.

20. Observe respiratory status. Repeat procedure if indicated.

May need to use standard suction catheter to reach into trachea if respiratory
status not improved (
21. Remove towel, cloth, or disposable drape and place in trash or in laundry if
soiled. Reposition patient; Sims’ or side-lying position encourages drainage and
should be used if patient has decreased level of consciousness.

(075) 600 - 1507

San Vicente West, Urdaneta City, Pangasinan
Bright future starts here ucu.edu.ph | ucuchs@ucu.edu.ph
 URDANETA CITY
UNIVERSITY College of Health Sciences
Bachelor of Science in Nursing
Owned and operated by the City Government of Urdaneta

22. Discard remainder of water or normal saline into appropriate receptacle. Rinse
basin in warm soapy water and dry with paper towels (check agency policy).
Discard disposable cup into appropriate receptacle.
23. Remove gloves, mask, or face shield and dispose of in appropriate receptacle.
Perform hand hygiene.
24. Position patient and provide oral hygiene as needed.

25. Compare assessment findings before and after procedure.

26. Auscultate chest and airways for adventitious sounds.

27. Inspect mouth for any vomitus or remaining secretions.

28. Obtain and record post suction SpO2 value. Compare with pre suction level.

29. Use Teach-Back: “I want to be sure I explained how to suction your mouth and
why it should be performed. Show me how you will use this suction catheter.”
Revise your instruction now or develop a plan for revised patient or family
caregiver teaching if patient or family caregiver is not able to teach back
correctly.
30. Proper Documentation

TOTAL

Remarks:

________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________

______________________________ ______________________________
Clinical Instructor Student’s Signature

(075) 600 - 1507

San Vicente West, Urdaneta City, Pangasinan
Bright future starts here ucu.edu.ph | ucuchs@ucu.edu.ph