St.

Michael’s College
College of Nursing
Iligan City

Name: Norhaina B. Amin Group: 1

Clinical Instructor: Zainne Sarip Banding Date: _______________

Oropharyngeal and Nasopharyngeal Suctioning

Concept: Aspiration of secretions through a catheter connected to a suction machine or suction outlet

Purpose: :
 To remove secretions that obstruct the airway
 To facilitate ventilation (either via nasopharynx or oropharynx)
 To obtain secretions for diagnostic purposes
 To prevent infection that may result from accumulated secretions

Equipment: Suction catheter, Sterile gloves, Paper drape, Sunction machine, Mask, Connecting tube, Small y-
adapter (if catheter does not have a sunction control port), Water-soluble lubricant, Sterile basin, Sterike normal
saline or water, Pulse oximeter and Stethoscope

Oral
Performed
Rationale
Procedure Written Rationale
Not
Yes No Done
Done
1. Assessment:
1. By following your
1. Assess for clinical signs doctors' orders,
indicating the need for your long-term
suctioning and noting for outcomes can
doctor’s order. immensely improve
2. Check for restlessness, and hey are able to
detect health
gurgling sounds during
conditions or
respiration. diseases early
3. Note for signs of 2. To determine
adventitious breath sounds whether gurgling
upon auscultation. sounds heard
4. Observe for any changes during speech or
in mental status, skin quiet breathing
color. 3. It is important to
5. Monitor the rate and distinguish normal
pattern of respirations respiratory sounds
including pulse rate from abnormal ones
in order to make
and rhythm.
correct diagnosis
6. Check oxygen and chart
saturation through improvement or
 pulse oximeter. otherwise
4. Skin color can
reflect a patient's
overall health
5. Gives the
opportunity to
reduce the
incidence of severe
illness and improve
the clinical
response for
patients
6. To determine if you
need to receive
supplemental
oxygen
2. Planning: 7. To prevent the
spread of
7. Perform hand hygiene. microorganisms
8. Assemble the 8. To save time and
equipment and bring it effort
near to working area.
Materials
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3. Implementation: 1. Checking
identification
1. Introduce self and verify the ensures client
client’s identity. safety through
2. Explain to the client what concept of correct
you are going to do, why is procedure for
correct client
it necessary, and how the
2. Explanation
client can cooperate. minimizes anxiety
3. Observe appropriate infection and fear, which can
control procedures. increase oxygen
4. Provide for client privacy. consumption
5. Position a conscious 3. To prevent
person who has a pathogens being
functional gag reflex in the passed from one
semi-Fowler’s position, with person to another
head turned to one side for 4. Preserve the dignity
oral suctioning or with neck of the patient
5. These positions
hyperextended for nasal
facilitate the
suctioning. insertion of the
6. Position an catheter and help
unconscious client in prevent aspiration
the lateral position, of secretion.
 facing you. 6. The lateral position
7. Place the towel or prevents the airway
moisture-resistant pad over from becoming
the pillow or under chin. obstructed and
promotes drainage
8. Set the pressure on the
of secretions
suction gauge, and turn on 7. To isolate the
the suction. surgical site from
9. Open the lubricant (if the other areas of
performing the patient's body
nasopharyngeal and nonsterile
suctioning). areas of the OR
table in order to
For oral and oropharyngeal contribute to
suction: reducing the risk of
10. Moisten the tip of the surgical site
infection
Yankauer suction catheter
8. Tube occlusion
with the sterile water or tests suction
saline. apparatus; higher
11. Pull tongue forward, if pressures cause
necessary, using gauze. excessive trauma
12. Do not apply suction (leave without enhancing
your finger off the port) secretion removal.
during the insertion. 9. Minimizing irritation
13. Advance the catheter about of mucosa
10–15cm (4–6 inches) 10. Sterile normal
along one side of the mouth saline or water is
used to lubricate
into the oropharynx.
the tip of the
14. It may be necessary during catheter, minimizing
oropharyngeal suctioning to the irritation of
apply suction to secretions mucosa during
that collect in the vestibule introduction
of the mouth and beneath 11. Ensuring to suction
the tongue. clearly
12. Since the patient
will not be able to
breathe well with
the catheter in
place
For nasopharyngeal and
13. To prevent mucosal
nasotracheal suction: irritation and injury
1. Open the lubricant, if
performing  Prepares lubricant
nasopharyngeal / while maintaining
nasotracheal sterility. Using
suctioning. water-soluble
2. Open the sterile suction lubricant helps
package. avoid lipoid
3. Set up the cup or aspiration
pneumonia.
container, touching only
Excessive lubricant
the outside. occludes catheter
4. Pour sterile water or saline
into the container.
5. Put on the sterile gloves, or
put a non-sterile glove on  Reduces
transmission of
the nondominant hand and
micoorganisms and
then a sterile glove on the maintains sterility of
dominant hand. suction catheter
6. With your sterile-gloved  Maintains catheter
hand, pick up the catheter, sterility. Connects
and attach it to the suction catheter to suction
unit.
7. Make an approximate
measure of the depth for the  Ensures equipment
insertion of the catheter, function
and test the equipment.
8. Measure the distance
 Ensures that
between the tip of the catheter tip reaches
client’s nose and the pharynx for
earlobe. suctioning
9. Mark the position on the
tube with the fingers of the
sterile-gloved hand.  Ensures equiment
10. Test the pressure of the function
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.
11. If needed, increase
supplemental oxygen.
12. Lubricate the catheter tip  Lubricates catheter
with sterile water, saline, or for easier insertion
water-soluble lubricant.
13. Remove oxygen with your
non-dominant hand, if
appropriate.
 For only 10 to 15
14. Without applying suction, seconds at a time to
insert the catheter the pre- minimize tissue
measured or recommended trauma
distance into either naris,
and advance it along the
floor of the nasal cavity.  Using force could
15. Never force the catheter cause pain and
against the obstruction. If further
one nostril is obstructed, try complications
the other.  Preparations for
suctioning
16. Apply your finger to the
suction control port to start
 suction, and gently rotate
the catheter.
17. Apply suction for 5–10  Minimize tissue
seconds while slowly trauma
withdrawing the catheter,
then remove your finger
from the control and
remove the catheter.  Minimize tissue
18.A suction attempt should trauma
last only 10–15 seconds.
During this time, the
catheter is inserted, the
suction applied and
discontinued, and the
catheter removed.
 Secretions that
19. Rinse and flush the catheter
remain in suction
and tubing with sterile water catheter or
or saline. connecting tubing
20. Relubricate the catheter, decrease suctioning
and repeat suctioning efficiency
until the air passage is  Suctioning can
clear. induce hypoxemia,
21. Allow sufficient time laryngospasm and
between each suction, bronchospasm
and limit suctioning to 5  Deep breathing
minutes in total. ventilates and
reoxygenates
22. Encourage the client to
alveoli
breathe deeply and to
cough between
suctions.  To collect the
23. Obtain a specimen, if mucus during
required. Use a sputum suctioning
trap. Attach the suction
catheter to the tubing of the
sputum trap.
24. Attach the suction tubing
to the sputum trap air
vent.
25. Suction the client. The
sputum trap will collect the
mucus during suctioning.
26. Remove the catheter from
the client. Disconnect the
sputum trap tubing from
the suction catheter.
Remove the suction tubing
from the trap air vent.
27. Connect the tubing of the
sputum trap to the air
vent.
 28. Connect the suction catheter
to the tubing.
29. Flush the catheter to  Help prevent the
remove secretions from spread of
microorganisms
the tubing.
 To clean your
30. Offer to assist the client with mouth and nose
oral or nasal hygiene. after the procedure
31. Assist the client to a  For better relaxation
position that facilitates
breathing.
32. Dispose of the catheter,
gloves, water, and waste
container. Wrap the  To avoid
catheter around your contamination
sterile- gloved hand and
hold the catheter as the
glove is removed over it for
disposal.
33. Rinse the suction tubing as
needed by inserting the  Secretions left in
end of the tubing into the tubing decrease
used water container. suctioninh efficieny
34. Empty and rinse the suction and provide
collection container as environment for
needed or indicated by microorganisms
protocol. Change the growth
suction tubing and
container daily.  To provide
34.Ensure that supplies are immediate access
available for the next to suction catheter
suctioning. for the next
procedure
4. Evaluation:
 Evaluation is
1. Assess the effectiveness of important in
suctioning. healthcare because
2. Auscultate the client’s breath it supports an
sounds to ensure they are evidence-based
clear of secretions. approach to
3. Observe skin color, practice delivery. It
is used to assist in
dyspnea, level of anxiety,
judging how well
and oxygen saturation something is
levels. working. Nurses are
4. Document relevant data. well placed to
5. Record amount, evaluate their
consistency, color, and services and
odor of sputum. practice, and to
6. Evaluate client’s breathing develop an
status before and after the evidence base for
procedure. effective care
7. Assess and record the delivery
frequency of suctioning.