a.

Sedation and Anesthesia- are given to

patients to help relax the musles
APPLYING PULSE OXIMETER specifically the breathing muscle
Ms. Bartolay | Jan. 29, ‘22 | Prelim
which is the diaphragm.
3. For patients with hemodynamic instability.
a. For example the patient is maternal
Pulse oximetry is a quick, easy non-invasive method
and report 3 days vaginal bleeding. 32
to assess the arterial blood oxygen saturation of a
weeks of gestation, when do we
client by using an external sensor.
measure the pulse and oxygen
saturation? Blood levels discrease and
2 Blood Vessels (carries blood) which is measured by
poor oxygen level which may lead to
a pulse oximeter:
Impaired Tissue Perfusion.
● Artery- carries oxygenated blood
b. Hemodynamic instability occurs
● Vein- carries deoxygenated blood
when there's abnormal blood
pressure, which can cause inadequate
It can rapidly detect even small changes in oxygen
blood flow to your child's organs
levels. These levels show how efficiently blood is
4. For general respiratory management patients
carrying oxygen to the extremities furthest from your
with long term pulmonary disease.
heart, including your arms and legs.
a. COPD
i. Emphysema
So for example na rotate kayo sa dr and nagkaroon kayo ng
high risk newborn or for example yung mother niyo nag ii. Chronic Bronchitis
present ng complications of labor and delivery biglang nag 5. For transport of patients who are unwell and
DOB, for example may blood clot na nagtravel towards the require oxygenation assessment
pulmonary or respiratory biglang bumara doon. Nagmanifest a. EMT (Emergency Medical
siya ng severe rapid breathing, you can easily get the pulse Technicians) - nurses may act
oximeter, use it, it will help you because it is quick, easy independently not just rushing for
non-invasive, hindi siya masakit. Malalaman mo don yung immediate care.
circulatory or bleeding problem because of abrupt loss of
6. For administration of drugs that may cause
fluids such as blood in our body which can alter our
respiratory depression like patient-controlled
circulatory system as easy as that.
analgesia.
Several types of sensor like finger sensor very a. Respiratory Drugs: (some examples)
common to adults. The finger is place between the clip i. Bronchodilators- dilation of the
mechanism. On one side of the clip are light emitting bronchi.
diodes. The beam of light goes through the tissue and ii. Mucolytics- makes mucus less
blood vessels and the photon detector receives light thick in consistency.
and measures the amount of light absorbed by iii. Expectorants- promotes
oxygenation and unoxygenated hemoglobin. Other secretion of sputum in air
types of sensors are on the toe, nose, ear, forehead passageway.
and around the hand or foot and use the same iv. Corticosteroids- Helps
principle of spectrometry. decrease vasodilation by
relaxing the inflammation in
Example Intervention: the blood vessel.
SPO2 (finding)= 90% Types of Oximeters
Hook to O2 support at 3lpm via NC 1. Finger Pulse Oximeter- common, portable
WOF (watch out for) respiratory distress signs and is accessible.

Indications
1. To monitor the effectiveness of oxygen /
respiratory therapy.
a. Nurses can do independent nursing
intervention without always relying on
Doctor’s order.
2. During and after procedures that may require
sedation / anesthesia or carry any kind of risk
of respiratory depression.

1
2. Handheld Pulse Oximeter- for bedridden
patients.

3. Tabletop Pulse Oximeter- for high risk

patients that may attack any moment.

Oxygenated and deoxygenated blood have different

absorption rates that is detected by the photodetector
in the pulse oximeter.
Normal SPO2 (Maternal)= 95%-100%
Less than the normal SPO2= Hypoxia
4. Wrist-Worn Pulse Oximeter- for discharged
patients and need continuous pulse
monitoring.

Hypoxemia (decrease oxygen in the blood) Hypoxia

(decreased oxygen in general or in the body).

5. Pediatric Pulse Oximeters People living with severe hypoxemia is usually seen in
patients with Congenital Heart Diseases tulad ng may
butas sa heart.

Equipment
● Alcohol Wipes
● Any type of pulse oximeter sensor
● Nail polish remover
Assessment
● Assess the client’s hemoglobin level.
○ because pulse oximetry measures the
percent of SaO2, the result s of
oxygenation status will be affected.
The results may appear normal if the
HgB level is low because all HgB
available to carry oxygen is completely
saturated therefore it is important to
know the HgB level.
○ Hemoglobin- transports oxygen.
○ CBC: RBC, WBC, Platelets, etc.
● Assess the clients color.
○ If with vasoconstriction of the
extremities, an inaccurate recording
maybe obtained.
● Assess the clients’ mental status.
○ because this will assist in general
evaluation of oxygen delivery to the
brain and be indicative of high levels
of CO2.
➼ Rationale: Check mental status as the brain
may not bereceiving enough oxygen and lead

2
 to poor oxygen supply in the brain that can
cause alterations in the level
consciousness.
● Assess the client’s pulse rate.
○ The pulse oximeter measures pulse
rate. Manually assessing pulse can be
used as a cross reference to indicate
functioning of the oximeter.
● Assess the area where the sensors will be
placed to determine whether it is an area with
adequate circulation.
● Remove nail polish which will interfere with
sensor measurements.
Age Special
Considerations
Infant & Child For infants- oximeter
probe may be placed on
the toe or foot.
➼ Rationale: Pressure
Ulcer may be caused by
skin integrity or tight
pulse oximeter.
Nursing Diagnosis:
Impaired Tissue Integrity
Older Adult Careful attention to the
patient’s skin integrity
and condition is
necessary to prevent
injury. Pressure or
tension from the probe,
as well as any adhesive
used can damage older,
dry thin skin.
Planning
● Oxygen levels will return to normal in blood
and tissues as evident by oxygen saturation
and skin color.
● Respiratory rate, pattern and depth will be
within the normal range for client.
● The client will not develop any skin or tissue
irritation or breakdown.
● The client will demonstrate methods to clear
secretions and maintain optimal oxygenation.
● Breathing efficiency and activity tolerance will
be increased.
● The client will understand the rationale for the
therapy.
Nursing Diagnosis
of Determine the related factors for the nursing diagnosis
based on the patient’s current status.
Appropriate nursing diagnosis may include:
• Ineffective tissue perfusion
• Impaired gas exchange
• Ineffective airway clearance
• Activity intolerance
Procedure
1. Introduce yourself. Identify the patient using at
least two identifiers.
➼ Rationale: Confirms patients identify by
checking patients
ID and asking their name. Positive
identification of the patient is essential to
ensure the intervention is administered to the
correct patient.
2. Explain what you are going to do and why you
are going to do it to the patient.
➼ Rationale: To ensure cooperation from the
patient. It also relieves anxiety.
3. Perform hand hygiene and provide privacy.
➼ Rationale: To prevent cross infection
because it deters the spread of
microorganisms.
4. Select an adequate site for application of the
sensor.
➼ Rationale: Adequate arterial pulse strength
is necessary for obtaining accurate SpO2
measurements.
a. Use the patient’s index, middle or ring
finger.
➼ Rationale: Fingers are easily accessible.
b. Check the proximal pulse and capillary
refill at the pulse closest to the site.
➼ Rationale: Brisk capillary refill and a strong
pulse indicate the circulation to the site is
adequate.
● Capillary Refill Test on
Anemia- pisilin hanggang
maging white yung nail bed
then release in less than 3
seconds to see if the
circulation is adequate.
c. If circulation at site is inadequate,
consider using the earlobe or bridge of
nose.
➼ Rationale: These alternate sites are highly
vascular alternatives.
d. Use a toe only if lower extremity
circulation is not compromised.
(Assessed mostly in infants).
➼ Rationale: Peripheral vascular disease is
common in lower extremities. Aorta that
supplies the oxygenated blood in the lower
extremities is the descending aorta.
3
 ➼ Rationale: Audible beep represents the
arterial pulse and fluctuating wave form or light
bar indicates the strength of the pulse. A weak
signal will produce an inaccurate recording of
the SpO2. Tone of beep reflectsSpO2 reading.
If SpO2 drops tone becomes lower in pitch.
5. Select proper equipment
● CBR s BRP= complete bed rest
a. If one finger is too large for the probe,
without bathroom privilege. (you will
use a smaller one. A pediatric probe
then give the patient a bed pan).
may be used for a small adult.
● CBR c BRP= complete bed rest with
➼ Rationale: Inaccurate readings can result if
bathroom privilege.
probe or sensor is not attached correctly.
9. Depending on the unit if possible, set alarms
b. Use probes appropriate for patient’s
on pulse oximeter. Check manufacturer’s
age and size.
alarm limits for high and low pulse rate
➼ Rationale: Probes come in adult, pediatric
settings.
and infant sizes.
➼ Rationale: Alarm provides additional
c. Check if patient is allergic to adhesive.
safeguard and signals when high or low limits
Anon-adhesive finger clip or
have been surpassed.
reflectance sensor is available.
➼ Rationale: A reaction may occur if patient is
allergic to adhesive substance.

10. Check oxygen saturation at regular intervals,

6. Prepare the monitoring site.
➼ Rationale: Skin oils, dirt or grime on the
site, polish and artificial nails can interfere with
the passage of light waves.
a. Cleanse the selected area with the
alcohol wipe or disposable cleansing
cloth. Allow the area to dry.
b. If necessary, remove nail polish and
artificial nails after checking
manufacturer’s instructions.
7. Apply probe securely to skin.
➼ Rationale: Secure attachment and proper
alignment promote satisfactory operation of
the equipment and accurate recording of the
SpO2.
a. Make sure that the light emitting
sensor and the light receiving sensor
are aligned opposite each other.
b. Light sensor to the detector- pulse
oximeter
as ordered by physician and signaled by
alarms. Monitor oxygen level.
➼ Rationale: Monitoring SpO2 provides
ongoing assessment of patient’s condition. A
low hemoglobin level may be satisfactory
saturated yet inadequate to meet a patient’s
oxygen needs.
➼ Rationale: Prolonged pressure may lead to
tissue necrosis. Adhesive sensor may cause
skin irritation.
11. Remove sensor on a regular basis and check
for skin irritation or signs of pressure.
➼ Rationale: Prolonged pressure may lead to
tissue necrosis. Adhesive sensor may cause
skin irritation.
12. Clean non disposable sensors according to
the manufacturer’s direction. Perform hand
hygiene.
➼ Rationale: Each deters the spread of
microorganisms and contaminants.

13. DOCUMENTATION
a. It should include the type of sensor
and location used the assessment of
8. Connect the sensor probe to the pulse
the proximal pulse and capillary refill,
oximeter, turn the oximeter on and check
pulse oximeter reading the amount of
operation of the equipment.
oxygen and delivery method if the

4
 patient is receiving supplement
oxygen , lung assessment if relevant
and any other relevant intervention
required as a result of the reading.
“What if po halimbawa handicapped yung patient,
automatic po ba sa toes ilalagay pulse oximeter?” Pero
may mga institutions na walang access sa ganon sa
earlobe at sa nasal probe, ihook mo na siya sa cardiac
monitor or may mga pulse oximeter kasi na pwede mo
ilagay sa chest area.
Indications:
“Less than 85% SPO2 is severe hypoxemia, is it
possible if the SPO2 is 70% and that the patient can’t
feel anything with that kind of SPO2 level? Normal
lang po ba for them pero may severe hypoxemia na
pala.” That is one of the manifestation of chronic or
mga congenital heart diseases. Yung mga patients na Assessment
meron sila butas sa heart. It is normal for them to have
82% or less than 85%, nagbabago kasi yung normal
rate ng isang tao depende sa condition niya.
PEDIATRIC SUCTIONING
(bulb, Oropharyngeal and nasal)
Ms. Bartolay | Jan. 29, ‘22 | Prelim
Suctioning - suction is used to clear retained or
excessive respiratory tract secretions in patients who
are unable to do so effectively for themselves.
2 types of suctioning
1. Bulb Suction
2. Oropharyngeal and nasal suction
Bulb Suction
Procedure (bulb syringe)
Equipment:
Indications:
● Increased oxygen needs
● To remove saliva, discharges, and
mucus in nasal area.
● To prevent aspiration of the
secretions
● An increase in CO2
Oropharyngeal and Nasal Suction
● maintain a patent airway
● to remove saliva,pulmonary secretions,blood,
vomitus, or foreignmaterial from the pharynx.
● to prevent aspiration of the secretions.
1. Assess lung sounds.
● Wheezes- high pitch, narrowing of airways and
usually define during exhalation
● Stridor- commonly found in the bronchial area,
gasping sound in the upper respiratory tract
● Fine Crackles- popping sound
● Coarse Crackles- lower pitched and moist
sounding
● Pleural Rub- raspy breathing sound caused by
inflammation of the tissues around lungs.
2. Assess oxygenation saturation level.
3. Assess respiratory status.
4. Assess the patient for signs of respiratory
distress.
● Intercostal retractions- the intercostal muscles
are sucked inward, between the ribs when
breathing and this is a sign of a blocked
airway.
● Subcostal retractions- if the belly pulls beneath
the breastbone.
● Nasal flaring- the body tend to get more
oxygen supply
● Gauze/tissue
● Goggles
● Clean gloves
● Rolled up blanket
● Underpad/clean cloth
● Nasal drops/saline
● Bulb syringe
1. Bring necessary equipment to the bedside
stand or overbed table
2. Perform hand hygiene and put on PPE, if
indicated.
3. Identify the patient and provide privacy.
5
4. Position child with head flat or slightly
elevated. You may use rolled blanket
➼ Rationale: the head needs to be higher than
the chest area to avoid aspiration
5. Assess respiratory status, including respiratory
rate, color, effort.
➼ Rationale: before doing the procedure,
obtain a baseline data to have a comparison
after.
6. If desired or if secretions are very thick, drop
normal saline drops into nares before
suctioning to loosen secretions.
● Drop 3 to 4 drops in each nostril.
● While holding your baby’s head, drop three
to four drops of the saline solution into
each nostril.
● Gently hold your baby’s head back for 1
minute to let the saline solution loosen the
mucus
7. Deflate bulb prior to inserting tip into infant's
ears/mouth by squeezing bulb.
8. Insert tip into infant’s nares/mouth
➼ Rationale: slowly insert and squeeze out
the tip instead of forcing it to prevent the
strong pressure and do it one at a time.
9. Allow bulb to inflate and remove syringe from
nares/mouth.
10. Expel secretions by squeeze the bulb onto a
tissue until all the mucus is removed.
➼ Rationale: repeat as necessary and make
sure that there is no fiber (hibla)
11. Repeat as necessary. After you have removed
all of the mucus, wipe your baby’s nose and
face with a tissue.
➼ Rationale: use another tissue to remove
mucus repeatedly
12. Repeat assessment of respiratory status.
13. Documentation
● Color, consistency, and amount of secretions
● Tolerance to the procedure
● Whether or not saline was used respiratory
status
● Frequency required to clear nares/mouth of
secretions
The indication of the bulb syringe is used if the
secretion are only shallow
Questions:
Ma’am piniperform po ba ito o kailangan ng
doctors order?
● Piniperform at nireready ito sa DR, kasi
paglabas ng bata sa extrauterine life ang first
priority ay airway kasi yung adaptation ng bata
6
 from intrauterine to extrauterine malaking Procedure for Mechanical Suction
bagay yun sa kanila so we really have to (Oropharyngeal and nasal)
assist them para makapag adapt, and
syempre dahil nasa amniotic fluid sila there is Choose correct catheter size
a tendency na naglalabas sila ng maraming
fluids so nakakatulong ang bulb syringe.
Kapag oral suctioning po ba same lang po siya
sa mouth
● Same lang basta ideflate muna at huwag
bobombahin kaya kailangan minsan itest mo
muna siya kasi minsan may natuyo ng plema
kaya kahit kunin mo hindi siya effective
Bakit yung iba sila na yung nahigop mismo ng
mucus sa ilong ng bata?
● Ginagawa ito as emergency uses, kailangan
kapag ang magulang yung hihigop make sure
na pahigop na yung bibig ng magulang. It is
not ideal and hygienic pero ginagamit ito
outside.
Anong gagawin mo if your mother is
hyperventilating? Ano ang common object na
gagamitin mo?
● Brown paper bag kasi less chemicals
compared sa mga plastic and nagiging The french sizes commonly use in neonates is 5-10
rebreather mask ito para magbalanced ang french.
oxygen and carbon dioxide.
Ano ang nangyayari kapag may Ang IV Cannula ay mas mataas ang number mas
hyperventilation? maliit ang size
● The usual rate of the gas exchange of carbon
dioxide and oxygen ay mas mabilis ibig Question: Paano malalaman kung what is the best
sabihin pwede ka maglabas ng maraming catheter size for the patient?
oxygen kaya mo siya tinatrap sa brown bag ● You have to check the nostril of the baby kasi
para yung nilalabas mong oxygen bumabalik minsan malaking bata siya pero maliit ang
sayo, wag mo na intindihin ang carbon dioxide butas ng ilong tapos kapag pinasukan hindi
kasi that is by product of metabolism makahinga so the best way is just ⅓ of the
Saan nga ba nanggagaling ang carbon dioxide nostril or maximum is 50% hindi siya dapat
at bakit kailangan nating tanggalin ang carbon completely occluded.
dioxide? ● The most common in adult is 16 french
● Kasi one of the by products ng metabolism ng (orange)
katawan natin when we eat, breathe it
produces carbon dioxide. But particularly in Equipment:
the respiratory system kaya sila nag gagas ● Suction catheter
exchange kasi tinatapon ng lungs yung hindi ➼ Rationale: choose the right catheter
kailangan at pinapalit niya dun sa oxygen na ● Suction machine
dadalhin ng heart na naglalabas ng ➼ Rationale: (for adults and pediatrics)
oxygenated pero finifilter niya dahil kinukuha pressured delivery system is available in lower
niya yung unoxygenated blood at dadalhin pressure to controlled, because when you
niya yun sa respiratory. hyperventilate the patient it will cause trauma
● Pag nagkakaroon ng respiratory distress ang in the lung fields.
pasyente babantayan mo yung cardiac status ● Sterile gloves
na tinatawag na cardio pulmonary distress ibig ● Underpad/clean clothes
sabihin the heart and the lungs are ● Sterile water
problematic ● Sterile canister
● Gauze
Part of the preparation of DR instruments (for ● Goggles
delivery) is the bulb suction ● Facemask
● Water-based lubricant

7
 ➼ Rationale: do not use or mix the petroleum ng nasocomial infections- those are the infections
jelly and oxygen because it is a kind of oil and that acquired during hospital during hospital stay
it can combustible it. Oxygen is one of the
ingredients of fire and its spread the fire.

Implementation
1. Gather equipment and bring them to the
bedside stand or overbed table.
➼ Rationale: Bringing everything to the
bedside conserves time and energy.
Arranging items nearby is convenient, saves
time, and avoids unnecessary stretching
and twisting of muscles on the part of the
nurse.
*make sure na kompleto ang gamit mo at hindi mo
pwedeng gawing x2 per equipment kasi hindi na
pwedeng ilabas yung gamit na pinasok na sa loob
ng kwarto kaya sayang ang resources
2. Perform hand hygiene and put on PPE, if
indicated.
➼ Rationale: Hand hygiene and PPE prevent
the spread of microorganisms. PPE is required
based on transmission precautions.
3. Introduce yourself to patient (if coherent)
and significant other.Identify the patient.
➼ Rationale: Establishing rapport to patient
and significant others promotes trust.
Identifying the patient ensures the
right patient receives the intervention and
helps prevent errors.
Pediatric room w/ guardian
* magpakilala sa magulang at ipaliwanag sa
kanila yung procedure na gagawin mo at the
same time kakausapin mo din yung bata kahit
hindi sila makasagot
4. Close curtains around bed and close the
door to the room, if possible.
➼ Rationale: This ensures the patient’s
privacy.
* depending on the set up kung NICU may mga
curtains pero yung iba tabi-tabi yung incubator pero
may distancing kasi yung incubator maraming
medical equipment na nakabalot, kapag pedia
naman definitely (pedia warder, pedia room) either
close the curtain or the door
5. Adjust bed or radiant warmer to
comfortable working height, usually elbow
height of the caregiver (VISN 8 Patient
Safety Center, 2009). Move the bedside table
close to your work area and raise it to waist
height.
➼ Rationale: Having the bed at the proper
height prevents back and muscle strain. The
bedside table provides a work surface and
helps maintain sterility of objects on the work
surface.

NICU/PICU w/o guardian

* special area and yung guardian ay nasa labas
kasi kailangan imaintain yung cleanliness of the
area and the sterility, ibig sabihin pag sterile area
ka lahat ng gamit as much as possible clean at
hindi galing sa labas kasi opportunity of the
microorganisms to enter the facility at magkaroon

8
 * always put the patient in radiant warmer or
droplight because the maturity of their body is not
fully adapted and well adjusted to the outside world
* when do suctioning tataasan mo para hindi mag
aspirate yung pasyente and also adjust the warmer
or the droplight ideally 20-40 inches away from the
client, wag masyadong malapit baka maburn and
wag itutok sa mukha, also adjust the table
according to you
6. Place towel or waterproof pad across the
patient’s chest.
➼ Rationale: This protects contamination of
body fluids and secretions onto patient’s body
and surroundings.
* laging standard, kailangan infection control
7. Assemble suction canister and connecting
tubing to suction source.
Set suction levels as follows: 80–100 mm Hg
for infants and children under 10–12 years,
100–120 mm Hg for older children.
Ensure appropriate resuscitation equipment
(mask, valve, bag) is at bedside.
➼ Rationale: Higher pressures can cause
excessive trauma, hypoxemia, and atelectasis.
FIGURE 1. Adjusting wall suction.
* ang mahalaga ay pressure gauge kasi ito ang
kailangan i manipulate
8. 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 into it.
➼ Rationale: Sterile normal saline or water is
used to lubricate the outside of the catheter,
minimizing irritation of mucosa during
introduction. It is also used to clear the
catheter between suction attempts.
* during this time na naka clean gloves ka pa lang
at piniprepare mo ang area mo clean technique pa
lang yun.
* kapag nagbibigay ng excessive negative pressure
nag totrauma yung mucosa and makakapag induce
ka pa lalo ng hypoxia.
9. Place a small amount of water-soluble
lubricant on the sterile field, taking care to
avoid touching the sterile field with the
lubricant package.
➼ Rationale: Lubricant facilitates passage of
the catheter and reduces trauma to mucous
membranes.
9
 *Still on clean technique

10. Increase the patient’s supplemental oxygen

level or apply supplemental oxygen per facility
policy or primary care provider order. Hook
pulse oximeter correctly.
➼ Rationale: Suctioning removes air from the
patient’s airway and can cause hypoxemia.
Hyperoxygenation can help prevent suction
induced hypoxemia.
*Set mo nang tama, check mo kung nagfoflow yung
oxygen, kung maayos yung tubings niya, then you
apply. Make sure it’s tight fitting but not too tight.
*Pagnakaoxygen, nakahook, nakapulse oximeter
lagi yan
*In this catheter, merong sterile and clean(non
sterile). Bawal hawakan ng left hand (nondominant)
yung sterile part ng catheter (yung buong tube). The
only part that can be held by your non sterile hand
is yung pangpress (blue item in picture). Kapag
nagtouch yung tube sa iba/kamay mo, need palitan
ng lahat yan (bagong catheter).

13. Apply lubricant to the first 2 to 3 inches of

the catheter, using the lubricant that was
placed on the sterile field.
*Still on clean technique ➼ Rationale: Lubricant facilitates passage of
the catheter and reduces trauma to mucous
11. Put on face shield or goggles and mask. membranes
Put on sterile gloves.

The dominant hand will manipulate the

catheter and must remain sterile. The
nondominant hand is considered clean rather
than sterile and will control the suction valve
(Y-port) on the catheter.
➼ Rationale: Handling the sterile catheter
using a sterile glove helps prevent introducing *Use your human anatomy (hand) to measure if
organisms into the respiratory tract; the clean there is no ruler. Tansyahin. You have to act
glove protects the nurse from microorganisms independently.
*Pagyung patient mo ay maraming secretions,
multiresistant bacteria, mga nakakahawa na 14. Determine the correct distance to advance
pedeng pumasok sa mucous membrane mo, use it suction catheter.
to protect yourself. Be extra careful if necessary. ➼ Rationale: The general guideline for
*Right (dominant) - sterile determining insertion distance for
*Left (nondominant) - non sterile nasopharyngeal suctioning for an individual
12. With dominant gloved hand, pick up sterile patient is to estimate the distance from the
catheter. Pick up the connecting tubing patient’s earlobe to the nose.
with the nondominant hand and connect
the tubing and suction catheter.
➼ Rationale: Sterility of the suction catheter is
maintained.

10
 *Pagmasyado mong pinasaok yan and yung
curvature ng nasal passage ng patient mo, tinusok
mo, pede mong matrauma yung inner part so
determine the correct distance.
*From the nose/nostril & mouth to the earlobe.
Dapat straight and hindi nakacurce. Wag niyong
ididikit yung tube sa kahit ano/pisnge since sterile.

17. Hold the catheter between your thumb and

forefinger. Do not apply suction as the
catheter is inserted.
*old school catheters don’t have increments. For
new ones, may numbers. For example, nameasure ➼ Rationale: Using suction while inserting the
mo is 6, hanggang dun lang yung maximum na catheter can cause trauma to the mucosa and
ipapasok mo, di mo siya itutuloy. Pero yung oral, remove oxygen from the respiratory tract.
pede mong iadjust since papasok sa oropharynx
Correct distance for insertion ensures proper
but meron ding maximum.
placement of the catheter
15. Moisten the catheter by dipping it into the
container of sterile saline. Occlude Y-tube
to check suction.
➼ Rationale: Lubricating the inside of the
catheter with saline helps move secretions in
the catheter. Checking suction ensures
equipment is working properly.

*Sa paghold ng catheter, hindi ka dapat nakagrasp

don. Use index finger and thumb.

18. Using a downward motion, aiming toward

*sterile canister, sterile water
*nakaconnect na sa suction machine, pedeng idikit
sa tubbing and connect them. To check the patency
of the catheter, you will put pressure. Pagnaglagay
ka ng ganon, iniistart mo yung suctioning,
pagnakarelease siya, hindi nagsusuction.
*You only suction when nasa loob ka na, hindi yung
habang pumapasok ka palang nagsusuction ka na.
Wag ka muna magpress, ipasok mo muna sa
desired measurement/distance and once you’re
ready, you press.
16. Remove the oxygen delivery device, if
appropriate.
➼ Rationale: *Hindi pede na nakaoxygen siya
habang gumagawa ka since nagnanarrow o
nagkakaroon ng confusion sa pag-exchange ng air.
So iakyat mo lang (using left hand), di mo kailangan
tanggalin kasi ibabalik mo rin.
midline, advance the catheter into the nare
no further than the pre-measured distance.
Suction the oropharynx first then the
nasopharynx. Do not force the catheter
through the nares.
➼ Rationale: Always suction the mouth of a
newborn before the nose, because suctioning
the nose first may trigger a reflex gasp,
possibly leading to aspiration if there is mucus
in the posterior throat. Follow mouth suctioning
with suction to the nose, because the nose is
the chief conduit for air in a newborn.
*aspirate kasi maiiritate siya, so pedeng lalong
pumasok yung mucus from the posterior throat to
the lungs.
Suctioning mouth before nose prevents
possible aspiration of oral secretions.

11
 Suctioning for longer than 10 to 15 seconds
robs the respiratory tract of oxygen, which may
result in hypoxemia.

Suctioning too quickly may be ineffective at

clearing all secretions.

For oropharyngeal suction, pull the tongue

forward using gauze. Advance the catheter
about 10– 15 cm along one side of the mouth.

For nasopharyngeal, insert the suction

catheter into the nostril and to the back of the
throat (nasopharynx) based on the length
measured.
20. Replace the oxygen delivery device using
If (+) resistance, try the other nostril. Keep your nondominant hand, if appropriate, and
your thumb off the suction control port. have the patient take several deep breaths.
*Pagtapos ka na, hindi mo siya susunod-sunodin.
Babalik mo yung oxygen supply niya then drain the
catheter in the water or canister. Flush in saline.
*Dapat kung anong nawalang oxygen sa kanya
during suctioning, mabalik mo at makapagrest siya.
*Gag reflex: as early as newborn, meron na. Some
take months. So very stressing sa kanila yung
situation.
➼ Rationale: Suctioning removes air from the
patient’s airway and can cause hypoxemia.
Hyperventilation can help prevent
suction-induced hypoxemia.
*If naiyak yung bata,ngumanganga, yung dila
lumalabas, you can use clean and new gauze. Use
21. Flush catheter with saline. Assess
your nondominant hand on it while the dominant
yung magpapasok ng catheter. Magkaiba sila ng
effectiveness of suctioning and repeat, as
trabaho. Pull tongue forward or baba, para needed, and according to patient’s tolerance.
magkaaccess ka sa gitna. Don’t force it. Wrap the suction catheter around your
* If necessary lang yan. If hindi naman at may dominant hand between attempts.
access ka na, pede mo na ipasok pero most of the ➼ Rationale: Flushing clears catheter and
time the baby is irritable unless walang malay for lubricates it for next insertion. Reassessment
example his APGAR score is zero. determines the need for additional suctioning.
*Mainit yung drop light, kaya possible na Wrapping prevents inadvertent contamination
pagpawisan.
of catheter.
19. Apply intermittent suctioning by covering
the suction control hole with thumb. Gently
rotate the catheter while withdrawing the
catheter. Limit continuous suction within the
airway to no more than 5 (infants)–15 (child)
seconds.
*Dahanin paikot. Hahatak lang pagnagpepress.
Repeat the catheter while withdrawing.
*Sa first round sa mouth, unahin muna yung saliva
and wag muna ipasok maigi, for 2nd round yung sa
mas loob. This is specially for those who have
meconium, amniotic fluid, or phlegm.

➼ Rationale: Turning the catheter as it is

withdrawn minimizes trauma to the mucosa.
12

22. Allow at least a 20-30 seconds interval if
additional suctioning is needed. Limit
suctioning to a total of 5 minutes. Alternate the
nares, unless contraindicated, if repeated
suctioning is required.
➼ Rationale: The interval allows for
reventilating and reoxygenation of airways.
Excessive suction passes contribute to
complications. Alternating nares reduces
trauma.
*Habang binibigyan sila ng time to
recuperate/recover sa suction, iflush yung catheter.
*If done na, wrap around yung tube sa kamay mo
kasi baka dumikit sa ibang areas - to avoid
contaminating it. Pede ring gumamit ng sterile towel
sa then place sa chest ng baby para mamaintain
yung sterility kahit tumama man dun.
23. When suctioning is completed, remove
gloves from dominant hand over the coiled
catheter, pulling them off inside out.
Remove glove from nondominant hand and
dispose of gloves, catheter, and container with
solution in the appropriate receptacle.
➼ Rationale: This technique reduces
transmission of microorganisms.
*Yung catheter dapat nasa loob ng gloves sa
pagtanggal
24. Turn off suction. Remove supplemental
oxygen placed for suctioning, if
appropriate.
➼ Rationale: Proper removal of PPE and hand
hygiene reduces risk of transmission of
microorganisms.
*If patient is nakaO2 support, no need. I-maintain
mo lang.
25. Discard used materials in designated
place. Remove glove from nondominant hand
and dispose of gloves, catheter, and container
with solution in the appropriate receptacle
➼ Rationale: Ensure proper dissemination of
waste.
*Itabi yung pedeng mareuse. Ibalik sa package or
any container ng hospital.
26. Proper removal of PPE, then perform
medical handwashing.
➼ Rationale: Removing PPE properly reduces
the risk for infection transmission and
contamination of other items. Hand hygiene
prevents the spread of microorganisms
*Handwashing for: exposed in bodily fluids like
blood, phlegm, secretions, open
*Hand rub: procedure with intact skin or vital signs
27. Reassess patient’s respiratory status,
including respiratory rate, effort, oxygen
saturation, and lung sounds.
➼ Rationale: This assesses effectiveness of
suctioning and the presence of complications
*Need second hand watch
*Visualization of the chest and abdomen,
check RR, heart rate, auscultate using the bell
and diaphragm on all lung fields - upper, lower,
basal, posterior, and anterior. Check for skin
turgor, cyanosis circulation (thumbs up)
28. Documentation
○ Document the time of suctioning
○ Your before, during, and after
intervention assessments,
○ Reason for suctioning
○ Route used/accessed
○ The characteristics and amount of
secretions.
○ Example:
13

Nurses Notes for Newborn
BABY GIRL BARTOLAY, NB/F under Dr. Bautista
* NB/F = Newborn, Female
PCAP-C
* The patient has Pediatric Community Acquired
Pneumonia - Type C
1/29/22; 06:00 AM
* Date and time
* FDAR: one of the types of nurses’ notes;
F- Focus (nursing diagnosis)
D- Data
A- Actions
R- Response (assessment afterwards)
F> Ineffective Airway Clearance
* … Related to excessive mucus production (PCAP-C:
has bacteria in lungs, problem: hypersecretion)
D> Vital signs: RR: 68 cpm, PR: 163 bpm; T: 36.3 C,
O2 sat: 93%; c labored breathing
(+) intercostal and subcostal retractions, (+) crackles
and wheezes at both basal lungfields,
(+) nasal and oral thick yellowish secretions; (+)
productive cough, pale, weak-looking and irritable.
c IVF #2 D10W 500 ml x 24 hrs via syringe pump,
intact at L cephalic vein and infusing well.
on BF c̅ SAP diet
* RR/Respiratory Rate: mataas, may signs of distress
[normal range (newborn): 30-60 cpm]
*PR/Pulse Rate: mataas [normal range: 120-160 bpm]
*T/Temperature: normal [normal range (pedia): 36.3
(Sometimes, yung pedia exempted from the rule.
Minsan mababa yan sa range ng adult, but for them,
it’s acceptable because the way the adaptation nila sa
labas, kaya continuous warmer lang siya.
*O2 Sat: mababa, mild hypoxia, mild difficulty of
breathing, kulang yung O2 na nakukuha niya [normal
range: 95%-100%]
*intercostal and subcostal retractions: moderate
*intercostal: chest area, ribs, intercostal spaces
*substernal: abdomen area (severe)
(Intercostal) (subcostal) (substernal)
*crackles and wheezes: through auscultation
*crackles: like fireworks sounds; cause: airway has
excess secretions like mucus
*wheezes: high pitched sound; cause: narrowing of
airways, usually heard at the end
*productive cough: when coughing, it has phlegm;
(you have to identify if it’s productive cough or dry
cough)
*BF c̅ SAP: Breastfeed with Strict Aspiration
Precaution
A> Established rapport by providing safety and
comfort. Kept thermoregulated under droplight at all
times. Performed nasal and oropharyngeal suctioning
after 30 mins post-neb.
Suction pressure set at 80 mmHg using Fr. 8.
Positioned on semi-fowlers position.
Maintained on O2 Support at 5 lpm via facemask and
NPO as ordered by Dr. Bautista.
Seen from time to time. Chest physiotherapy done.
Monitored for signs of respiratory distress.
*Established rapport - depends to the area; to
significant others; establish trust for non coherent by
making them feel that their environment is safe such
as by providing thermoregulation, side rails, bassinet
*post-neb: neb=nebulization. Nurses give Salbutamol
muna para lumambot siya. After 30 mins, suction na.
*Fr = French
*Chest physiotherapy = indicated pagmaraming
phlegm and post-nebulization. It is an independent
nursing intervention. Airway clearance technique. Para
bumaba yung plema. Gentle and repetitive na pagpalo
sa harap at likod
R> Vital signs: RR: 60 cpm; PR: 152 bpm; T: 36.8 C,
O2 sat=95% w/ O2 support 5lpm via FM,
still with crackles and wheezes, and productive cough.
The patient is asleep.
*RR: normal
Evaluation
● The expected outcome is met when the patient
exhibits improved breath sounds and a clear
and patent airway. In addition, the oxygen
saturation level is within acceptable
parameters, and the patient does not exhibit
signs or symptoms of respiratory distress or
complications.
14
Nursing Considerations
● Suctioning frequency is based on clinical
assessment.
● Never suction vigorously, because this irritates
the mucous membrane and could leave a
portal of entry for infection.
● WOF: hypoxemia, cardiac dysrhythmias,
trauma, atelectasis, infection, bleeding, and
pain.
● Maintaining aseptic technique and following
facility guidelines and procedures to prevent
potential hazards
● Avoid suctioning for 30 minutes to 1 hour after
feeding
● Do not suction for longer than 10 seconds at a
time
● Suction only when necessary
● Don ot exceed suction pressure of 100 mmHg
● Oxygen source and bag and mask should be
available
● Always suction the mouth of a newborn before
the nose
*For severe cases, need ng katulong sa
pagsuctioning.
*If sterile towel is not available, use the inner
paper/wrapper from the sterile gloves
(improvised)
*pagmayresistance, wag ipilit. Dun sa kabilang
nostril simulan o pedeng magpatak ng nasal
drops during mechanical suctioning. Possible
na magbleed kapag pinilit.
Different Manifestations/Signs of Respiratory
Distress (RDS) in Children
● Croup with stridor and retractions
● Sternal retractions
● Rib retractions (wave paghinga)
● See saw or paradoxical breathing pattern
(audible even without auscultation)
● Tracheal tug
● Head bobbing in an infant
● Subcostal retractions
● Meconium stain
Question and Answers
● Pagkapasok kunyari hindi ginamit yung left
hand para sa gauze sa dila then pagkapasok,
umiyak na po, tutuloy po ba yung suction?
○ *It’s normal since may response siya
sa stimulus - didila, magcoucough,
iiyak. Pero as long as yung tip ng
catheter is nasa loob na, no need for
the gauze.
○ *Yung ibang bata na may ipin na,
minsan kinakagat nila yan. As much
as possible, before you do suctioning,
may mga management yan:
bronchodilators, expectorants,
mucolytic, nebulizations - para
lumambot para pagnagsuction mabilis.
○ *Yung iba, iniiswaddle, since
gumagalaw sila:
○
● Palagi bang magkasama yung nasal and
oropharyngeal suction? Pagginawa yung isa
dapat ding gawin yung isa pa
○ *It depends. Pagnakita mong walang
lumalabas na sipon, kahit hindi na
pero usually since bukas ang airway,
yung both oral and nasal passage,
minsan nagspipsill over sa ilong.
Check mo kahit bulb syringe lang. One
at a time. Sa ilong kahit magkasunod
siya pero ideally 20-25 secs interval sa
oral and nasal. Pagnostril to another,
kahit few secs lang.
● Anong gagawin if may kasamang dugo sa
pagsuction?
○ *Nangyayari na may dugo, kapag
masyadong mabilis (biglaan) at
malakas yung pagsuction. Yung
surface (lalamunan/dinadaanan ng
tubing) nagkakaroong ng trauma since
it’s fragile. But you don’t have to worry
about it. Wag lang too much blood
since ibang situation na yun. Kapag
slight or blood streaks lang okay lang.
Dapat bright red blood, meaning fresh
pa. Pero kapag coffee grounds color -
old blood clots, might have an internal
bleeding na matagal na. You also
need to know the cause of injury.
Kapag may blood, be gentle. Follow
the anatomy of respiratory system sa
pagpasok ng tubing. Even in adult,
nangyayari to.
● One of the risk of post-term baby: makakain
ng meconium
● Suction depending on your assessment.
Kapag merong severe distress, dalawa na
kayo minsan tatawagin na doctor. Refer it if
nagdedecline na - patient is lethargic, check
pulse oximeter. Assistant will auscultate. Ikaw,
sterile ka pa rin hanggang dumating yung
doctor dahil ikaw yung hands nila but
sometimes nagstesterile rin yung doctor.
● If ongoing yung oropharyngeal, possible na
magvomit. If nangyari, stop the suctioning and
15
turn the patient to the left/right kasi baka
mag-aspirate.

16