1320 Unit 10 ● Promoting Physiologic Health
A B
Figure 49.11 ■ A, Nasal cannula; B, mustache reservoir nasal cannula; C, pendant reservoir nasal cannula.
B–C, Shirlee Snyder.
Reservoir nasal cannulas are oxygen-conserving devices
and are also called Oxymizer oxygen-conserving devices.
They are used primarily in the home setting. The reservoir
nasal cannula stores oxygen in the reservoir while the client
breathes out and then delivers a 100% oxygen bolus when
the client breathes in. As a result it delivers a higher oxygen
concentration at a lower flow rate than the plain nasal can-
nula because it conserves oxygen. It can deliver FiO2 of 0.5
Administering Oxygen by Cannula, Face Mask, or Face Tent
Before administering oxygen, check (a) the order for oxygen, includ-
ing the administering device and the liter flow rate (L/min) or the
percentage of oxygen; (b) the levels of oxygen (PaO2) and carbon
SKILL 49.1
dioxide (PaCO2) in the client’s arterial blood (PaO2 is normally 80 to
PURPOSES
Cannula
• To deliver a relatively low concentration of oxygen when only
minimal oxygen support is required
• To allow uninterrupted delivery of oxygen while the client ingests
food or fluids
ASSESSMENT
See also Skill 29.11, Assessing the Thorax and Lungs, on
pages 611–614.
Assess
• Skin and mucous membrane color: Note whether cyanosis is
present, presence of mucus, sputum production, and imped-
ance of airflow.
• Breathing patterns: Note depth of respirations and presence of
tachypnea, bradypnea, or orthopnea.
• Chest movements: Note whether there are any intercostal,
substernal, suprasternal, supraclavicular, or tracheal retractions
during inspiration or expiration.
M49_BERM9793_11_GE_C49.indd 1320
C
or greater, while providing the same benefits of a plain nasal
cannula. The two styles of reservoir nasal cannulas (Oxymiz-
ers) are the mustache and pendant styles (see Figure 49.11B
and C). Humidification is not necessary with the reservoir
nasal cannula, because it collects water vapor while the client
breathes out and returns it when the client breathes in.
Administering oxygen by cannula is detailed in
Skill 49.1.
100 mmHg; PaCO2 is normally 35 to 45 mmHg); and (c) whether the
client has COPD. Note: If the client has not had arterial blood gases
ordered, oxygen saturation should be checked using a noninvasive
oximeter.
Face Mask
• To provide moderate oxygen support and a higher concentra-
tion of oxygen or humidity than is provided by cannula
• To provide a high flow of oxygen when attached to a Venturi
system
Face Tent
• To provide high humidity
• To provide oxygen when a mask is poorly tolerated
• Chest wall configuration (e.g., kyphosis, unequal chest
expansion, barrel chest).
• Lung sounds audible by ear and auscultating the chest.
• Presence of clinical signs of hypoxemia: tachycardia,
tachypnea, restlessness, dyspnea, cyanosis, and confusion.
Tachycardia and tachypnea are often early signs. Confusion is a
later sign of severe oxygen deprivation.
• Presence of clinical signs of hypercarbia (hypercapnia):
restlessness, hypertension, headache, lethargy, tremor, or
elevated carbon dioxide levels in the blood.
27/01/2021 18:05

Administering Oxygen by Cannula, Face Mask, or Face Tent—continued
• Presence of clinical signs of hyperoxic acute lung injury: tracheal
irritation and cough, dyspnea, and decreased pulmonary
ventilation.
Determine
• Vital signs, including pulse rate and quality, and respiratory rate,
rhythm, and depth.
• Whether the client has COPD. A high carbon dioxide level in
the blood is the normal stimulus to breathe. However, people
PLANNING
Consult with a respiratory therapist as needed in the beginning and
during ongoing care of clients receiving ordered oxygen therapy.
In many agencies, the respiratory therapist establishes the initial
ASSIGNMENT
Initiating the administration of oxygen is considered similar to admin-
istering a medication and is not assigned to assistive personnel (AP).
However, reapplying the oxygen delivery device may be performed by
the AP, and many aspects of the client’s response to oxygen therapy
are observed during usual care and may be recorded by individuals
other than the nurse. Abnormal findings must be validated and inter-
preted by the nurse. The nurse is also responsible for ensuring that
the correct delivery method is being used.
Equipment
Cannula
• Oxygen supply with a flow meter and adapter
• Humidifier with distilled water or tap water according to agency
protocol
IMPLEMENTATION
Preparation
1. Determine the need for oxygen therapy, and verify the order for
the therapy.
• Perform a respiratory assessment to develop baseline data
if not already available.
2. Prepare the client and support individual(s).
• Assist the client to a semi-Fowler’s position if possible.
Rationale: This position permits easier chest expansion
and hence easier breathing.
• Explain that oxygen is not dangerous when safety precautions
are observed. Inform the client and support individual(s) about
the safety precautions connected with oxygen use.
Performance
1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how to par-
ticipate. Discuss how the effects of the oxygen therapy will be
used in planning further care or treatments.
2. Perform hand hygiene and observe other appropriate infection
prevention procedures.
3. Provide for client privacy, if appropriate.
4. Set up the oxygen equipment and the humidifier.
• Attach the flow meter to the wall outlet or tank. The flow
meter should be in the off position.
• If needed, fill the humidifier bottle. (This can be done before
coming to the bedside.)
• Attach the humidifier bottle to the base of the flow meter.
• Attach the prescribed oxygen tubing and delivery device
to the humidifier.
5. Turn on the oxygen at the prescribed rate and ensure proper
functioning.
M49_BERM9793_11_GE_C49.indd 1321
Chapter 49 ● Oxygenation 1321
with COPD may have a chronically high carbon dioxide level,
and their stimulus to breathe is hypoxemia. During continu-
ous oxygen administration, arterial blood gas levels of oxygen
SKILL 49.1
(PaO2) and carbon dioxide (PaCO2) are measured periodically to
monitor hypoxemia.
• Results of diagnostic studies such as chest x-ray.
• Hemoglobin, hematocrit, and complete blood count.
• Oxygen saturation levels.
• Pulmonary function tests, if available.
equipment and client teaching. However, it is important for the nurse
to continually assess the client’s need for oxygenation and oxygen
therapy.
• Nasal cannula and tubing
• Tape (optional)
• Padding for the elastic band (optional)
Face Mask
• Oxygen supply with a flow meter and adapter
• Humidifier with distilled water or tap water according to agency
protocol
• Prescribed face mask of the appropriate size
• Padding for the elastic band (optional)
Face Tent
• Oxygen supply with a flow meter and adapter
• Humidifier with distilled water or tap water according to agency
protocol
• Face tent of the appropriate size
• Check that the oxygen is flowing freely through the
tubing. There should be no kinks in the tubing, and the
connections should be airtight. There should be bubbles
in the humidifier as the oxygen flows through. You
should feel the oxygen at the outlets of the cannula, mask,
or tent.
• Set the oxygen at the flow rate ordered.
6. Apply the appropriate oxygen delivery device.
Cannula
• Put the cannula over the client’s face, with the outlet prongs
fitting into the nares and the tubing hooked around the ears
(see Figure 49.11A).
• If the cannula will not stay in place, tape it at the sides of
the face.
• Pad the tubing and band over the ears and cheekbones as
needed.
Face Mask
• Guide the mask toward the client’s face, and apply it from the
nose downward.
• Fit the mask to the contours of the client’s face (see Figure
49.12A). Rationale: The mask should mold to the face so that
very little oxygen escapes into the eyes or around the cheeks
and chin.
• Secure the elastic band around the client’s head so that the mask
is comfortable but snug.
• Pad the band behind the ears and over bony prominences.
Rationale: Padding will prevent irritation from the mask.
Face Tent
• Place the tent over the client’s face, and secure the ties around
the head (see Figure 49.13).
Continued on page 1322
27/01/2021 18:05
 1322 Unit 10 ● Promoting Physiologic Health
Administering Oxygen by Cannula, Face Mask, or Face Tent—continued
7. Assess the client regularly.
• Assess the client’s vital signs, level of anxiety, color, and
ease of respirations, and provide support while the cli-
SKILL 49.1
ent adjusts to the device. Some clients may complain of
claustrophobia.
• Assess the client in 15 to 30 minutes, depending on the
client’s condition, and regularly thereafter.
• Assess the client regularly for clinical signs of hypoxia,
tachycardia, confusion, dyspnea, restlessness, and
cyanosis. Review oxygen saturation or arterial blood gas
results if they are available.
Nasal Cannula
• Assess the client’s nares for encrustations and irritation. Apply
a water-soluble lubricant as required to soothe the mucous
membranes.
• Assess the top of the client’s ears for any signs of irritation from
the cannula tubing. If present, padding with a gauze pad may
help relieve the discomfort.
Face Mask or Tent
• Inspect the facial skin frequently for dampness or chafing, and
dry and treat it as needed.
EVALUATION
• Perform follow-up based on findings that deviated from
expected or normal for the client. Relate findings to previous
data if available (e.g., check oxygen saturation to evaluate
adequate oxygenation).
LIFESPAN CONSIDERATIONS Oxygen Delivery Equipment
INFANTS
Oxygen Hood
• An oxygen hood is a rigid plastic dome that encloses an infant’s
head. It provides precise oxygen levels and high humidity.
• The gas should not be allowed to blow directly into the infant’s
face, and the hood should not rub against the infant’s neck,
chin, or shoulder.
CHILDREN
Oxygen Tent
• The tent consists of a rectangular, clear, plastic canopy with
outlets that connect to an oxygen or compressed air source
and to a humidifier that moisturizes the air or oxygen.
• Because the enclosed tent becomes very warm, some type of
cooling mechanism is provided to maintain the temperature at
20°C to 21°C (68°F to 70°F).
• Cover the child with a gown or a cotton blanket. Some agen-
cies provide gowns with hoods, or a small towel may be
Face Mask
Face masks that cover the client’s nose and mouth may be
used for oxygen inhalation. Most masks are made of clear,
pliable plastic that can be molded to fit the face. They are
held to the client’s head with elastic bands. Some have a
metal clip that can be bent over the bridge of the nose for
a snug fit. Exhalation ports on the sides of the mask allow
exhaled carbon dioxide to escape.
M49_BERM9793_11_GE_C49.indd 1322
8. Inspect the equipment on a regular basis.
• Check the liter flow and the level of water in the humidi-
fier in 30 minutes and whenever providing care to the
client.
• Be sure that water is not collecting in dependent loops of
the tubing.
• Make sure that safety precautions are being followed.
9. Document findings in the client record using forms or
checklists supplemented by narrative notes when
appropriate.
SAMPLE DOCUMENTATION
9/16/2020 0930 Returned from physical therapy with c/o dyspnea.
Resp. 26/min, shallow. P-92, BP 160/98, SpO2 92%. Skin warm, no
cyanosis. Lung sounds clear, no retractions. Oxygen per nasal can-
nula applied @ 2 L/min. P. Isola, RN
9/16/2020 1000 No further c/o of dyspnea. Resp. 20/min,
P 88, BP 152/92, SpO2 96%. oxygen per nasal cannula continues
@ 2 L/min. P. Isola, RN
• Report significant deviations from normal to the primary care
provider.
wrapped around the head. The child needs protection from
chilling and from the dampness and condensation in the tent.
• Flood the tent with oxygen by setting the flow meter at 15 L/min
for about 5 minutes. Then, adjust the flow meter according to
orders. Flooding the tent quickly increases the oxygen to the
desired level.
• The tent can deliver approximately 30% oxygen.
• Children may fight having a mask placed on their faces. They
are often fearful when placed in oxygen tents or hoods. These
are normal responses that vary based on experience, develop-
mental stage, degree of threat to body image, and attachment
or abandonment issues. Providing safe toys and a beloved
blanket or pillow to hold can help, as can fostering the parent–
child bond even though separated by the plastic. Encourage
parents to interact with their child around and through the tub-
ing and tent.
Some masks have reservoir bags, which provide
higher oxygen concentrations to the client. A portion of
the client’s expired air is directed into the bag. Because
this air comes from the upper respiratory passages (e.g.,
the trachea and bronchi), where it does not take part in
gaseous exchange, its oxygen concentration remains the
same as that of inspired air.
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 Chapter 49 ● Oxygenation 1323

A variety of oxygen masks are marketed: of 6 to 15 L/min (Smith et al., 2017, p. 1189). One-way
valves on the mask and between the reservoir bag and
• The simple face mask delivers oxygen concentra-
the mask prevent the room air and the client’s exhaled
tions from 35% to 65% at liter flows of 8 to 12 L/min,
air from entering the bag so only the oxygen in the bag
respectively (Smith, Duell, Martin, Aebersold, &
is inspired (Figure 49.12C). In some cases, one of the
Gonzalez, 2017, p. 1189) (Figure 49.12A ■).
side valves is removed so that the client can still inhale
• The partial rebreather mask delivers oxygen concen-
room air if the oxygen supply is accidentally cut off. To
trations of 40% to 60% at liter flows of 6 to 10 L/min,
prevent carbon dioxide buildup, the nonrebreather bag
respectively (Smith et al., 2017, p. 1189). The oxygen res-
must not totally deflate during inspiration. If it does,
ervoir bag that is attached allows the client to rebreathe
the nurse can correct this problem by increasing the
about the first third of the exhaled air in conjunction
liter flow of oxygen.
with oxygen (Figure 49.12B). Thus, it increases the FiO2
• The Venturi mask delivers oxygen concentrations varying
by recycling expired oxygen. The partial rebreather bag
from 24% to 40% or 50% at liter flows of 4 to 10 L/min
must not totally deflate during inspiration to avoid
(Figure 49.12D). The Venturi mask has wide-bore tubing
carbon dioxide buildup. If this problem occurs, the
and color-coded jet adapters that correspond to a pre-
nurse increases the liter flow of oxygen so that the bag
cise oxygen concentration and liter flow. For example, in
remains one-third to one-half full.
some cases, a blue adapter delivers a 24% concentration
• The nonrebreather mask delivers the highest oxygen
of oxygen at 4 L/min, and a green adapter delivers a 35%
concentration possible—60% to 100%—by means other
concentration of oxygen at 8 L/min. However, colors and
than intubation or mechanical ventilation, at liter flows

A B

C D
Figure 49.12 ■ A, A simple face mask; B, a partial rebreather mask; C, a nonrebreather mask; D, a Venturi mask.

M49_BERM9793_11_GE_C49.indd 1323 27/01/2021 18:06

 1330 Unit 10 ● Promoting Physiologic Health
Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning
PURPOSES
• To remove secretions that obstruct the airway
• To facilitate ventilation
SKILL 49.2
ASSESSMENT
Assess for clinical signs indicating the need for suctioning:
• Restlessness, anxiety
• Noisy respirations
• Adventitious (abnormal) breath sounds when the chest is
auscultated
• Change in mental status
PLANNING
Assignment
Oral suctioning using a Yankauer suction tube can be assigned to
AP and to the client or family, if appropriate, since this is not a sterile
procedure. The nurse needs to review the procedure and important
points such as not applying suction during insertion of the tube to
avoid trauma to the mucous membrane. Oropharyngeal suctioning
uses a suction catheter and, although not a sterile procedure, should
be performed by a nurse or respiratory therapist. Suctioning can
stimulate the gag reflex, hypoxia, and dysrhythmias that may require
problem-solving. In contrast, nasopharyngeal and nasotracheal suc-
tioning use sterile technique and require application of knowledge
and problem-solving and should be performed by the nurse or respi-
ratory therapist.
Equipment
Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning
(Using Sterile Technique)
• Towel or moisture-resistant pad
IMPLEMENTATION
Performance
1. Prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client what
you are going to do, why it is necessary, and how to participate.
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. Rationale:
Knowing that the procedure will relieve breathing problems is
often reassuring and enlists the client’s cooperation.
2. Perform hand hygiene and observe other appropriate infection
prevention procedures.
3. Provide for client privacy.
4. Prepare the client.
• Position a conscious client who has a functional gag reflex
in the semi-Fowler’s position with the head turned to one
side for oral suctioning or with the neck hyperextended
for nasal suctioning. Rationale: These positions facilitate
the insertion of the catheter and help prevent aspiration of
secretions.
• Position an unconscious client in the lateral position, facing
you. Rationale: This position allows the tongue to fall for-
ward, so that it will not obstruct the catheter on insertion.
The lateral position also facilitates drainage of secretions
from the pharynx and prevents the possibility of aspiration.
• Place the towel or moisture-resistant pad over the pillow or
under the chin.
5. Prepare the equipment.
• Turn the suction device on and set to appropriate nega-
tive pressure on the suction gauge. The amount of nega-
tive pressure should be high enough to clear secretions
M49_BERM9793_11_GE_C49.indd 1330
• To obtain secretions for diagnostic purposes
• To prevent infection that may result from accumulated secretions
• Skin color
• Rate and pattern of respirations
• Pulse rate and rhythm
• Decreased oxygen saturation
• Portable or wall suction machine with tubing, collection recep-
tacle, and suction pressure gauge
• Sterile disposable container for fluids
• Sterile normal saline or water
• Goggles or face shield, if appropriate
• Moisture-resistant disposal bag
• Sterile gloves
• Sterile suction catheter kit (#12 to #18 Fr for adults, #8 to #10 Fr
for children, and #5 to #8 Fr for infants)
• Water-soluble lubricant
• Y-connector
• Sputum trap, if specimen is to be collected
Oral and Oropharyngeal Suctioning (Using Clean Technique)
• Yankauer suction catheter or suction catheter kit
• Clean gloves
but not too high. Rationale: Too high of a pressure can
cause the catheter to adhere to the tracheal wall and
cause irritation or trauma. A rule of thumb is to use the
lowest amount of suction pressure needed to clear the
secretions.
For Oral and Oropharyngeal Suction
• Apply clean gloves.
• Moisten the tip of the Yankauer or suction catheter with sterile
water or saline. Rationale: This reduces friction and eases
insertion.
• Pull the tongue forward, if necessary, using gauze.
• Do not apply suction (that is, leave your finger off the port)
during insertion. Rationale: Applying suction during insertion
causes trauma to the mucous membrane.
• Advance the catheter about 10 to 15 cm (4 to 6 in.) along one
side of the mouth into the oropharynx. Rationale: Directing the
catheter along the side prevents gagging.
• It may be necessary during oropharyngeal suctioning to apply
suction to secretions that collect in the mouth and beneath the
tongue.
• Remove and discard gloves.
• Perform hand hygiene.
For Nasopharyngeal and Nasotracheal Suction
• Open the lubricant.
• Open the sterile suction package.
a. Set up the cup or container, touching only the outside.
b. Pour sterile water or saline into the container.
27/01/2021 18:06

Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning—continued
c. Apply the sterile gloves, or apply an unsterile glove on the
nondominant hand and then a sterile glove on the domi-
nant hand. Rationale: The sterile gloved hand maintains
the sterility of the suction catheter, and the unsterile glove
prevents the transmission of the microorganisms to the
nurse.
• With your sterile gloved hand, pick up the catheter and attach
it to the suction unit. ❶
6. 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.
• If needed, apply or increase supplemental oxygen.
7. Lubricate and introduce the catheter.
• Lubricate the catheter tip with sterile water, saline, or
water-soluble lubricant. Rationale: This reduces friction
and eases insertion.
• Remove oxygen with the nondominant hand, if
appropriate.
• Without applying suction, insert the catheter into either
naris and advance it along the floor of the nasal cavity.
Rationale: This avoids the nasal turbinates.
• Never force the catheter against an obstruction. If one
nostril is obstructed, try the other.
8. Perform suctioning.
• Apply your finger to the suction control port to start suc-
tion, and gently rotate the catheter. Rationale: Gentle
rotation of the catheter ensures that all surfaces are
reached and prevents trauma to any one area of the respi-
ratory mucosa due to prolonged suction.
• Apply suction for 5 to 10 seconds while slowly withdraw-
ing the catheter, then remove your finger from the control
and remove the catheter. Rationale: Intermittent suction
reduces the occurrence of trauma or irritation to the tra-
chea and nasopharynx.
• A suction attempt should last only 10 to 15 seconds. Dur-
ing this time, the catheter is inserted, the suction applied
and discontinued, and the catheter removed.
9. Rinse the catheter and repeat suctioning as above if
necessary.
• Rinse and flush the catheter and tubing with sterile water
or saline.
• Relubricate the catheter, and repeat suctioning until the air
passage is clear.
• Allow sufficient time between each suction for ventilation
and oxygenation. Limit suctioning to 5 minutes in total.
To
suction
Suction
control
Sterile
glove
Thumb control
To tip
To suction
❶ Attaching the catheter to the suction unit.
M49_BERM9793_11_GE_C49.indd 1331
Chapter 49 ● Oxygenation 1331
Rationale: Applying suction for too long may cause secre-
tions to increase or may decrease the client’s oxygen supply.
• Encourage the client to breathe deeply and to cough
SKILL 49.2
between suctions. Use supplemental oxygen, if appropri-
ate. Rationale: Coughing and deep breathing help carry
secretions from the trachea and bronchi into the pharynx,
where they can be reached with the suction catheter.
Deep breathing and supplemental oxygen replenish the
oxygen supply that was decreased during the suctioning
process.
10. Obtain a specimen if required.
• Use a sputum trap ❷ as follows:
a. Attach the suction catheter to the tubing of the sputum
trap.
b. Attach the suction tubing to the sputum trap air vent.
c. Suction the client. The sputum trap will collect the
mucus during suctioning.
d. Remove the catheter from the client. Disconnect the
sputum trap tubing from the suction catheter. Remove
the suction tubing from the trap air vent.
e. Connect the tubing of the sputum trap to the air vent.
Rationale: This retains any microorganisms in the
sputum trap.
• Connect the suction catheter to the tubing.
• Flush the catheter to remove secretions from the tubing.
11. Promote client comfort.
• Offer to assist the client with oral or nasal hygiene.
• Assist the client to a position that facilitates breathing.
12. Dispose of equipment and ensure availability for the next
suction.
• Dispose of the catheter, gloves, water, and waste
container.
a. Rinse the suction tubing as needed by inserting the end
of the tubing into the used water container.
b. Wrap the catheter around your sterile gloved hand and
hold the catheter as the glove is removed over it for
disposal.
• Perform hand hygiene.
❷ A sputum collection trap.
Continued on page 1332
27/01/2021 18:06
 1332 Unit 10 ● Promoting Physiologic Health
Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning—continued
• Empty and rinse the suction collection container as needed
or indicated by protocol. Change the suction tubing and
container daily.
SKILL 49.2
• Ensure that supplies are available for the next suctioning
(suction kit, gloves, water or normal saline).
13. Assess the effectiveness of suctioning.
• Auscultate the client’s breath sounds to ensure they are
clear of secretions. Observe skin color, dyspnea, level of
anxiety, and oxygen saturation levels.
14. Document relevant data.
• 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 respira-
tory status before and after the procedure. This may include
lung sounds, rate and character of breathing, and oxygen
saturation.
EVALUATION
• Conduct appropriate follow-up, such as appearance of
secretions suctioned; breath sounds; respiratory rate, rhythm,
and depth; pulse rate and rhythm; and skin color.
• Compare findings to previous assessment data if available.
LIFESPAN CONSIDERATIONS Suctioning
INFANTS
• A bulb syringe is used to remove secretions from an infant’s
nose or mouth. Care needs to be taken to avoid stimulating the
gag reflex.
CHILDREN
• A catheter is used to remove secretions from an older child’s
mouth or nose.
duskiness, or cyanosis), restlessness, tachycardia, or
decreased oxygen saturation (SpO2) levels (also called O2
sat) may indicate the need for suctioning. Good nursing
judgment and critical thinking are necessary. Suction-
ing irritates mucous membranes, can increase secretions
if performed too frequently, and can cause the client’s
oxygen saturation to drop further, put the client in bron-
chospasm, and if the client has a head injury, cause the
intracranial pressure to increase. In other words, suc-
tioning is based on clinical need versus a fixed schedule.
In addition to removing secretions that obstruct the
airway and facilitating ventilation, suctioning can be per-
formed to obtain secretions for diagnostic purposes and
to prevent infection that may result from accumulated
secretions.
QSEN Patient-Centered Care: Suctioning
The nurse who is providing care in the home setting for
a client who requires suctioning needs to consider the
following:
• Teach clients and families that the most important
aspect of infection control is frequent hand washing.
M49_BERM9793_11_GE_C49.indd 1332
• 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.
SAMPLE DOCUMENTATION
12/12/2020 0830 Producing large amounts of thick, tenacious white
mucus to back of oral pharynx but unable to expectorate into tissue.
Client uses Yankauer suction tube as needed. O2 sat increased from
89% before suctioning to 93% after suctioning. RR also decreased
from 26 to 18–20 after suctioning. Lungs clear to auscultation
throughout all lobes. Continuous O2 at 2 L/min via n/c. Will continue
to reassess every hour. L. Webb, RN
• Report significant deviations from normal to the primary care
provider.
OLDER ADULTS
• Older adults often have cardiac or pulmonary disease, thus
increasing their susceptibility to hypoxemia related to suction-
ing. Watch closely for signs of hypoxemia. If noted, stop suc-
tioning and hyperoxygenate.
• Airway suctioning in the home is considered a clean
procedure.
• The catheter or Yankauer should be flushed by suc-
tioning recently boiled or distilled water to rinse away
mucus, followed by the suctioning of air through the
device to dry the internal surface and, thus, discourage
bacterial growth. The outer surface of the device may
be wiped with alcohol or hydrogen peroxide. The suc-
tion catheter or Yankauer should be allowed to dry and
then be stored in a clean, dry area.
• Suction catheters treated in the manner described above
may be reused. It is recommended that catheters be dis-
carded after 24 hours. Yankauer suction tubes may be
cleaned, boiled, and reused.
Following endotracheal intubation or a tracheos-
tomy, the trachea and surrounding respiratory tissues
are irritated and react by producing excessive secre-
tions. Sterile suctioning is necessary to remove these
secretions from the trachea and bronchi to maintain a
patent airway. The frequency of suctioning depends on
the client’s health and how recently the intubation was
done. Suctioning may be necessary in clients who have
27/01/2021 18:06