oxygenation checklist

ADMINISTERING OXYGEN BY CANNULA, FACE MASK, OR FACE TENT

Overview:

Oxygen is a basic need; it is required for life. Adequate oxygenation is essential for

cerebral functioning. The cerebral cortex can tolerate hypoxia for only 3-5 minutes before

permanent damage occurs. Nurses frequently assists clients in meeting oxygen needs.

Indication:

When a client has inadequate ventilation or impaired pulmonary gas exchange,

oxygen (O2) therapy may be needed to prevent hypoxia. The primary care provider

prescribes O2 therapy, the method of delivery, and the liter flow per minute. In hospitals

and long-term care facilities, O2 is usually piped into wall outlets at the client’s bedside. In

other facilities, pressurized tanks or cylinders of O2 are used. Small, portable cylinders of

O2 are available for clients who require oxygen therapy at home. O2 is a dry gas, so

humidifying devices are essential to add water vapour to the inspired air, especially if the

liter flow is >2 L/min.

Oxygen Delivery Devices:

Cannula – The cannula is disposable plastic tube with two prongs for insertion into

the nostrils. It fits around the head or loops over the ears to hold it in place and is

connected by tubing to the O2 source. It is easy to apply, relatively comfortable, and allows

the client to eat and talk. It is adequate for rates of 2-6 L/min. Above 6 L/min it is not

effective.

Face Mask – Masks cover the client’s nose and mouth. They have exhalation ports

on the sides to allow exhaled carbon dioxide to escape. It is important that the mask be of

appropriate size for the client.

Simple face mask - Delivers O2 concentration of 40%-60% at flows of 5-8 L/min,

respectively

Partial rebreather mask – Delivers O2 concentrations of 60-90% at flows of 6-10

L/min, respectively.

Nonrebreather mask – Delivers the highest possible of O2 concentration (95%-

100%), except for intubation or mechanical ventilation, at flows of 10-15 L/min.

Face Tent – Some clients do not tolerate masks well; they may respond with

anxiety or even panic. A face tent is similar to a mask, but larger and open at the top. It fits

snugly around the client’s jaw line, but is open at the top over the nose. It delivers a

concentration of 30%-50% at 4-8 L/min.

Transtracheal catheter – is placed through a surgically created tract in the lower

neck directly into the trachea. Once the trach has matured, the client removes and cleans

the catheter two or four times per day. Oxygen applied to the catheter at less than 1 L/min

need not be humidified, and rates above 5 L/min can be administered.

Safety Precautions:

Place cautionary sings reading “No Smoking: Oxygen is in Use” on the client’s

door, at the foot or head of bed, and on the oxygen equipment.

Instruct the client and visitors about the hazard of smoking with oxygen in use.

Make sure that electrical equipment (e.g. razors, hearing aids, radios, televisions,

and heating pads) is in good working order to prevent occurrence of short-circuit

sparks.

Avoid materials that generate static electricity, such as woollen blankets and

synthetic fabrics. Cotton blankets are used, and nurses are advised to wear

cotton fabrics.

Avoid, the use of volatile, flammable materials, such as oils, greases, alcohol, and

ether, near clients receiving oxygen. Avoid alcohol back rubs, and take nail polish

removers and the like away form the immediate vicinity.

Ground electric monitoring equipment, suction machines, and portable diagnostic

machines

Make known location of fire extinguishers, and make sure personnel are trained in

their used.

Assessment:

Signs of hypoxia: tachycardia, tachypnea, dyspnea, pallor, cyanosis

Signs of hypercabia: restlessness, hypertension, headache

Signs of oxygen toxicity: tracheal irritation, cough, decreased pulmonary

ventilation

Special Considerations:

Older adults are prone to dehydration that causes dry mucous membranes.

Ciliary action decreases with age, causing decreased clearing of the airways.

Muscular structures of the pharynx and larynx atrophy with age.

Less ventilation in the lower lobes of the older adult causes secretions to pool or

predispose to pneumonia.

Equipment:

Cannula

Oxygen supply with a flow meter and adapter

Humidifier with distilled water or tap water according to agency protocol

Nasal cannula and tubing

Tape

Padding for the elastic band

Face Mask



Prescribed face mask of the appropriate size

Padding for the elastic band

Face Tent



Face tent of the appropriate size

PROCEDURE RATIONALEPreparation

1. Determine the need for oxygen therapy,

verify the order for the therapy.

2. Prepare the client and support people.

Assist the client to a semi-Fowler’s

position if possible.

Explain that oxygen is not dangerous

when safety precautions are

observed. Inform the client and

support people about the safety

precautions connected with oxygen

use.

Performance

1. Explain to the client what you are going

to do, why is it necessary, and how he or

she can cooperate. Discuss how the

effects of the oxygen therapy will be

used in planning further care or

treatments.

2. Wash hands and observe appropriate

infection control procedures.

3. Set up oxygen equipment and the

humidifier.

Attach 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 humidifier bottle to the base of

the meter.

Attach the prescribed oxygen tubing

and delivery device to the humidifier.

PROCEDURE4. Turn on the oxygen at the prescribed

rate, and ensure proper functioning.

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 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, for example.

5. 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 elastic band around the

head.

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.

Secure the elastic band around the

client’s head so that the mask is

comfortable but snug.

PROCEDURE Pad the band behind the ears and

over bony prominences.

Face Tent

Place the tent over the client’s face,

and secure the ties around the head

7. Assess client regularly.

Assess the client’s vital signs, level of

anxiety, color, and ease of

respirations, and provide support

while the client adjusts to the device.

Assess the client in 15-30 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 arterial blood gas 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.

Face Mask or Tent

Inspect the facial skin frequently for

dampness or chafing, and dry and

treat it as needed.

PROCEDURE8. Inspect the equipment on a regular basis

Check the liter flow and the level of

water in the humidifier in 30 minutes

and whenever providing care to the

client.

Make sure safety precautions are

being followed

9. Document findings in the client record

using forms or checklists supplemented

by narrative notes when appropriate.

TEACHING DEEP – BREATHING EXERCISES

Definition:

Lung inflation techniques include diaphragmatic breathing exercises, apical and basal

lung expansion exercises, and use of blow bottles, sustained maximal inspiration (SMI)

devices , or intermittent positive pressure breathing (IPPB) apparatuses.

Apical Expansion exercises are often required for clients who restrict their upper

chest movement because of pain from severe respiratory disease or surgery eg, lobectomy.

Purpose:

To promote the exchange of gases in the lungs and strengthen the muscles used for

breathing.

Indication:

For clients with restricted chest expansion such as people with chronic obstructive

pulmonary disease (COPD) or people recovering from thoracic surgery.

PROCEDURE RATIONALE1. Assess the client’s condition and identify

anything that may affect the success of

the procedure.

Factors like client’s anxiety may affect the

client’s ability to follow the procedure. In

addition, pain on the part of the client may

alter client’s learning capability.

Abdominal (diaphragmatic ) and Pursed-Lip

Breathing

2. Explain to the client that diaphragmatic

breathing can help the person breath

more deeply and with less effort.

A person who understands and accepts the

importance of deep breathing is more likely

to cooperate and participate in the exercise.

3. Have the client assume either a

comfortable semi-Fowler’s position with

knees flexed, back supported, and with

one head pillow or a supine position with

one head pillow and knees flexed. After

learning, the client can practice.

The semi-Fowler’s and supine position with

knees flexed help relax the abdominal

muscles.

4. Have the client place one or both hands

on the abdomen just below the ribs.

This position will aid in the accurate

observation of the patient’s chest expansion.

PROCEDURE RATIONALE5. Instruct the client to breath in deeply

through the nose with the mouth closed,

to stay relaxed, not to arch the back, and

to concentrate on feeling the abdomen

rise as far as possible.

6. If the client has difficulty raising the

abdomen, instruct the person to take a

quick, forceful inhalation through the

nose.

7. Instruct the client to purse the lips as if

about to whistle; to breath out slowly and

gently, making a slow “ whooshing “

sound; to avoid puffing out the cheeks; to

concentrate on feeling the abdomen fall

or sink; and to tighten the abdominal

muscles while breathing out.

8. If the client has COPD, teach the “double

cough” technique. Have the client

a. Breath in through the nose and inflate

the lungs to the mid inspiration point,

rather than to the full deep inspiration

point.

b. Simultaneously exhale and cough two

or more abrupt, sharp coughs in rapid

succession.

9. Instruct the client to use this exercise

whenever feeling short of breath to

increase it gradually 5-10 minutes four

times a day.

APICAL EXPANSION EXERCISES

10. Place your fingers below the client’s

clavicles and exert moderate pressure, or

have the client place his or her fingers

over the same area.

PROCEDURE RATIONALE11. Instruct the client to inhale through the

nose and to concentrate on pushing the

upper chest upward and forward against

the fingers.

12. Have the client hold the inhalation for a

few seconds.

13. Have the client exhale through the

mouth or nose slowly, quietly and

passively while concentrating on moving

the upper chest inward and downward.

14. Instruct the client to perform the

exercise for at least five respirations four

times a day.

BASAL EXPANSION EXERCISES

14. Place the palms of your hands in the area

of the lower ribs along the midaxillary

lines, and exert moderate pressure, or

have the client place his or her hands

over the same areas.

15. Instruct the client to inhale through the

nose and to concentrate on moving the

lower chest outward against the hands.

16. Have the client hold the inhalation for a

few seconds.

17. Have the client exhale through the nose

or mouth slowly, quietly and passively. If

the person has COPD, observe the rate

and character of the exhalation. Normal

exhalation is slow, and the upper chest

appears relaxed. If the exhalation

appears difficult or there is in drawing of

the upper chest, encourage pursed-lip

exhalation.

PROCEDURE RATIONALE18. Instruct the client to perform this

exercise at least five respirations four

times a day.

19. Correct the patient’s breathing technique

as necessary.

ASSISTING CLIENTS TO USE INCENTIVE SPIROMETRY

Definition:

Incentive spirometry is a method of encouraging voluntary deep breathing by

providing visual feedback to clients about inspiratory volume.

Purpose:

It is used to promote deep breathing to prevent or treat atelectasis in the

postoperative client.

Equipment:

Incentive spirometer

PROCEDURE RATIONALE1. Wash hands.

2. Instruct client to assume semi-Fowler’s or

high Fowler’s position.

3. Either aet or indicate to client on the

device scale, the volume level to be

attained with each breath.

4. Demonstarte to client how to place

mouthpiece of spirometer so that lips

completely cover mouthpiece.

5. Instruct client to inhale slowly and

maintain constant flow through unit.

When maximal inspiration is reached,

client should hold breath for 2 to 3

seconds and then exhale slowly.

6. Instruct client to breath normally for

short period.

7. Have client repeat maneuver until

volume goals are achieved.

8. Wash hands.

9. Record the procedure done and client’s

ability to perform it.

ADMINISTERING PERCUSSION, VIBRATION,

AND POSTURAL DRAINAGE TO ADULTS

Definition:

Percussion sometimes called clapping or cupping, is forcefully striking the skin with

cupped hands.

Vibration is a series of vigorous quivering produced through hands that are placed

flat against chest wall.

Postural drainage is the drainage, by gravity, of secretions from various lung

segments.

Indication:

For clients who produce greater than 30cc of sputum per day or have evidence of

atelectasis by chest x-ray examination.

Contraindication:

1. 1.Percussion is contraindicated in clients with bleeding disorders, osteoporosis, or

fractured ribs.

Considerations:

Postural drainage, percussion and vibration is best tolerated if done between meals ,

at least two hours after the patient has eaten, to decrease the possibility of vomiting.

Purpose:

1. To mechanically dislodge and loosen mucous secretions.

2. Facilitate drainage of mucous secretions by gravity.

Equipment:

1. A bed that can be placed in Trendelenburg position.

2. Towel

PROCEDURE RATIONALE1. Provide visual and auditory privacy.

2. Assist the client to the appropriate

position for postural drainage.

Drainage of the upper lobe

3. Have the client lie back at a 30o angle.

Percuss and vibrate between the

clavicles and above the scapulae.

PROCEDURE RATIONALE4. Have the client sit upright in a chair or in

bed with the head bent slightly forward.

Percuss and vibrate the area between

the clavicles and scapulae.

5. Have the client lie on a flat bed with

pillows under the knees to flex

them.Percuss and vibrate the upper

chest below the clavicles down to the

nipple line, except for women. The

breasts of women are not percussed,

because percussion may cause pain.

Drainage of the right middle lobe and lower

division of the left upper lobe

6. Elevate the foot of the bed about 15o or

40cm and have the client lie on the left

side. Help the client to lean back slightly

against pillows extending at the back

from the shoulder to the hip. A pillow

may be placed between the knees for

comfort. For a male, percuss and vibrate

over the right side of the chest at the

level of the nipple between the 4rth and

6th ribs For a female, position the heel of

your hand toward the axilla and your

cupped fingers extending forward

beneath the breast to percuss and

vibrate beneath the breast.

7. Elevate the foot of the bed as in step 6,

and have the client lie as in step 6

except on the right side.Percuss and

vibrate the right side of the chest as in

step7.

Drainage of the lower lobes

8. Have the client lie on the abdomen on a

flat bed, and place two pillows under the

hips. Percuss and vibrate the middle

area of the back on both sides of the

spine.

PROCEDURE RATIONALE9. Have the client lie on the unaffected

side, with the upper arm over the head.

Elevate the foot of the bed about 30o or

45 cm , or to the height tolerated by the

client. Place one pillow between the

knees. Another under the head is

optional.Percuss and vibrate the affected

side of the chest over the lower ribs,

inferior to the axilla.

10. Have the client lie partly on the

unaffected side and partly on the

abdomen. Elevate the foot of the bed

about 30o or 45cm (18in.), or to the

height tolerated by the client. As an

alternative, elevate the hips with pillows.

Percuss and vibrate the uppermost side

of the lower ribs.

11. Have the client lie prone. Elevate the

foot of the bed about 30o or 45cm

(18in.), or to the height tolerated by the

client. Elevate the hips on two or three

pillows to produce a jackknife position

from the knees to the shoulders.Percuss

and vibrate over the lower ribs on both

sides close to the spine, but not directly

over the spine or the kidneys.

PERCUSSION

12. Ensure that the area to be percussed is

covered.

13. Ask the client to breath slowly and

deeply.

14. Cup your hands,ie, old your fingers and

thumb together , and flex them slightly

to form a cup, as you would to scoop up

water.

PROCEDURE RATIONALE15. Relax your wrists, and flex your elbows.

16. With both hands cupped, alternately flex

and extend the wrists rapidly to slap the

chest. The hands must remain cupped so

that air cushions the impact, to avoid

injuring the client.

17. Percuss each affected lung segments for

1-2 minutes.

VIBRATION

18. Place your flattened hands, one over the

other (or side by side) against the

affected chest area.

19. Ask the client to inhale deeply through

the mouth and exhale slowly through

pursed lips or the nose.

20. During the exhalation, straighten your

elbows, and lean slightly against the

client’s chest while tensing your arm and

shoulder muscles in isometric

contractions.

21. Vibrate during five exhalations over one

affected lung segment.

22. Encourage the client to cough and

expectorate secretions into the sputum

container. Offer the client mouthwash.

23. Auscultate the client’s lungs, and

compare the findings to the baseline

data.

24. Document the percussion, vibration, and

postural drainage and assessments.

Note the amount, color, and character of

expectorated secretions.

STEAM INHALATION

Definition:

A treatment to provide warm, moist air for the patient to breath.

Indication:

1. Irritation (tickling or pain in throat) by moistening mucous membranes.

2. Acute or chronic inflammation and congestion of mucous membranes of nose and

throat due to colds and bronchitis.

3. Coughing (relaxes muscles).

4. Dry or thick secretions.

Purposes:

1. To relieve swelling, inflammation, congestion and pain in the nose and throat in

upper respiratory infections.

2. To stimulate expectoration.

3. To reduce dryness of mucous membrane.

4. To relieve spasmodic breathing.

Equipment:

Pitcher

Basin

Boiling water

Paper cone

Bath towel and face towel (patient’s gown)

Drug ordered (optional)

NOTE: If an electric inhaler/ vaporizer is used, please study operation manual/ package.

PROCEDURE RATIONALE1. Check doctor’s order.

2. Explain procedure to client.

3. Wash hands.

4. Place boiling water about 1/3 to ½ full in

a pitcher.

5. Add ordered medication, if any.

6. Bring pitcher on a basin to the bedside.

Place on a firm surface.

PROCEDURE RATIONALE7. Assist client to assume convenient

position. May sit at edge of bed. Provide

privacy PRN.

8. Place paper cone on mouth of pitcher.

9. Place bath towel over client’s chest.

Provide face towel over client’s forehead

and eyes as necessary. At about one foot

away from the paper cone, have the

client inhale steam.

10. Remove pitcher at the end of prescribed

period. Wipe client’s face and make him

comfortable. Protect from cold air.

11. Wash used article with soap and water

(except cone). Rinse and dry and return

to proper place. Wash hands.

12. Record client’s response to therapy.

OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING

Definition:

Suctioning is the aspiration of secretions, often through a rubber or polyethylene

catheter connected to a suction machine or outlet. Oropharyngeal or nasopharyngeal

suctioning removes secretions from the upper respiratory tract.

Suctioning is the aspiration of secretions by a rubber catheter connected to a suction

machine with an application of a negative pressure to create a vacuum to enable secretions

to move from an area of higher pressure (the airway) to an area of lower pressure (the

suction bottle).

Indications:

This procedure is indicated when the client:

1. Is unable to cough and expectorate secretions effectively (e.g., infants and

comatose patients);

2. Is unable to swallow;

3. Makes light bubbling or rattling breath sounds that indicate the accumulation of

secretions in the respiratory tract; and

4. Is dyspneic or appears cyanotic.

Purposes:

1. To remove secretions that obstruct the airway;

2. To facilitate respiratory ventilation;

3. To obtain secretions for diagnostic purposes; and

4. To prevent infection that may result from accumulated secretions in the

respiratory tract.

Special Considerations:

1. Perform suctioning several minutes before mealtime.

2. Suction client immediately if he is cyanotic.

3. Report to the nurse or physician significant changes observed in the client’s

condition after suctioning.

4. Have standby oxygen at bedside.

Equipments:

1. Towels or pads

2. Emesis basin lined with paper

3. Portable or wall suction machine: includes a collection bottle, a tubing system

connected to the suction catheter, and a gauge that registers the degree of

suction

4. Sterile disposable container for sterile fluids

5. Sterile normal saline or water

6. Sterile gloves

7. Sterile suction catheter

a. For adults - #12 to # 18

b. For children - # 8 to # 10

c. For infants - # 5 to # 8

Note: If both oropharynx and nasopharynx are to be suctioned, one sterile

catheter is required for each.

Types of Suction Catheter

1. Open-tipped catheter – has an opening at the end and several openings

along the sides. It is effective for thick mucus plugs, but it can irritate the

tissue.

2. Whistle-tipped catheter – has a slanted opening at the tip.

Most catheters have a thumb port on the side, which is used to control the

suction. Several openings along the sides of the tip of the suction catheter

ensures distribution of negative pressure of the suction over a wide area,

thus preventing excessive irritation of any area of the respiratory mucous

membrane.

8. Water-soluble lubricant or glass of sterile water

9. Y-connector

10. Sterile gauzes

11. Moisture-resistant disposable bag

12. Sputum trap or cup, if specimen is to be collected

13. Sterile forceps (in cases where institution practices such or in absence of gloves)

14. Resuscitation bag (Ambu bag) connected to 100% oxygen

PROCEDURE RATIONALEA. Prepare the client.

1. Wash hands and observe other

appropriate infection control procedures

(e.g., gloves, goggles.

2. Gather necessary equipment and

supplies.

3. Explain to the client, regardless of level

of consciousness, the purpose and

rationale of the procedure. Provide

information that suctioning will relieve

breathing difficulty and the procedure

is painless but may stimulate the

cough, gag, or sneeze reflex.

PROCEDURE4. Assess for signs and symptoms

indicating upper airway secretions:

gurgling respirations, restlessness,

vomitus in the mouth, and drooling.

Monitor HR, RR, color, and ease of

respirations.

5. Position the client correctly.

For oropharyngeal and

nasopharyngeal suctioning:

a. Position a conscious person 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.

b. Position an unconscious client in

the lateral position facing you.

6. Place the towel or pad over the pillow or

under the chin. Provide emesis basin

under the chin or side of the face.

B. Prepare the equipment.

7. Set the pressure on the suction gauge

and turn on the suction. Many suction

devices are calibrated to three

pressure ranges:

Wall unit

Adult: 100-120 mmHg

Child: 95-110 mmHg

Infant: 50-95 mmHg

Portable unit

Adult: 10-15 mmHg

Child: 5-10 mmHg

Infant: 2-5 mmHg

PROCEDURE8. Hyperoxygenate client before inserting

catheter and suctioning.

9. Open the sterile suction package.

10. Set up the cup or container, touching

only its outside.

11. Pour sterile water or saline into the

sterile container.

12. Don the sterile gloves, or don a

nonsterile glove on the non-dominant

hand and sterile glove on the

dominant hand.

13. With you sterile gloved hand, pick up

the catheter, and attach it to the

suction unit.

14. Open the lubricant if performing

nasopharyngeal suctioning.

C. Make an approximate measure of the depth

for the insertion of the catheter and test

the equipment.

For oropharyngeal and nasopharyngeal

suctioning:

15. Measure the distance between the tip

of the client’s nose and the earlobe or

about 13cm (5in) for an adult. The

appropriate distance for an infant or

small child is 4 to 8 cm (1.6 to 3.2 in)

or 8 to 12 cm (3.2 to 4.8 in) for an

older child.

For nasal tracheal suctioning,

measure the distance between

the tip of the client’s nose to the

earlobe and then along the side of

the neck to the thyroid cartilage

(Adam’s apple). For oral tracheal

suctioning, measure from the

mouth to the midsternum.

PROCEDURE16. Mark the position on the tube with the

fingers of the sterile gloved hand.

17. 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.

D. Lubricate and introduce the catheter.

For nasopharyngeal suction:

a. Lubricate the catheter tip with

water-soluble lubricant.

b. Without applying suction, insert the

catheter the premeasured or

recommended distance into either

nares, and advance it along the floor

of the nasal cavity.

c. Never force the catheter against an

obstruction. If one nostril is

obstructed, try the other.

For an orpharyngeal suction:

a. Moisten tip with sterile water or

saline.

b. Pull the tongue forward, if

necessary, using gauze.

c. Do not apply suction during

insertion.

d. Gently advance the catheter about 4

to 6 inches along one side of the

mouth into the oropharynx.

PROCEDUREE. Perform suctioning.

18. Apply your finger to the suction control

port to start suction, and gently rotate

the catheter. Suction intermittently as

catheter is withdrawn.

19. Apply suction for 5 to 10 seconds; then

remove your finger form the control,

and remove the catheter. A suction

attempt should last only 10 to 15

seconds. During this time, the catheter

is inserted, the suction applied and

discontinued, and the catheter

removed.

It may be necessary during

oropharyngeal suctioning to apply

suction to secretions that collect in the

vestibule of the mouth and beneath

the tongue.

F. Clean the catheter, and repeat suctioning

as above.

20. Wipe off the catheter with sterile

gauze if it is thickly coated with

secretions. Dispose of the gauze in a

moisture-resistant bag.

21. Flush the catheter with sterile water or

saline.

22. Relubricate the catheter, and repeat

suctioning until the air passage is

clear.

Note: Allow 20- to 30-second

intervals between each suction,

and limit suction to 5 minutes in

total.

23. Alternate nares for repeat suctioning.

PROCEDURE24. Encourage client to breathe deeply

and to cough between suctions.

G. Obtain a specimen if required.

a. Attach the suction catheter to the

rubber tubing of the sputum trap.

b. Attach the suction tubing to the

sputum trap air vent.

c. Suction the client’s nasopharynx or

oropharynx. The sputum trap will

collect the mucus during

suctioning.

d. Remove the catheter from the

client. Disconnect the sputum trap

rubber tubing from the trap air

vent.

e. Connect the rubber tubing of the

sputum trap to the air vent.

f. Flush the catheter to remove

secretions from the tubing.

H. Promote client comfort.

25. Offer to assist the client with oral or

nasal hygiene.

I. Dispose of equipment and ensure

availability for the next suction.

26. Dispose of the catheter, gloves, water

and waste container. Wrap the

catheter around your sterile glove and

roll it inside the glove for disposal.

PROCEDURE27. To ensure that equipment is available

for the next suctioning, change suction

collection bottles and tubing daily or

more frequently as necessary.

J. Assess the effectiveness of suctioning.

28. Auscultate the client’s breathing

sounds to ensure they are clear

secretions. Observe for restlessness or

presence of oral secretions.

K. Wash hands.

L. Document relevant data.

a. Record the procedure: the amount,

consistency, color, and odor of

sputum (e.g., foamy, white mucus:

thick, green-tinged mucus; or blood-

flecked mucus), client’s breathing

status before and after the

procedure and the client’s reaction

to the procedure.

b. If the technique is carried out

frequently, e.g., q1h, it may be

appropriate to record only once, at

the end of the shift; however, the

frequency of the suctioning must be

recorded.

oxygenation checklist

Documents