Preparing Medications from Ampules

ASSESSMENT
Assess
• Client allergies to medication
• Specific drug action, side effects, interactions, and adverse reactions
• Client’s knowledge of and learning needs about the medication
• Intended route of parenteral medication to determine appropriate size of syringe and needle for
the client
• Ordered medication for clarity and expiration date
• Perform appropriate assessments (e.g., vital signs, laboratory results) specific to the medication.
• Determine if the assessment data effect administration of the medication (i.e., is it appropriate to
administer the medication or does the medication need to be held or the primary care provider
notified)

PLANNING
Assignment
Preparing medications from ampules involves knowledge and use of sterile skills. Therefore, these
techniques are not assigned to AP.

Equipment
• Client’s MAR or computer printout
• Ampule of sterile medication
• File (if ampule is not scored) and small gauze square or plastic ampule opener
• Antiseptic swabs
• Syringe
• Needle for administering the medication
• Filter needle or filter straw for withdrawing medication from the ampule

IMPLEMENTATION
Preparation
1. Check the MAR.
• Check the label on the ampule carefully against the MAR to make sure that the correct
medication is being prepared.
• Follow the three checks for administering medications. Read the label on the medication (1) when
it is taken from the medication cart, (2) before withdrawing the medication, and (3) after
withdrawing the medication.

2. Organize the equipment.

Performance
1. Perform hand hygiene and observe other appropriate infection prevention procedures.
2. Prepare the medication ampule for drug withdrawal.
• Flick the upper stem of the ampule several times with a fingernail.
Rationale: This will bring all medication down to the
main portion of the ampule.
• Use an ampule opener or place a piece of sterile gauze or alcohol wipe between your thumb and
the ampule neck or around the ampule neck, and break off the top by bending it toward you to
ensure the ampule is broken away from yourself and away from others.
Rationale: The sterile gauze protects the fingers from the broken glass, and any glass fragments will
spray away from the nurse.
• Dispose of the top of the ampule in the sharp container.
3. Withdraw the medication.
• Place the ampule on a flat surface.
• Attach the filter needle or straw to the syringe.
Rationale: The filter needle or straw prevents glass particles from being withdrawn with the
medication.
• Remove the cap from the filter needle or filter straw and insert the needle or straw into the center
of the ampule. Do not touch the rim of the ampule with the needle or straw tip or shaft.
Rationale: This will keep the needle or straw sterile. Withdraw all of the drug.
• Hold the ampule slightly on its side, if necessary, to obtain all of the medication.
• Dispose of the filter needle or straw and ampule by placing them in a sharp container.
• If giving an injection replace the filter needle or filter straw with a regular needle, tighten the cap
at the hub of the needle, expel bubbles, and push the prescribed amount of solution into the
needle.
• Discard excess medication into an acceptable receptacle, depending on the ordered amount.

Preparing Medications from Vials

PLANNING
Assignment
Preparing medications from vials involves knowledge and use of sterile technique. Therefore, these
techniques are not assigned to AP.

Equipment
• Client’s MAR or computer printout
 • Vial of sterile medication
• Antiseptic swabs
• Safety needle and syringe
• Filter needle (check agency policy)
• Sterile water or normal saline, if drug is in powdered form
IMPLEMENTATION

Preparation
• Follow the same preparation as described in Skill 35.2.

Performance
1. Perform hand hygiene and observe other appropriate infection
prevention procedures.
2. Prepare the medication vial for drug withdrawal.
• Mix the solution, if necessary, by rotating the vial between the palms of the hands, not by
shaking.
Rationale: Some vials contain aqueous suspensions, which settle when they stand. In some instances,
shaking is contraindicated because it may cause the mixture to foam.
• Remove the protective cap, or clean the rubber cap of a previously opened vial with an antiseptic
wipe by rubbing in a circular motion.
Rationale: The antiseptic cleans the cap and reduces the number of microorganisms.
3. Withdraw the medication.
• Attach a filter needle, as agency practice dictates, to draw up premixed liquid medications from
MDVs.
Rationale: Using the filter needle prevents any solid particles from being drawn up through the needle.
• Ensure that the needle is firmly attached to the syringe.
• Remove the cap from the needle, then draw up into the syringe the amount of air equal to the
volume of the medication to be withdrawn.
• Carefully insert the needle into the upright vial through the center of the rubber cap, maintaining
the sterility of the needle.
• Inject the air into the vial, keeping the bevel of the needle above the surface of the medication.
Rationale: The air will allow the medication to be drawn out easily because negative pressure will not
be created inside the vial. The bevel is kept above the medication to avoid creating bubbles in the
medication.
• Withdraw the prescribed amount of medication using either
• of the following methods:
a. Hold the vial down (i.e., with the base lower than the top), move the needle tip so that it is below
the fluid level, and withdraw the medication. Avoid drawing up the last drops of the vial.
Rationale: Proponents of this method say that keeping the vial in the upright position while
withdrawing the medication allows particulate matter to precipitate out of the solution. Leaving the last
few drops reduces the chance of withdrawing foreign particles, or
b. Invert the vial, ensure the needle tip is below the fluid level, and gradually withdraw the
medication.
Rationale: Keeping the tip of the needle below the fluid level prevents air from being drawn into the
syringe.
• Hold the syringe and vial at eye level to determine that the correct dosage of drug is drawn into
the syringe. Eject air remaining at the top of the syringe into the vial.
• When the correct volume of medication plus a little more (e.g., 0.25 mL) is obtained, withdraw
the needle from the vial, and replace the cap over the needle using the scoop method, thus
maintaining its sterility.
 • If necessary, tap the syringe barrel to dislodge any air bubbles present in the syringe. Carefully
and slowly expel the air and any excess medication from the syringe, maintaining the “needle up”
position.
Rationale: The tapping motion will cause the air bubbles to rise to the top of the syringe where they
can be ejected out of the syringe. Sometimes when ejecting the air bubbles, the resulting amount of
medication is less than ordered. Drawing up a little extra medication, as in the previous step, helps
avoid this.
• If giving an injection, replace the filter needle, if used, with a safety needle of the correct gauge
and length. Eject air from the new needle and verify correct medication volume before injecting
the client.

Variation: Preparing and Using Multidose Vials

• Read the manufacturer’s directions.
• Withdraw an equivalent amount of air from the vial before adding the diluent, unless otherwise
indicated by the directions.
• Add the amount of sterile water or saline indicated in the directions.
• If an MDV is reconstituted, label the vial with the date and time it was prepared, the amount of
drug contained in each milliliter o solution, and your initials.
Rationale: Time is an important factor to consider in the expiration of these medications.
• Once the medication is reconstituted, store it in a refrigerator or as recommended by the
manufacturer.
• Discard the vial if sterility is compromised or questionable.
• Remember to use a sterile syringe and needle for each access to the MDV.

Mixing Medication from One Syringe

ASSESSMENT
Assess
• Client allergies to medications
• Specific drug action, side effects, interactions, and adverse reactions
• Client’s knowledge of and learning needs about the medications
• Intended route of parenteral medication to determine appropriate size of syringe and needle for
the client
• Ordered medications for clarity and expiration date
• Determine that the two medications are compatible.

PLANNING
Assignment
Mixing medications in one syringe involves knowledge and use of aseptic technique. Therefore, this
procedure is not assigned to AP.

Equipment
 • Client’s MAR or computer printout
• Two vials of medication; one vial and one ampule; two ampules; or one vial or ampule and one
cartridge
• Antiseptic swabs
• Sterile syringe and safety needle or insulin syringe and needle (If insulin is being given, use a
small-gauge hypodermic needle, e.g., #26 gauge.)
• Additional sterile subcutaneous or intramuscular safety needle (optional)

IMPLEMENTATION
Preparation
1. Check the MAR.
• Check the label on the medications carefully against the MAR to make sure that the correct
medication is being prepared.
• Follow the three checks for administering medications. Read the label on the medication (1) when
it is taken from the medication cart, (2) before withdrawing the medication, and (3) after
withdrawing the medication.
• Before preparing and combining the medications, ensure that the total volume of the injection is
appropriate for the injection site.
2. Organize the equipment.

Performance
1. Perform hand hygiene and observe other appropriate infection prevention procedures.
2. Prepare the medication ampule or vial for drug withdrawal.
• Inspect the appearance of the medication for clarity. Note, however, that some medications are
always cloudy.
Rationale: Preparations that have changed in appearance should be discarded.
• If using insulin, thoroughly mix the solution in each vial prior to administration. Rotate the vials
between the palms of the hands.
Rationale: Mixing ensures an adequate concentration and thus an accurate dose. Shaking insulin
vials can make the medication frothy, making precise measurement difficult.
• Clean the tops of the vials with antiseptic swabs.
3. Withdraw the medications.
Mixing Medications from Two Vials
• Take the syringe and draw up a volume of air equal to the volume of medications to be withdrawn
from both vials A and B.
• Inject a volume of air equal to the volume of medication to be withdrawn into vial A. Make sure
the needle does not touch the solution.
Rationale: This prevents cross-contamination of the medications.
• Withdraw the needle from vial A and inject the remaining air into vial B.
• Withdraw the required amount of medication from vial B.
Rationale: The same needle is used to inject air into and withdraw medication from the second vial. It
must not be contaminated with the medication in vial A.
• Using a newly attached sterile needle, withdraw the required amount of medication from vial A.
Avoid pushing the plunger because that will introduce medication B into vial A. If using a
syringe with a fused needle, withdraw the medication from vial A. The syringe now contains a
mixture of medications from vials A and B.
Rationale: With this method, neither vial is contaminated by microorganisms or by medication from
the other vial.
Be careful to withdraw only the ordered amount and to not create
air bubbles.
Rationale: The syringe now contains two medications and an excess amount cannot be returned to the
vial. See also the Variation later in this skill.

Mixing Medications from One Vial and One Ampule

• First prepare and withdraw the medication from the vial.
Rationale: Ampules do not require the addition of air prior to withdrawal of the drug.
• Then withdraw the required amount of medication from the ampule.

Mixing Medications from One Cartridge and One Vial or Ampule

• First ensure that the correct dose of the medication is in the cartridge. Discard any excess
medication and air.
• Draw up the required medication from a vial or ampule into the cartridge. Note that when
withdrawing medication from a vial, an equal amount of air must first be injected into the vial.
• If the total volume to be injected exceeds the capacity of the cartridge, use a syringe with
sufficient capacity to withdraw the desired amount of medication from the vial or ampule, and
transfer the required amount from the cartridge to the syringe.

Variation: Mixing Insulins

The following is an example of mixing 10 units of regular insulin and 30 units of NPH insulin, which
contains protamine.
• Inject 30 units of air into the NPH vial and withdraw the needle. (There should be no insulin in
the needle.) The needle should not touch the insulin.
• Inject 10 units of air into the regular insulin vial and immediately withdraw 10 units of regular
insulin and always withdraw the regular insulin first.
Rationale: This minimizes the possibility of the regular insulin becoming contaminated with the
additional protein in the NPH.
• Reinsert the needle into the NPH insulin vial and withdraw 30 units of NPH insulin. (The air was
previously injected into
• the vial.) Be careful to withdraw only the ordered amount and to not create air bubbles. If excess
medication has been drawn up, discard the syringe and begin the procedure over again.
Rationale: The syringe now contains two medications, and an excess amount cannot be returned to
the vial because the syringe contains regular insulin, which, if returned to the NPH vial, would dilute
the NPH with regular insulin. The NPH vial would not provide accurate future dosages of NPH
insulin.
• By using this method, you avoid adding NPH insulin to the regular insulin.

Clinical Alert!
One way to determine which insulin to withdraw first is to remember
the saying “Clear before cloudy.” (Regular insulin is clear and
NPH is cloudy due to the proteins in the insulin.)
Safety Alert
Insulin is a high-alert medication, meaning that it can cause significant
client harm if used in error. Check the health agency’s policy
regarding administration because some agencies may require insulin
doses to be checked by two nurses.
Perform Indwelling Urinary Catheterization
PURPOSES
Straight catheter:
• To relieve discomfort due to bladder distention
• To assess the amount of residual urine if the bladder empties incompletely
• To obtain a sterile urine specimen
• To empty the bladder completely prior to surgery.

Indwelling catheter:
• To relieve urinary retention or bladder outlet obstruction
• For selected surgical procedures
• To facilitate accurate measurement of urinary output for critically ill clients whose output needs
to be monitored hourly
• To provide for intermittent or continuous bladder drainage and/ or irrigation
• To prevent urine from contacting an incision after perineal surgery if needed
• To assist in healing of open sacral or perineal wounds in incontinent clients
• To improve comfort for end-of-life care if needed.
SKILL 47.2
ASSESSMENT
• Determine the most appropriate method of catheterization based on the purpose and any criteria
specified in the order such as total amount of urine to be removed or size of catheter to be used.
• Use a straight catheter if only a one-time urine specimen is needed, if amount of residual urine is
being measured, or if temporary emptying of the bladder is required.
• Use an indwelling catheter if the bladder must remain empty, intermittent catheterization is
contraindicated, or continuous urine measurement or collection is needed.
• Assess the client’s overall condition. Determine if the client is able to participate and hold still
during the procedure and if the client can be positioned supine with head relatively flat. For
female clients, determine if she can have knees bent and hips externally rotated.
• Determine when the client last voided or was last catheterized.
• If catheterization is being performed because the client has been unable to void, when possible,
complete a bladder scan to assess the amount of urine present in the bladder.
Rationale: This prevents catheterizing the bladder when insufficient urine is present. Often, a
minimum of 500 to 800 mL of urine indicates urinary retention and the client should be reassessed
until that amount is present.

PLANNING
• Allow adequate time to perform the catheterization. Although the entire procedure can require as
little as 15 minutes, several sources of difficulty could result in a much longer period of time. If
possible, it should not be performed just prior to or after a meal.
• Some agencies require two nurses to be present for the procedure: one to perform the
catheterization and the other to assist with positioning and ensure there is no break in aseptic
technique.
• Some clients may feel uncomfortable being catheterized by nurses of the opposite gender. If this
is the case, obtain the client’s permission. Also consider whether agency policy requires or
encourages having an individual of the client’s same gender present for the procedure.

Assignment
Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is
not assigned to AP.

Equipment
For a straight catheterization:
Straight catheterization kit:
• Sterile straight catheter of appropriate size
• Sterile gloves
• Waterproof drape(s)
• Antiseptic solution
• Cleansing balls
• Forceps
• Water-soluble lubricant
• Urine receptacle
• Specimen container. (An extra catheter should also be at hand in case of a break in aseptic
technique.)

• For an indwelling catheter:

Closed catheterization kit:
• Sterile indwelling catheter of appropriate size
• Sterile gloves
• Waterproof drape(s)
• Antiseptic solution
• Cleansing balls
• Forceps
• Water-soluble lubricant
• Syringe prefilled with sterile water in amount specified by catheter manufacturer
• Collection bag and tubing
• 5–10 mL 2% Xylocaine gel or water-soluble lubricant for male urethral injection (if agency
permits)
• Clean gloves
• Supplies for performing perineal cleansing
• Bath blanket or sheet for draping the client
• Adequate lighting (Obtain a flashlight or lamp if necessary.)
• (An extra catheter should also be at hand in case of a break in
 • aseptic technique.)
I2MPLEMENTATION
Preparation
• If using a catheterization kit, read the label carefully to ensure that all necessary items are
included.
• Apply clean gloves and perform routine perineal care to cleanse the meatus from gross
contamination. For women, use this time to locate the urinary meatus relative to surrounding
structures.
• Remove and discard gloves.
• Perform hand hygiene.

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.
2. Perform hand hygiene and observe other appropriate infection prevention procedures.
3. Provide for client privacy.
4. Place the client in the appropriate position and drape all areas except the perineum.
• Female: supine with knees flexed, feet about 2 feet apart, and hips slightly externally rotated, if
possible
• Male: supine, thighs slightly abducted or apart
5. Establish adequate lighting. Stand on the client’s right if you are right-handed, on the client’s left
if you are left-handed.
6. If using a collecting bag and it is not contained within the catheterization kit, open the drainage
package and place the end of the tubing within reach.
Rationale: Because one hand is needed to hold the catheter once it is in place, open the package while
two hands are still available.
7. If agency policy permits, apply clean gloves and inject 10 to 15 mL Xylocaine gel into the urethra
of the male client. Wipe the underside of the penile shaft to distribute the gel up the urethra. Wait
at least 5 minutes for the gel to take effect before inserting the catheter.
8. Remove and discard gloves.
• Perform hand hygiene.
9. Open the catheterization kit. Place a waterproof drape under the buttocks (female) or penis
(male) without contaminating the center of the drape with your hands.
10. Apply sterile gloves.
11. Organize the remaining supplies:
• Saturate the cleansing balls with the antiseptic solution.
• Open the lubricant package.
• Remove the specimen container and place it nearby with the lid loosely on top.
• Remove plastic covering of indwelling catheter.
12. Lubricate the catheter 2.5 to 5 cm (1 to 2 in.) for females, 15 to 17.5 cm (6 to 7 in.) for males, and
place it with the drainage end inside the collection container.
13. Attach the prefilled syringe to the indwelling catheter inflation hub. Do not pre-inflate the
balloon.
Rationale: Pre-inflation is no longer recommended and may cause microtears, risking infection.
14. If desired, place the fenestrated drape over the perineum, exposing the urinary meatus.
15. Cleanse the meatus. Note: The nondominant hand is considered contaminated once it touches the
client’s skin.
 • Females: Use your nondominant hand to spread the labia so that the meatus is visible. Establish
firm but gentle pressure on the labia. The antiseptic may make the tissues slippery but the labia
must not be allowed to return over the cleaned meatus. Note: Location of the urethral meatus is
best identified during the cleansing process. Pick up a cleansing ball with the forceps in your
dominant hand and wipe one side of the labia majora in an anteroposterior direction. Use great
care that wiping the client does not contaminate this sterile hand. Use a new ball for the opposite
side. Repeat for the labia minora. Use the last ball to cleanse directly over the meatus.
• Males: Use your nondominant hand to grasp the penis just below the glans. If necessary, retract
the foreskin. Hold the penis firmly upright, with slight tension.
Rationale: Lifting the penis in this manner helps straighten the urethra. Pick up a cleansing ball with
the forceps in your dominant hand and wipe from the center of the meatus in a circular motion
around the glans. Use great care that wiping the client does not contaminate the sterile hand. Use a
new ball and repeat 3 more times. The antiseptic may make the tissues slippery but the foreskin
must not be allowed to return over the cleaned meatus nor the penis be dropped.
16. Insert the catheter.
• Grasp the catheter firmly 5 to 7.5 cm (2 to 3 in.) from the tip. Ask the client to take a slow deep
breath and insert the catheter as the client exhales. Slight resistance is expected as the catheter
passes through the sphincter. If necessary, twist the catheter or hold pressure on the catheter until
the sphincter relaxes.
• Advance the catheter 5 cm (2 in.) farther after the urine begins to flow through it.
Rationale: This is to be sure it is fully in the bladder, will not easily fall out, and the balloon is in the
bladder completely. For male clients, advance the catheter to the “Y” bifurcation of the catheter.
• If the catheter accidentally contacts the labia or slips into the vagina, it is considered
contaminated and a new, sterile catheter must be used. The contaminated catheter may be left in
the vagina until the new catheter is inserted to help avoid mistaking the vaginal opening for the
urethral meatus.
17. Hold the catheter with the nondominant hand.
18. For an indwelling catheter, inflate the IUC balloon with the designated volume.
• Without releasing the catheter (and, for females, without releasing the labia), hold the inflation
valve between two fingers of your nondominant hand while you attach the syringe (if not left
attached earlier) and inflate with your dominant hand. If the client complains of discomfort,
immediately withdraw the instilled fluid, advance the catheter farther, and attempt to inflate the
balloon again.
• Pull gently on the catheter until resistance is felt to ensure that the balloon has inflated and to
place it in the trigone of the bladder.
19. Collect a urine specimen if needed. For a straight catheter, allow 20 to 30 mL to flow into the
bottle without touching the catheter to the bottle. For an indwelling catheter pre-attached to a
drainage bag, a specimen may be taken from the bag this initial time only
20. Allow the straight catheter to continue draining into the urine receptacle. If necessary (e.g.,
open system), attach the drainage end of an indwelling catheter to the collecting tubing and bag.
21. Examine and measure the urine. In some cases, only 750-1000 mL of urine are to be drained
from the bladder at
one time. Check agency policy for further instructions if this should occur.
22. Remove the straight catheter when urine flow stops. For an indwelling catheter, secure the
catheter tubing to the thigh for female clients or the upper thigh or lower abdomen for male clients
to prevent movement on the urethra or excessive tension or pulling on the indwelling balloon.
Adhesive and non-adhesive catheter-securing devices are available and should be used to secure the
catheter tubing to the client.
Rationale: This prevents unnecessary trauma to the urethra.
23. Next, hang the bag below the level of the bladder. No tubing should fall below the top of the bag.
24. Wipe any remaining antiseptic or lubricant from the perineal area. Replace the foreskin if
retracted earlier. Return the client to a comfortable position. Instruct the client on positioning and
moving with the catheter in place.
25. Discard all used supplies in appropriate receptacles.
26. Remove and discard gloves.
• Perform hand hygiene.
27. Document the catheterization procedure including catheter size and results in the client record
using forms or checklists supplemented by narrative notes when appropriate.
SAMPLE DOCUMENTATION
2/24/2020 0530 Client agreed to insertion of pre-op catheter as
per order. #16 Fr Foley with 5-mL balloon inserted without difficulty,
secured to thigh, connected to continuous drainage. Immediate
return of 300 mL pale, clear, yellow urine. G. Hampton, RN
EVALUATION
• Notify the primary care provider of the catheterization results.
• Perform a detailed follow-up based on findings that deviated from expected or normal for the client.
Compare findings to previous assessment data if available.
• Teach the client how to care for the indwelling catheter, to drink more fluids, and provide other
appropriate instructions.
LIFESPAN CONSIDERATIONS
INFANTS AND CHILDREN
• Adapt the size of the catheter for pediatric clients.
• Ask a family member to assist in holding the child during catheterization, if appropriate.
OLDER ADULTS
When catheterizing older clients, be very attentive to problems of limited movement, especially in the
hips. Arthritis, or previous hip or knee surgery, may limit their movement and cause discomfort. Modify
the position (e.g., side-lying) as needed to perform the procedure safely and comfortably. For women,
obtain the assistance of another nurse to flex and hold the client’s knees and hips as necessary or place her
in a modified Sims’ position.

Administering Oxygen by Cannula, Face Mask, or Face Tent

Before administering oxygen, check (a) the order for oxygen, including the administering device and the
liter flow rate (L/min) or the percentage of oxygen; (b) the levels of oxygen (PaO2) and carbon dioxide
(PaCO2) in the client’s arterial blood (PaO2 is normally 80 to 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.

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
Face Mask
• To provide moderate oxygen support and a higher concentration 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

ASSESSMENT
Assess
• Skin and mucous membrane color: Note whether cyanosis is present, presence of mucus, sputum
production, and impedance 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.
• 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.
• 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 with COPD may have a chronically high carbon dioxide level, and their
stimulus to breathe is hypoxemia. During continuous oxygen administration, arterial blood gas
levels of oxygen (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.
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
equipment and client teaching. However, it is important for the nurse to continually assess the client’s
need for oxygenation and oxygen therapy.

ASSIGNMENT
Initiating the administration of oxygen is considered similar to administering 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
interpreted 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
• 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

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 participate. 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.
• 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
• 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
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
7. Assess the 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. 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.

8. 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.
• 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 cannula
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

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).
• Report significant deviations from normal to the primary care provider.
Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning
Oral, Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning
PURPOSES
• To remove secretions that obstruct the airway
• To facilitate ventilation
• To obtain secretions for diagnostic purposes
• To prevent infection that may result from accumulated secretions
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
• Skin color
• Rate and pattern of respirations
• Pulse rate and rhythm
• Decreased oxygen saturation

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 suctioning
use sterile technique and require application of knowledge and problem-solving and should be performed
by the nurse or respiratory therapist.

Equipment
Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning (Using Sterile Technique)
• Towel or moisture-resistant pad
• Portable or wall suction machine with tubing, collection receptacle, 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
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 forward, 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 negative pressure on the suction gauge. The
amount of negative pressure should be high enough to clear secretions 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.
c. Apply the sterile gloves, or apply an unsterile glove on the nondominant hand and then a sterile
glove on the dominant 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.
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 suction, 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 respiratory mucosa due to prolonged suction.
• Apply suction for 5 to 10 seconds while slowly withdrawing 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 trachea and
nasopharynx.
• 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.
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 by
5 minutes in total.
Rationale: Applying suction for too long may cause secretions to increase or may decrease the
client’s oxygen supply.
• Encourage the client to breathe deeply and to cough between suctions. Use supplemental oxygen,
if appropriate.
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.
• Empty and rinse the suction collection container as needed or indicated by protocol. Change the
suction tubing and container daily.
• 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 respiratory status
before and after the procedure. This may include lung sounds, rate and character of breathing, and
oxygen saturation.
• 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

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.
• Report significant deviations from normal to the primary care provider.