S

FUNDAMENTALS OF
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NURSING LAB
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G Associate Prof. Rhea G. Gacuya,RN,MAN

St. Luke’s College of Nursing

https://images.app.goo.gl/N2erCjJi6zMiA5cD9
 ASSESSMENT
1. Identify patient using two
identifiers
2. Assesses for signs and symptoms
of upper and lower airway
obstruction requiring suctioning:
abnormal respiratory rate,
adventitious sounds on inspiration or
expiration, drooling in mouth and
coughing without clearing secretions
from airway.
https://images.app.goo.gl/NKbGL2TghNaSJ8oy9
 ASSESSMENT
3. Assesses signs and symptoms
associated with hypoxia and
hypercapnia, decreased SpO2,
increased pulse and BP, decreased
level of consciousness and cyanosis

4. Assess patient’s understanding of

procedure

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/lowspo2_Large.jpg
 PLANNING
1. Explains to patient how procedure
will help clear airway and relieve
breathing problems and that
temporary coughing, sneezing,
gagging or shortness of breath is
normal. Encourages patient to cough
out secretions.
2. Explains importance of and
encourage coughing when catheter is
introduced. https://images.app.goo.gl/c4Uh7sZPjTqZdaLL8
 PLANNING

3. Assists patient with assuming

comfortable position (usually semi-
fowler’s or sitting upright with head
hyperextended, unless
contraindicated).
Stand on patient’s right if you are
right-handed or on patient’s left if
you are left-handed.
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 PLANNING
4. If not in place, position pulse
oximeter on patient’s finger. Take
reading and leave pulse oximeter
in place.
5. Places towel across patient’s
chest

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 IMPLEMENTATION
1. Performs hand hygiene. Apply
mask, gown, goggles or face shield
is splashing is likely.

https://images.app.goo.gl/t5eLPU4phrjuAwa9A

2. Connects one end of connecting

tubing to suction machine and
place other end in convenient
location near patient.
 IMPLEMENTATION
3. Turns suction device on and set
vacuum regulator to appropriate
negative pressure:
120 to 150 mmHg for adults
60 to 100 mmHg for
children
40 to 60 mmHg for infants
 IMPLEMENTATION
4. If indicated, increase
supplemental Oxygen therapy to
100%. Encourages patient to deep
breathe.
5.Opens appropriate suction
catheter using aseptic technique
and leaving catheter in sterile
wrapper. Do not allow suction
catheter to touch any nonsterile
surfaces
 IMPLEMENTATION
6.Fills rinsing glass with
approximately 100ml of sterile
water or NSS into the rinsing glass.

https://images.app.goo.gl/GrP7rBWrpU79xbNHA

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 IMPLEMENTATION
7.Applies gloves:

a. Apply clean glove to each hand or

dominant hand for oropharyngeal
suctioning
b. Apply sterile glove to each hand or
nonsterile gloves to nondominant
hand and sterile glove to dominant
hand for nasopharyngeal,
nasotracheal artificial airway
(Endotracheal tube (ET tube)
/Tracheostomy tube)
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 IMPLEMENTATION
8.Picks up suction catheter with
dominant hand without touching
nonsterile surface. Picks up
connecting tubing with
nondominant hand. Secure
catheter to tubing.
9.Moistens catheter tip by dipping
tip of the catheter into the sterile
NSS.
 IMPLEMENTATION
10.Suction airway
a. Oropharyngeal Suctioning

Insert Yankauer catheter into

patient’s mouth. Apply suction
once the catheter is in patient’s
mouth, move catheter around
mouth along gum line to pharynx.
Then apply suction and move
catheter around mouth until https://images.app.goo.gl/V5df3bw
secretions are cleared. pfABaFxbZ7
 IMPLEMENTATION
b.Artificial airway (tracheostomy
or endotracheal [ET] tube)
suctioning
1) Check that equipment is
functioning properly by placing
tip of catheter into basin and
suctioning small amount of
saline by occluding suction vent.
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 IMPLEMENTATION
2) Hyperoxygenate patient
before suctioning using
manual resuscitation bag
and increasing FiO2 for
several minutes

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 IMPLEMENTATION
3.If patient is receiving invasive
mechanical ventilation, open
swivel adapter or, if necessary,
remove oxygen- or humidity-
delivery device with
nondominant hand.
 IMPLEMENTATION
4. Advise patient that you are about
to begin suctioning and, without
applying suction, gently but quickly
insert catheter using dominant
thumb and forefinger into artificial
airway.
 IMPLEMENTATION
5.Apply intermittent suction no
longer than 10 seconds.
Apply intermittent suction by
placing and releasing
nondominant thumb over vent of
catheter; slowly withdraw
catheter while rotating it back
and forth between dominant
thumb and forefinger.
https://images.app.goo.gl/SiafoTtyzC6bdGXPA
 IMPLEMENTATION
6. If patient is receiving invasive
mechanical ventilation, close
swivel adapter or replace oxygen-
delivery device.
7.Encourage patient to deep https://images.app.goo.gl/hr8DmTtHBuhmxTUX8
breathe if able. Some patients
respond well to several manual
breaths from the mechanical
ventilator or bag-valve mask
https://images.app.goo.gl/Gbmkq7CM8gpbFfmx9
 IMPLEMENTATION
(8) Rinse catheter and connecting
tubing with normal saline until
clear. Use continuous suction.
 IMPLEMENTATION
9. Assess patient’s
cardiopulmonary status for
secretion clearance and
complications.
Allow adequate time (at least 1
full minute) between suction
passes for ventilation and
hyperoxygenation.
 IMPLEMENTATION
10. Perform nasopharyngeal and
oropharyngeal suctioning if
necessary. After performing
nasopharyngeal and oropharyngeal
suctioning, catheter is
contaminated; do not reinsert into
ET or tracheostomy tube

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 IMPLEMENTATION
11. Complete procedure.
a. Place Yankauer catheter in a clean,
dry area for reuse with suction turned
off or within patient’s reach with
suction on if patient is capable of
suctioning self.

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 IMPLEMENTATION
b. Disconnect nasal and artificial
airway catheters from connecting
tubing. Turn off suction. Roll catheter
around fingers of dominant hand. Pull
glove off inside out so catheter
remains in glove. Pull off other glove
over first glove in same way to contain
contaminants. Discard into
appropriate receptacle. Turn off
suction device.
 IMPLEMENTATION
c. Remove towel and place in laundry
or remove drape and discard in
appropriate receptacle.
d. Reposition patient as indicated by
condition. Reapply clean gloves for
patient’s personal care (e.g., oral
hygiene).
e. If indicated, readjust oxygen to
original level.
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 IMPLEMENTATION
f. Discard remainder of normal saline
into appropriate receptacle. If basin is
disposable, discard into appropriate
receptacle. If basin is reusable, rinse
and place in soiled utility room.
g. Remove and discard goggles, mask, https://images.app.goo.gl/reLgBGzo8YVduHEJ8
or face shield and perform hand
hygiene
h. Place unopened suction kit on
suction machine table or at head of
bed according to institution
preference.https://images.app.goo.gl/d47DfVGPj7EA6pFh8
 EVALUATION
1.Compare patient’s vital signs and
SpO2 saturation before and after
suctioning.
2.Ask patient if breathing is easier and
congestion is decreased.
https://images.app.goo.gl/etzzyYRDzR7DvqRs7
3.Auscultate lungs and compare
patient’s respiratory assessment
before and after suctioning.
4.Observe airway secretions.
5.Observe patient perform
oropharyngeal suctioning.

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 RECORDING AND REPORTING

1.Record amount, consistency,

color, and odor of secretions and
patient’s response to procedure in
the chart.
2. Record and report patient’s
presuctioning and postsuctioning
cardiopulmonary status.
3. Document your evaluation of
patient learning
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