Procedure Checklist

Performing Oropharyngeal Suctioning

Name: ________________________________________ Date:____________________________

Head Nurse:_________________________________ Performance Grade:____________

Grading:

3- Very Satisfactory 1- Needs Improvement

2- Satisfactory 0- Not Observed

Preparation Performed Mastered CommentsYes No

1. Assess

Assess your facility's policy to determine whether a physician's order is required for oropharyngeal suctioning.

Assess the client's blood gas or oxygen saturation values and check vital signs.

Assess the client's ability to cough and deep breathe to determine the ability to move secretions up the tracheobronchial tree.

2. Assemble Equipments

Wall suction or portable suction unit Connecting tubing Sterile normal saline solution Disposable sterile container Sterile suction catheter (#10 to #16 French

for an adult) Sterile gloves Clean gloves Goggles Oropharyngeal airway (optional for

frequent suctioning) Overbed table Waterproof trash bag Towel

Procedure1. Introduce yourself and verify the client’s

identity. Explain to the client what you are going to do, why it is necessary and how the

client can cooperate.2. Perform hand washing and observe

appropriate infection control procedures.3. Provide for client privacy4. Positions the patient:

a. For oropharyngeal suctioning: Semi-Fowler’s position with his head turned toward the nurse

5. Places the linen-saver pad or towel on the patient’s chest.

6. Puts on a face shield or goggles7. Turns on the wall suction or portable

suction machine and adjusts the pressure regulator according to policy

8. Tests the suction equipment by occluding the connection tubing

9. Opens the suction catheter kit or the gathered equipment if a kit is not available If using the nasal approach, opens the water-soluble lubricant

10. Dons sterile gloves; keeps the dominant hand sterile; considers nondominant hand nonsterile

11. Pours sterile saline into the sterile container, using the nondominant hand

12. Picks up the suction catheter with the dominant hand and attaches it to the connection tubing (to suction).

13. Puts the tip of the suction catheter into the sterile container of normal saline solution and suctions a small amount of normal saline solution through the suction catheter. Applies suction by placing a finger over the suction control port.

14. Approximates the depth to which to insert the suction catheter: a. Oropharyngeal suctioning: Measures the distance between the edge of the patient’s mouth and the tip of the patient’s ear lobe.

15. . Lubricates and inserts the suction catheter: a. Oropharyngeal suctioning 1) Lubricates the catheter tip with normal saline.2) Using the dominant hand, gently but quickly inserts the suction catheter along the side of the patient’s mouth into the oropharynx. 3) Advances the suction catheter quickly to the premeasured distance (usually 7 to 10 cm in the adult), being careful not to force

the catheter.16. Places a finger (thumb) over the suction

control port of the suction catheter and starts suctioning the patient. Applies suction while withdrawing the catheter in a continuous rotating motion

17. Limits suctioning to 5 to 10 seconds.18. After the catheter is withdrawn, clears it by

placing the tip of the catheter into the container of sterile saline and applying suction

19. . Lubricates the catheter and repeats suctioning as needed, allowing at least 20-second intervals between suctioning. For nasopharyngeal suctioning, alternates nares each time suction is repeated.

20. Coils the suction catheter in the dominant hand. Pulls the sterile glove off over the coiled catheter. (Alternatively, wraps the catheter around the dominant gloved hand and holds the catheter while removing the glove over it.)

21. Flush the connecting tubing with normal saline solution. Discard the used items and replace with new supplies so they are ready for the next suctioning.

22. Remove personal protective equipment and wash your hands.

23. Let the client rest after suctioning while you continue to observe him. The frequency and duration of suctioning depend on the client's tolerance for the procedure and on any complications

24. Record the date, time, reason for suctioning, and technique used; amount, color, consistency, and odor (if any) of the secretions; the client's respiratory status before and after the procedure; any complications and the nursing action taken; and the client's tolerance for the procedureTotal:

______________________________ ___________________

Signature over printed name Head Nurse