OROPHARYNGEAL/ ORONASAL/ SUCTIONING
DEFINITION: It is the removal of airway secretions from the mouth and nose.
PURPOSE:
1. To remove secretions from the airway and prevent airway obstruction;
2. Promote respiratory function.
ASSESSMENT:
1. Assess oxygen saturation level.
2. Assess respiration and signs of respiratory distress.
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SPECIAL CONSIDERATION:
1. Clients who need to be suctioned usually have coarse lung sounds.
2. Clients may become tachypneic when they need to be suctioned.
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3. Hyperoxygenate only when there is no blockage in the airway.
4. Perform oral hygiene after suctioning.
EQUIPMENT/SUPPLIES:
1. Suction catheter
2. Pair of sterile gloves
3. Glass of sterile water
C 6. Sterile gauze
7. Clean towel
8. Suction apparatus
IMPLEMENTATION:
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Suggested Actions Rationale
1. Check physician’s orders. Ensures accuracy and prevents errors.
2. Perform hand hygiene. Prevents cross contamination and
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further spread of infection.
3. Prepare the materials Saves time and effort.
needed.
4. Identify the client by Confirms identity of client.
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asking for the name or
checking the identification
band.
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5. Introduce yourself to the Establishes rapport.
client.
6. Explain procedure to client. Alleviates the fear and gain
cooperation.
7. Assess client’s status. Care is always individualized according
to a client’s needs.
Suggested Actions Rationale
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
8. Adjust the bed to the Make both the client and the nurse feel
appropriate height. Lower at ease in the performance of the
the side rail on the working procedure.
side.
9. Provide privacy. This is basic to human dignity, and
provision of privacy demonstrates
respect.
10. Assist client to Fowler’s or Helps client to cough and breathe more
Semi- Fowler’s position. easily. These positions also use
gravity to aid in catheter insertion.
11. Turn suction to appropriate Negative pressure must be at safe level,
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pressure in adults. or damage to tracheal mucosa may
occur.
12. Place clean towel if being Towel or waterproof pad protects client
used, or waterproof pad and bed linens. Wearing protective
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across client’s chest. Don equipment protects the nurse against
goggles, mask and gown, if contamination of secretions from
necessary. mucous membranes.
13. Open sterile kit or set up
equipment and prepare to
suction.
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a) Place sterile drape, if Protects client and bed linens.
available, across client’s
chest.
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b) Open sterile container or Maintains sterile setup.
set up and place on
bedside table or over
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bed table without
contaminating inner
surface. Pour sterile
saline into it.
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c) Don sterile gloves, or Maintains sterility of procedure and
one sterile glove on protects the nurse from
dominant hand and microorganisms.
clean glove on non-
A
dominant hand.
Suggested Actions Rationale
d) Connect sterile suction Prevents introduction of organisms into
catheter to suction the respiratory tract.
tubing that is held with
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
clean gloved hand.
14. Holding catheter with Lubricates the catheter.
sterile dominant hand,
moisten by dipping it into
the sterile water. Check
suction on catheter by
occluding the suction port.
15. Remove oxygen delivery .
setup with unsterile gloved
hand if it still in place.
16. Using sterile glove hand, Suctioning while inserting catheter can
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gently and quickly insert cause trauma to mucosa and removes
catheter into oral mucosa oxygen from the respiratory tract.
or the nares.
Oropharyngeal
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a. Run catheter along gum
line to the pharynx in a
circular motion, keeping
the catheter moving.
Nasopharyngeal
a. Raise the tip of the
client’s nose with your
nondominant hand.
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This straightens the passageway and
facilitate insertion of the catheter.
b. Without applying
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suction, gently insert the
suction catheter into the
client’s nares.
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c. Roll the catheter
between your fingers to
help it advance through
the turbinates.
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d. Continue to advance the
catheter, approximately
5” to 6” (12.7 cm-15
cm), until you reach the
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pool of secretions of the
client begins to cough.
e. Do not occlude suction
port when inserting
catheter.
Suggested Actions Rationale
17. Apply intermittent suction
port with thumb of
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
unsterile gloved hand.
a. Gently rotate catheter Remove secretions from the
with thumb and index respiratory tract and prevents
finger of sterile gloved injury to the oral/nasal mucosa.
hand as catheter is
being withdrawn.
b. Do not allow Suctioning for longer than 10 seconds
suctioning to continue may result in hypoxia.
for more than 10
seconds.
c. Encourage client to Reoxygenate the lungs.
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cough and deep
breathe between
suctioning.
18. Flush the catheter with Cleanse catheter and lubricates it.
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saline and repeat
suctioning as needed.
a. Allow client to rest at Helps compensate for hypoxia induced by
least 1 minute between suctioning.
suctioning, and replace
oxygen delivery setup if
necessary.
b. Limit number of
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Multiple suctioning results to increased
suctioning to three amount of secretions.
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times.
19. When procedure is
completed, turn off suction
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and disconnect catheter
from suction tubing.
20. Reapply oxygen supply if Determine whether respiratory
indicated. Auscultate chest passageways have been cleared of
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to evaluate breath sounds. secretions.
21. Place client in a Improves well-being.
comfortable position.
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22. Place needed items and Facilitates comfort; provides ready access
call bell within client’s for communication.
reach.
23. Raise side rails and lower Prevents accidental falls.
the bed to the lowest
position.
Suggested Actions Rationale
24. Remove equipment and Promotes clean environment with
dispose supplies used. necessary equipment ready for
future use.
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
25. Perform hand hygiene. Reduces spread of microorganism
26. Document and report Evaluates client’s response to
client’s response to procedure.
procedure.
DOCUMENTATION:
Record;
a. Time of suctioning and the Provides for communication and
nature and amount of continuity of care.
secretions.
b. Note the character of
client’s respiration before
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and after suctioning.
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C
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N
D
A
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
ORONASAL SUCTIONING
Suggested Actions Correctly Partially Not Remarks
Done Done Done
1. Check physician’s orders.
2. Perform hand hygiene.
3. Prepare the materials
needed.
4. Identify the client by
N
asking for the name or
checking the
identification band.
5. Introduce yourself to the
O
client.
6. Explain procedure to
client.
7. Assess client’s status.
8. Adjust the bed to the
appropriate height.
Lower the side rail on the
working side.
C
9. Provide privacy.
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10. Assist client to Fowler’s
or Semi- Fowler’s
position.
N
11. Turn suction to
appropriate pressure in
adults.
12. Place clean towel if being
D
used, or waterproof pad
across client’s chest. Don
goggles, mask and gown,
if necessary.
A
13. Open sterile kit or set up
equipment and prepare
to suction.
a. Place sterile drape, if
available, across
client’s chest.
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
Suggested Actions Correctly Partially Not Remarks
Done Done Done
b. Open sterile
container or set up
and place on bedside
table or over bed
table without
contaminating inner
surface. Pour sterile
saline into it.
c. Don sterile gloves, or
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one sterile glove on
dominant hand and
clean glove on non-
dominant hand.
O
d. Connect sterile
suction catheter to
suction tubing that is
held with clean
gloved hand.
14. Holding catheter with
sterile dominant hand,
moisten by dipping it into
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the sterile water. Check
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suction on catheter by
occluding the suction
port.
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15. Remove oxygen delivery
setup with unsterile
gloved hand if it still in
place.
D
16. Using sterile glove hand,
gently and quickly insert
catheter into oral mucosa
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or the nares.
Oropharyngeal
a. Run catheter along
gum line to the
pharynx in a circular
motion, keeping the
catheter moving.
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
Suggested Actions Correctly Partially Not Remarks
Done Done Done
Nasopharyngeal
a. Raise the tip of the
client’s nose with your
nondominant hand.
b. Without applying
suction, gently insert
the suction catheter
into the client’s nares.
c. Roll the catheter
N
between your fingers
to help it advance
through the
turbinates.
O
d. Continue to advance
the catheter,
approximately 5” to 6”
(12.7 cm-15 cm), until
you reach the pool of
secretions of the client
begins to cough.
e. Do not occlude suction
C
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port when inserting
catheter.
17. Apply intermittent
suction port with thumb
N
of unsterile gloved hand.
a. Gently rotate catheter
with thumb and index
finger of sterile
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gloved hand as
catheter is being
withdrawn.
A
b. Do not allow
suctioning to continue
for more than 10
seconds.
c. Encourage client to
cough and deep
breathe between
suctioning.
18. Flush the catheter with
saline and repeat
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
suctioning as needed.
Suggested Actions Correctly Partially Not Remarks
Done Done Done
a. Allow client to rest at
least 1 minute
between suctioning,
and replace oxygen
delivery setup if
necessary.
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b. Limit number of
suctioning to three
times.
19. When procedure is
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completed, turn off
suction and disconnect
catheter from suction
tubing.
20. Reapply oxygen supply if
indicated. Auscultate
chest to evaluate breath
sounds.
C
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21. Place client in a
comfortable position.
22. Place needed items and
call bell within client’s
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reach.
23. Raise side rails and lower
the bed to the lowest
position.
D
24. Remove equipment and
dispose supplies used.
25. Perform hand hygiene.
A
26. Document and report
client’s response to
procedure.
DOCUMENTATION:
Record;
a. Time of suctioning and
the nature and
amount of secretions.
b. Note the character of
client’s respiration
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
before and after
suctioning.
ATTITUDE CRITERION
3 2 1 REMARKS
1. Behavior
2. Compliance to prescribed
uniform
3. Completion of other Tasks
(Assignment, Reflection
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Journal, etc.)
4. Time Efficiency
Score: 3 x ______ = ________ Total Weight/_____ = ________
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2 x ______ = ________ (no. of items)
1 x ______ = ________ SCORE : _________
EQUIVALENT:__________
K(__%) = _________%
S(__%)
A(__%)
Total
=
=
=
_________%
_________%
_________%
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______________________________________________ _______________
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Signature of Student Over Printed Name Date
______________________________________________ _______________
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Signature of Clinical Instructor Over Printed Name Date
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A
This instructional material is exclusively for ADNU College of Nursing only. Reproduction, sharing and distribution is strictly not
allowed.
