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
 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

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
PROCEDURE RATIONALE
Preparation
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.
PROCEDURE
4. 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.
PROCEDURE
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.

 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 RATIONALE
1. Assess the client’s condition and identify Factors like client’s anxiety may affect the
anything that may affect the success of client’s ability to follow the procedure. In
the procedure. addition, pain on the part of the client may
alter client’s learning capability.

Abdominal (diaphragmatic ) and Pursed-Lip A person who understands and accepts the
Breathing importance of deep breathing is more likely
2. Explain to the client that diaphragmatic to cooperate and participate in the exercise.
breathing can help the person breath
more deeply and with less effort.

3. Have the client assume either a The semi-Fowler’s and supine position with
comfortable semi-Fowler’s position with knees flexed help relax the abdominal
knees flexed, back supported, and with muscles.
one head pillow or a supine position with
one head pillow and knees flexed. After
learning, the client can practice.

4. Have the client place one or both hands This position will aid in the accurate
on the abdomen just below the ribs. observation of the patient’s chest expansion.

PROCEDURE RATIONALE
5. 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 RATIONALE
11. 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 RATIONALE
18. 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 RATIONALE
1. 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 RATIONALE
1. 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 RATIONALE
4. 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 RATIONALE
9. 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 RATIONALE
15. 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 RATIONALE
1. 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 RATIONALE
7. 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 RATIONALE
A. 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.

PROCEDURE
4. 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

PROCEDURE
8. 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.
PROCEDURE
16. 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.

PROCEDURE
E. 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.

PROCEDURE
24. 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.

PROCEDURE
27. 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.