MEDICAL-SURGICAL

SKILLS
ENDOTRACHEAL TUBE
SUCTIONING
 ENDOTRACHEAL
TUBE
SUCTIONING

The purpose of suctioning is to maintain a patent airway and remove pulmonary

secretions, blood, vomitus, or foreign material from the airway. When suctioning via
an endotracheal tube, the goal is to remove secretions that are not accessible to cilia
bypassed by the tube itself. Remember, tracheal suctioning can lead to hypoxemia,
cardiac dysrhythmias, trauma, atelectasis, infection, bleeding, and pain, so it is
imperative to be diligent in maintaining aseptic technique and following facility
guidelines and procedures to prevent potential hazards. Frequency of suctioning is
based on clinical assessment.
MATERIALS
EQUIPMENT
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 NURSING ASSESSMENT
1. Assess client’s vital signs, breath sounds and signs
and symptoms of respiratory distress.

2. Assess for pain and the potential to cause pain during

the intervention.

3. Assess appropriate suction catheter depth.

8
PROCEDURE
1. Check and verify doctor's order.
2. Identify the client with two identifiers and
explain the procedure.
3.Do hand washing. Put PPEs if indicated.
4. Close curtains around bed and close the
door to the room, if possible.
9
PROCEDURE
5. Assess patient’s pain and administer pain
medication, if indicated.

6. Explain what you are going to do and the reason to

the patient, even if the patient does not appear to be
alert. Reassure the patient you will interrupt
procedure if he or she indicates respiratory difficulty.
10
PROCEDURE
7. Adjust bed to comfortable working position, usually
elbow height of the caregiver. Lower side rail closest
to you. If the patient is conscious, place him or her in a
semi-Fowler’s position.

11
PROCEDURE
7. Position the client:
For the unconscious patient: side-lying position
facing toward the health care provider

12
PROCEDURE
8. Place towel or
waterproof pad
across patient’s
chest.

13
PROCEDURE
9. Turn suction to appropriate pressure (Figure 2).
For a wall unit for an adult: 100–120 mm Hg (Roman, 2005); neonates: 60–80
mm Hg; infants: 80–100 mm Hg; children: 80–100 mm Hg; adolescents: 80–
120 mm Hg (Ireton, 2007). For a portable unit for an adult: 10–15 cm Hg;
neonates:
6–8 cm Hg; infants 8–10 cm Hg; children 8–10 cm Hg; adolescents: 8-10 cm
Hg.

14
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PROCEDURE
10. Put on a disposable, clean glove and occlude the end of the
connecting tubing to check suction pressure. Place the connecting
tubing in a convenient location. Place the resuscitation bag
connected to oxygen within convenient reach, if using.

11. Open sterile suction package using aseptic technique. The

open wrapper becomes a sterile field to hold other supplies.
Carefully remove the sterile container, touching only the outside
surface. Set it up on the work surface and pour sterile
saline into it. 16
PROCEDURE
12. Put on face shield or goggles and mask. Put on sterile gloves.

13. With dominant gloved hand, pick up sterile catheter. Pick up

the connecting tubing with the nondominant hand and connect
the tubing and suction catheter.

14. Moisten the catheter by dipping it into the container of sterile

saline, unless it is a silicone catheter. Occlude Y-tube to check
suction.
17
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PROCEDURE

19
PROCEDURE

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PROCEDURE
15. Hyperventilate the patient
using your nondominant hand
and a manual resuscitation
bag and delivering three to six
breaths or use the sigh
mechanism on a mechanical
ventilator.

22
PROCEDURE
16. Open the adapter on the
mechanical ventilator tubing or
remove the manual
resuscitation bag with your
nondominant hand.

17. Using your dominant hand,

gently and quickly insert the
catheter into the trachea.
23
PROCEDURE
18. Apply suction by
intermittently occluding the Y-
port on the
catheter with the thumb of
your nondominant hand, and
gently
rotate the catheter as it is
being withdrawn.
24
PROCEDURE
19. Hyperventilate the patient using your nondominant hand and
a manual resuscitation bag and delivering three to six breaths.

20. Flush catheter with saline.

21. Allow at least a 30-second to 1-minute interval if additional

suctioning is needed. No more than three suction passes should
be made per suctioning episode. Suction the oropharynx after
suctioning the trachea. Do not reinsert in the endotracheal tube
after suctioning the mouth. 25
PROCEDURE
22. When suctioning is completed, remove gloves from dominant
hand over the coiled catheter, pulling it off inside-out. Remove
glove from nondominant hand and dispose of gloves, catheter,
and container with solution in the appropriate receptacle.
Assist patient to a comfortable position. Raise bed rail and
place bed in the lowest position.

23. Turn off suction. Remove face shield or goggles

and mask. Perform hand hygiene.
26
PROCEDURE
24. Offer oral hygiene after suctioning.

25. Reassess patient’s respiratory status, including respiratory

rate, effort, oxygen saturation, and lung sounds.

26. Remove additional PPE, if used. Perform hand

hygiene.

27. Document observation and procedure.

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TRACHEOSTOMY
CARE
 INTRODUCTION
TRACHEOSTOMY
CARE

The nurse is responsible for either replacing a disposable inner cannula or cleaning a non-
disposable inner cannula. The inner cannula requires replacement or cleaning to prevent
accumulation of secretions that can interfere with respiration and occlude the airway. Because
soiled tracheostomy dressings place the patient at risk for the development of skin breakdown
and infection, regularly change dressings and tracheostomy collar or ties. Use gauze dressings
that are not filled with cotton to prevent aspiration of foreign bodies (e.g., lint or cotton fibers)
into the trachea. Clean the skin around a tracheostomy to prevent buildup of dried secretions
and skin breakdown.
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MATERIALS
EQUIPMENT
37
 • Disposable inner
• Disposable gloves
tracheostomy cannula,
• Sterile gloves
appropriate size for patient
• Goggles and mask or face
• Sterile suction catheter and
shield
glove set
• Additional PPE, as
• Commercially prepared
indicated
tracheostomy or drain
• Sterile normal saline
dressing
• Sterile cup or basin
• Commercially prepared
• Sterile cotton-tipped
tracheostomy holder
applicators
• Plastic disposal bag
• Sterile gauze sponges
• Additional nurse 38
 NURSING ASSESSMENT
1. Assess for signs and symptoms of the need to perform tracheostomy care,
which include soiled dressings and holder or ties, secretions in the
tracheostomy tube, and diminished airflow through the tracheostomy, or in
accordance with facility policy.

2. Assess insertion site for any redness or purulent drainage; if present, these
may signify an infection.

3. Assess patient for pain. If tracheostomy is new, pain medication may be

needed before performing tracheostomy care.
39
 NURSING ASSESSMENT
4. Assess lung sounds and oxygen saturation levels. Lung sounds should be
equal in all lobes, with an oxygen saturation level above 93%. If tracheostomy
is dislodged, lung sounds and oxygen saturation level will diminish.

5. Inspect the area on the posterior portion of the neck for any skin
breakdown that may result from irritation or pressure from tracheostomy
holder or ties.

40
PROCEDURE
1. Check and verify doctor's order.
2. Identify the client with two identifiers and
explain the procedure.
3.Do hand washing. Put PPEs if indicated.
4. Close curtains around bed and close the
door to the room, if possible.
41
PROCEDURE
5. Determine the need for tracheostomy care. Assess
patient’s pain and administer pain medication, if
indicated.

6. Explain what you are going to do and the reason to

the patient, even if the patient does not appear to be
alert. Reassure the patient you will interrupt
procedure if he or she indicates respiratory difficulty. 42
PROCEDURE
7. Adjust bed to comfortable working position, usually
elbow height of the caregiver. Lower side rail closest
to you. If the patient is conscious, place him or her in a
semi-Fowler’s position.

43
PROCEDURE
7. Position the client:
For the unconscious patient: side-lying position
facing toward the health care provider

44
PROCEDURE
8. Put on face shield or goggles and mask. Suction
tracheostomy, if necessary. If tracheostomy has just
been suctioned, remove soiled site dressing and
discard before removal of gloves used to perform
suctioning.

45
46
PROCEDURE
CLEANING THE TRACHEOSTOMY: DISPOSABLE INNER
CANNULA
9. Carefully open the package with the new
disposable inner cannula, taking care not to
contaminate the cannula or the inside of the package.
Carefully open the package with the sterile cotton-
tipped applicators, taking care not to contaminate
them. Open sterile cup or basin and fill 0.5 inch deep
with saline. Open the plastic disposable bag and place
within reach on work surface. 47
48
PROCEDURE
10. Put on disposable gloves.

11. Remove the oxygen source if one is present. Stabilize the

outer cannula and faceplate of the tracheostomy with your
nondominant hand. Grasp the locking mechanism of the inner
cannula with your dominant hand. Press the tabs and release
lock (Figure 2). Gently remove inner cannula and place in
disposal bag. If not already removed, remove site dressing and
dispose of it in the trash.
49
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PROCEDURE
12. Discard gloves and put on sterile gloves. Pick up
the new inner cannula with your dominant hand,
stabilize the faceplate with your nondominant hand,
and gently insert the new inner cannula into the outer
cannula. Press the tabs to allow the lock to grab the
outer cannula (Figure 3). Reapply oxygen source, if
needed.
51
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PROCEDURE
APPLYING CLEAN DRESSING AND HOLDER
13. Remove oxygen source, if necessary. Dip cotton-
tipped applicator or gauze sponge in cup or basin with
sterile saline and clean stoma under faceplate. Use
each applicator or sponge only once, moving from
stoma site outward (Figure 4).

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PROCEDURE
14. Pat skin gently with dry 4 x4 gauze sponge.

15. Slide commercially prepared tracheostomy

dressing or prefolded non–cotton-filled 4 x4-inch
dressing under the faceplate.

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PROCEDURE
16. Change the tracheostomy holder:
a. Obtain the assistance of a second individual to hold the tracheostomy tube in
place while the old collar is removed and the new collar is placed.
b. Open the package for the new tracheostomy collar.
c. Both nurses should put on clean gloves.
d. One nurse holds the faceplate while the other pulls up the Velcro tabs. Gently
remove the collar.
e. The first nurse continues to hold the tracheostomy faceplate.

f. The other nurse places the collar around the patient’s neck and inserts first
one tab, then the other, into the openings on the faceplate and secures the Velcro
tabs on the tracheostomy holder (Figure 5).
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PROCEDURE
g. Check the fit of the tracheostomy collar. You should
be able to fit one finger between the neck and the
collar. Check to make sure that the patient can flex
neck comfortably. Reapply oxygen source, if
necessary (Figure 6).

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PROCEDURE
17. Remove gloves. Assist patient to a comfortable position. Raise the bed
rail and place the bed in the lowest position.

18. Remove face shield or goggles and mask. Remove additional PPE, if
used. Perform hand hygiene.

19. Reassess patient’s respiratory status, including respiratory rate, effort,

oxygen saturation, and lung sounds.

20. Document the procedures and all observations.

62
 SUCTIONING
TRACHEOSTOMY: OPEN
SYSTEM
 INTRODUCTION
SUCTIONING
TRACHEOSTOMY:
OPEN SYSTEM

Suctioning through a tracheostomy is indicated to maintain a patent airway. Tracheal suctioning

can lead to hypoxemia, cardiac dysrhythmias, trauma, atelectasis, infection, bleeding, and pain.
It is imperative to be diligent in maintaining aseptic technique and following facility guidelines
and procedures to prevent potential hazards. Suctioning frequency is based on clinical
assessment to determine the need for suctioning.
MATERIALS
EQUIPMENT
66
67
68
 NURSING ASSESSMENT
1. Assess lung sounds. Patients who need to be suctioned may have wheezes, crackles, or gurgling
present.

2. Assess oxygenation saturation level. Oxygen saturation usually decreases when a patient needs
to be suctioned.

3. Assess respiratory status, including respiratory rate and depth. Patients may become
tachypneic when they need to be suctioned. Additional indications for suctioning via a
tracheostomy tube include secretions in the tube, acute respiratory distress, and frequent or
sustained coughing.

4. Assess for pain and the potential to cause pain during the intervention. Perform individualized
pain management in response to the patient’s needs(Arroyo-Novoa, et al., 2007). If the patient
has had abdominal surgery or other procedures, administer pain medication before suctioning.

5. Assess appropriate suction catheter depth.

69
PROCEDURE
1. Check and verify doctor's order.
2. Identify the client with two
identifiers.
3. Do hand washing. Put PPEs if
indicated.
4. Close curtains around bed and close
the door to the room, if possible. 70
PROCEDURE
5. Determine the need for suctioning. Verify the suction order
in the patient’s chart. Assess for pain or the potential to cause
pain. Administer pain medication, as prescribed, before
suctioning.

6. Explain to the patient what you are going to do and the

reason or doing it, even if the patient does not appear to be
alert. Reassure the patient you will interrupt the procedure if
he or she indicates respiratory difficulty.
71
PROCEDURE
7. Adjust bed to comfortable working position, usually
elbow height of the caregiver. Lower side rail closest
to you. If patient is conscious, place him or her in a
semi-Fowler’s position. If patient is unconscious, place
him or her in the lateral position, facing you. Move the
overbed table close to your work area and raise to
waist height.
72
73
PROCEDURE
8. Place towel or
waterproof pad
across patient’s
chest.

74
PROCEDURE
9. Turn suction to appropriate pressure (Figure 2).
For a wall unit for an adult: 100–120 mm Hg (Roman, 2005); neonates: 60–
80 mm Hg; infants: 80–100 mm Hg; children: 80–100 mm Hg; adolescents:
80–120 mm Hg (Ireton, 2007). For a portable unit for an adult: 10–15 cm
Hg; neonates:
6–8 cm Hg; infants 8–10 cm Hg; children 8–10 cm Hg; adolescents: 8-10
cm Hg.
10. Put on a disposable, clean glove and occlude the end of the connecting
tubing to check suction pressure. Place the connecting tubing in a
convenient location. If using, place resuscitation bag connected to oxygen
within convenient reach.
75
76
PROCEDURE
11. Open sterile suction package using aseptic technique. The open
wrapper or container becomes a sterile field to hold other supplies.
Carefully remove the sterile container, touching only the outside surface.
Set it up on the work surface and pour sterile saline into it.

12. Put on face shield or goggles and mask (Figure 3). Put on sterile gloves.
The dominant hand will manipulate the catheter and must remain sterile.
The nondominant hand is considered clean rather than sterile and will
control the suction valve (Y-port) on the catheter.

77
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PROCEDURE
13. With dominant
gloved hand, pick up
sterile catheter. Pick
up the connecting
tubing with the
nondominant hand and
connect
the tubing and suction
catheter (Figure 4).
79
PROCEDURE
14. Moisten the
catheter by dipping it
into the container of
sterile saline, unless it
is a silicone catheter
(Figure 5). Occlude Y-
tube to check suction
(Figure 6).
80
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PROCEDURE
15. Using your nondominant hand and a manual resuscitation bag,
hyperventilate the patient, delivering three to six breaths or use the sigh
mechanism on a mechanical ventilator.

16. Open the adapter on the mechanical ventilator tubing or remove

oxygen delivery setup with your nondominant hand.

17. Using your dominant hand, gently and quickly insert catheter into
trachea. Advance the catheter to the predetermined length. Do not occlude
Y-port when inserting catheter.
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PROCEDURE
18. Apply suction by
intermittently occluding the Y-
port on the catheter with the
thumb of your nondominant
hand, and gently rotate the
catheter as it is being
withdrawn (Figure 7). Do not
suction for more than 10 to 15
seconds at a time.

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PROCEDURE
19. Hyperventilate the patient using your nondominant hand
and a manual resuscitation bag, delivering three to six breaths.
Replace the oxygen delivery device, if applicable, using your
nondominant hand and have the patient take several deep
breaths.

20. Flush catheter with saline. Assess the effectiveness of

suctioning and repeat, as needed, and according to patient’s
tolerance. Wrap the suction catheter around your dominant
hand between attempts.
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PROCEDURE
21. Allow at least a 30-second to 1-minute interval if additional suctioning is
needed. No more than three suction passes should be made per suctioning
episode. Encourage the patient to cough and deep breathe between
suctioning.

22. When suctioning is completed, remove gloves from dominant hand over
the coiled catheter, pulling it off inside out (Figure 8). Remove glove from
nondominant hand and dispose of gloves, catheter, and container with
solution in the appropriate receptacle. Assist patient to a comfortable
position. Raise bed rail and place bed in the lowest position.
85
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PROCEDURE
23. Turn off suction. Remove supplemental oxygen placed for suctioning, if
appropriate. Remove face shield or goggles and mask. Perform hand
hygiene.

24. Offer oral hygiene after suctioning.

25. Reassess patient’s respiratory status, including respiratory rate, effort, oxygen
saturation, and lung sounds.

26. Remove additional PPE, if used. Perform hand hygiene.

27. Document the procedure and other observations.

87