OROPHARYNGEAL ANS NASOPHARYNGEAL SUCTIONING

4= Competent 3= Very Good 2=Good 1= Needs Improvement

PROCEDURE 4 3 2 1

ASSESSMENT: Assess for clinical signs indicating the need for suctioning:
• Restlessness, anxiety • Noisy respirations • Adventitious (abnormal) breath
sounds when the chest is auscultated • Change in mental status Skin color •
Rate and pattern of respirations • Pulse rate and rhythm • Decreased oxygen
saturation
PLANNING: The nurse needs to review the procedure and important points
such as not applying suction during insertion of the tube to avoid trauma to the
mucous membrane

Equipment:
Portable or wall suction machine with tubing
Sterile disposable container for fluids
Sterile normal saline or water (lubrication & rinsing)
Goggles or face shield (if needed)
Sterile gloves for Nasopharyngeal suctioning
Clean gloves for Oropharyngeal suctioning
Sterile suction catheter kit (#12 to #18 Fr for adults, #8 to #10 Fr for children,
#5 to #8 Fr for infants)
Water-soluble lubricant
Drape/ Under pad

IMPLEMENTATION:
PERFORMANCE
1. Introduce self and verify the client’s identity using agency protocol.
Explain the procedure, and how to participate.
Rationale: Knowing that the procedure will relieve breathing problems
and obtain client’s cooperation.
Provide privacy.
2. Perform hand hygiene and observe other appropriate infection
prevention procedures
3. Prepare the client. • Position a conscious client 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. Rationale: These positions facilitate the insertion of the
catheter and help prevent aspiration of secretions
4 . Position an unconscious client in the lateral position, facing you.
Rationale: This position allows the tongue to fall forward, so that it will
not obstruct the catheter on insertion. The lateral position also
facilitates drainage of secretions from the pharynx and prevents the
possibility of aspiration.
5. Place the towel or under pad under the chin.
 6. Prepare the equipment: Turn the suction device on and set to
appropriate negative pressure on the suction gauge. The amount of
negative pressure should be high enough to clear secretions
For Oral Suctioning
7. Apply clean gloves.
8. Moisten the tip of the suction catheter with sterile water
or saline. Rationale: This reduces friction and eases insertion
9. Do not apply suction (that is, leave your finger off the port) during
insertion. Rationale: Applying suction during insertion causes trauma to
the mucous membrane.
10. Advance the catheter (Pediatric - 3-4 inches), (Adult – 4-6 inches)
along one side of the mouth into the oropharynx.
Rationale: Directing the catheter along the side prevents gagging.
For each suction 5 – 10 seconds duration should be observed with 20 –
30 seconds interval.
Rationale: To allow the patient for hyperventilation & oxygenation

11. It may be necessary during oropharyngeal suctioning to apply suction to

secretions that collect in the mouth and beneath the tongue.
12. Remove and discard gloves
13. Perform hand hygiene.
Nasopharyngeal Suctioning
14. Open the sterile suction catheter.
15. With your sterile gloved hand, pick up the catheter and attach it to the
suction unit.
16. Test the pressure of the suction and the patency of the catheter.
(Pediatric – 80-120mmHg, Adult – less than 200mmHg)

17. Lubricate the catheter tip with sterile water, saline, or water-soluble
lubricant. Rationale: This reduces friction and eases insertion.
18. Without applying suction, insert the catheter into either nares and
advance it along the floor of the nasal cavity. Rationale: This avoids the
nasal turbinate. • Never force the catheter against an obstruction.

19. Apply your finger to the suction control port to start suction, and gently
rotate the catheter. Rationale: Gentle rotation of catheter ensures that
all secretions are suctioned & prevents mucosal trauma.
 20. Apply suction for 5 to 10 seconds & do an intermittent suctioning the
air passage is clear.
Rationale: Intermittent suction reduces the occurrence of
trauma or irritation to the trachea and nasopharynx
21. Rinse and flush the catheter and tubing with sterile water or saline.
22. Allow sufficient time between each suction for ventilation and
oxygenation. Limit suctioning to 5 minutes in total.
Rationale: Applying suction for too long may cause secretions to
increase or may decrease the client’s oxygen supply
23. Encourage the client to breathe deeply and to cough between suctions.
Use supplemental oxygen, if appropriate.
24. Obtain a specimen if required.
25. Promote client comfort.
• Offer & assist for oral or nasal hygiene.
• Assist to a position that facilitates breathing
26. Wrap the catheter around your sterile gloved hand and hold the
catheter as the glove is removed over it for disposal
27. Perform hand hygiene.
28. Observe skin color, dyspnea, level of anxiety, and
oxygen saturation levels.
29. Record the procedure: the amount, consistency, color, and odor of
sputum (foamy, white mucus; thick, green-tinged mucus; or blood-
flecked mucus) and the client’s respiratory status before and after the
procedure. This may include lung sounds, rate and character of
breathing, and oxygen saturation
Total = 116
Reference: Berman , A., Snyder, S. J., & Frandsen, G. (2021). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition. Upper Saddle River, N.J: Pearson Prentice Hall.

STUDENT’S DOCUMENTATION

Date:
Time:
Name of Patient:
Procedure Performed:
Patient’s response: Tolerated Not tolerated
Other pertinent documentation:

Student Nurse’s Name and Signature

Name Score
Year and section CI Signature