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, To develop a baseline data if not already
verify the order for the therapy. available

2. Prepare the client and support people. This position permits easier chest expansion
• Assist the client to a semi-Fowler’s and hence easier breathing
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 By explaining the procedure the nurse can
to do, why is it necessary, and how he help to allay anxiety.
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 To prevent transfer of micoorganisms

infection control procedures.

3. Set up oxygen equipment and the Dry gasses dehydrate the respiratory
humidifier. mucous membrane.
• 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 RATIONALE
4. Turn on the oxygen at the prescribed
rate, and ensure proper functioning.
• Check that the oxygen is flowing Kinks of the tubes obstruct the flow of air to
freely through the tubing. There the client
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 Bubbles in the water indicate that oxygen
ordered, for example. flow is satisfactory

5. Apply the appropriate oxygen delivery

device.
Cannula
• Put the cannula over the client’s face, Correct placement of the prongs facilitate
with the outlet prongs fitting into the oxygen administration.
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 To reduce irritation and pressure on the
ears and cheekbones as needed. cheek or behind the ears.

Face Mask
• Guide the mask toward the client’s The mask should mold to the face so that
face, and apply it from the nose very little oxygen escapes into the eyes or
 downward. around the cheek and chin

• Fit the mask to the contours of the

client’s face.

• Secure the elastic band around the Mask that fits snugly to clients face
client’s head so that the mask is minimizes the loss of oxygen.
comfortable but snug. Padding will prevent irritation from the
mask.
 PROCEDURE RATIONALE
• 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 Continuous assessment provides information
anxiety, color, and ease of if the client is tolerating the oxygen therapy
respirations, and provide support well or not and prevents possible
while the client adjusts to the device. complications.

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

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

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
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.
RATIONALE
When a person breaths in, the diaphragm
contracts (drops), the lungs fill with air and
the abdomen rises or protrudes.

6. If the client has difficulty raising the With a quick sniff, the client will feel the
abdomen, instruct the person to take a abdomen rise.
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.
Pursing the lips creates a resistance to air
flowing out of the lungs , increases pressure
within the bronchi, and minimizes the
collapse of smaller bronchioles , a common
problem for clients with COPD. While the
client breaths out, the diaphragm relaxes
(rises) and the abdomen sinks. Tightening
the abdominal muscles helps a person to
exhale more effectively.

8. If the client has COPD, teach the “double A very forceful cough by a client with COPD
cough” technique. Have the client can case small airway collapse. With two or
a. Breath in through the nose and inflate more abrupt coughs, the first one loosens
the lungs to the mid inspiration point, secretions; while subsequent facilitate
rather than to the full deep inspiration movement of secretions toward the upper
point. airways.

b. Simultaneously exhale and cough two

or more abrupt, sharp coughs in rapid
succession.

9. Instruct the client to use this exercise Regular practice enables a person eventually
whenever feeling short of breath to to do this type of breathing without
increase it gradually 5-10 minutes four conscious effort.
times a day.

APICAL EXPANSION EXERCISES

10. Place your fingers below the client’s This hand position enables evaluation of the
clavicles and exert moderate pressure, or depth of apical inhalation.
have the client place his or her fingers
over the same area.
 PROCEDURE RATIONALE
11. Instruct the client to inhale through the This helps aerate the apical areas of the
nose and to concentrate on pushing the upper lung lobes.
upper chest upward and forward against
the fingers.

12. Have the client hold the inhalation for a This promotes aeration of the alveoli.
few seconds.

13. Have the client exhale through the This allows for more comfortable alveolar
mouth or nose slowly, quietly and expansion. Slow movement usually creates
passively while concentrating on moving less discomfort than rapid movement does.
the upper chest inward and downward.

14. Instruct the client to perform the Repeating the exercise helps to reexpand
exercise for at least five respirations four lung tissue, eliminate secretions, and
times a day. minimize flattening of the upper chest wall.

BASAL EXPANSION EXERCISES

14. Place the palms of your hands in the This hand position enables evaluation and
area of the lower ribs along the comparison of the depth of bilateral basal
midaxillary lines, and exert moderate inspiration.
pressure, or have the client place his or
her hands over the same areas.

15. Instruct the client to inhale through the To encourage complete lung expansion.
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 This allows for more comfortable elveolar
or mouth slowly, quietly and passively. If expansion. Slow movement usually creates
the person has COPD, observe the rate less discomfort than rapid movement does.
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 Repetition helps to reexpand lung tissue and
exercise at least five respirations four eliminates secretions.
times a day.

19. Correct the patient’s breathing technique To encourage complete lung expansion.
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. Reduces transmission of microorganisms.

2. Instruct client to assume semi-Fowler’s Promotes optimal lung expansion.

or high Fowler’s position.

3. Either aet or indicate to client on the Establishes goal to volume level necessary
device scale, the volume level to be for lung expansion.
attained with each breath.

4. Demonstarte to client how to place Demonstration is reliable technique for

mouthpiece of spirometer so that lips teaching psychomotor skills and enables
completely cover mouthpiece. client to ask questions.

5. Instruct client to inhale slowly and Maintains maximal inspiration and reduces
maintain constant flow through unit. risk of progressive collapse of individual
When maximal inspiration is reached, alveoli. Slow breath prevents or minimizes
client should hold breath for 2 to 3 pain from sudden pressure changes in chest.
seconds and then exhale slowly.

6. Instruct client to breath normally for Prevents hyperventilation and fatigue.

short period.

7. Have client repeat maneuver until Ensures correct use of spirometer.

 volume goals are achieved.

8. Wash hands. Reduces transmission of microorganisms.

9. Record the procedure done and client’s Documents client’s education and provides
ability to perform it. data for instructional follow-up.
 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. Coughing and expectorating secretions can
embarrass the client and disturb others.

2. Assist the client to the appropriate To provide the appropriate position for
 position for postural drainage. postural drainage.

Drainage of the upper lobe To drain the apical segments of the upper
3. Have the client lie back at a 30o angle. lobes.
Percuss and vibrate between the
clavicles and above the scapulae.
 PROCEDURE RATIONALE
4. Have the client sit upright in a chair or in To drain the posterior segments of the
bed with the head bent slightly forward. upper lobes.
Percuss and vibrate the area between
the clavicles and scapulae.

5. Have the client lie on a flat bed with To drain the anterior segments of the upper
pillows under the knees to flex lobes.
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 To drain the right lateral and medial
40cm and have the client lie on the left segments.
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, To drain the left lingular segments.
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 To drain the superior segment
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 To drain the anterior basal segment.
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 To drain the lateral basal segments.
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 To drain the posterior basal segments.
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 Percussing skin directly can cause
covered. discomfort.

13. Ask the client to breath slowly and Slow deep breathing promotes relaxation.
deeply.
14. Cup your hands,ie, old your fingers and Cupped hands trap the air against the chest.
thumb together , and flex them slightly The trapped air sets up vibrations through
to form a cup, as you would to scoop up the chest wall to the secretions , helping to
water. loosen them.
 PROCEDURE RATIONALE
15. Relax your wrists, and flex your elbows. Relaxed wrists, and flexed elbows help
obtain a rapid ,hollow, popping action.

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.
These blows are transmitted through the
tissue and help loosen secretions in the lung
segment immediately below the area struck.
The percussing action should produce a
hollow, popping sound when done correctly.

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 This preserves the normal inspiratory-
the mouth and exhale slowly through expiratory ratio and encourages maximum
pursed lips or the nose. filling and emptying of the alveoli.

20. During the exhalation, straighten your Isometric contractions will transmit fine
elbows, and lean slightly against the vibrations through the client’s chest wall.
client’s chest while tensing your arm and
shoulder muscles in isometric
contractions.

21. Vibrate during five exhalations over one Vibrating over a specific five times will
affected lung segment. loosen the secretion.

22. Encourage the client to cough and To remove unpalatable taste of the mucus
expectorate secretions into the sputum secretions from the mouth.
container. Offer the client mouthwash.

23. Auscultate the client’s lungs, and To check for the effectiveness of the
compare the findings to the baseline intervention.
 data.

24. Document the percussion, vibration, and Anything done to a client undocumented is
postural drainage and assessments. considered not done.
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. Steam inhalation may be initiated by a
doctor’s order.

2. Explain procedure to client. To ensure client operation.

3. Wash hands. Hand washing deter the spread of infection.

4. Place boiling water about 1/3 to ½ full in Boiling water provides moist heat for
a pitcher. inhalation.

5. Add ordered medication, if any. In some instance, drug may be administered

via steam inhalation.

6. Bring pitcher on a basin to the bedside. To enable the health worker to safely bring
Place on a firm surface. equipment to bedside.
 PROCEDURE
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.
RATIONALE
To provide comfort during procedure.
Paper cone directs steam to client’s nose.
To provide a safe distance from the stream.
A towel may be provided to protect client’s
eyes if the steam is perceived to be too hot
for the client’s eyes.
To provide to client protection from cold air
prevents chilling caused by marked change
in air temperature. This may counteract the
benefits of inhalation.
To prevent spread of infection.
For proper documentation of procedure.
 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.
2. Water-soluble lubricant or glass of sterile water
3. Y-connector
4. Sterile gauzes
5. Moisture-resistant disposable bag
6. Sputum trap or cup, if specimen is to be collected
7. Sterile forceps (in cases where institution practices such or in absence of gloves)
8. Resuscitation bag (Ambu bag) connected to 100% oxygen

PROCEDURE RATIONALE
A. Prepare the client.
1. Wash hands and observe other For infection control.
appropriate infection control procedures
(e.g., gloves, goggles.

2. Gather necessary equipment and Knowing that the procedure will relive
supplies. breathing problems is often reassuring and
enlists client cooperation.

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 RATIONALE
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 This position facilitates the insertion of the
has a functional gag reflex in the catheter and helps prevent aspiration of
semi-Fowler’s position with the pulmonary secretions and gastrointestinal (GI)
head turned to one side for oral contents.
suctioning or with the neck
hyperextended for nasal
suctioning.

b. Position an unconscious client in
the lateral position facing you.
This position allows the tongue to fall forward,
so that it will not obstruct the catheter on
insertion. Lateral position also facilitates
drainage of secretions from the pharynx and
prevents the possibility of aspiration.

6. Place the towel or pad over the To protect the client’s gown and pillow from
pillow or under the chin. Provide soiling.
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
Suction should be ready to save time and
effort when performing the procedure.
Calibrated pressure ranges provides safe but
• Adult: 100-120 mmHg effective negative pressure according to the
• Child: 95-110 mmHg client’s age and decreases possibility of
• Infant: 50-95 mmHg hypoxemia damage to mucous membranes.
• Portable unit
• Adult: 10-15 mmHg
• Child: 5-10 mmHg
• Infant: 2-5 mmHg
 PROCEDURE RATIONALE
8. Hyperoxygenate client before To provide sufficient amount of oxygen
inserting catheter and suctioning. necessary before 10-15 seconds of 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 The sterile gloved hand maintains the sterility
nonsterile glove on the non-dominant of the suction catheter, and the unsterile glove
hand and sterile glove on the prevents the transmission of the
dominant hand. microorganisms to the nurse.

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 Appropriate length ensures the catheter
the tip of the client’s nose and the remains in pharyngeal region. Insertion past
earlobe or about 13cm (5in) for an this point places catheter in trachea.
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, Premeasuring the correct length for catheter
measure the distance between insertion prior to suctioning prevents
the tip of the client’s nose to the unnecessary trauma to the tracheal mucosa.
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 RATIONALE
16. Mark the position on the tube
with the fingers of the sterile gloved
hand.

17. Test the pressure of the suction Ensures that equipment is functioning prior to
and the patency of the catheter by insertion.
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 This reduces friction and eases insertion.
water-soluble lubricant.

b. Without applying suction, insert Gentle insertion without applying suction

the catheter the premeasured or prevents trayma to the mucous membranes.
recommended distance into either Directing the catheter along the floor of the
nares, and advance it along the nasal cavity avoids the nasal turbinates.
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 This reduces friction and eases insertion.
saline.

b. Pull the tongue forward, if

necessary, using gauze.

c. Do not apply suction during Doing so causes trauma to the mucous

insertion. membranes.
d. Gently advance the catheter about 4 Directing the catheter along the side prevents
to 6 inches along one side of the gagging.
mouth into the oropharynx.
 PROCEDURE
B. 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.
RATIONALE
Occlusion of control port activates suction
pressure. Gentle rotation of the catheter
ensures that all surfaces are reached and
prevents trauma to any one area of the
respiratory mucosa due to prolonged suction.

19. Apply suction for 5 to 10 Suctioning longer than 10-15 seconds robs the
seconds; then remove your finger respiratory tract of oxygen which may result to
form the control, and remove the hypoxia, hypoxemia, and other
catheter. A suction attempt should last cardiopulmonary complications.
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.

C. 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 Rinsing the catheter helps remove secretions
water or saline. from the tubing and lubricates it for next
suctioning.

22. Relubricate the catheter, and Applying suction for too long may cause
repeat suctioning until the air passage secretions to increase or decrease the client’s
is clear. oxygen supply.
 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 RATIONALE
24. Encourage client to breathe Coughing and deep breathing help carry
deeply and to cough between suctions. secretions from the trachea and bronchi into
the pharynx, where they can be reached with
the suction catheter.

D. 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 This retains any microorganisms in the sputum
oropharynx. The sputum trap will trap.
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.

E. Promote client comfort.

25. Offer to assist the client with Respiratory secretions that are allowed to
oral or nasal hygiene. accumulate in the mouth are irritating to the
mucous membranes and unpleasant to the
taste.

F. Dispose of equipment and ensure

availability for the next suction.
26. Dispose of the catheter, gloves, Reduces spread of bacteria from suction
water and waste container. Wrap the equipment.
catheter around your sterile glove and
roll it inside the glove for disposal.
 PROCEDURE RATIONALE
27. To ensure that equipment is
available for the next suctioning,
change suction collection bottles and
tubing daily or more frequently as
necessary.

G. 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.

H. Wash hands.

I. 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.