Critical Elements of Performance Checklist;Evaluation in clinical nursing education involves the cognitive, affective, and psychomotordomains. The psychomotor domain involves the performance of tasks.

2. Assess client for signs and symptoms associated ______________________________________________________ with hypoxia and hypercapnia.

3. Assess client for risk factors for upper or lower ______________________________________________________ airway obstruction.

4. Identify contraindications to nasotracheal ______________________________________________________ suctioning.

5. Obtain sputum microbiology data. ______________________________________________________ 6. Assess client’s understanding of procedure. ______________________________________________________ 7. Explain to client how procedure will help clear ______________________________________________________ airway and relieve breathing problems and that temporary coughing, sneezing, gagging, or shortness of breath is normal.

8. Encourage client to cough out secretions. ______________________________________________________ 9. Instruct client to practice coughing, if able. ______________________________________________________ 10. Instruct client to splint surgical incisions, ______________________________________________________ if necessary.

11. Assist client with assuming position comfortable ______________________________________________________ for nurse and client.

12. Place pulse oximeter on client’s finger. Take reading, ______________________________________________________ and leave pulse oximeter in place.

13. Place towel across client’s chest. ______________________________________________________ 14. Perform hand hygiene, and apply face shield ______________________________________________________ if splashing is likely.

15. Connect one end of connecting tubing to suction ______________________________________________________ machine, and place other end in convenient location near client. Turn suction device on, and set vacuum regulator to appropriate negative pressure.

16. If indicated, increase supplemental oxygen therapy ______________________________________________________ to 100% or as ordered by health care provider.

Encourage client to deep breathe.

17. Preparation for all types of suctioning: A. Open appropriate suction kit or catheter with ______________________________________________________ use of aseptic technique. If sterile drape is available, place it across client’s chest or on the over-bed table.

Do not allow the suction catheter to touch any nonsterile surfaces.

B. Unwrap or open sterile basin, and place on ______________________________________________________ bedside table. Fill basin or cup with approximately 100 mL of sterile normal saline solution or water.

C. Connect one end of connecting tubing to suction ______________________________________________________ machine. Place other end in convenient location near client. Check that equipment is functioning properly by suctioning a small amount of water from basin.

D. Turn on suction device. Set regulator to ______________________________________________________ appropriate negative pressure: 100 to 150 mm Hg for adults.

18. Suction airway. A. Oropharyngeal suctioning(1) Apply clean disposable glove to dominant ______________________________________________________ hand.

(2) Remove oxygen mask if present. Nasal ______________________________________________________ cannula remains in place.

(3) Insert catheter into client’s mouth. With ______________________________________________________ suction applied, move catheter around mouth, including pharynx and gum line, until secretions are cleared. Checklist-A52501.indd 294 Checklist-A52501.indd 294 4/18/2008 1:39:27 AM 4/18/2008 1:39:27 AM Copyright \251 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Continued (4) Encourage client to cough, and repeat ______________________________________________________ suctioning if needed. Replace oxygen mask if used.

(5) Suction water from basin through catheter ______________________________________________________ until catheter is cleared of secretions.

(6) Place catheter in a clean, dry area for reuse ______________________________________________________ with suction turned off or within client’s reach, with suction on, if client is capable of suctioning self.

B. Nasopharyngeal and nasotracheal suctioning (1) If indicated, increase supplemental oxygen ______________________________________________________ therapy to 100% or as ordered by health care provider. Encourage client’s deep breathing.

(2) Open lubricant. Squeeze small amount onto ______________________________________________________ open sterile catheter package without touching package.

(3) Apply sterile glove to each hand, or apply ______________________________________________________ nonsterile glove to nondominant hand and sterile glove to dominant hand.

(4) Pick up suction catheter with dominant ______________________________________________________ hand without touching nonsterile surfaces.

Pick up connecting tubing with nondominant hand. Secure catheter to tubing.

(5) Check that the equipment is functioning ______________________________________________________ properly by suctioning small amount of normal saline solution from basin.

(6) Lightly coat distal 6 to 8 cm (2 to 3 inches) ______________________________________________________ of catheter with water-soluble lubricant.

(7) Remove oxygen delivery device, if ______________________________________________________ applicable, with nondominant hand.

Without applying suction and using dominant thumb and forefinger, gently insert catheter into naris during inhalation.

a. Nasopharyngeal i. Follow natural course of naris; slightly ______________________________________________________ slant catheter downward, and advance to back of pharynx. In adults insert catheter about 16 cm; in older children, 8 to 12 cm (3 to 5 inches); in infants and young children, 4 to 8 cm (2 to 3 inches). (Rule of thumb is to insert catheter distance from tip of nose [or mouth] to base of earlobe.) ii. Apply intermittent suction for up to ______________________________________________________ 10 to 15 seconds by placing and releasing nondominant thumb over catheter vent. Slowly withdraw catheter while rotating it back and forth between thumb and forefinger.

b. Nasotracheal i. Follow natural course of naris, and ______________________________________________________ advance catheter slightly slanted and downward to just above entrance into trachea.

ii. Allow client to take a breath. ______________________________________________________ iii. Quickly insert catheter about 16 to ______________________________________________________ 20 cm (6 to 8 inches in adult) into trachea. Client will begin to cough.

N OTE : In older children advance 14 to 20 cm (5 1/2 to 8 inches); in young children and infants, 8 to 14 cm (3 to 5 1/2 inches). S U NP Comments Checklist-A52501.indd 295 Checklist-A52501.indd 295 4/18/2008 1:39:27 AM 4/18/2008 1:39:27 AM Copyright \251 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Continued S U NP Comments iv. Positioning option for nasotracheal ______________________________________________________ suctioning: In some instances turning client’s head to right helps suction the left mainstem bronchus; turning head to left helps suction the right mainstem bronchus. If you feel resistance after insertion of catheter for maximum recommended distance, catheter has probably hit carina. Pull catheter back 1 cm before applying suction.

v . Apply intermittent suction for up to ______________________________________________________ 10 to 15 seconds by placing and releasing nondominant thumb over vent of catheter and slowly withdrawing catheter while rotating it back and forth between dominant thumb and forefinger.

vi. Encourage client to cough. ______________________________________________________ vii. Replace oxygen device, if applicable. ______________________________________________________ (8) Rinse catheter and connecting tubing with ______________________________________________________ normal saline or water until cleared.

(9) Assess for need to repeat suctioning ______________________________________________________ procedure. Allow adequate time between suction passes for ventilation and oxygenation. When possible ask client to deep breathe and cough, or preoxygenate with 100% supplemental oxygen.

C. Performing artificial airway suctioning (1) Apply face shield. ______________________________________________________ (2) Prepare proper suction catheter. ______________________________________________________ (3) Apply one sterile glove to each hand, or ______________________________________________________ apply nonsterile glove to nondominant hand and sterile glove to dominant hand.

(4) Pick up suction catheter with dominant ______________________________________________________ hand without touching nonsterile surfaces. Pick up connecting tubing with nondominant hand. Secure catheter to tubing.

(5) Check that equipment is functioning ______________________________________________________ properly by suctioning small amount of saline from basin.

(6) Hyperinflate and/or hyperoxygenate ______________________________________________________ client before suctioning, using manual resuscitation Ambu-bag connected to oxygen source or sigh mechanism on mechanical ventilator. Some mechanical ventilators have a button that when pushed delivers 100% oxygen for a few minutes and then resets to the previous value.

(7) If client is receiving mechanical ______________________________________________________ ventilation, open swivel adapter or if necessary remove oxygen or humidity delivery device with nondominant hand.

(8) Without applying suction, gently but ______________________________________________________ quickly insert catheter using dominant thumb and forefinger into artificial airway (best to time catheter insertion with inspiration) until you meet resistance or client coughs; then pull back 1 cm (½ inch).

(9) Apply intermittent suction by placing and ______________________________________________________ releasing nondominant thumb over vent of catheter; slowly withdraw catheter while rotating it back and forth between dominant thumb and forefinger.

Encourage client to cough. Watch for respiratory distress. Checklist-A52501.indd 296 Checklist-A52501.indd 296 4/18/2008 1:39:27 AM 4/18/2008 1:39:27 AM Copyright \251 2011 by Mosby, Inc., an affiliate of Elsevier Inc. (10) If client is receiving mechanical ______________________________________________________ ventilation, close swivel adapter or replace oxygen delivery device.

(11) Encourage client to deep breathe, if able. ______________________________________________________ Some clients respond well to several manual breaths from the mechanical ventilator or Ambu-bag.

(12) Rinse catheter and connecting tubing ______________________________________________________ with normal saline until clear. Use continuous suction.

(13) Assess client’s cardiopulmonary status ______________________________________________________ for secretion clearance and complications.

Repeat Steps 18C(6) through 18C(12) once or twice more to clear secretions. Allow adequate time (at least 1 full minute) between suction passes for ventilation and hyperoxygenation.

(14) Perform nasopharyngeal and ______________________________________________________ oropharyngeal suctioning (Steps 18A, 18B).

(15) After performing nasopharyngeal and ______________________________________________________ oropharyngeal suctioning, catheter is contaminated; do not reinsert into endotracheal tube or tracheostomy tube.

19. Complete procedure. A. Disconnect catheter from connecting tubing. ______________________________________________________ Roll catheter around fingers of dominant hand.

Pull glove off inside out so that catheter remains in glove. Pull off other glove over first glove in same way to contain contaminants. Discard into appropriate receptacle. Turn off suction device.

B. Remove towel and place in laundry, or remove ______________________________________________________ drape and discard in appropriate receptacle.

C. Reposition client as indicated by condition. ______________________________________________________ Reapply clean gloves for client’s personal care (e.g., oral hygiene).

D. If indicated, readjust oxygen to original level. ______________________________________________________ E. Discard remainder of normal saline into ______________________________________________________ appropriate receptacle. If basin is disposable, discard into appropriate receptacle. If basin is reusable, rinse and place in soiled utility room.

F. Remove and discard face shield, and perform ______________________________________________________ hand hygiene.

G. Place unopened suction kit on suction machine ______________________________________________________ table or at head of bed according to institution preference.

20. Compare client’s vital signs and pulse oximetry ______________________________________________________ saturation before and after suctioning.

21. Ask client if breathing is easier and if congestion ______________________________________________________ is decreased.

22. Auscultate lungs for change in adventitious lung ______________________________________________________ sounds.

23. Observe airway secretions. ______________________________________________________ 24. Record the amount, consistency, color, and odor of ______________________________________________________ secretions and client’s response to procedure; document client’s presuctioning and postsuctioning cardiopulmonary status. S U NP Comments Checklist-A52501.indd 297 Checklist-A52501.indd 297 4/18/2008 1:39:27 AM 4/18/2008 1:39:27 AM Copyright \251 2011 by Mosby, Inc., an affiliate of Elsevier Inc.