Fundamentals In Nursing, Nursing Procedure

This care plan assumes that the patient is conscious. However, if the patient is
unconscious he should be nursed on his side (to prevent his tongue blocking the
airway and to facilitate the drainage of secretions) and an artificial airway may be
required. Oral or nasopharyngeal suctioning may be used. Oral suction is used
for
unconscious or semi!conscious patients, e.g. post!operative recovery patients
who are vomiting and do not have a gag refle" to preventthem from inhaling
vomit or secretions
patients who have had oral surgery or trauma resulting in blood and mucous
secretions which need to be removed
patients who are too weak to e"pectorate sputum from the pharyn".
Oral and nasopharyngeal suction are not the same as tracheal suction as they
do not completely occlude a patient#s airway. $s suctioning by these routes does
not enter a sterile area the procedure is clean, rather than aseptic. However, the
%ankuer (oral) sucker should be used for one patient only and changed daily. &t
can be a very distressing procedure
for the patient and should not be undertaken for prolonged periods. &t may be
used in con'unction with a (uedel airway if the airway needs to be maintained.
Equipment for oral suctioning
)uction machine*piped suction.
)uction tubing and oral suction catheter (e.g. %ankuer sucker).
)terile distilled water.
+ace mask.
,ye shield.
Towel or absorbent pad to protect patient#s clothes and bed linen.
(loves.
Procedure for oral suctioning
,"plain procedure to -r .arrett. (,ven if the patient is unconscious e"planations
should be given, since many unconscious individuals are able to hear.)
/ash hands.
0repare equipment.
$ttach suction tubing to suction machine and attach oral sucker to suction tubing,
ensuring a tight fit.
TIP: You should regularly check that the suction machine is working and
ready for use by plugging it in, switching it on and
kinking the suction tubing. This should cause the pressure dial to rise.
Ensure that clean suction tubing is changed between
patients, and that a Yankuer (oral sucker and fle!ible catheters are easily
accessible to the machine.
0osition -r .arrett in a semi!recumbent position with head turned towards you. &f
he is unconscious he should be nursed in a semi!prone position, facing you.
0lace a towel or pad under -r .arrett#s chin.
)witch the suction machine on and set suction level. Oral or nasopharyngeal
suction should be gentle so that the mucous membrane, teeth, or gums are not
damaged. &deal suction levels for oral suction have little supporting evidence but
e"perience suggests that 12 kilopascals (k0a) or 312 mmHg for wall suction units
is the ma"imum pressure.
0ut on gloves, eye shield and mask.
$sk -r .arrett to open his mouth and assist him if necessary.
&nsert the %ankuer sucker into the mouth along one side and guide it along the
inside of the cheek towards the oropharyn" without applying suction. )uction is
prevented by either kinking the suction catheter or leaving the hole in the
%ankuer sucker open.
$pply suction by either unkinking the tubing or occluding the hole in the %ankuer
sucker, and remove secretions and debris from mouth as required. 4o not force
the sucker between the teeth or touch the posterior pharyngeal wall of the soft
palate as it can make the patient gag or vomit.
5elease suction and remove oral sucker from -r .arrett#s mouth. Oral suction
should not be for prolonged periods as it can be very distressing to the patient.
TIP: "old your breath while you suction because when you feel the need to
breathe again that will indicate that the episode of
suctioning is long enough.
6lean the sucker and tubing by suctioning through sterile water until all debris
has been cleared.
&f further suctioning is required allow -r .arrett to rest for at least 72 seconds
and repeat above procedure. &f he is able, ask him to deep breathe and*or cough
between suctions so that secretions can rise to the upper airway.
/ash hands.
4ocument the quantity, colour, consistency and odour of secretions and the
patient#s response to the procedure.