Question

ACTIVE LEARNINO TEMPAE Nursing Skill STUDENT NAME MOOULE CHAPTER sea naMe Airuay Description of Skill CONSIDERATIONS Indications Nursing Interventions (pre, intra, post) Outcomes/Evaluation Client Education Potential Complications Nursing Interventions ACTIVE LEARNING TEMPLATES

Answer 1

ANSWER

Airway management: Tracheostomy suctioning.

Description of skill.

   It is the removal of secretions from the tracheobroncheal tree through an

   endotracheal tube with the help of a mechanical suction device.

Indications.

* To maintain patient airway by removing secretions.

* Prevent lower respiratory tract infection from retained secretions.

Nursing interventions.

Pre procedure.

    * Assess the rate of respiration and auscultate breath sounds and

      heart rate to identify need of suctioning.

   * Explain procedure to the patient.

   * Place semi flower position if patient is conscious otherwise place in

     a lateral position to avoid airway obstruction and easily drain secretions.

   * Check the functioning of suction apparatus and manual resuscitation

     connected to hundred percentage oxygen source for use if complications

     occur.

Intra procerdure.

    * Wash hands and wear gloves.

    * Open the sterile tray and take towel from it and place into

       the patient chest.

    * Open the sterile pack and place catheter into the sterile tray

       fill the bowel with sterile water.

    * Wear gloves and if the patient is on ventilator disconnect it for

       suctioning

    * Connect suction catheter to suction source.

    * Ventilate and oxygenate patient with resuscitation bag atleast four to

       five times to prevent hypoxia during suctioning.

    * Lubricate the catheter in a sterile saline for easy insertion and in the case

       silicon catheter no lubrication is needed.

    * Switch on the suction source and pinch the catheter if no Y spot is available

      then insert into the tracheal tube.

    * Insertion five inches in the case of adults and less than five inches in children.

      to avoid trauma or mucosal injury.

    * Applying suction by releasing thumb from Y port or release pinch on the catheter.

    * Suction application should not be more than 10 seconds and hyperventilate three

       to five times between suction or promote patient to cough to avoid hypoxia.

    * Clean the catheter between suctioning process by dip into sterile solution bottle.

    * After the airway become clean return patient to the ventilator and also suction

      oropharynx using another suction catheter.

    * At the end of procedure stop suction and remove suction cath and gloves then

      dispose in appropriate containers as per hospital policy.

Post procedure.

   * Clean the resuscitation bag and mask and replace articles used for suctioning.

   * Auscultate the lung sounds to assess whether airway is cleared of secretions.

   * Record the procedure in nurses record with time,amount and colour of secretions.

Outcome / Evaluation.

   * Evaluate the current respiratory status.

   * Evaluate the comfort level of patient.

   * Observe for complications due to suctioning.

Client education.

* Educate about importance of oral hygiene to prevent airway infection.

* Instruct to inform care provider if any breathing problem occur after suctioning.

* Instruct patient take deep breath between suctioning.

Potential complications.

* Airway mucosal trauma.

* Tachycardia.

* Atelectasis.

* Tachypnea.

* Changes in blood pressure.

* Hypoxia.

Nursing interventions.

* Hyperventilate patient before and in between suctioning.

* Provide oral suctioning along with tracheal suctioning to

   avoid accumulation of secretions.

* Auscultate breath sounds after suctioning and if any changes

   happened report immediately to the physician.

* Encourage concious patient to cough and deep breath between

   suctioning.

* Application of suction only a maximum of 10 seconds.

* Provide psychological support to reduce anxiety level due to repiratory

    discomfort.