Basic Clinical Nursing

Skills
(An Update)

By: Elaine Graziel Cheng R.N.

 SUCTIONING
NASOPHARYN
GEAL AND
OROPHARYNGE
AL AREAS
Equipment:
1.Portable suction machine or wall
suction unit with receptacle and
tubing
2.Appropriate length suction
catheter
3.Clean gloves
4.Sterile saline or water
5.Oxygen source and administration
device
6.Personal protective equipment
 Indications for Suctioning:
1. Ineffective cough.
2. Client with
depressed level of
consciousness.
3. Thick, tenacious
mucus
4. Impaired pulmonary
function.
Procedure:

1.Determine need for suctioning. Administer pain

medication before suctioning to postoperative patient.

2. Explain procedure to patient.

3. Assemble equipment.
4. Perform hand hygiene.

5. Adjust bed to comfortable working position. Lower side

rail closet to you. Place patient in a semi-Fowler’s position
if he or she is conscious. An unconscious patient should
be placed in the lateral position facing you.

6. Place towel or waterproof pad across patient’s chest

 Turn suction to appropriate
7.
pressure.

Wall unit
Adult: 100 to 120 cm Hg
Child: 95 to 110 cm Hg
Infant: 50 to 95 cm Hg

Portable unit
Adult: 10 to 15 cm Hg
Child: 5 to 10 cm Hg
Infant: 2 to 5 cm Hg
8. Open sterile suction package. Set up sterile
container, touching only the outside surface,
and pour sterile saline into it.

9. Don sterile gloves. The dominant hand that

will handle catheter must remain sterile,
whereas the nondominant hand is considered
clean rather than sterile.

10. With sterile gloves. The dominant hand,

pick up sterile catheter and connect to suction
tubing held with unsterile hand.

11. Moisten catheter by dipping it into

container of sterile saline. Occlude Y-tube to
check suction.
12. Estimate the distance from earlobe to nostril
and place thumb and forefinger of gloved hand
at that point on catheter.

13. Gently insert catheter with suction off by

leaving the vent on the Y-connector open. Slip
catheter gently along the floor of an
unobstructed nostril toward trachea to suction
the nasopharynx. Or insert catheter along side
of mouth toward trachea to suction the
oropharynx. Never apply suction as catheter is
introduced.

14. Apply suction by occluding suctioning port

with your thumb. Gently rotate catheter as it is
being withdraw. Do not allow suctioning to
15. Flush the catheter with saline and repeat
suctioning as needed and according to patient’s
toleration of the procedure.

16. Allow at least a 20- to 30-second interval if

additional suctioning is needed. The nares should
be alternated when repeated suctioning required.
Do not force the catheter through the nares.
Encourage patient to cough and breathe deeply
between suctioning.

17. When suctioning is completed, remove gloves

inside out and dispose of gloves, catheter, and
container with solution in proper receptacle.
Perform hand hygiene. 18. Use auscultation to
listen to chest and breath sounds to assess
19. Record time of suctioning and nature
and amount of secretions. Also note the
character of the patient’s respirations
before and after suctioning.

20. Offer oral hygiene after suctioning.

Suctioning the
Tracheostomy
Procedure:

1.Explain the procedure to the patient and reassure

him or her that you will interrupt the procedure if
the patient indicates respiratory difficulty.

2.Administer pain medication to postoperative

patient before suctioning.

3.Gather equipment and provide privacy for patient.

Perform hand hygiene.

4. Assist the patient to a semi-Fowler’s or Fowler’s

position if conscious. An unconscious patient should
be placed in the lateral position facing you.
5. Turn suction to appropriate pressure.

6. Place clean towel, if being used, across

patient’s chest. Don goggles, mask, and
gown, if necessary.

7. Open sterile kit or set up equipment and

prepare to suction.

8. Moisten catheter by dipping it into the

container of sterile saline, unless it is one of
the newer silicone catheters that does not
require lubrication.

9. Remove oxygen delivery setup with unsterile

gloved hand if it is still in place
10. Using sterile gloved hand, gently and quickly insert
catheter into the trachea. Advance about 10 to 12.5 cm
(4-5 inches) or until patient coughs. Do not occlude Y-
port when inserting catheter.

11. Apply intermittent suction by occluding Y-port with

thumb and index finger of sterile gloved hand as
catheter is being withdraw. Do not allow suctioning to
continue for more than 10 seconds. Hyperventilate
three to five times between suctioning or encourage
patient to cough and deep breathe between suctioning.

12. Flush catheter with saline and repeat suctioning as

needed and according to patient’s tolerance of the
procedure. Allow patient to rest at least 1 minute
between suctioning, and replace oxygen delivery setup
if necessary. Limit suctioning events to three times.
13. When procedure is completed, turn off suction
and disconnect catheter from suction tubing.
Remove gloves inside out and dispose of gloves,
catheter, and container with solution in proper
receptacle. Perform hand hygiene.

14. Adjust patient’s position. Auscultate chest to

evaluate breath sounds.

15. Record time of suctioning and nature and

amount of secretions. Also note character of
patient’s respirations before and after suctioning.

16. Offer oral hygiene.

Suctioning with Closed
Suction System
1. Explain procedure

2. Perform hand hygiene and don gloves.

3. Place client in fowler’s or semi-fowler’s

position.

4. Turn on suction source.

5. Connect oxygen source to side arm of

tube connector.

6. Hyperoxygenate client.

7. Open access valve and advance catheter

within plastic sleeve into client’s artificial
8. With nondominant hand, activate suction
valve.
Intermittently apply suction while withdrawing
catheter completely.

9. Repeat as necessary. Allow time between

suctioning.

10. Attach saline vial to catheter irrigation

port; inject saline while applying suction to
rinse catheter and tubing, then close irrigation
port and suction valve.

11. Remove syringe, release suction and lock

mechanism.
 Providing
Tracheostomy
Care
Equipment:
Procedure:
1. Explain procedure to patient.
2. If tracheostomy tube has been
suctioned, remove soiled dressing
from around tube and discard with
gloves on removal.
3. Perform hand hygiene and open
necessary supplies
Cleaning A Nondisposable Inner
Cannula
4. Prepare supplies before cleaning inner
cannula. 
– Open tracheostomy care kit and separate basins,
touching only the edges. If kit is not available, open
two sterile basins.
– Fill one basin fraction ½-inch (1.25 cm) deep with
hydrogen peroxide.
– Fill other basin fraction ½-inch (1.25 cm) deep with
saline.
– Open sterile brush or pipe cleaners if they are not
already in cleaning kit. Open additional sterile gauze
pad.
5. Don disposable gloves.

6. Remove oxygen source if one is present. Rotate lock on

inner cannula in a counterclockwise motion to release it.

7. Gently remove inner cannula and carefully drop it in

basin with hydrogen peroxide. Remove gloves and
discard.

8. Clean inner cannula.

– Don sterile gloves.
– Remove inner cannula from soaking solution. Moisten brush
or pipe cleaners in saline and insert into tube, using back-
and-forth motion.
– Agitate cannula in saline solution. Remove and tap against
inner surface of basin.
– Place on sterile gauze pad.
9. Suction outer cannula using sterile technique.
10. Replace inner cannula into outer cannula. Turn lock
clockwise and make sure that inner cannula is secure.
Reapply oxygen source if needed.

Replacing Disposable Inner Cannula

11. Release lock. Gently remove inner cannula and place in
disposable bag. Discard gloves and don sterile ones to
insert new cannula. Replace with appropriately sized new
cannula. Engage lock on inner cannula.
Applying Clean Dressing and Tape
12. Dip cotton-tipped applicator in saline and clean
stoma under faceplate. Use each applicator only
once, moving from stoma site outward.
13. Apply hydrogen peroxide to area around stoma,
faceplate, and outer cannula if secretions prove
difficult to remove. Rinse area with saline.
14. Pat skin gently with dry 4 x 4 gauze.
15. Slide commercially prepared tracheostomy
dressing or prefolded non-cotton-filled 4 x 4
dressing under faceplate.
16. Change tracheostomy tape.
– Leave soiled tape in place until new one is applied.
– Cut piece of tape that is twice the neck circumference plus 4
inches (10 cm). Trim ends on the diagonal.
– Insert one end of tape through faceplate opening alongside old
tape. Pull through until both ends are even.
– Slide both tapes under patient’s neck and insert one end through
remaining opening on other side of faceplate. Pull snugly and tie
ends in double square knot. Check that patient can flex neck
comfortably.
– Carefully remove old tape. Reapply oxygen source if necessary. 

17. Remove gloves and discard. Perform hand hygiene. Assess

patient’s respirations. Document assessments and
completion of procedure.
Chest
Tube
Care
And
Monitorin
g
 Introduction
• Trauma, disease, or surgery can interrupt the closed
negative-pressure system of the lungs, causing the lung
to collapse.  Air or fluid may leak into the pleural
cavity.  A chest tube is inserted and a closed chest
drainage system  is attached to promote drainage of air
and fluid. Chest tubes are used after chest surgery and
chest trauma and for pnuemothorax or hemothorax to
promote lung re-expansion
 Terms and definitions
a.         Pneumothorax – collection of air in the
pleura space
b.         Hemothorax – an accumulation of blood
and fluid in the pleural cavity between the
parietal and visceral pleurae, usually as the
result of trauma
c.         Chest tubes – a catheter inserted through
the thorax to remove air and fluids from the
pleural space and to reestablish normal
intrapleural and intrapulmonic pressures
Care of patients with chest
tubes
a.         Assess patient for respiratory distress and
chest pain, breath sounds over affected lung area,
and stable vital signs
b.         Observe for increase respiratory distress
c.         Observe the following:
(1)        Chest tube dressing, ensure tubing is
patent
(2)        Tubing kinks, dependent loops or clots
(3)        Chest drainage system, which should be
upright and below level of tube insertion 
d.         Provide two shodded hemostats for each chest tube,
attached to top of patient’s bed with adhesive tape.  Chest tubes
are only clamped under specific circumstances:

(1)        To assess air leak

(2)        To quickly empty or change collection bottle or chamber;
performed by soldier medic who has received training in
procedure
(3)        To change disposable systems; have new system ready
to be connected before clamping tube so that transfer can be
rapid and drainage system reestablished
(4)        To change a broken water-seal bottle in the event that
no sterile solution container is available
(5)        To assess if patient is ready to have chest tube removed
(which is done by physician’s order); the solider medic must
monitor patient for recreation of pneumothorax
e. Position the patient to permit optimal drainage
(1)        Semi-Flower’s position to evacuate air (pneumothorax)
(2)        High Flower’s position to drain fluid (hemothorax)
f.          Maintain tube connection between chest and drainage tubes
intact and taped
(1)        Water-seal vent must be without occlusion
(2)        Suction-control chamber vent must be without occlusion
when suction is used
g.         Coil excess tubing on mattress next to patient. Secure with
rubber band and safety pin or system’s clamp
h.         Adjust tubing to hang in straight line from top of mattress to
drainage chamber. If chest tube is draining fluid, indicate time (e.g.,
0900) that drainage was begun on drainage bottle’s adhesive tape
or on write-on surface of disposable commercial system
(1)        Strip or milk chest tube only per MD/PA orders only
(2)        Follow local policy for this procedure
 Problem solving with chest
tubes
a.         Problem:  Air leak
(1)        Problem:  Continuous bubbling is seen in water-seal
bottle/chamber, indicating that leak is between patient and
water seal
(a)        Locate leak
(b)        Tighten loose connection between patient and water
seal
(c)        Loose connections cause air to enter system.
(d)        Leaks are corrected when constant bubbling stops
(2)        Problem:  Bubbling continues, indicating that air leak
has not been corrected
(a)        Cross-clamp chest tube close to patient’s chest, if
bubbling stops, air leak is inside the patient’s thorax or at
chest tube insertion site
(b)        Unclamp tube and notify physician immediately!
(c)        Reinforce chest dressing
Warning:         Leaving chest tube clamped caused a
tension pneumothorax and mediastinal shift
 
(3)        Problem:  Bubbling continues, indicating that leak
is not in the patient’s chest or at the insertion site
(a)        Gradually move clamps down drainage tubing
away from patient and toward suction-control
chamber, moving one clamp at a time
(b)        When bubbling stops, leak is in section of
tubing or connection distal to the clamp
(c)        Replace tubing or secure connection and
release clamp

(4)        Problem:  Bubbling continues, indicating that leak

is not in tubing
(a)        Leak is in drainage system
(b)        Change drainage system
b.         Problem:  Tension pneumothorax is present

(1)        Problems:  Severe respiratory distress or chest pain

(a)        Determine that chest tubes are not clamped, kinked, or
occluded. Locate leak
(b)        Obstructed chest tubes trap air in intrapleural space
when air leak originates within patient
(2)        Problem:  Absence of breath sounds on affected side
(a)        Notify physician immediately
(3)        Problems:  Hyperresonance on affected side, mediastinal
shift to unaffected side, tracheal shift to unaffected side,
hypotenstion or tachycardia
(a)        Immediately prepare for another chest tube insertion
(b)        Obtain a flutter (Heimlich) valve or large-guage needle
for short-term emergency release or air in intrapleural space
(c)        Have emergency equipment (oxygen and code cart)
near patient
(4)        Problem:  Dependent loops of drainage tubing have
trapped fluid
(a)        Drain tubing contents into drainage bottle
(b)        Coil excess tubing on mattress and secure in place
(5)        Problem:  Water seal is disconnected
(a)        Connect water seal
(b)        Tape connection
(6)        Problem:  Water-seal bottle is broken
(a)        Insert distal end of water-seal tube into sterile
solution so that tip is 2 cm below surface
(b)        Set up new water-seal bottle
(c)        If no sterile solution is available, double clamp chest
tube while preparing new bottle
(7)        Problem:  Water-seal tube is no longer submerged in
sterile fluid
(a)        Add sterile solution to water-seal bottle until distal
tip is 2 cm under surface
(b)        Or set water-seal bottle upright so that tip is
submerged