CU-PPT-21.pdf - (see Figure 50-12 A). If the cannula will...

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Unformatted text preview: (see Figure 50-12 A). If the cannula will not stay in place, tape it at the sides of the face. • Pad the tubing and band over the ears and cheekbones as EVALUATION needed. • Perform follow-up based on findings that deviated from Face Mask expected or normal for the client. Relate findings to previous • Guide the mask toward the client's face, and apply it from data if available (e.g., check oxygen saturation to evaluate the nose downward. adequate oxygenation). • Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning PURPOSES To remove secretions that obstruct the airway • To facilitate ventilation To obtain secretions for diagnostic purposes To prevent infection that may result from accumulated secretions ASSESSMENT Assess for clinical signs indicating the need for suctioning: Restlessness, anxiety • Noisy respirations • Adventitious (abnormal) breath sounds when the chest is auscultated Change in mental status Skin color Rate and pattern of respirations Pulse rate and rhythm Decreased oxygen saturation PLANNING DELEGATION Oral suctioning using a Yankauer suction tube can be delegated to UAP and to the client or family, if appropriate, since this is not a sterile procedure. The nurse needs to review the procedure and important points such as not applying suction during insertion of the tube to avoid trauma to the mucous membrane. Oropharyngeal suctioning uses a suction catheter and, although not a sterile procedure, should be performed by a nurse or respiratory therapist. Suctioning can stimulate the gag reflex, hypoxia, and dysrhythmias that may require problem solving. In contrast, nasopharyngeal and nasotracheal suctioning use sterile technique and require application of knowledge and problem solving and should be performed by the nurse or respiratory therapist. INTERPROFESSIONAL PRACTICE Suctioning a client may be within the scope of practice for specific health care providers. For example, in addition to nurses, respiratory therapists may help suction a client. Although the respiratory therapist may verbally communicate their findings and plan to the health care team members, the nurse must also know where to locate their documentation in the client's medical record. IMPLEMENTATION Performance 1. Prior to performing the procedure, introduce self and verify the client's identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Inform the client that suctioning will relieve breathing difficulty and that Iha procedure is painless but may be uncomfortable and stimulate the cough, gag, or sneeze reflex. Rationale: Knowing that the procedure will relieve breathing problems is often reassuring and enlists the client's cooperation. 2. Perform hand hygiene and observe other appropriate infection prevention procedures. 3. Provide for client privacy. Equipment Oral and Nasopharyngeal/Nasotracheal Suctioning (Using Sterile Technique) Towel or moisture-resistant pad Portable or wall suction machine with tubing, collection receptacle, and suction pressure gauge Sterile disposable container for fluids Sterile normal saline or water Goggles or face shield, if appropriate Moisture-resistant disposal bag Sputum trap, if specimen is to be collected Oral and Oropharyngeal Suctioning (Using Clean Technique) • Yankauer suction catheter or suction catheter kit • Clean gloves Nasopharyngeal or Nasotracheal Suctioning (Using Sterile Technique) • Sterile gloves Sterile suction catheter kit (#12 to #18Fr for adults, #8 to #10 Fr for children, and #5 to #8 Fr for infants) Water-soluble lubricant Y-connector 4. Prepare the client. Position a conscious person who has a functional gag reflex in the semi-Fowler's position with the head turned to one side for oral suctioning or with the neck hyperextended for nasal suctioning. Rationale: These positions facilitate the insertion of the catheter and help prevent aspiration of secretions. Position an unconscious client in the lateral position, facing you. Rationale: This position allows the tongue to fall forward, so that it will not obstruct the catheter on insertion. The lateral position also facilitates drainage of secretions from the pharynx and prevents the possibility of aspiration. Place the towel or moisture-resistant pad over the pillow or under the chin. ...
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