Unformatted text preview: • Ensure that supplies are available for the next suctioning
(suction kit, gloves, water or normal saline).
13. Assess the effectiveness of suctioning.
• Auscultate the client's breath sounds to ensure they are
clear of secretions. Observe skin color, dyspnea, level of
anxiety, and oxygen saturation levels.
14. Document relevant data.
Record the procedure: the amount, ccnsistency, color, and
odor of sputum (e.g., foamy, white mucus; thick, greentinged mucus; or blood-flecked mucus) and the client's
respiratory status before and after the procedure. This may
include lung sounds, rate and character of breathing, and
If the procedure is carried out frequently (e.g., every hour),
it may be appropriate to record only once, at the end of
the shift; however, the frequency of the suctioning must be
recorded. SAMPLE DOCUMENTATION @ A sputum collection trap. 12/12/2015 0830 Producing large amounts of thick, tenacious white
mucus to back of oral pharynx but unable to expectorate into tissue.
Uses Yankauer suction tube as needed. O sat increased from 89%
before suctioning to 93% after suctioning. RR also decreased from
26 to 18-20 after suctioning. Lungs clear to auscultation throughout
all lobes. Continuous O, at 2 L/min via n/c. Will continue to reassess
q hour. ---------------L. Webb, RN EVALUATION
• Conduct appropriate follow-up, such as appearance of secretions suctioned; breath sounds; respiratory rate, rhythm, and
depth; pulse rate and rhythm; and skin color. • Compare findings to previous assessment data if available.
Report significant deviations from normal to the primary care
provider. I WORKSHEET
Direction: Accomplish the worksheet.
Johti Singh is a 39-year-old secretary who was admitted to the hospital with an elevated temperature,
fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals that Ms. Singh
has had a “bad cold” for several weeks that just wouldn’t go away. She has been dieting for several
months and skipping meals. Ms. Singh mentions that in addition to her full-time job as a secretary she
is attending college classes two evenings a week. She has smoked one package of cigarettes per day
since she was 18 years old. Chest x-ray confirms pneumonia.
Height: 167.6 cm (5960)
Weight: 54.4 kg (120 lb)
Temperature: 39.4°C (103°F)
Pulse: 68 beats/min
Blood pressure: 118/70 mmHg ...
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