Suctioning is an important nursing procedure that helps remove secretions from a patient’s airway. Before performing suctioning, it is crucial that nurses complete a thorough assessment. This ensures suctioning is truly indicated and helps minimize risks and complications.
Assessing the Need for Suctioning
The first step is to determine if suctioning is actually required. Signs a patient may need suctioning include:
- Audible secretions in the airway
- Inability to clear secretions effectively with coughing
- Evidence of copious secretions pooling in the oropharynx or tracheostomy site
- Increased work of breathing or signs of respiratory distress such as nasal flaring, intercostal retractions, decreased oxygen saturation
- Choking or gagging on secretions
- Restlessness or anxiety due to secretions
- Gurgling respirations
However, if the patient is able to effectively clear secretions by swallowing or coughing, suctioning may not be necessary. Suctioning should only be performed when the benefits outweigh the risks.
Assessing Vital Signs
It is important to assess the patient’s vital signs before beginning suctioning. This provides a baseline for comparison after the procedure. Pay particular attention to:
- Heart rate – Increased heart rate may indicate the patient is anxious or in distress
- Respiratory rate – Increased rate may signal increased work of breathing
- Oxygen saturation – Low levels identify need for additional oxygen
- Blood pressure – Elevated blood pressure could be sign of anxiety or pain
A full set of vital signs including temperature provides important information about the patient’s status and ability to tolerate suctioning.
Assessing Breath Sounds
Listening to breath sounds before and after suctioning allows nurses to evaluate the effectiveness of the procedure. Assess for:
- Location of secretions – Upper, middle, or lower lobes
- Presence of crackles, wheezing, rhonchi, decreased air movement
- Equality of breath sounds bilaterally
Compare breath sounds before and after suctioning to determine if further interventions are needed.
Assessing Oxygenation Status
Patients requiring frequent suctioning are often hypoxic. Careful evaluation of oxygenation status is required.
- Note oxygen flow rate and delivery device
- Assess capillary refill time
- Observe skin color – cyanosis, pallor, or flushing can indicate oxygenation problems
- Check pulse oximetry readings
- Note restlessness, confusion, somnolence – may signal hypoxia
- Assess arterial blood gases if available
Increase supplemental oxygen as needed before suctioning to prevent further hypoxemia.
Assessing Level of Consciousness
Determine the patient’s level of consciousness and ability to protect their airway:
- Is the patient alert and able to follow commands?
- Does the patient have an intact gag reflex?
- Can they cough effectively on verbal cue?
If the gag reflex is impaired or the patient has a decreased level of consciousness, special care must be taken to avoid injury during suctioning.
Assessing for Signs of Infection
Carefully observe the quality and quantity of secretions. Note:
- Color – purulent yellow, green, or bloody secretions may indicate infection
- Consistency – thick, tenacious secretions are often a sign of infection
- Odor – foul-smelling secretions can signal a respiratory infection
- Quantity – copious amounts of secretions may require antibiotic therapy
Notify the provider if suctioned secretions appear abnormal, as this could indicate pneumonia or bronchitis.
Assessing the Patient’s Anxiety Level
Suctioning can be uncomfortable or frightening for patients. Be alert for signs of anxiety including:
- Restlessness or agitation
- Increased respiratory rate
- Furrowed brow or fearful expression
- Verbalization of feelings
Provide reassurance, education about what to expect, and consider administering anxiolytic medication if prescribed.
Assessing Allergies and Risk of Infection
Identify any allergies or sensitivities to latex, betadine, or other substances used during suctioning. Note status of standard precautions including isolation and transmission-based precautions if applicable.
Assessing Airway Anatomy
Familiarize yourself with the patient’s specific airway anatomy before suctioning:
- Presence of an artificial airway – Endotracheal tube? Tracheostomy? When was it inserted?
- Oral anatomy – Ability to open mouth, presence of loose teeth, tubes, wires, or devices
- Presence of facial trauma that could impact suctioning
- Anatomical deviations, tumors, trauma, surgery that alter typical airway landmarks
Understanding the patient’s unique anatomy allows suctioning to be performed safely and effectively.
Assessing Equipment Function
Prior to beginning suctioning, assess equipment:
- Is suction device turned on and reading correct pressures?
- Is Yankauer catheter or suction catheter present?
- Is sterile water available for saline instillation if needed?
- Are oxygen, suction tubing, and catheter clean and in working order with no cracks or debris?
- Is suction canister empty and functioning properly?
Malfunctioning equipment could lead to complications or inadequate suctioning.
Comprehensive assessment prior to suctioning is vital. This allows nurses to determine if suctioning is truly indicated, minimize risks to the patient, provide appropriate interventions, and maximize the effectiveness of the procedure. Key assessment components include evaluating the need for suctioning, vital signs, breath sounds, oxygenation status, level of consciousness, secretions, anxiety level, allergies/precautions, airway anatomy, and equipment function.