A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A.
Rinse the catheter to remove secretions.
B.
Don sterile gloves.
C.
Apply suction while rotating the catheter.
D.
Insert the catheter during the client’s inspiration.
E.
Turn on the suction and set the pressure.
The Correct Answer and Explanation is:
The correct sequence for performing nasotracheal suctioning is as follows:
- B. Don sterile gloves.
- E. Turn on the suction and set the pressure.
- A. Rinse the catheter to remove secretions.
- D. Insert the catheter during the client’s inspiration.
- C. Apply suction while rotating the catheter.
Explanation
1. Don Sterile Gloves (Step B): The first step is to don sterile gloves to maintain a sterile field. This is essential because the airway is a sterile area, and the introduction of non-sterile materials can lead to infections. Proper glove technique reduces the risk of contamination during the procedure.
2. Turn on the Suction and Set the Pressure (Step E): After ensuring that you are using sterile gloves, the next step is to turn on the suction machine and set the appropriate pressure. For adults, the recommended suction pressure typically ranges from 80 to 120 mmHg. Setting this correctly beforehand ensures that the suction will be effective but not so high that it could cause trauma to the airway.
3. Rinse the Catheter to Remove Secretions (Step A): Rinsing the catheter is an important preparatory step. It clears any residual secretions from previous use, ensuring that the catheter is clean and functioning properly. This step helps maximize the effectiveness of the suctioning process.
4. Insert the Catheter During the Client’s Inspiration (Step D): Inserting the catheter while the client inhales is crucial. This technique opens the airway wider, making it easier to navigate the catheter through the trachea and minimizing the risk of stimulating a cough reflex, which can cause discomfort.
5. Apply Suction While Rotating the Catheter (Step C): Finally, suction is applied while gently rotating the catheter. This method helps to ensure that all areas of the airway are adequately cleared of secretions. The rotation facilitates dislodging mucus from the airway walls, improving the efficacy of the suctioning process.
By following this sequence, nurses can effectively manage airway secretions while ensuring patient safety and comfort.