A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy.
Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?
A.
Inserts the catheter without applying suction.
B.
Waits for 2 min between suctions.
C.
Applies suction for 15 seconds.
D.
Encourages the client to cough during suctioning.
The Correct Answer and Explanation is:
The correct answer is C. Applies suction for 15 seconds.
Explanation:
Suctioning a tracheostomy is a critical procedure that requires careful technique to ensure the safety and comfort of the client. Here’s a breakdown of the correct practice and why option C requires intervention:
A. Inserts the catheter without applying suction.
This action is appropriate and recommended. The catheter should be inserted into the tracheostomy without suction to avoid causing trauma to the mucosa. Suctioning should only be applied once the catheter is correctly positioned.
B. Waits for 2 min between suctions.
This is also a correct practice. Waiting for about 1-2 minutes between suctions allows the client to recover and helps prevent hypoxia and trauma to the airway. It gives the mucosa time to rehydrate and minimize damage.
C. Applies suction for 15 seconds.
This action requires intervention because it exceeds the recommended duration for suctioning. The standard practice is to apply suction for no more than 10-15 seconds. Prolonged suctioning can cause hypoxia (low oxygen levels), irritation, and trauma to the airway. It can also increase the risk of complications such as bronchospasm or damage to the tracheal lining. Suctioning should be brief to minimize these risks and ensure patient safety.
D. Encourages the client to cough during suctioning.
Encouraging the client to cough can help dislodge mucus and facilitate the clearing of the airway. It is a common practice to improve the effectiveness of suctioning and help the patient clear secretions. However, this should be done gently to avoid causing discomfort or stress.
In summary, the staff nurse should intervene if the newly licensed nurse applies suction for 15 seconds, as this duration exceeds the safe limit and can have adverse effects on the client’s respiratory status. Proper suctioning technique is crucial for maintaining airway patency and ensuring patient safety.