Ch 14: Oxygenation - Suctioning an Endotracheal Tube (ETT): Closed System (Video Available on Course Point - 05:48)

The intensive care nurse is caring for a client requiring frequent endotracheal suctioning while on a mechanical ventilator. During the suctioning process, the client is unintentionally extubated. What should the nurse do? Select all that apply.

- Remain with the client. - Notify the health care provider. - Assess the client's vital signs. Rationale: The nurse should remain with the client and call for help to notify the health care provider. The client's vital signs including a pulse oximeter reading and the ability to breathe without assistance should be assessed. The nurse should be ready to deliver assisted breaths with a bag-valve mask or administer oxygen, if needed. Although the client will require intubation, the nurse would not perform the intubation. There is no need for the nurse to initiate CPR.

Place in order, from first to last, the actions the nurse will perform when suctioning a client using a closed system suction. Use all options.

1. Explain the procedure to the client. 2. Turn on the suction at the wall unit. 3. Grasp the suction catheter through the protective sheath. 4. Withdraw the catheter while applying intermittent suction. 5. Assess the client's respiratory status for improvement. Rationale: The nurse should first explain the procedure to the client, assist client to comfortable position, and then turn the suction on at the wall unit and attach the tubing. Next, the nurse should grasp the catheter through the protective sheath and slowly advance the catheter without suction. The nurse should then slowly withdraw the catheter using intermittent suction to remove secretions from the airway. Once the procedure is completed, the nurse should assess the client's respiratory status to evaluate effectiveness of the intervention.

The nurse is caring for a client whose respirations are supported by a ventilator. The nurse is preparing to suction the client's endotracheal tube using a closed suctioning system. Place the following steps in the correct order. Use all options.

1. Hyperventilate the client. 2. Turn the catheter safety cap to enable the suction button. 3. Grasp the catheter and advance it to the predetermined length. 4. Depress the suction button to apply intermittent suction. 5. Clear secretions from the sheath. 6. Turn the catheter safety cap to disable the suction button. Rationale: Hyperoxygenating and hyperventilating before suctioning helps to decrease the effects of oxygen removal during suctioning. The safety button keeps the client from accidentally depressing the button and decreasing the oxygen saturation. Insertion of the suction catheter to a predetermined distance, no more than 1 cm past the length of the endotracheal tube, avoids contact with the trachea and carina, reducing the effects of tracheal mucosal damage. Pressing the suction button allows the nurse to apply intermittent suction. Flushing cleans and clears the catheter and lubricates it for next insertion. By turning the safety button, the suction is blocked at the catheter so the suction cannot remove oxygen from the endotracheal tube.

After assessing clients with a tracheostomy, which client will the nurse suction?

A client with rhonchi in upper airways noted on auscultation. Rationale: The nurse should only suction when assessment findings indicate a need to suction. Rhonchi noted on assessment indicate the client needs to be suctioned to clear the airway. Limiting suctioning to only when assessment findings indicate the need helps to minimize potential trauma to the mucosa. Adventitious breath sounds (secretions, rhonchi, rales) indicate a need to suction to clear the airway. Failure to recognize the indications and the need to clear the client's airway will diminish the client's oxygen saturation. An oxygen saturation of 97% is well within the desired range and does not indicate a need to suction. Suction should never be scheduled or done just because it has not been done in 4 hours; it should only be done when assessment findings indicate a need. Diminished gag reflex is not remedied by suctioning.

The nurse has just finished suctioning a client with a tracheostomy. Which action should the nurse take next?

Assess the client's lung sounds. Rationale: Upon completion of the procedure, the nurse would reassess the client's respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds. This determines the effectiveness of the suctioning and the presence of any complications. This is the evaluation step of the nursing process. Asking about the need for pain medication should have happened before the procedure. The nurse cannot document the procedure until effectiveness has been documented and respiratory status reassessed. While reminding the client to use the call bell is important, this would not be the nurses next step. It should be done before the nurse leaves the client's room.

A nurse is preparing to suction a client using a closed system endotracheal tube (ET) already in place. After inserting the saline dosette (or syringe) into the port, what would the nurse do next?

Hyperventilate the client using the sigh button on the ventilator. Rationale: First, the nurse would hyperventilate the client using the sigh button on the ventilator. Next, the nurse would turn the safety cap on suction button to enable it to depress easily, grasp the catheter through the protective sheath about 6 in (15 cm) from ET, and, lastly, gently insert the catheter into the endotracheal tube and release the catheter. The nurse should not occlude the Y-port when inserting the catheter.

The nurse is preparing to perform suctioning using a closed system endotracheal tube for a client who is on a mechanical ventilator. What should the nurse do first?

Set the suction to the appropriate pressure. Rationale: First, the nurse should set the suction to the appropriate pressure of less than 150 mmHg. The nurse should only then open the package, insert the saline into the port, and, lastly, hyperventilate the client prior to suctioning.

When suctioning the tracheostomy, when would the nurse suction the oral cavity?

Shortly after suctioning the tracheostomy. Rationale: The oral cavity would be suctioned with a separate single-use, disposable catheter following the suctioning of the tracheostomy. In addition, the nurse would perform oral hygiene for the client. Suctioning of the oral cavity removes secretions that are stagnant in the mouth and pharynx, reducing the risk of infection.

The nurse is suctioning a client on a mechanical ventilator using a closed system endotracheal tube. In the process of advancing the catheter, the nurse meets resistance. What should the nurse do?

Withdraw the catheter at least 0.5 in (1.25 cm) before applying suction Rationale: If resistance is met the carina or tracheal mucosa has been hit, the catheter is past the length of the endotracheal tube. The nurse should withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. There is no need for the nurse to remove the catheter completely and start over. Turning the catheter is done while withdrawing the catheter to help clean surfaces of the respiratory tract. Turning the catheter counterclockwise and advancing it will not bring the catheter out of the airway mucosa or carina. Continuing to apply suction would cause damage to the airway mucosa.

While suctioning a client, the nurse inserts a closed-system suction catheter into the tracheostomy tube and meets resistance. Which action should the nurse take?

Withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. Rationale: If the nurse meets resistance, the carina or tracheal mucosa has been hit. The nurse would withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. In this situation, the catheter does not need to be removed or changed, and the health care provider does not need to be called. To clean the catheter between suctioning passes, saline is inserted into the port prior to inserting the suction catheter.