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Skills Lab 4
Tracheostomy Suctioning
| Question | Answer |
|---|---|
| 1 (1pt) | Check chart for order |
| 2 (1pt) | Review policy and procedure |
| 3 (1pt) | State goals: (a) patient's airways will be patent. (b) patient will be free of respiratory tract infections from retain secretions or cross contamination. (c) sterility will be maintained |
| 4 (4pt) | Gather equipment |
| 5 (1pt) | Provides privacy for patient |
| 6 (2pt) | Perform hand hygiene |
| 7 (5pt) | Prepares patient: (1) Identifies two ways (a) name band and MR# (b) chart. (2) Checks for allergies. (3) Expains procedure to patient. (4) Establish method of communication during procedure. (5) Allow patient verbalization |
| 8 (2pt) | Raise bed to working height, rail up on the opposite side |
| 9 (2pt) | Correctly positions patient and drapes accordingly, usually Semi-Fowlers or Fowlers |
| 9 (***) | May put PPE on before assessment in case of splash |
| 10 (5pt) | Assessment: (a) s/sx of obstructed airway (↑RR, ↑HR, ↓LOC, presence of cough, secretions, restlessness, cyanosis). (b) auscultate breath sounds for rales/rhonci, ↓breath sounds |
| 11 (2pt) | Turns on and adjusts suction machine to the appropriate range: (a) portable: 7-15 in/hg. (b) 100-120mm/Hg |
| 12 (2pt) | Opens bottle of sterile saline and places connection tubing within reach |
| 13 (2pt) | Applies face shield (verbalize gown if splash risk) |
| 14 (3pt) | Aseptically opens suction kit on over-bed table |
| 15 (Part 1) (3pt) | Removes basin: (a) pours sterile NS into basin |
| 15 (Part 2) (***) | APPLIES STERILE GLOVES CORRECTLY |
| 15 (Part 3) (3pt) | (b) picks up sterile catheter with dominant, sterile hand |
| 16 (4pt) | With non-dominant hand, picks up and attaches connection tube to suction catheter without contaminating catheter |
| 17 (***) | MAINTAINS STERILITY OF SUCTION CATHETER AND STERILE HAND HOLDING CATHETER THROUGHOUT TRACH SUCTIONING |
| 18 (4pt) | Tests suction by occluding the port with non-dominant contaminated hand, wrapping catheter around dominant, sterile hand to maintain sterility until ready to suction (this also moistens the catheter tip). |
| 19 (Procedure: 1) (***) | HYPEROXYGENATES BEFORE SUCTIONING USING AMBU 3-5 BREATHS WITH 100% OXYGEN |
| 20 (Procedure: 2) (4pt) | Without applying suction, gently but quickly inserts catheter into trachea until resistance is met, using dominant sterile hand. Pulls catheter back 1 cm. |
| 21 (Procedure: 3) (***) | VERBALIZES NOT TO EXCEED 10 SECOND LIMIT ON SUCTIONING |
| 22 (Procedure: 4) (6pt) | Applies intermittent suction by placing and releasing non-dominant, contaminated thumb over vent on catheter |
| 23 (Procedure: 5) (3pt) | Withdraws catheter while rotating between thumb and forefinger of dominant, sterile hand |
| 24 (Procedure: 6) (***) | HYPEROXYGENATES PATIENT AFTER SUCTIONING WITH 3-5 BREATHS 100% OXYGEN. |
| 25 (Procedure: 7) (2pt) | Rinses catheter with sterile saline |
| 26 (Procedure: 8) (2pt) | Assesses need for repeat suctioning by listening for presence of secretions. |
| 27 (Procedure: 9) (3pt) | Repeat above steps if necessary with one full minute between suction passes for ventilation and reoxygenation |
| 28 (Procedure: 10) (2pt) | Replaces patient oxygen if in use. |
| 29 (Procedure: 11) (3pt) | Suction nasal/oropharyngeal airways last: verbalize not to reenter trach at this point |
| 30 (Procedure: 12) (3pt) | Disconnects catheter from connection tubing and rolls catheter around fingers of dominant hand |
| 31 (Procedure: 13) (3pt) | Pulls glove off so that catheter remains in glove. Removes other glove, careful not to contaminate skin |
| 32 (Procedure: 14) (1pt) | Removes face shield/gown |
| 33 (Procedure: 15) (1pt) | Discards and clean equipment according to policy and turns off machine |
| 34 (Post-Procedure: 1) (5pt) | Follow-Up Care: (a) auscultate breath sounds to evaluate effectiveness of suctioning. (b) mark intercom at nurse station. (c) ask if breathing is easier. (d) oral/lip care. (e)continue to assess and suction PRN; perform trach care if needed |
| 35 (Post-Procedure: 2) (4pt) | Follow-Up Education: (a) instruct patient to call if difficulty breathing occurs or if suctioning or mouth care is needed. (b) encourage patient to turn, cough, and deep breath every 2 hours to promote clear airway. |
| 36 (Post-Procedure: 3) (4pt) | Leave patient safe and comfortable: (a) side rails up. (b) call light in reach. (c) bed in lowest position. (d) positioned comfortably |
| 37 (Post-Procedure: 4) (2pt) | Performs hand hygiene |
| 38 (Post-Procedure: 5) (Part 1) (8pt) | Documents procedure appropriately with descriptive analysis: (a) date and time. (b) respiratory assessment before and after procedure. (c) type of suctioning performed and equipment used. |
| 38 (Post-Procedure: 5) (Part 2) (8pt) | (d) secretions obtained (amount, color, consistency). (e) patient tolerance. (f) patient eduaction. (g) signature |
Created by:
maggardba
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