TOWN OF FAIRFIELD HEALTH DEPARTMENT PUBLIC HEALTH NURSING

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1 TOWN OF FAIRFIELD HEALTH DEPARTMENT PUBLIC HEALTH NURSING PROGRAM: School Health APPROVED BY: Board of Health School Medical Advisor POLICY: With Portable Suction Machine DATE: March 14, 1994 POLICY DEFINITION: The term oronasopharyngeal pertains to structures of the mouth, nose and throat. Suctioning is a method of removing fluid from an area by vacuum. A portable suction machine is a device for applying negative pressure to a drainage tube. PURPOSE: To maintain an open airway through the nose and/or mouth by removing fluid and/or excess secretions by use of a suction catheter inserted through the mouth or nostril; to stimulate the cough reflex. Suctioning is used for the student who is unable to clear his or her airway effectively with coughing and expectoration. Suctioning is only indicated when secretions are audible in the airway, or when there are signs of airway obstruction or oxygen deficit. The procedure should be done as often as necessary depending on the student s condition. SCHOOL PERSONNEL WHO MAY APPROPRIATELY PROVIDE CARE OR ASSIST THE STUDENT: a) School Nurse, R.N., or L.P.N. CONSULTATION: Those responsible for providing care, training and supervision may need to obtain consultation from their clinical supervisor or from other health care providers in the community. DELEGATION DECISION: By the school nurse. Oronasopharyngeal suctioning cannot be delegated to unlicensed personnel. TRAINING AND SUPERVISION: To be determined/provided by the school nurse. CIRCUMSTANCES WHICH REQUIRE SCHOOL NURSE ACTION: Respiratory distress including dyspnea and cyanosis; difficulty swallowing; vomiting; oronasopharyngeal suction has never been needed previously. PHYSICIAN S ORDER REQUIRED: Yes. PARENT/GUARDIAN PERMISSION REQUIRED: Yes. 2.

2 SPECIAL CONSIDERATIONS: 1. Oronasopharyngeal suction is normally a clean procedure (not a sterile procedure) because the catheter does not progress past the pharynx). 2. Always suction through the nose first then through the mouth. The mouth has many more bacteria in it. Do not suction the nose with the same catheter that has already been used to suction the mouth. 3. Discard suction catheter after single use. Do not reuse catheter next time suction is needed. 4. Routine, non-emergency suctioning should be done in a clean, private area outside of the classroom, such as the health office, or in a corner of the classroom. Suctioning can be a noisy procedure and may be distracting or disruptive to the rest of the class. 5. Frequent assessment of student s status must be done during suctioning: observe for increased dyspnea and/or anxiety caused by hypoxia. Hypoxia can result because oxygen from the oronasopharynx is removed with the secretions. 6. Correct catheter size is crucial and is determined according to the student s size and physical condition. 7. Bloody aspirate can result from prolonged or traumatic suctioning. Water-soluble lubricant can help to minimize trauma. 8. Be alert when performing this procedure on students receiving anticoagulant therapy or who have blood dyscrasias because these conditions increase the risk for bleeding. 9. Suctioning is performed when the student needs assistance in clearing secretions from the airway. Indications of this include: - Noisy, rattling, or gurgling breathing sounds. - Secretions (mucous or saliva) pooling in the back of the throat. - Respiratory distress, i.e., difficulty breathing, restlessness, paleness, excessive coughing or choking, cyanosis. The student may request suctioning and may request suctioning and may be able to assist with the procedure. 3.

3 10. For a student who requires suctioning, the Individual Health Care Plan should include -The student s medical diagnosis and possible complications arising from the condition or treatment. - The student s baseline respiratory status (color, respiratory rate, pulse, usual amount of secretions, and frequency of suctioning. - Signs of respiratory distress and usual indications for suctioning. - The student s ability to request assistance. 11. Various types of suction machine models are available. Always read manufacturer s instructions carefully. PROCEDURE Note - read manufacturer s instructions which accompany suction machine and then keep with machine. EQUIPMENT: Provided by parent: (unless special arrangements are made) a) Portable suction machine, including collection bottle and connecting tubing. b) Suction catheter (#12 French or #14 French or #10 French for children, pediatric feeding (NG) tube for infant). c) (Optional) Water-soluble lubricant, e.g., Surgilube, K-Y Jelly. d) Normal saline solution or water to clean catheter, with disposable container. e) Clean disposable gloves, mask, goggles. Disposable gown if soiling likely. f) Medical waste bag. STEPS: a) Provide an environment that is comfortable, private, has a table or counter top for equipment, access to a grounded wall outlet, sink. Assemble equipment. b) Assess patient s condition prior to treatment: observe color, behavior, respiratory rate, and pulse rate. c) Explain the procedure to student in age-appropriate terms if he/she is unresponsive. Inform the student that suctioning may stimulate coughing or gagging. Continue to reassure the student during the procedure. (Anxiety and fear can increase oxygen consumption). If able, allow student to assist with the procedure. 4. d) Wash your hands.

4 e) Place student in Semi-Fowler s or high Fowler s position, if tolerated, to promote lung expansion and effective coughing. f) Encourage student to cough first then breathe slowly and deeply several times before beginning suction. If student is receiving oxygen therapy, evaluate his/her need for pre-oxygenation. Indications for pre-oxygenation may include cyanosis, restlessness, stridor, increased respiratory rate, increased pulse rate. g) Turn on the suction unit and set the pressure according to manufacturer s instructions (usually mg Hg for children). Occlude the end of the connecting tubing to check suction pressure. h) Open suction catheter. i) Fill container with saline or water. j) Put on clean gloves. k) In your dominant hand hold the catheter and attach appropriate end to the tubing of the suction machine. Use your non-dominant hand to control the suction valve while your dominant hand manipulates the catheter. l) (optional) Place a small amount of water-soluble lubricant on the catheter tip to facilitate passage of the catheter during nasal insertion. For Nasal Insertion: a) Without allowing catheter to touch the child, measure the length of the catheter from the tip of the patient s nose to his earlobe to determine the correct insertion length and ensure that the catheter won t pass into the trachea. Make a mental note of the length required for proper insertion. b) With dominant hand dip the catheter into the water or saline and suction a small to lubricate the tip. Also, dip end of catheter in water soluble lubricant. c) Raise the tip of the child s nose with your non-dominant hand to straighten the passageway and facilitate insertion of the catheter. Without applying suction gently insert the suction catheter into the child s nostril on a slight downward slant. Roll the catheter back and forth between your fingers to help advance it through the turbinates. Ask child to take slow deep breaths through the mouth. Continue to advance the catheter until you reach the pool of secretions or the student begins to cough. d) Apply suction as you withdraw the catheter. Simultaneously, roll the catheter between your fingers as you remove it. Repeat procedure and alternate nostrils. 5. For Oral Insertion:

5 For Both Nasal and Oral Insertion: a) To facilitate catheter insertion, have child turn head toward you. Without applying suction, gently insert the catheter into the mouth. Advance the catheter along the side of the mouth until you reach the pool of secretions or the child begins to cough. Suction both sides of the child s mouth and pharyngeal area. Use continuous rotating motion to minimize trauma to the mucosa. a) For infants and young children, never apply suction for more than 5 seconds at a time to minimize trauma. For older children, never apply suction for more than 10 seconds at a time. b) Allow child to rest after each suction period to reduce the risk of hypoxia. Administer oxygen, if indicated, between suction periods. c) If secretions are thick, dip the catheter in the cup of saline or water and apply suction in between passes to clear it. d) Repeat suctioning until gurgling or bubbling sounds stop and respirations are quiet. e) Assess child s status continually throughout suction procedure. Completion of Procedure: a) Pull your gloves off over the coiled catheter. Discard the catheter, gloves, and emptied saline/water container into the medical waste bag. Also discard mask and gown if contaminated into medical waste bag. Decontaminate goggles if needed. b) Flush the connecting tube with normal saline solution or water. c) Replace the used items so they are ready for the next suctioning. d) Wash your hands. DOCUMENTATION: Record the date, time, reason for suctioning, and technique used; amount, color, consistency and odor (if any) of the secretions; the student s respiratory status before and after the procedure; any complications and the nursing action taken; the student s tolerance for the procedure; any teaching done with the student, teacher, or parent. 6. REFERENCES: Nursing Procedures, Springhouse, Pa Springhouse Corporation Nurse s Reference Library Intermed

6 Communications, 1983, Springhouse, Pa. Tabers Medical Dictionary #14, F.A. Davis Company, Philadelphia, Pa. Serving Students With Special Needs State of Connecticut Department of Education 1992 Project School Care - Children Assisted By Medical Technology In Educational Settings: Guidelines For Care, Children s Hospital, Boston, MA, 1989 The Lippincott Manual of Nursing Practice, Fifth Edition, J.B. Lippincott Co., New York 1991

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