22.3 Assessments Related to Airway Suctioning
Open Resources for Nursing (Open RN)
Subjective Assessment
If appropriate, perform a focused interview collecting a brief history of respiratory conditions and assess for feelings of shortness of breath (dyspnea), sputum production, and coughing.
Objective Assessment
Prior to suctioning, a baseline assessment for indications of respiratory distress and the need for suctioning should be obtained and documented, including, but not limited to, the following:
- Secretions from the mouth and/or tracheal stoma
- Auscultation of lung sounds
- Heart rate
- Respiratory rate
- Cardiac rhythm
- Oxygen saturation
- Skin color and perfusion
- Effectiveness of cough[1]
Prepare the patient by explaining the procedure and providing adequate sedation and pain relief as needed. Place the patient in semi-Fowler’s position if conscious or in a lateral position facing you if they are unconscious. While suctioning the patient, if signs of worsening respiratory distress occur, stop the procedure and request emergency assistance. The following should be monitored during and following the procedure:
- Lung sounds
- Skin color
- Breathing pattern and rate
- Oxygenation (pulse oximeter)
- Pulse rate
- Dysrhythmias if electrocardiogram is available
- Color, consistency, and volume of secretions
- Presence of bleeding or evidence of physical trauma
- Subjective response including pain
- Cough
- Laryngospasm (spasm of the vocal cords that can result in airway obstruction)[2]
After completing suctioning, the outcomes from the procedure should be evaluated and documented, including the following:
- Improvement of lung sounds
- Removal of secretions
- Improvement of pulse oximetry
- Decreased work of breathing
- Stabilized respiratory rate
- Decreased dyspnea
Be aware that the patient’s lung sounds may not clear completely after suctioning, but the removal of secretions should improve the patency of the patient’s airway.
Potential complications resulting from this procedure include nasal irritation/bleeding, gagging/vomiting, discomfort and pain, and uncontrolled coughing. Potential adverse reactions include mucosal hemorrhage, laceration of nasal turbinate, perforation of the pharynx, hypoxia/hypoxemia, cardiac dysrhythmias/arrest, bradycardia, elevated blood pressure, hypotension, respiratory arrest, laryngospasm, bronchoconstriction, bronchospasm, hospital-acquired infection, atelectasis, increased intracranial pressure, and pneumothorax.
- American Association for Respiratory Care. (2004). AARC clinical practice guideline: Nasotracheal suctioning - 2004 revision & update. Respiratory Care, 49(9), 1080-1084. https://www.aarc.org/wp-content/uploads/2014/08/09.04.1080.pdf ↵
- American Association for Respiratory Care. (2004). AARC clinical practice guideline: Nasotracheal suctioning - 2004 revision & update. Respiratory Care, 49(9), 1080-1084. https://www.aarc.org/wp-content/uploads/2014/08/09.04.1080.pdf ↵