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Question

Difficulty: MediumReduction of Risk Potential

A nurse is preparing to perform open airway suctioning for an adult client with a tracheostomy tube. To reduce the risk of procedure-related complications such as hypoxia and mucosal trauma, arrange the following actions in the correct chronological sequence.

  1. 1Verify the wall suction pressure is set between 80 and 120 mm Hg.
  2. 2Hyperoxygenate the client with 100% oxygen.
  3. 3Insert the sterile suction catheter without applying suction.
  4. 4Apply intermittent suction while rotating and withdrawing the catheter for no more than 15 seconds.
  5. 5Rinse the catheter with sterile saline and reassess the client's respiratory status.

Answer

The correct sequence is: Verify suction pressure, hyperoxygenate the client, insert the catheter without suction, apply intermittent suction during withdrawal, and finally rinse the catheter and reassess.
Safe tracheostomy suctioning requires a systematic approach to mitigate procedural risks. First, verifying safe suction pressure (80 to 120 mm Hg) prevents barotrauma. Next, hyperoxygenating the client provides a vital oxygen reserve to offset the oxygen lost during the procedure. Inserting the catheter without suction protects the tracheal lining from stripping and injury. Suctioning is then applied intermittently during withdrawal for a maximum of 15 seconds to safely evacuate secretions without causing profound hypoxia. Finally, rinsing the catheter and reassessing the client ensures the airway is clear and stable.

Step-by-Step Solution

1
Verify the wall suction pressure is set between 80 and 120 mm Hg.
Suction equipment is confirmed to be at a safe negative pressure level.
Setting the pressure correctly before starting prevents excessive negative pressure from causing atelectasis or damaging the delicate tracheal mucosa.
2
Hyperoxygenate the client with 100% oxygen.
The client's functional residual capacity is filled with oxygen.
Suctioning removes oxygen along with secretions; pre-oxygenating creates a safe reserve to prevent profound hypoxemia.
3
Insert the sterile suction catheter without applying suction.
The catheter reaches the necessary depth (typically until resistance is met or the client coughs).
Applying suction during insertion pulls the mucosal tissue into the catheter eyelets, causing severe trauma and bleeding.
4
Apply intermittent suction while rotating and withdrawing the catheter for no more than 15 seconds.
Secretions are safely cleared from the airway.
Limiting suction time to 15 seconds or less and rotating the catheter minimizes the risk of hypoxia and prevents the catheter from adhering to one area of the mucosa.
5
Rinse the catheter with sterile saline and reassess the client's respiratory status.
The suction tubing is cleared, and the client's clinical status is evaluated.
Clearing the tubing prepares it for subsequent passes if needed, while reassessment confirms airway clearance and client stability.

Key Concept

Safe Tracheostomy Suctioning Protocol
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Topics

Reduction of Risk Potential

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