Skills Procedures

Question 1

How frequently should we suction patients?

Answer 1

Only as clinically indicated, and not as a routine, fixed, scheduled treatment; i.e. indicators suggesting the patient is experiencing respiratory distress

Question 2

When should we withdraw the suction catheter?

Answer 2

If patient requires additional oxygen (remember, o2 being suctioned out), and presents with signs of respiratory distress, cardiac compensation or any adverse effects during the procedure

Question 3

Describe the steps of preparing for suction:

Answer 3

1) Hand hygiene
2) Patient identifiers
3) Assess patient for signs of airway compromise or inadequate oxygenation (e.g. thick secretions unable to be cleared with coughing, decreased breath sounds, signs of compensation, etc.)
4) Assist patient into semi-Fowler or Fowler positioning
5) Determine appropriate depth to advance suction catheter (determined by artificial airway and adapter)
6) test suction and ensure it is functional
7) Progress with close or open suction technique

Question 4

Describe the steps of closed-suctioning:

Answer 4

1) Turn suction apparatus on, and adjust to less than 150 mmHg (use only high enough to effectively remove secretions without causing damage to airway)
2) test negative pressure by occluding end of tubing before attaching to suction catheter
3) Connect suction tubing to suction port or unlock thumb valve
4) Hyper-oxygenate patient 30-60 seconds prior to suctioning
5) Gently insert catheter into airway with the control vent of suction catheter open - pull back 1-2cm when resistance is met
6) Depress control vent of suction catheter to apply con’t suction
7) Withdraw catheter into sterile catheter sleeve q15 seconds
8) con’t as tolerated, 20-30 seconds in-between, may need two to four suctioning passes to clear secretions. Should not be exceeded d/t oxygen de-sating and cardiopulmonary complications
9) Clear upper airway with a Yankauer suction catheter to adequately clear all secretions
10) Rinse catheter and tubing with sterile NS until clear
11) Turn off suction

Question 5

Describe the steps of open suctioning:

Answer 5

1) Ensure appropriate PPE’s (e.g. mask) in place
2) Set suction apparatus on and to less than 150 mmHg (adult)
3) Check negative pressure by occluding end of tubing before attaching to suction catheter
4) Using aseptic technique, open sterile catheter package, exposing connecting end and connect catheter to the suction tubing
5) Apply sterile gloves
6) Pick up suction catheter, and connect suction catheter to connecting tubing
7) Check equipment is functioning by suctioning small amount of sterile saline
8) Hyperoxygenate patient
9) Gently insert catheter into artificial airway with control vent of suction catheter open
10) Depress control vent to apply con’t suction, maximum 15 seconds at a time
11) Max 2-4 passes, with 20-30 seconds between attempts
12) Perform oral suctioning
13) Rinse catheter and connect tubing with NS, suctioning until tubing clear
14) Turn off catheter

Question 6

What do we do if the patient does not tolerate open suctioning, even with hyperoxygenation?

Answer 6

• Ensure O2 set at 100%
• Maintain positive end-expiratory pressure (PEEP) during suctioning
• Allow longer recovery intervals between suction passes
• If pt does not tolerate still, switch to a closed-suction technique

Question 7

How do we complete suctioning?

Answer 7

• Ensure baseline return of O2 sats
• Assess volume, consistency and color of airway secretion
• Maintain suction collecting tubing and canisters for subsequent suctioning episodes
• Assess and treat pain
• Discard supplies, remove PPEs and perform hand hygiene
• Document procedure

Question 8

Describe the procedure for trach site care:

Answer 8

1) Position patient into semi-fowlers, with towel across chest
2) Hand hygiene & mask
3) Assess need for suctioning
4) Prepare equipment on bedside table (e.g. disposable inner cannula, supplies for cleaning a reusable inner cannula)
5) Remove soiled trach drsing and apply gloves
6) Care for inner cannula (new or reusable)
7) Assess stoma site (e.g. drainage, redness)
8) Use gauze moistened with NS to clean, and dry with dry gauze
9) Clean neckplate and external trach port with NS, dry with gauze
10) Apply drain sponge around stoma
11) Change trach tube holder (velcro) if necessary
12) Hold trach securely and align strap under neck
13) Assess resp status; apply oxygen and assess O2; document!

Question 9

Describe how to do trach care for a disposable inner cannula:

Answer 9

1) Remove new cannula from package, sterile technique
2) Support trach face-plate while withdrawing inner cannula
3) Replace with new cannula, lock into position
4) Dispose of old cannula
5) Reapply oxygen and assess O2

Question 10

Describe how to do trach care for a re-usable cannula:

Answer 10

1) Remove inner cannula and clean according to protocol (e.g. some places hydrogen peroxide basin, others with NS)
2) Place O2 over trach
3) Use small brush to remove inside secretions (and outside) inner cannula
4) Rinse with normal saline
5) Reinsert inner cannula and lock in place
6) Reapply oxygen and assess O2

Question 11

Describe frequency of trach assessments:

Answer 11

• Resp assessment with unit admission, beginning of every shift and Q4h / PRN
• Assessment should include type and size of airway; cuff inflated or deflated; resp rate; breath sounds; O2 and oxygen delivery type; O2 sats; ensuring emergency equipment at bedside

Question 12

What are signs and symptoms of poor trach tolerance?

Answer 12

• Increased secretions
• Increased need for suctioning
• Labour respiration’s
• Decrease in O2
• Restlessness
• Increased coughing and unable to clear secretions with cough

Question 13

What do we do when a trach is obstructed?

Answer 13

• Suspect this if unable to suction upper part of trach and suspect there is an obstruction with device
• Immediately notify RT
• Remove inner cannula and/or deflate cuff and attempt suction
• If obstruction still persists, instill NS to irrigate and attempt suction again
• If unable to relieve obstruction or ventilate a patient with a trach, call a code blue and ventilate using a face-mask

Question 14

What do we do if there is accidental extubation?

Answer 14

• Assess for resp distress
• Apply oxygen and notify RT and physician stat
• Urgency of notification of interdisc. team depends on degree of resp. assessment
• If not ventilating at all, call code blue and initiate ventilation using a resuscitation or face mask

Question 15

When do we flush on CVC’s?

Answer 15

• Prior to each intermit infusion in order to assess placement and patency
• After each infusion to prevent mixing of medications
• After blood sampling
• On a routine basis to maintain patency
• To all lumens post injection of contrast media
• Should never be forcibly flushed!

Question 16

Where is flushing on CVC’s typically done?

Answer 16

Usually only through a neutral displacement cap; the only times flushing is done by connecting flush directly to hub are after a blood draw (remember, caps have to be changed if blood in them) or after declotting with alteplase

Question 17

When is locking performed?

Answer 17

To maintain patency and prevent occlusion by instilling solution in an intermittently used CVC

Question 18

Describe how to flush CVC’s:

Answer 18

1) Verify pt, gather equipment and perform hand hygiene
2) Don non-sterile gloves
3) Set up work space (should be recently cleaned)
4) Set up equipment
5) Perform hand hygiene
6) Clean hub of cap with alcohol swab and allow to dry
7) Attach 10 cc NS syringe and attach to cap
8) Un-clamp (if applicable)
9) Slowly aspirate blood to confirm patency, do NOT bring back into cap!
10) Flush using turbulent method, not flushing if resistance met (if resistance AND unable to aspirate, refer to declotting with alteplase)
11) Remove syringe and discard
12) Flush with additional 20 cc of NS or proceed to locking procedure
13) Document

Question 19

How frequently do we flush a short term CVC, that is open ended and non-valved?

Answer 19

Using NS, flush q12h while not in use

Question 20

How frequently do we flush a long-term PICC that is open ended and non-valved?

Answer 20

Q12h with NS while not in use

Question 21

How frequently do we flush a long-term PICC that is open-ended and proximal valved? What about close-ended and distally valved?

Answer 21

• For open ended in acute care, q24h; in community, q7days if no issues
• For close-ended, q7 days
• These also apply open and closed ended long-term tunneled CVC’s

Question 22

What safety equipment has to be at the bedside of a patient with a chest tube?

Answer 22

• Alcohol swabs
• 4x4 gauze
• Smooth-edged clamps
• bottle of sterile water
• 4x4 occlusive drsg’s
• Clean gloves

Question 23

While working with a patient with a chest tube, what conditions should we report to the physician?

Answer 23

• Increasing resp distress
• New or worsening subcut emphysema
• New or increasing air leak
• Sudden cessation of air leak
• Presence of a clot in the tube causing a blockage
• Sudden surge of drainage (>200 cc’s in 30 min)
• Change in color or consistency of drainage

Question 24

If a patient has a chest tube accidentally come out of place, and they have a 3-sided drsg, when would we lift the unsecured portion?

Answer 24

Periodically during exhalation only, lift unsecured portion to allow air to exit the intrapleural space

Question 25

When do we use alcohol swabs OR sterile water in the case of a tube disconnect from the pleur-evac unit?

Answer 25

• Cleanse ends of tube and unit with alcohol swabs and reconnect if not visibly contaminated
• If end visibly contaminated, place tube in sterile water until a new drainage system can be set up