A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?
A. Continue to suction.
B. Notify the physician immediately.
C. Stop the procedure and reoxygenate the client.
D. Ensure that the suction is limited to 15 seconds.
Correct Answer: C. Stop the procedure and reoxygenate the client.
During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
Option A: Suction gently and intermittently, use proper catheter size and technique. Clears airway and pool of secretions without injury to the trachea, prolonged suctioning causes vagal stimulation and bradycardia and high pressure may damage the mucosa of the trachea.
Option B: Monitor arterial blood gasses and oxygen saturation. Pulse oximetry is a useful tool to detect early changes in oxygen saturation. Oxygen saturation should be kept at 90% or greater. Increasing PaCo2 and decreasing PaO2 are signs of hypoxemia and respiratory acidosis.
Option D: Brief, 10-second suction duration is usually recommended to avoid mucosal damage and prolonged hypoxia. Hypoxia can be profound from occlusion, interruption of oxygen supply, and prolonged suctioning.
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