Ateneo de Zamboanga University College of Nursing Nursing Skills Output (NSO) ENDOTRACHEAL TUBE CARE

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Description: i Endotracheal tube management consists of ensuring a patent (open and unblocked) airway, suctioning pulmonary and oral secretions, and providing frequent oral and/or nasal care.

II. Purpose: 1. To maintain a patent airway. 2. To prevent infection. 3. To maintain skin integrity. 4. To prevent tube displacement III. Equipments: i Towel i Endotracheal and oral pharyngeal suction equipment i 1- or 1 1/2-inch wide adhesive or waterproof tape (do not use paper or silk tape) or commercial ET tube holder and mouth guard (follow manufacturer's instructions for securing) i Gloves (two pairs) Procedures: Observe for signs and symptoms of need to perform ET tube care: soiled or loose tape; pressure sore or naris, lips, or corner of mouth; and excess nasal or oral secretions. Observe for factors that increase risk of complications from ET tube: type and size of tube, movement of tube up and down trachea (in and out), duration of tube placement, cuff overinflation or underinflation, presence of facial trauma, malnutrition, and neck or thoracic radiation. Assess client's knowledge of procedure. Obtain another nurse's assistance in this procedure. Explain procedure and client's participation, including importance of the following: not biting or moving ET tube with tongue; trying not to cough when tape is off ET tube; keeping hands down and not pulling on tubing; removal of tape from face can be uncomfortable. Assist client to assume position comfortable for both nurse and client (usually supine or semi-Fowler's). Place towel across chest. Wash hands. Apply face shield if indicated.

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Administer endotracheal, nasopharyngeal, and oropharyngeal suction. Connect oral suction catheter to suction source. Prepare tape. Cut a piece of tape long enough to go completely around client's head from naris to naris plus 6 inches: adult 24-48 cm (1 to 2 feet). Lay tape adhesive side up on bedside table. Cut and lay 8 to 16 cm (3 to 6 inches) of tape, adhesive sides together, in center of long strip to prevent tape from sticking to hair. Smaller strip of tape should cover area between ears around back of head. Apply gloves. Instruct helper to apply pair of gloves and hold ET tube firmly at client's lips or naris. Note the number marking on the ET tube at the gum line. Carefully remove tape from ET tube and client's fact. Use adhesive remover swab to remove excess adhesive left on face after tape removal. Wash adhesive remover from face. Remove oral airway or bite block, if present, and place on towel. Do not remove oral airway if client is actively biting ET tube. Clean mouth, gums, and teeth opposite ET tube with non-alcohol-based mouthwash solution and sponge-tipped applicators. Brush teeth as indicated. If necessary, administer oropharyngeal suctioning with Yankauer suction catheter. Oral ET tube only: Remembering "cm" ET tube making at lips or gums, with help of assistant move ET tube to opposite side or center of mouth. Do not change tube depth. Repeat oral cleaning on opposite side of mouth. Clean face and neck with soapy washcloth, rinse, and dry. Shave male client as necessary. Pour small amount of skin protectant on clean 2 X 2 inch gauze and dot on upper lip (oral ET tube) or across nose (nasal ET tube) and cheeks to ear. Allow to dry completely. Slip tape under client's head and neck, adhesive side up. Take care not to twist tape or catch hair. Do not allow tape to stick to itself. It helps to gently stick tape to tongue blade, which serves as a guide. Then slide tongue blade under client's neck. Center tape so that double-faced tape extends around back of neck from ear to ear. On one side of face, secure tape from ear to naris (nasal ET tube) or over lip to ET tube (oral ET tube). Tear remaining tape in half lengthwise, forming two pieces that are 1/2 to 3/4 inches wide. Secure bottom half of tape across upper lip (oral ET tube) or across top of nose (nasal ET tube) to opposite ear. Wrap top half of tape around tube and up from bottom. Tape should encircle tube at least two times for security. Gently pull other side of tape firmly to pick up slack and secure to opposite side of face and ET tube the same as the first piece. Discard soiled items in appropriate receptacle. Remove towel and place in laundry. Reposition client.

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Nursing Responsibilities: i Remove gloves and face shield, discard in receptacle, and wash hands. Place clean items (e.g., tincture of benzoin, mouthwash, access swabs) in place of storage. i Compare respiratory assessments before and after ET tube care. i Observe depth and position of ET tube according to physician recommendation. i Assess security of tape by gently tugging at tube. i Assess skin around mouth and oral mucous membranes for intactness and pressure areas. i Note or Kardex with pencil: appropriate depth of ET tube, frequency of ET tube care, pressure sore care needed, and designated intervals. i Record in nurses' notes: assessments before and after care, supplies used, client's tolerance of procedure, and frequency and extent of ET tube care.

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Illustrations:

Sources: http://www.public.coe.edu/~lstrosch/Nursing/endotrachtubecarechecklist.htm www.rn.com/getpdf.php/615.pd http://www.ncnm.ie/hanna/publications/Trach-Guidelines.pdf http://www.brooksidepress.org/Products/Nursing_Care_of_the_Surgical_Patient/im ages/md0915_img_17.jpg http://www.corexcel.com/courses/body.vent7.htm

Arcillas, Avigale B. BSN III- D

Mrs. Araceli Pison, RN Clinical Instructor