Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 14-10

Securing an Endotracheal Tube (Continued)

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12. Take one of the 3-mL syringes or tongue blades and pass it
    under the patient’s neck so that there is a 3-mL syringe on
    either side of the patient’s head.


13. Put on disposable gloves. Have the assistant put on gloves
    as well.
    14.Provide oral care, including suctioning the oral cavity.


14. Take note of the ‘cm’ position markings on the tube. Begin
    to unwrap old tape from around the endotracheal tube.
    After one side is unwrapped, have assistant hold the endo-
    tracheal tube as close to the lips or nares as possible to
    offer stabilization.


15. Carefully remove the remaining tape from the endotracheal
    tube. After tape is removed, have assistant gently and
    slowly move endotracheal tube (if orally intubated) to the
    other side of the mouth. Assess mouth for any skin break-
    down. Before applying new tape, make sure that markings
    on endotracheal tube are at same spot as when retaping
    began.


16. Remove old tape from cheeks and side of face. Use
    adhesive remover to remove excess adhesive from tape.
    Clean the face and neck with washcloth and cleanser. If
    patient has facial hair, consider shaving cheeks. Pat cheeks
    dry with the towel.


17. Apply the skin barrier to the patient’s face (under nose,
    cheeks, and lower lip) where the tape will sit. Unroll one
    side of the tape. Ensure that nonstick part of tape remains
    behind patient’s neck while pulling firmly on the tape.
    Place adhesive portion of tape snugly against patient’s
    cheek.Split the tape in half from the end to the corner of
    the mouth.


18. Place the top-half piece of tape under the patient’s nose.
    Wrap the lower half around the tube in one direction, such
    as over and around the tube. Fold over tab on end of tape.


19. Unwrap second side of tape. Split to corner of the mouth.
    Place the bottom-half piece of tape along the patient’s
    lower lip. Wrap the top half around the tube in the oppo-
    site direction, such as below and around the tube. Fold
    over tab on end of tape. Ensure tape is secure.
    21.Auscultate lung sounds. Assess for cyanosis, oxygen satu-
    ration, chest symmetry, and stability of endotracheal tube.
    Again check to ensure that the tube is at the correct depth.

ExcellentSatisfactoryNeeds Practice