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

304

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

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 14-10

Securing an Endotracheal Tube

Goal:The tube remains in place, and the patient maintains

bilaterally equal and clear lung sounds. Comments

1. Bring necessary equipment to the bedside stand or overbed
   table.


2. Perform hand hygiene and put on PPE, if indicated.


3. Identify the patient.


4. Close curtains around bed and close the door to the room,
   if possible.


5. Assess the need for endotracheal tube retaping. Administer
   pain medication or sedation, as prescribed, before attempt-
   ing to retape endotracheal tube.Explain the procedure to
   the patient.


6. Obtain the assistance of a second individual to hold the
   endotracheal tube in place while the old tape is removed
   and the new tape is placed.


7. Adjust the bed to a comfortable working position, usually
   elbow height of the caregiver (VISN 8 Patient Safety Cen-
   ter, 2009). Lower side rail closest to you. If the patient is
   conscious, place him or her in a semi-Fowler’s position. If
   the patient is unconscious, place him or her in the lateral
   position, facing you. Move the overbed table close to your
   work area and raise to waist height.Place a trash recepta-
   cle within easy reach of work area.


8. Put on face shield or goggles and mask. Suction patient as
   described in Skill 14-8 or 14-9.


9. Measure a piece of tape for the length needed to reach
   around the patient’s neck to the mouth plus 8 inches. Cut
   tape. Lay it adhesive-side up on the table.


10. Cut another piece of tape long enough to reach from one
    jaw around the back of the neck to the other jaw. Lay this
    piece on the center of the longer piece on the table, match-
    ing the tapes’ adhesive sides together.


11. Take one 3-mL syringe or tongue blade and wrap the
    sticky tape around the syringe until the nonsticky area is
    reached. Do this for the other side as well.

ExcellentSatisfactoryNeeds Practice