et tube care, tracheostomy care

8/14/2019 ET Tube Care, Tracheostomy Care

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ET Tube Care,T Tube Care,Tracheostomy Care andracheostomy Care andSuct ion inguct ion ing


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PERFORMING ENDOTRACHEAL

TUBE CARE

Observe for signs and symptoms of need toperform 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 oftube, movement of tube up and down trachea(in and out), duration of tube placement, cuffoverinflation or underinflation, presence offacial trauma, malnutrition, and neck orthoracic radiation.

Assess client's knowledge of procedure.


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Obtain another nurse's assistance in thisprocedure.

Explain procedure and client's participation,including importance of the following: notbiting or moving ET tube with tongue; tryingnot to cough when tape is off ET tube;

keeping hands down and not pulling ontubing; removal of tape from face can beuncomfortable.

Assist client to assume position comfortable for

both nurse and client (usually supine or semi-Fowler's).


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Place towel across chest.

Wash hands. Apply face shield if indicated.

Administer endotracheal, nasopharyngeal, andoropharyngeal suction.

Connect oral suction catheter to suctionsource.

Prepare tape. Cut a piece of tape long enoughto go completely around client's head fromnares to nares 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 6inches) of tape, adhesive sides together, incenter of long strip to prevent tape fromsticking to hair. Smaller strip of tape should

cover area between ears around back ofhead.


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Apply gloves. Instruct helper to apply pair ofgloves and hold ET tube firmly at client's lipsor nares. Note the number marking on the ETtube at the gum line.

Carefully remove tape from ET tube andclient's fact.

Use adhesive remover swab to remove excessadhesive 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 oralairway if client is actively biting ET tube.

Clean mouth, gums, and teeth opposite ETtube with non-alcohol-based mouthwash

solution and sponge-tipped applicators. Brushteeth as indicated


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Oral ET tube only: Remembering "cm" ET tubemaking at lips or gums, with help of assistantmove ET tube to opposite side or center of

mouth. Do not change tube depth.

Repeat oral cleaning on opposite side ofmouth.

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 ETtube) or across nose (nasal ET tube) andcheeks to ear. Allow to dry completely.


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Slip tape under client's head and neck,adhesive side up. Take care not to twist tapeor catch hair. Do not allow tape to stick to

itself. It helps to gently stick tape to tongueblade, which serves as a guide. Then slidetongue blade under client's neck. Center tapeso that double-faced tape extends aroundback of neck from ear to ear.

On one side of face, secure tape from ear tonaris (nasal ET tube) or over lip to ET tube(oral ET tube). Tear remaining tape in halflengthwise, forming two pieces that are 1/2 to

3/4 inches wide. Secure bottom half of tapeacross upper lip (oral ET tube) or across topof nose (nasal ET tube) to opposite ear. Wraptop half of tape around tube and up frombottom. Tape should encircle tube at least two

times for security.


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Gently pull other side of tape firmly to pick upslack and secure to opposite side of face andET tube the same as the first piece.

Discard soiled items in appropriate receptacle.Remove towel and place in laundry.

Reposition client.

Remove gloves and face shield, discard inreceptacle, and wash hands. Place cleanitems (e.g., tincture of benzoin, mouthwash,access swabs) in place of storage.

Compare respiratory assessments before andafter ET tube care.


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Observe depth and position of ET tubeaccording to physician recommendation.

Assess security of tape by gently tugging attube.

Assess skin around mouth and oral mucousmembranes for intactness and pressure

areas.Note or Kardex with pencil: appropriate depth

of ET tube, frequency of ET tube care,pressure sore care needed, and designated

intervals.Record in nurses' notes: assessments before

and after care, supplies used, client'stolerance of procedure, and frequency and

extent of ET tube care.


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OROPHARYNGEAL

SUCTIONING


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1. Assess indications for

suctioning:Audible secretions during

respirationAdventitious breath sounds

(auscultated)


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2. Position:Conscious: Semi-Fowlers

position

Unconscious: Lateralposition


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3.Pressure of suction equipment, toprevent trauma to mucous

membrane of airways:Wall unit:

Adult: 100-120mmHG

Child: 95-110mmHgInfant: 50-95mmHg

Portable unit:

Adult: 10-15mmHGChild: 5-10mmHg

Infant: 2-5mmHg


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4. Appropriate size of sterilesuction catheter, to preventtrauma to mucous membraneof airways:

Adult: Fr. 12-18Child: Fr. 8-10

Infant: Fr. 5-8


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5. Don sterile gloves. Sterile techniqueprevents introduction of

microorganisms into the respiratorytract.

. :6 Le n g th of ca th e te r-measure from the tip of the

clie n t's n o se to th e e a rlo b e o r a b o u t

( )1 3 cm 5 in in ad u lt


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7. Lubricate catheter, toreduce friction

Oropharyngeal tip- sterile water or NSS


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8. Apply suction during

withdrawal of the suctioncatheter (never during

insertion) to preventtrauma to the mucous

membrane.


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9. Apply suction for 5-10seconds (maximum 15seconds). Over

suctioning causeshypoxia.


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10. Hyperventilate clientwith 100% oxygen before

and after suctioning toprevent hypoxia,

11 All 20 30 d


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11. Allow 20-30 secondinterval between each

suction to bring up mucoussecretions into the upper

airways, and preventhypoxia.


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12. Provide oral hygiene.


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13. Dispose contaminated

equipments/articles safely.To prevent contamination to

the environmentUse one sterile suction catheter for each

episode of suctioning


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14. Assess effectivenessof suctioning

Auscultate chest for clear breath sounds


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15. Document relevant

data.

et tube care, tracheostomy care

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