All patients with endotracheal tube require meticulous mouth care every 2 hours. Repositioning and manipulation of endotracheal tube should only be done by experienced nurses or respiratory therapist to prevent accidental displacement of endotracheal tube. Breath sounds should be assessed before, after, and during endotracheal tubecare. Confused patients who requireendotracheal tube care will require more than one nursing professional to perform ETT care to prevent inadvertent displacement while tube is not secure. Male patients may require shaving of beard and mustache to adequately secure endotracheal tube. The risk for accidental extubation exists during endotracheal tube care; therefore, reintubation equipment should be readily available.
Relevant nursing diagnosis included Ineffective airway clearance and Potential impaired tissue integrity. It is expected that the ETT is positioned on opposite side of mouth after tube care and
retaping. ETT depth is the same as when care started. Tape is clean and secured to ETT and cheeks. ETT patency is maintained, as evidenced by absences of high peak airway pressures, adequate oxygen saturation.
1. Wash hands and apply gloves.
Prevents transmission of microorganisms.
2. Perform oropharyngeal suctioning
Removes secretions and decreases patient’s need to cough during the procedure.
3. Prepare tape. Have an available assistant hold endotracheal tubetube securely.
Allows nurse to have one hand secure to the endotracheal tube throughout the procedure.
Prevents accidental extubation and maintains correct endotracheal tube position and depth.
4. Carefully remove tape from endotracheal tube and patient’s face.
Use adhesive remover to remove extra adhesive; discard tape into proper receptacles.
Promotes access to skin beneath tape for visualization and hygiene.
5. Clean mouth, gums, and teeth on opposite side of tube with mouthwash swabs and solution.Move tube to opposite side and repeat cleaning.
Allows access and complete visualization of the oral cavity. Promotes hygiene, and reduces oral cavity infections.
6. Clean face with soapy washcloth and towel dry.Use tincture of benzoin swab on cheeks and chin. Allow to dry completely. Protects skin, and makes skin more receptive to skin taping.
7. Pass tape under patient’s neck with adhesive side up. Careful not to twist tape. Center tape. On one side of face, secure tape across cheek. Tear remaining tape in half lengthwise. Secure top half of tape above upper lip and bottom half around endotracheal tube. On other side of face firmly remove slack, and secure to face.Tear tape lengthwise. Secure bottom half to lip and top half to endotracheal tube.
Secures tube to face, and positions tube at proper place and depth.
8. Wash oral airway with hydrogen peroxide, and rinse with normal saline.
Prevents transmissions of microorganisms.
9. Reinsert oral airway using tongue depressor to displace tongue inferiorly, allow proper positioning of oral airway, and prevent oral trauma.
Prevents trauma to oral cavity and allows access for oropharyngeal airway.
Prohibits patient from biting endotracheal tube.
10. Check endotracheal tube cuff pressure.
11. Discard soiled items, and wash hands.
Reduces transmission of microorganisms.