The nurse is working on a long-term rehabilitation unit, is providing care for a 46-year-old woman who was the victim of a violent crime and suffered a head injury. The patient has an endotracheal tube, which is secured with tape
The tape is crusted with dried secretions. The nurse is providing personal hygiene for the patient and needs to replace the tape. What is the best way for the nurse to remove the tape? a. Soak it with warm moist washcloths.
b. Pull it gently away from the skin.
c. Saturate it with denatured alcohol.
d. Soak it with adhesive remover.
A
When patients have nasogastric, feeding, or endotracheal tubes inserted through the nose, change the tape, anchoring the tube at least once a day. When the tape becomes moist from nasal secretions, the skin and mucosa can easily become macerated (softened by soaking). Friction from a tube causes tissue injury. Anchor tubing correctly with tape or fixative devices to minimize tension or friction on the nares. Pulling away gently is preferred after soaking with warm moist clothes. Alcohol and adhesive remover are not recommended.
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