The nurse is caring for the client who has an oral endotracheal tube (ET). Which does the nurse implement?
1. Rotate the ET position daily at the mouth.
2. Use twill tape to secure the ET around ears.
3. Restrict oral and gum care with client ET.
4. Suction ET with sterile Yankauer catheter.
1
1. To avoid perioral skin breakdown, the nurse moves the ET daily from one side of the mouth to the other to avoid prolonged skin pressure leading to skin breakdown.
2. The nurse uses narrow adhesive tape or a commercial ET holder to maintain the tube's position in the client's airway. At the time of intubation, an x-ray confirms the ET's position and the nurse records the numerical value marking the tube's position. Daily client assessment confirms placement of the ET by checking the numerical placement value. The client's airway depends on maintaining proper ET placement, so the nurse secures the ET firmly in place.
3. Oral and gum care are critical nursing interventions to prevent infection and restore client health and well-being.
4. A Yankauer catheter is suitable for oral suctioning.
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