WHEN YOUR PATIENT has an endotracheal (ET) tube, the more securely it's held in place, the less her risk of unintended extubation. In addition to securing the ET tube, a commercial holder gives you better access for oral care than a twill or tape securement and decreases the risk of hospital-acquired pneumonia, lip and facial skin breakdown, and contamination by secretions.
The Dale(R) Stabilock(TM) ET tube holder shown here provides a secure method of ET tube stabilization. Follow hospital policy for securing and changing ET tube holders. The manufacturer of this device recommends replacing the adhesive base every 3 days and the neckband as needed.
Document the change of the ET-tube holder, the date and time, the position of the tube's proximal end (based on the numeric mark), the condition of your patient's lips and skin, methods to confirm ET-tube placement before and after the procedure, and the patient's response.
Preparing for change
Teach your patient and her family that the ET tube is necessary to help her breathe and that changing the tube holder helps keep the tube secure. Explain that you'll inspect her skin and lips while changing the tube holder and ask her cooperation in keeping the tube in place during the procedure.
Perform hand hygiene and put on clean gloves and a face mask. Add eye protection if secretions pose a chance of contamination. Make sure your patient has had a chest X-ray and that you perform the following assessments to confirm proper ET-tube placement:
* Auscultate for equal bilateral breath sounds and look for symmetrical chest expansion.
* Use an end-tidal carbon dioxide detector to confirm proper ET-tube placement.
* Note the numeric mark on the ET tube at the level of the patient's front teeth, nares, or gum line. (You'll refer to this later.)
* Assess the skin around her lips and all around her neck for breakdown, irritation, edema, and signs of infection. The areas touching the tube are vulnerable to breakdown, especially if she has herpetic lesions, burns, or traumatic face injuries.
Applying the tube holder
1. Get a new ET-tube holder and tape. With your patient's ET tube securely held in place, remove the used securement device, as shown.
Keeping the ET tube at the same relative position when it's unsecured is important so it doesn't move deeper or higher in the patient's airway. If possible, have an assistant secure the tube while you change the tube holder.
If you must work alone, have all equipment prepared and within easy reach (including peeling the liner from the adhesive-backed base and trimming the base if necessary for fit). Support the tube and rest the heel of your hand against the patient's jaw or cheek to anchor it before you remove the old tube holder.
2. Peel the liner from the new adhesive-backed base and place the adhesive base horizontally on the skin above your patient's upper lip.
3. Align the tubing channel over the ET tube. Press the neckband onto the Velcro(R) portion of the base and press the tubing channel onto the tube.
4. Using a spiral motion, tightly tape around the channel and the ET tube to at least 1 inch beyond the channel.
5. Draw the ends of the neckband behind your patient's neck and just below her ears. Pull open the Velcro(R) closures on both ends. Crisscross the ends before pressing the Velcro(R) on the outside of the neckband to secure them as shown. (This prevents skin irritation.)
6. Pass one finger between the neckband and your patient's skin to make sure the neckband isn't too tight.
Jan Foster is an assistant professor at Texas Woman's University, Houston, and president of Nursing Inquiry & Intervention, Inc., The Woodlands, Tex.
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