Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur

College of Nursing

NURSING PROCEDURE: Retaping an Endotracheal Tube

STEPS 3 2 1

1. Explain procedure to patient and reassure him or her that you will
interrupt procedure if the patient indicates respiratory difficulty.
Administer pain medication and or sedation before attempting to re-
tape endotracheal tube.

2. Gather equipment and provide privacy for patient.

3. Perform hand hygiene.

4. Suction patient as previous described in Skill 14-16.

5. Cut tape. Use enough tape to go around patient’s neck to the mouth
plus 8 inches.

6. Cut another piece of tape long enough to reach from one jaw,
around the backside of the neck to the other jaw. Match the tapes’
adhesive sides together in the center of the longer piece of tape.

7. Take one 3-mL syringe and wrap the sticky tape around the syringe
until the non-sticky area is reached. Do this for the other side as well.

8. Take one 3-mL syringes and pass it under the patient’s neck so that
there is a 3-mL syringe on either side of the patient’s head.

9. Don disposable gloves. (Have assistant don gloves as well.)

10. Provide oral care, including suctioning the oral cavity.

11. Begin to unwrap old tape from around the endotracheal tube.
After one side is unwrapped, have assistant hold tube to offer
stabilization. Instruct assistant to hold tube as close to the lips or nares
as possible.

12. After tape is removed, have assistant gently and slowly move
endotracheal tube (if orally intubated) to the other side of the mouth.
Assess mouth for any skin breakdown. Before applying new tape, make
sure that markings on endotracheal tube are at same spot as when re-
taping began.

13. Remove old tape from cheeks and side of face. Wash area to
remove old tape and benzoin. If patient is male, consider shaving
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur

College of Nursing

cheeks. Pat cheeks dry with a 4”x4” gauze.

14. Consider applying benzoin. Unroll one side of the tape. Ensure that
non-sticky part of tape remains behind patient’s neck while pulling
firmly on the tape. Place adhesive portion of tape snugly against
patient’s cheek. Split the tape in half from the end to the corner of the
mouth.

15. Wrap the top half-piece of split tape around the tube in one
direction and then secure it across the upper lip. Wrap the bottom
half-piece around the endotracheal tube in the opposite direction and
secure the tape beneath the lower lip. Fold over tab on end of tape.

16. Unwrap second piece of tape. Split to corner of the mouth.

Reversing the order, place bottom piece of tape on the top lip. Wrap
to piece of tape in a counterclockwise manner and secure to the lower
lip. Fold over tab on end of tape.

17. Auscultating lung sounds. Assess for cyanosis, oxygen saturation,

chest symmetry, and stableness of endotracheal tube. Again check to
ensure that the tube is at the correct depth.

18. If endotracheal tube is cuffed, check pressure of balloon by

attaching a hand-help pressure gauge to the pilot balloon of the
endotracheal tube.

19. Remove gloves and perform hand hygiene.

20. Document the procedure, including the depth of the endotracheal

tube from teeth or lips; anount, consistency, and color secretions
suctioned; presence of any pressure ulcers; lung sound; oxygen
saturation; skin color; cuff pressure; and chest symmetry.

___________________ _______________________
Student’s Name Clinical Instructor

LEGEND:

3 - Mastered
2 - Performed
1 - Not Performed