Final answer:
The correct nursing action for endotracheal tube care is to regularly rotate the tube to the opposite side of the mouth, perform oral cavity inspections, securely tape the tube without folding the tape lengthwise, and importantly, use a two-person technique for safe and effective management.
Step-by-step explanation:
Performing endotracheal tube care is vital for the maintenance of an open airway in a patient, especially post-surgery when muscles necessary for respiration are recuperating from anesthesia. The appropriate nursing action during this procedure is to rotate the endotracheal tube to the opposite side of the mouth to prevent pressure sores. It is recommended to perform the rotation regularly, not only if a lesion has developed. Inspecting the oral cavity using tongue blades is also common to check for sores or lesions. The tube should be secured properly, without folding the tape lengthwise, as this could cause adherence to the patient's hair or skin. Additionally, it is crucial that this procedure is carried out with two people for safety and accuracy, ensuring that the tube position is maintained and the patient's neck and head are not unduly manipulated during the care.
The procedure must be done meticulously, with one person stabilizing the patient's head and the tube, while the other performs the care tasks. This dual approach minimizes the risk of accidental extubation or discomfort to the patient. Additionally, during procedures, the health care team should always follow protocols such as in-use tests, which monitor the correct use of disinfectants, and adhere to aseptic techniques while handling equipment and performing surgical tasks. Furthermore, communication and collaboration are paramount as the team should review important details aloud, emphasizing the importance of following checklists and protocols to enhance patient safety.