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Care of the Intubated Patient (Pediatric & Neonatal) (7.11-P)

Care of the Intubated Patient (Pediatric & Neonatal) (7.11-P) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Pulmonary

7.11-P

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
September 30,
2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 7.11P

Original
Revision

Page
1
of 6

Title: Care of the Intubated Patient (Pediatric
& Neonatal)

I. PURPOSE

To establish the nursing practice standard for the care of the intubated patient to
support and maintain an airway for ventilation for patients with respiratory
compromise and minimize complications.

II. POLICY

A. The Registered Nurse (RN) will ensure the endotracheal tube (ETT) is secure and
is maintained in proper position.
B. The RN will take actions to avoid an unplanned extubation (UE)
C. The RN will ensure adequate patency of the ETT.
D. The RN will adhere to the ventilator associated pneumonia (VAP) prevention
Bundle.
E. The RN will continually monitor, assess and evaluate adequacy of ventilation.

NOTE: For adult information, refer to UWHC Nursing Patient Care Policy 7.11A, Care of
the Intubated Patient (Adult).

III. GENERAL PROCEDURE

A. The nurse in collaboration with the respiratory therapist (RT) will perform
interventions to ensure safety for the intubated patient.
1. The ventilator setting will be checked and documented on the RT
Ventilator Flowsheet in the patient’s clinical record by the RT . The RN
will review ventilator settings at least one time per shift.
2. Ventilator settings will only be adjusted by RT
3. A call light and/or communication tool will be readily available for all
patients capable of using them.
4. An oxygen flow meter, appropriate size mask and resuscitation bag will be
ready at the bedside of all intubated patients. This equipment should be
checked by RT and the nurse at the beginning of each shift.
B. The nurse will ensure the ET tube is secure and in proper position
1. Upon initial intubation, correct placement of the ETT should be confirmed
by auscultation of bilateral breath sounds, assessment of oxygenation, as
well as assessment of color change on an end tidal carbon dioxide
detector.
a. Confirmation of correct tube position should be verified by chest
x-ray. Once correct tube position is confirmed, the cm marking at



Page 2 of 6

the gum or teeth should be documented in the electronic health
record.
i. If cm markings are not visible, measure centimeters from
tooth/gum to the end of the ETT, not including the
connection piece or adapter.
b. The ETT should be secured with an approved commercial tube
holder or by a standard taping process. (see related documents)
c. If there are any changes from the recorded position, this indicates
that the tube is inadequately secured and should be re-secured.
d. If at any time the commercial securement device becomes loose, or
the tape securement is loose, the ETT needs to be resecured
immediately. The commercial securement device needs to be
changed every 7 days or sooner if no longer secure.
2. Assess position and security of tube and skin condition at points of
contact, at least every 4 hours or more frequently if redness or
breakdown is noted.
a. Assessment includes the following:
i. Centimeter marking at the nare, teeth or gum.
ii. The orientation of the tube which is described as center, left
or right.
iii. Condition of the site assessing for areas of skin breakdown.
b. The security of the ETT can be threatened if adhesion is lost
between tape and tube or tube holder and skin, or in agitated
patients.
c. Additional indications for re-securing the ETT are skin or mucus
membrane breakdown, soiled tape moist with mucus secretions or
perspiration.
d. Oral tubes should be secured so that lateral pull from ventilator
tubing does not lead to pressure injury of the lips at the corners of
the mouth.
i. Reposition oral tubes to the opposite side of midline every
time the ETT is resecured. .
ii. Repositioning the ETT will help prevent lip and mucosal
pressure lesions.
3. Securing or re-securing of the ETT tube (see related documents)
a. A minimum of two trained staff must be present for all ETT
securements and re-securements.
b. Re-securement should be done following a standard process for the
commercial tube holder or tape (see related documents)
c. : When securing or re-securing the ETT, be careful to avoid cutting
the pilot balloon which will deflate the ETT cuff. If this happens,
assess the patient’s tolerance and seek medical or anesthesia
assistance.
d. A physician or other person skilled in intubation should be
available for any significant repositioning.





Page 3 of 6

C. Endotracheal Tube Patency (Individualized frequency of suctioning is based on
patient’s clinical condition not on a routine)
1. Open suctioning for ventilated neonatal and pediatric patients
a. Equipment
i. Bedside Suction Information Sheet is provided by RT (see
related document))
ii. Personal protective equipment (PPE) (i.e., sterile gloves,
eye protection and mask)
iii. Appropriately sized sterile disposable suction catheter kit
iv. Wall suction gauge and canister system or portable suction
unit with appropriate settings
• Infants: 60-100 mmHg
• Children: 80-100 mmHg
• Adolescents: 80-120 mmHg

v. Resuscitation bag
vi. Sterile water or saline solution for catheter clearance
b. Procedure
i. Perform hand hygiene according to UWHC Hospital
Administrative Policy 13.08, Hand Hygiene.
ii. Prior to ETT suctioning, suction the oral pharynx.
iii. Validate that suction is ON
iv. Preoxygenation (Patients receiving mechanical ventilation
may need increased levels of oxygen prior to and during the
suctioning procedure.)
v. Open the sterile disposable suction kit. Put sterile gloves
on. The suctioning hand must remain sterile throughout
procedure; the other glove can be clean.
vi. Suction to depth as indicated on Bedside Suction
Information Sheet.
vii. Provide positive pressure breaths between suction passes at
pressure settings of the ventilator.
viii. Clear suction catheter with sterile water or saline.
ix. Repeat as needed to clear secretions
2. Closed in-line device for ventilated neonatal and pediatric patients
(preferred first line method for suctioning)
a. Equipment
i. Bedside Suction Information Sheet (see related document
ii. PPE (clean gloves)
iii. Appropriately sized in-line suction catheter
iv. Wall suction gauge and canister system or portable suction
unit with appropriate settings:
• Infants: 60-100 mmHg
• Children: 80-100 mmHg
• Adolescents: 80-120 mmHg
v. Resuscitation bag
vi. Pink saline lavage vials for catheter clearance



Page 4 of 6


b. Procedure
i. Perform hand hygiene according to UWHC Hospital
Administrative Policy 13.08, Hand Hygiene.
ii. Prior to ETT suctioning, suction the oral pharynx.
iii. Connect suction tubing to in-line device
iv. Preoxygenate (Patients receiving mechanical ventilation
may need increased levels of oxygen prior to and during the
suctioning procedure.)
v. Unlock the Thumb control valve.
vi. Suction to depth as indicated on Bedside Suction
Information Sheet.
• Advance catheter down the ETT to the appropriate
depth per bedside reference sheet and depress
thumb control valve, applying suction and slowly
withdraw catheter until the black tip is visible in
dome. May need multiple passes.
vii. Upon completion of suctioning, assure the black tip
remains visible in dome, irrigate catheter by depressing the
thumb control valve while instilling saline into irrigation
port.
viii. When catheter is clear of secretions, turn and lock thumb
control valve. Remove pink saline vial and cap off port.
ix. The in-line suction will be maintained as a close circuit and
changed by RT every seven (7) days.
D. Adequacy of Ventilation
1. Assess oxygenation, ventilation and acid base balance.
a. Monitor pulse oximetry and end tidal CO2.
b. Assess work of breathing, chest rise, and auscultate breath sounds.
c. Monitor blood gases per provider order
E. Preventing Unplanned Extubation (UE)
1. High risk situations are defined as circumstances that place an intubated
patient at risk for an UE. These situations include but are not limited to the
following:
a. Bedside imaging
b. Bedside procedures (i.e.: central line insertion, weights, surgical
interventions, etc…)
c. Repositioning
d. Holding or kangaroo care
e. Patient transport
2. All high risk situations require two trained staff members to be present for
the duration of the high risk situation. Prior to the high risk situation a
time out in patient care should occur, for staff to assign roles, assuring one
person’s sole responsibility is to watch or hold the ETT
F. Documentation
1. The RN should document the following in the electronic health record
a. Depth of insertion at the gum, teeth, or nare upon intubation, with



Page 5 of 6

assessments, and anytime the ETT is resecured
b. Securement status and condition of surrounding skin with each
assessment
c. Suctioning of the ETT, including amount and description of the
sputum
G. Pediatric and Neonatal Ventilator Associated Pneumonia (VAP) Prevention
1. Refer to the Prevention of Ventilator Associated Pneumonia
Pediatric/Neonatal- Inpatient Clinical Practice Guideline

IV. UWHC CROSS REFERENCES
A. Clinical Practice Guideline- Prevention of Ventilator Associated Pneumonia-
Pediatric/Neonatal
B. Hospital Administrative Policy 13.08, Hand Hygiene
C. Nursing Patient Care Policy 7.11A, Care of the Intubated Patient (Adult)
D. Nursing Patient Care Policy 13.16, Basic Care – Inpatient Pediatrics (Birth-18
years of age)
E. Respiratory Care Services Policy 1.40, Cleaning and Changing of Patient Care
Equipment
F. Respiratory Care Services Policy 1.55, Manual Resuscitation
G. Respiratory Care Services Policy 3.20, Pulse Oximetry Check & Continuous
Monitoring (Includes Ambulating SPO2)
H. Respiratory Care Services Policy 3.43, Placement, Care and Removal of
Endotracheal Tubes

V. REFERENCES

A. Hazinski, M. F. (2012). Nursing care of the critically ill child (3
rd
Ed.). St. Louis,
MO: Mosby Elsevier.
B. Kline-Tilford, A. M., Sorce, L. R., Levin, D. L., Anas, N.G. (2013). Pulmonary
Disorders in Nursing Care of the Critically Ill Child. (3
rd
Ed.) St. Louis, MO:
Elsevier Mosby.
C. Loughead, J. L., Brennan, R. A., DeJuilio, P., Camposeo, V., Wengert, J., &
Cooke, D. (2008). Reducing accidental extubation in neonates. Jt Comm J Qual
Patient Saf, 34(3), 164-70, 125.
D. Marrow, B. M., & Argent, A. C. (2008). A comprehensive review of pediatrics
endotracheal suctioning: effects, indications and clinical practice. Pediatric
Critical Care Medicine, 9(5), 465-477.
E. Spence, K., Gillies, D., & Waterworth, L. (2009). Deep versus shallow suction of
endotracheal tubes in ventilated neonates and young adults (Review). The
Cochrane Collaboration-The Cochrane Library. Issue 4. Retrieved from
http://www.thecochranelibrary.com.
F. Verger, J. T., & Lebet, R. M. (2008). AACN procedure manual for pediatric acute
and critical care. St. Louis, MO: Saunders Elsevier.
G. Verklan, M. T., & Walden, M. (2015). Core curriculum for neonatal intensive
care nursing 5
th
Ed.). St. Louis, MO: Saunders Elsevier.





Page 6 of 6


VI. REVIEWED BY

Clinical Nurse Specialist, NICU
Clinical Nurse Specialist, PICU
Manager, Pediatric Respiratory Care Services
Nursing Patient Care Policy and Procedure Committee, September 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer