Trinity Valley Community College s1

TRINITY VALLEY COMMUNITY COLLEGE ASSOCIATE DEGREE NURSING RNSG 1216

PROCEDURE GUIDE AND CHECK-OFF SHEET ORAL CARE FOR THE UNCONSCIOUS PATIENT

Oral hygiene is provided to maintain the integrity of the teeth, gums, mucous membranes, and lips. The frequency of performing oral care on the unconscious patient is indicated by the patient’s condition.

Delegation: This procedure may delegated to unlicensed assistive personnel that have proper training. The nurse retains the responsibility of the assessment.

Procedure Scientific Rationale 1. The following equipment is needed for this skill: a. towels b. emesis basin c. oral suction equipment d. tongue blade with soft gauze e. soft toothbrush/toothettes f. toothpaste or equivalent g. water h. 10 ml syringe i. lubricant for lips j. hydrogen peroxide solution (optional) k. gloves l. mouthwash. 2. Remove dentures if present. Allows access to the gums. 3. Turn patient on side-lying/lateral position. Prevents aspiration since gag and swallowing reflexes may not be intact. 4. Maintain functional alignment of neck with Fluid will flow out of the mouth and not back into the pillow. throat. 5. Place towel over patient’s chest. Prevents soiling of gown and linen. 6. Place emesis basin under chin to catch oral Prevents soiling of gown and linen. fluid. 5. Have oral suction available (bulb suction, Oral suctioning may be needed if fluids reach the back of catheter, or yankauer). the throat. Removal of contents will help prevent aspiration. 8. Keep mouth open with a tongue blade covered Foam sponged or gauzed tongue blades should be used with soft gauze padding over the tongue blade. instead of fingers since the bite reflex may be intact. Human bites are painful, dangerous, and may cause infections to the caregiver. 9. Brush teeth, clean tongue and gums, with soft Toothpaste and toothbrush are abrasive in removing toothbrush or tooth-ettes, toothpaste, and debris. Mouthwash reduces halitosis. Brushing the tongue small amounts of water. and gums increases circulation to the areas. 10. Rinse mouth with water and mouthwash (half If teeth and gums have an unusually thick coating, you may & half) with 10 ml syringe; repeat this step as use half strength peroxide and mouthwash mixture. needed. Peroxide is abrasive to healthy tissue but may be used with water in diluted form to debride sordes (dark incrustations on the lips or teeth on patients with prolonged fever) until

201 Procedure Scientific Rationale healthy tissue is apparent.

11. Allow contents to drain into the basin and suction as needed. 12. Replace clean dentures after completion of oral Retains gum shape with denture form for comfort and care. appearance. 13. Apply water-soluble lubricant to the lips. Oxygen can be combustible with oil-based products. Moisture prevents the lips from cracking and bleeding. 14. Document assessment of teeth, gums, and oral All data must be entered in patient’s record. mucosa. 15. Report any abnormal data to the appropriate Any abnormal finding must have a corresponding nursing personnel. action.

N:ADN/ADN Syllabus/CBC Curriculum/Level I/1216/Performance Checklist for Basic Skills - Oral Care for the Unconscious Patient Reviewed 04/16