Personal Hygiene and Grooming
Performing Oral Hygiene for an Unconscious Patient
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Take the Review Test:
Safety
- Assess the patient for the presence or absence of a gag reflex.
- Use Standard Precautions when providing oral care, including wearing clean gloves. Additional precautions requiring other personal protective equipment (PPE) may be necessary, depending on the patient’s condition.
- Do not use your fingers to inspect the mouth of an unconscious or unresponsive patient. Always use a tongue blade to avoid the patient’s reflex to bite down.
- Place the unconscious or unresponsive patient in the Sims’ or side-lying position, with the patient’s head turned to the side and toward the mattress in a dependent position. Raise the head of the bed to at least 30 degrees.
- Protect the patient from choking and aspiration. Follow Aspiration Precautions by using an oral suction catheter to clear oral secretions. The safest technique is to have two nurses provide care: you perform oral care while another nurse or NAP suctions secretions as necessary with a Yankauer suction tip.
- Routine suctioning of the mouth and pharynx is required to manage oral secretions in order to reduce the risk for aspiration.
Equipment
(Roll cursor over items to see labels)
Toothette sponges (or soft pediatric toothbrushes)
Mouthwash or antibacterial solution (i.e. chlorhexidine)
Flouride toothpaste
Tongue blade
Penlight
Oral airway
Yankauer suction catheter
Water soluble lip moisturizer
Water glass with cool water
Towel and washcloth
Emesis basin
Clean gloves
PrintableDelegation
After assessing the patient for a gag reflex, the skill of performing oral care for an unconscious or debilitated patient can be delegated to nursing assistive personnel (NAP). Be sure to inform NAP of the following:
- Discuss proper positioning of the patient for mouth care.
- Explain any special precautions, such as Aspiration Precautions.
- Review the use of an oral suction catheter to clear oral secretions.
- Instruct NAP to report to you any signs of impaired integrity of the oral mucosa.
- Instruct NAP to report to you immediately any bleeding of mucosa or gums, or excessive coughing or choking.
Preparation
- Assess the environment for safety, such as checking the room for spills, making sure equipment is working properly, and ensuring that the bed is in the locked, low position.
- Perform hand hygiene, and apply clean gloves.
- Test for the presence of a gag reflex by placing a tongue blade on the back half of the tongue.
- Inspect the condition of the oral cavity with a tongue blade and penlight.
- Remove gloves and perform hand hygiene.
- Assess the patient’s risk for oral hygiene problems, including the following:
- Dehydration
- Presence of nasogastric or oxygen tubes
- Mouth breathing
- Receiving chemotherapeutic drugs
- Having radiation therapy to the head and/or neck
- Presence of an artificial airway or endotracheal tube
- Having a blood-clotting disorder, such as leukemia or aplastic anemia
- Having had oral surgery or trauma to the mouth
- Aging
- Chemical injury
- Diabetes mellitus
- Assess the patient’s respiration on an ongoing basis.
Follow-up
- Assess the patient for aspiration. If aspiration is suspected, perform the following:
- In order to maintain airway patency, suction the oral airway as secretions accumulate.
- Elevate the head of the bed to facilitate breathing.
- Notify the physician, and prepare the patient for a chest x-ray examination.
- Apply clean gloves, and inspect the oral cavity for cleanliness. Compare your preprocedure and postprocedure findings. Schedule the frequency of oral care based on the patient’s condition. An unconscious or unresponsive patient requires mouth care as often as every 1 to 2 hours.
Documentation
- Record the oral care procedure, including the patient’s ability to cooperate and whether suctioning was necessary.
- Document and report any pertinent observations, such as the presence of a gag reflex and the presence of bleeding gums, dry mucosa, ulcerations, or crusts on the tongue.
- Report any unusual findings to the nurse in charge or to the health care provider.
Review Questions
1. When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what?
Assessing the patient’s gag reflex
Inspecting the patient’s oral cavity- Placing the bed in a flat position
- Connecting the suction equipment
CORRECT. Assessing the patient's gag reflex by placing a tongue blade on the back half of the tongue reduces the risk of choking by determining the patient’s ability to swallow before mouth care is administered.
INCORRECT. The nurse inspects the oral cavity after assessing the patient’s gag reflex.
INCORRECT. The nurse places the bed in a flat position before providing mouth care but after assessing the gag reflex.
INCORRECT. Suction equipment might be needed if the nurse first determines that the patient has an absent or poor gag reflex.
2. What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided?
- To make the oral cavity easily accessible
- To prevent possible musculoskeletal injury
- To reduce plaque buildup in the mouth
- To reduce the risk of aspiration
INCORRECT. Although the side-lying position does allow the nurse to reach the oral cavity easily, accessibility is not the reason this position is used.
INCORRECT. Reducing the risk of musculoskeletal injury is not the reason the side-lying position is used.
INCORRECT. Placement of the patient in the side-lying position does not reduce plaque buildup in the mouth.
CORRECT. An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration.
3. The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient’s mouth?
- Upside down, or with the curve facing up
- Right side up, or with the curve facing down
- With the curve angled toward the patient’s left cheek
- With the curve angled toward the patient’s right cheek
CORRECT. The oral airway should be inserted upside down into the patient’s mouth, and then turned sideways and over the tongue to keep the teeth apart.
INCORRECT. The oral airway should not be inserted right side up, because the curve must fit over the patient’s tongue.
INCORRECT. This approach is incorrect. The curve cannot be angled toward the patient’s cheek.
INCORRECT. This approach is incorrect. The curve cannot be angled toward the patient’s cheek.
4. When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line?
- To give the nurse a firm grip on the brush handle
- To ensure that the bristles reach all tooth surfaces
- To allow the bristles to reach beneath the gum line
- To reduce pressure on sensitive oral tissues
INCORRECT. Holding the toothbrush so that its bristles are at a 45-degree angle does not necessarily ensure a firm grip on the brush handle.
INCORRECT. Holding the toothbrush so that its bristles are at a 45-degree angle does not, by itself, allow the bristles to reach all tooth surfaces.
CORRECT. The toothbrush is held at this angle to allow the bristles to sweep away plaque beneath the gum line.
INCORRECT. Holding the toothbrush so that its bristles are at a 45-degree angle does not necessarily reduce pressure on oral tissues.
5. What must the nurse avoid when brushing the tongue of an unconscious patient?
INCORRECT. Dislodging bacteria so that it can be removed is a primary reason for brushing the tongue.
CORRECT. If the patient has a gag reflex, the nurse must be careful not to stimulate it while brushing the back of the tongue, since gagging could cause aspiration of secretions.
INCORRECT. Moistening the mucosa is a primary reason for brushing the tongue.
INCORRECT. Suction may be used to remove oral secretions and bacteria as the tongue is brushed.
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