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COLLEGE OF NURSING
CLINICAL PERFORMANCE CHECKLIST
RETURN DEMONSTRATION
0RAL CARE FOR UNCONSCIOUS PATIENT
NAME: DATE:
YEAR & SECTION: GROUP # RATING:
RATING SCALE:

REMARKS

ASSESSMENT:
1. Identify patient using at least two identifiers.
2. Assess environment for safety
3. Perform hand hygiene and apply clean gloves
4. Assess for presence of gag reflex
5. Inspect condition of oral cavity
6. Remove gloves, performed hand hygiene
7. Assess patient’s risk for oral hygiene problems
8. Assess patient’s respirations or oxygen saturation

REMARKS

PLANNING:
1. Identify expected outcomes
2. Gather equipment and supplies:
a. waterproof
b. towel
c. emesis basin
d. mouthwash solution
e. two cups
f. three oral swabs
g. padded tongue blade
h. lip balm
3. Explained procedure to patient and family
 REMARKS

IMPLEMENTATION:
1. Provide privacy, Perform hand hygiene and apply clean gloves
2. Place towel on over-bed table, arranged equipment, turned on
sunction machine and connected tubing if necessary.
3. Raise bed to appropriate height, lower side rail and positioned
patient appropriately on his/her right side and place pillow
behind her back
4. Always assume that the unconscious resident can hear you
(always talk to him and let him know what's happening). Introduce
yourself to the patient and state that you will do oral care to
him/her
5. Elevate the head of the bed a little bit.
6. Place a towel under patient’s face. Remove denture if there is
presence of denture. Place an emesis basin near patient’s chin
and under the mouth
7. Oral care:
a. Start the oral care by using a solution of one part
mouthwash to three parts water
b. Use the first oral swab with mouthwash solution to
clean the outside of the teeth and inside of the cheeks (making
sure to insert the oral swab in her mouth) and place the used
oral swab in the emesis basin after using
c. Place padded tongue blade in between patient’s teeth
to hold mouth open ( if the mouth cannot be opened on its
own)
d. Use the next oral swab with mouthwash solution to clean
the inside of patient’s teeth, the tongue and the roof of the
mouth. Place the used oral swab in the emesis basin.
e. After the mouth is clean, use the last oral swab with water
in order to wipe around the entire mouth and to help rinse
the excess mouthwash . Place the used oral swab in the
emesis basin.
8. Remove the emesis basin
9. Use the towel to dry patient’s face
10. The last step will be to apply lip balm, as long as patient is not
on oxygen inhalation therapy (don't use petroleum-based
products to patients with oxygen inhalation therapy because
oxygen is combustible)
11. Clean up the supplies and remove the towel and place the
towel in the laundry hamper
12. Inform patient that procedure was completed , returned
 patient to proper place and position head of the bed back
down to 30 degrees. Leave call light in reach.
13. Removed and disposed gloves in proper receptacle, performed
hand hygiene.

REMARKS
EVALUATION:
1. Applied clean gloves, inspected oral cavity.
2. Asked caregiver to explain how to prevent choking while
providing mouth care
3. Identified expected outcomes

REMARKS
RECORDING AND REPORTING:
1. Recorded procedure, appearance of oral cavity, presence of
gag reflex, and patient’s response in appropriate log.
2. Documented evaluation of patient’s learning.
3. Reported unusual findings to nurse in charge or health care
provider.

REMARKS:
Correctly done ✓
NOT DONE- X
Incorrectly done-INC

SCORING:
Correctly done procedures = 100
1-2 Incorrectly done/ Not done step/s = 95
3-5 Incorrectly done/ Not done steps = 90
6-10 Incorrectly done/ Not done steps = 85
>10 Incorrectly done/ Not done steps = 75

COMMENTS/RECOMMENDATIONS:______________________________________________________________
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