ORAL HYGIENE (UNCONSCIOUS)

DEFINITION

care of the teeth, gums, lips and tongue of an unconscious or debilitated patient

ASSESSMENT

1. Assess condition of patient's oral cavity, teeth, gums and mouth.

2. Assess for color, lesions, tenderness, inflammation, intactness of teeth and degree of

moisture or dryness of the oral cavity.

3. Observe the external and internal lips.

4. Assess the palate (roof and floor of mouth) and inspect under the tongue.

5. Assess the entire oral mucosa, noting the inside of the nasopharyngeal area.

6. Observe the tongue, note tip, cides, back position and underside.

OBJECTIVES

1. To remove plaque and bacteria producing agents from the oral cavity

2. To allow the nurse to assess the patient's oral health status, knowledge and routine of oral

care

3. To decrease the possibility of irritation or infection of the oral cavity and prevent sore

formation

4. To refresh and provide comfort to the patient

5. To remove unpleasant tastes and odors from the oral cavity thereby preventing bad breath

(Halitosis)

6. To provide teaching when appropriate

EQUIPMENT

1. Gloves
2. Soft toothbrush or sponge toothette/Cotton applicator
3. Tongue blade padded with a 4 x 4 gauze sponge
4. Water, mouthwash or hydrogen peroxide (H,02)
5. Towel
6. Water-soluble lubricant for lips
7. Suction catheter with suction apparatus (optional)
8. Emesis basin

SPECIAL CONSIDERATIONS

1. Suction apparatus or bulb should be available at bedside for emergency use.

2. If mouthwash is used, always rinse the mouth with water following steps as in cleaning to
3. avoid mouth irritations.
4. A patient receiving chemotherapy medication may have bleeding gums and extremely
5. sensitive mucous membranes. Use a soft sponge toothette for cleaning or substitute a
 ORAL HYGIENE (UNCONSCIOUS)
6. salt-water rinse (1/2 teaspoon salt in one (1) cup of warm water) for brushing of teeth.
EVALUATION
1. Teeth are free of plaque.
2. Mucosa is moist, intact and has a uniform color.
3. Tongue is well hydrated as well as the lips are smooth and hydrated.
4. Bacteria producing agent is removed from oral cavity thereby preventing halitosis.
5. Client experiences no oral discomfort.
STEPS
1. Gather equipment needed at the bedside
2. Explain the procedure to the client or
significant others.
3. Wash hands and put on gloves.
4. Raise head of bed to a comfortable height.
Lower the near side rail. Turn the client on the
side towards you, with the client's head tilted
down toward the mattress.
5. Place a towel and emesis basin under the
client's chin. Have suction catheter and
apparatus available if needed.
6. Open client's mouth and insert the padded
tongue blade toward the back molar area.
Never insert your fingers into the client's
mouth.
7. Dip a toothette sponge/soft toothbrush/cotton
applicator or another padded tongue blade in
water, mouthwash, or diluted hydrogen
peroxide. Move it back and forth gently across
the client's teeth and chewing areas. Cleanse
the roof of the mouth and the inner check area.
Do not use toothpaste.
8. Rinse the areas, using a clean toothette/cotton
applicator or padded tongue blade moistened
in water. Suction any drainage if necessary.
9. Apply water-soluble lubricant or moisturizer to
the client's lips
10. Reposition the client. Lower the bed and raise
the side rail again.
11. Discard any contaminated items in biohazard
bag.
12. Remove gloves and wash your hands.
13. Document assessments on the heath record.
RATIONALE
Organization facilitates accurate skill
performance
Allows debilitated client to anticipate
procedure without anxiety; unconscious client
may retain ability to hear. Relaxes patient.
Reduces transmission of microorganisms;
gloves prevent contact with
microorganisms in blood or saliva.
Proper positioning prevents back strain
Tilting the head downward encourages fluid
to drain
The towel protects the client and the bed.
The emesis basin and suction equipment
facilitate drainage from the client's mouth.
The tongue blade assists in keeping the
client's mouth open. As a reflex
mechanism, the client may bite down if
fingers are placed in his or her mouth.
Friction cleanses the teeth. Cleaning
solutions aid in removing residue on the
client's teeth and in softening encrusted
areas.
Toothpaste may foam and cause aspiration
Rinsing or suctioning removes cleaning
solution and debris
Applying lubricant prevent lips from drying
or cracking
Repositioning with the bed at the proper
height and side rails raised provides for the
client's comfort and safety.
Promote proper disposal of contaminated
materials.
Hand washing prevents the spread of
infection.
Documentation provides communication
and coordination of care.
ORAL HYGIENE (UNCONSCIOUS)