Steps Rationale: Providing Oral Care (For The Unconscious Client)

Providing Oral Care (for the Unconscious Client)
Purposes:
- To maintain the intactness and health of the lips, tongue and mucous membranes of the mouth
- To prevent oral infections
- To clean and moisten the membranes of the mouth and lips
STEPS RATIONALE
1. Assess
 Inspect lips, gums, oral mucosa and This will help the nurse to know the right and proper
tongue for deviations from normal performance of giving oral care to the client
 Identify presence of gum problems
such as tooth caries, halitosis, To avoid doing procedures that are contraindicated
gingivitis or loose or broken teeth for the client
 Forgag reflex, if necessary
2. Assemble equipment:
 Towel For the organization of performance as well as to
 Curve Basin save time and effort.
 Disposable clean gloves
 Bite-block to hold the mouth open and
teeth apart
 Toothbrush
 Cup of tepid water
 Denture cleaner
 Tissue or piece of gauze to remove
dentures
 Denture container as needed
 Mouthwash
 Rubber-tipped bulb syringe
 Suction catheter with suction
apparatus, if aspirationis concern
 Foam swabs and cleaning solution for
cleaning the mucous membrane
 Water-soluble lip moisturiser
Procedure
1. Introduce yourself and verify client’s identity. So the client will be comfortable or at ease while you
Explain what are you going to do, why is it are performing the procedure.
necessary and how the client can cooperate Promotes client cooperation
2. Perform hand hygiene To prevent the spread of microorganisms
3. Provide client privacy For the client’s comfort
4. Prepare the client

a. In this position, the saliva automatically
a. Position the unconscious client in a side
runs out by gravity rather than being aspiratedintothe
lying position, with the head of the bed
lungs. This position is chosen for the
lowered
unconsciousclient receiving mouth care.
b. Place the towel under the client’s chin
c. Place the curved basin against the client’s
If the client’s head cannot be lowered, turn it to one
chin and lower cheek to receive the fluid from
side so that the fluid will readily run out of the mouth
the mouth
or pool in the side ofthe mouth, where it can be
d. Put on gloves
suctioned.
5. Clean the teeth, and rinse the mouth.
a. If the client has the natural teeth, brush the
teeth as described in the skill: Brushing and
flossing teeth. Brush carefully to avoid
injuring the gums. If the client has an artificial
teeth, clean them as described in the
variation component of the skill: brushing and
flossing teeth.
b. Rinse the client’s mouth by drawing about b. If the solution is injected with force, some of it may
10ml of water or alcohol-free mouthwash into flow down the client’s throat and be aspirated into
the syringe and injecting it gently into each the lungs
side of the mouth
c. Watch carefully to make sure that all the c. Fluid remaining in the mouth may be aspirated into
rinsing solution has run out of the mouth into the lungs.
the basin. If not, suction the fluid from the
mouth.
d. Repeat rinsing until the mouth is free of
dentifrice
6. Inspect and clean the oral tissues.
a. If the tissues appear dry or unclean, clean them

with the foam swabs or gauze and cleaning solution
following agency policy.
b. Use a moistened foam swab to wipe the mucous b. To prevent the transfer of microorganisms from
membrane of one cheek. Discard the swab in a one area to another.
wastecontainer; use a fresh one to clean the next
area.
c. Clean all mouth tissues in an orderly progression,

using separate applicators: the cheeks, roof of the
mouth, base of the mouth, and tongue.
d. Observe the tissues closely for inflammation and

dryness.
e. Rinse the client’s mouth as described in step 5.
f. Remove and discard the gloves

7. Ensure client comfort.
a. Remove the basin, and dry around the client’s
mouthwith the towel. Replace artificial dentures, if
indicated.
b. Lubrication prevents cracking and subsequent
b. Lubricate the client’s lips with water-soluble
infection.
moisturizer.
c. Prevent spread of microorganisms
c. Remove and discard gloves. Perform hand
hygiene.
8. Document:
a. Assessment of the teeth, tongue, gums, and oral
mucosa.
b. Any problems such as sores orinflammation and
swelling of the gums.

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Providing Oral Care (for the Unconscious Client)

- To prevent oral infections

- To clean and moisten the membranes of the mouth and lips

4. Prepare the client

a. If the tissues appear dry or unclean, clean them

c. Clean all mouth tissues in an orderly progression,

d. Observe the tissues closely for inflammation and

e. Rinse the client’s mouth as described in step 5.

f. Remove and discard the gloves

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