Definition
Performing oral care for an unconscious patient is a critical nursing procedure that helps prevent aspiration, infection, and mucosal breakdown. Because the patient cannot protect their own airway or perform self-care, this task requires meticulous technique and safety precautions.
Purposes
- To maintain integrity of the lips, tongue, and mucous membrane of the mouth.
- To prevent and treat oral infection.
- To clean and moisturize oral mucous membrane.
- To stimulate salivation.
- To prevent dental caries and tooth decay.
- To prevent halitosis.
Articles
- Small mackintosh and face towel
- Artery forceps.
- Dissecting forceps/thumb forceps
- Small bowl with mouthwash solution or normal saline.
- Kidney tray.
- Emollient.
- Tongue depressor.
- Clean gloves.
- Cotton applicator.
- Small jug with plain water.
- Mouth gag.
- Suction apparatus.
- Square gauze piece (2″x2″)
Procedure
| NURSING ACTIONS | RATIONALE | |
| 1. | Before procedure Assess patient’s oral hygiene. | Certain conditions, such as coated tongue, ulceration/red dry swollen tongue, halitosis, immunosuppressed patients with diabetes mellitus etc., may require frequent oral care. |
| 2. | Test for the presence of gag reflex by placing tongue blade on back half of tongue. | Reveals whether the patient is at risk of aspiration. |
| 3. | Check the doctor’s orders for specific precautions regarding the movement and positioning of patient. | Prevents injury to patient. |
| 4. | Explain the procedure to patient and/or relatives. | Unconscious patients may retain the ability to hear. |
| 5. | During procedures Pull curtains. | Provides privacy. |
| 6. | Raise bed to comfortable working level and arrange articles by bedside. | Use of good body mechanics prevents fatigue. |
| 7. | Position the patient on side, head turned toward you. | Allows secretions to drain from mouth instead of collecting in back of pharynx and thus preventing aspiration. |
| 8. | Place towel and mackintosh under the patient’s head and spread one towel over chest and an emesis basin under the chin. | Collects saliva that may drool from the mouth and prevents soiling bed. |
| 9. | Raise side rails of bed on both sides. | Prevents the patient from falling. |
| 10. | Wash hands and don gloves. | Reduces transfer of microorganisms. |
| 11. | Lower the side rails on the working side. | Use of good body mechanics prevents fatigue. |
| 12. | Do not pour water into the mouth of an unconscious patient. | Prevents aspiration of fluid into the lungs because of poor gag reflux. |
| 13. | Separate the upper and lower teeth with padded tongue depressor by inserting it quickly and gently if required. | Provides access to oral cavity. |
| 14. | Take gauze piece with the dissecting forceps. | |
| 15. | Wrap the gauze piece around the artery forceps covering its tip. Moisten the gauze piece with normal saline or dip in the cleaning agent. | Covering tip of forceps prevents injury to the mucous membrane and gums. |
| 16. | Swab each tooth gently but firmly and clean all the sides of the tooth. Clean chewing surface first and then inner and outer surface from gum to crown. | Ensures thorough cleaning and prevents injury to the oral mucous membrane and gums. |
| 17. | Clean lower teeth on both sides followed by upper teeth on both sides. | |
| 18. | Gently swab the roof of the mouth, gums, and inner side of cheeks. | |
| 19. | Clean the tongue from back to front using artery forceps covered with gauze. | Ensures thorough cleaning of the tongue. |
| 20. | Clean the teeth and tongue in similar way using plain water. | Ensures thorough removal of dentifrice or cleaning agent which may cause unpleasant taste. |
| 21. | Apply emollient to the lips using cotton applicators. | Lubricates the lips to prevent drying and cracking. |
| 22. | Position the patient in a comfortable position. Raise side rails, lower bed. | |
| 23. | After procedure: Replace all the articles after discarding the waste, remove gloves, discard it, and wash hands. | Prevents transfer of microorganisms. |
| 24. | Record date, time, solution used, condition of mouth, and any abnormalities, such as bleeding/inflammation. |
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
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