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Oral care is important not only to prevent dental caries but also to improve the patient`s self-image.
Oral care should be done at least twice a day for ambulatory patients.
Equipment: Toothbrush
Toothpaste Emesis basin Glass with cool water Disposable gloves Towel
ASSESSMENT: Assess patient`s oral cavity and dentition. Look for any caries,sore, or white patches. The
white patches may indicate a fungal infection called thrush. Assess patient`s ability to perform own
care.
NURSING DIAGNOSIS: Determine the related factors for the nursing diagnosis based on the patient`s
current status. Possible nursing diagnoses may include:
Deficient Knowledge
OUTCOME IDENTIFICATION
AND PLANNING: The expected outcome to achieve when performing oral care is that patient`s
mouth and teeth will be clean; the patient will exhibit a positive body image; and the patient will
verbalize the importance of oral care.
IMPLEMENTATION RATIONALE
ACTION
EVALUATION
The expected outcomes are met when the patient receives oral care, experiences little to no
discomfort, states mouth feels refreshed,and demonstrates understanding of reason for proper
oral care.
ASSESSMENT:
Assess the patient`s level of consciousness and overall ability to assist with oral care and
respond to directions. Inspect the patient`s oral cavity and teeth. Look for any caries,sores, or
White patches. The white patches may indicates a fungal infection called thrush. Assess the
patient`s ability to perform care.
NURSING DIAGNOSIS:
Determine the related factors for the nursing diagnosis based on the patient`s current status.
Possible nursing diagnoses may include:
Ineffective Health Maintenance
Impaired Oral Mucous Membrane
Disturbed Body Image
Deficient Knowledge
OUTCOME IDENTIFICATION
AND PLANNING
THE expected outcome to achieve when performing oral care is that the patient`s mouth
and teeth will be clean; the patient will participate as much as possible with oral care; the
patient will demonstrate improvement in body image; and the patient will verbalize an
understanding about the importance of oral care.
IMPLEMENTATION
ACTION
1. Explain procedure to patient.
2. Explanation facilitates cooperation.
3. Perform hand hygiene and don disposable gloves.
4. Hand hygiene and disposable gloves deter the spread of microorganisms.
5. Assemble equipment on overbed table within reach .
6. Organization facilitates performance of task.
7. Provided privacy of patient. Adjust height of bed to a comfortable position. Lower one side
rail and position patient on the side, with head tilted forward. Place towel across patient`s
chest and emesis basin in position under chin.
8. The side-lying position with head forward prevent aspiration of fluid into lungs. Towel and
emesis basin protects patient from dampness.
9. Open patient`s mouth and gently insert a padded tongue blade between back molar if
necessary.
10. A padded tongue blade keeps the mouth open for easier cleaning and prevents the patient
from biting the nurse`s fingers.
11. If teeth are present,brush carefully with toothbrush and paste. Remove dentures if and
clean before replacing. Use a toothtte or gauze –padded tongue blade moistened with
normal saline or dilute mouthwash solution to gently cleanse gums, mucous
membranes,and tongue.
12. Toothbrush or padded blade provides friction necessary to clean areas where plaque and
tartar accumulate. Hydrogen peroxide is considered an irritant and is not longer
recommended.the mechanical action of cleansing is more important than the solution used.
13. Use gauze –padded tongue blade dipped in mouthwash solution to rinse the oral cavity. If
desired, insert rubber tip of the irrigating syringe into patient`s mouth and rinse gently with
a small amount of water. Position patient`s head to allow for return of water or use suction
apparatus to remove the water from oral cavity.
14. Rinsing helps cleanse debris from the mouth. Forcefull irrigation may cause aspiration.
15. Apply lubricant to patient`s lips.
16. This prevents drying and cracking of lips.
17. Remove equipment and return patient to a position of comfort. Raise side rail and lower
bed. Record any unusual bleeding or inflammation.
18. This promotes oral hygiene and provides for oral assessment. Raised side rail and lowered
bed maintain patient safety.
19. Perform hand hygiene.
20. Hand hygiene deters the spread of microorganisms.
EVALUATION:
The expected outcomes are met when the patient`s oral cavity is clean and patient states or
demonstrates improved body image. In addition, the patient verbalizes a basis understanding of
the need for oral care if alert and oriented.
Patient begins to cough and gag during oral care: Stop performing oral care. Assist patient onto
side and remove secretion from mouth with suction.
Patient begins to bite on padded tonque blade. Do not jerk tonque blade out. Wait for patient
to relax mouth before removing padded tongue blade.
SPECIAL CONSIDERATIONS
A patient receiving chemotherapy medication may have bleeding gums and extremely sensitive
mucous membranes. Use a soft sponge toothette for cleaning, or substitute a salt water rinse(.5
teaspoon salt I 1cup of warm water) for brushing of teeth.