Skill 41

Mouth Care

Unconscious or Debilitated Patients

Unconscious or debilitated patients pose challenges because of their risk for alterations of the oral cavity from the dryness of mucous membranes, the presence of thickened secretions, and the inability to eat or drink. Dryness of the oral mucosa is also caused by mouth breathing and oxygen therapy. Unconscious or debilitated patients are also at risk for aspiration. Although saliva production is decreased, saliva is present and can pool in the back of the oral cavity, which is another contributing factor that places the patient at risk of aspiration. The secretions in the oral cavity change very rapidly to gram-negative pneumonia-producing bacteria if aspiration occurs.

Evaluate the level and frequency of oral care on a daily basis during assessment of the oral cavity. Routine suctioning of the mouth and pharynx is required to manage oral secretions to reduce the risk for aspiration. Chlorhexidine 2% gel or mouth rinse every 12 hours has been shown to effectively prevent ventilator-associated pneumonia (VAP) (Labeau et al., 2011). Research also suggests that toothbrushing provides additional benefit in reducing colonization of dental plaque (Berry et al., 2011).

Delegation Considerations

The skill of providing oral hygiene to an unconscious or debilitated patient can be delegated to nursing assistive personnel (NAP). The nurse must first assess the patient for a gag reflex. The nurse instructs the NAP to:

▪ Properly position patient for mouth care.

▪ Be aware of special precautions such as aspiration precautions.

▪ Use an oral suction catheter for clearing oral secretions.

▪ Report signs of impaired integrity of oral mucosa to the nurse.

▪ Report any bleeding of mucosa or gums, excessive coughing, or choking to the nurse.

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