The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client’s daily care?
A. Assess the oral cavity each time mouth care is given and record observations.
B. Use a soft toothbrush to brush the client’s teeth after each meal.
C. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours.
D. Rinse the client’s mouth with mouthwash several times a day.
Correct Answer: B. Use a soft toothbrush to brush the client’s teeth after each meal.
A soft toothbrush should be used to brush the client’s teeth after each meal and more often as needed. Mechanical cleaning is necessary to maintain oral health, simulate gingiva, and remove plaque. Gently brush teeth in circular motions at a 45-degree angle to the gum line. Brush for 1-2 minutes to remove plaque build-up.
Option A: Assessing the oral cavity and recording observations is the responsibility of the nurse, not the nursing assistant. Inspect the patient’s oral cavity (lips, gums, teeth, tongue, inside cheeks, and mucosa of floor and roof of the mouth) for any sign of dryness, edema, redness, bleeding, or other debris.
Option C: Swabbing with a safe foam applicator does not provide enough friction to clean the mouth. In a comatose patient, use an Asepto syringe or irrigating bulb without a needle to rinse the oral cavity. Swab or use oral suction to remove pooled secretions
Option D: Mouthwash can be a drying irritant and is not recommended for frequent use. Use 0.05% Cetylpyridinium Chloride (antifungal and antibacterial) containing mouthwash to reduce the risk of infection and to remove plaque.
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