Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client’s mouth with a padded tongue blade.
D. Cleaning the client’s mouth and teeth with a toothbrush.
Correct Answer: A. Placing the client on the back with a small pillow under the head.
A helpless client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. Observe the patient for paroxysms of coughing, food dribbling out or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids.
Option B: It may be necessary to suction, so having suction equipment at the bedside is necessary. Consult with a speech therapist to evaluate gag re?exes; assist in teaching alternate swallowing techniques, advise the patient to take smaller boluses of food, and inform the patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated.
Option C: Padded tongue blades are safe to use. Have the patient sit upright, preferably on chair, when eating and drinking; advance diet as tolerated. Prepare for GI feedings through a tube if indicated; elevate the head of bed during feedings, check tube position before feeding, administer feeding slowly, and ensure that the cuff of tracheostomy tube is in?ated (if applicable); monitor and report excessive retained or residual feeding.
Option D: A toothbrush is appropriate to use. Encourage personal hygiene activities as soon as the patient can sit up; select suitable self-care activities that can be carried out with one hand.
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