A practical nurse is providing oral care to a client who is unconscious and unable to swallow. Arrange the following nursing actions in the correct chronological sequence to ensure client safety and hygiene. (Place the first action at the top and the last action at the bottom.)
- 1Position the client in a side-lying or lateral position with the head of the bed flat or slightly elevated.
- 2Place a towel under the client's chin and position an emesis basin against the dependent cheek.
- 3Gently separate the client's upper and lower teeth using a padded tongue blade.
- 4Clean the teeth, gums, and tongue using a moistened sponge swab.
- 5Apply a water-soluble lubricant to the client's lips.
Answer
The correct sequence begins with protecting the airway by positioning the client in a side-lying position. Next, the nurse places a towel and emesis basin to catch fluids. The mouth is then safely opened using a padded tongue blade, followed by cleaning the oral cavity with a moistened sponge swab. Finally, the nurse applies a water-soluble lubricant to the client's lips.
Safety is the highest clinical priority when providing care to an unconscious client who has lost their protective swallow and gag reflexes. The nurse must first secure the airway by placing the client in a side-lying position to prevent aspiration. Once the airway is protected, the nurse prepares the immediate environment for cleanliness. The mouth is safely accessed using appropriate equipment (a padded tongue blade) to prevent injury, the hygiene is performed, and finally, comfort measures (lubricant) are applied to the lips.
Step-by-Step Solution
Key Concept
Oral Care for the Unconscious Client