A practical nurse is preparing to provide oral hygiene for a client who is unresponsive following a severe traumatic brain injury. In what order should the nurse perform the following actions? (Arrange the steps from first to last.)
- 1Place the client in a side-lying position.
- 2Place a towel under the chin and position an emesis basin against the cheek.
- 3Insert a padded tongue blade gently between the back teeth.
- 4Clean the teeth and oral mucosa using a moistened foam swab.
- 5Apply a water-soluble moisturizer to the client's lips.
Answer
The nurse must first place the client in a side-lying position, followed by placing a towel and emesis basin, inserting a padded tongue blade, cleaning the oral mucosa, and finally applying a lip moisturizer.
The correct sequence prioritizes airway safety above all else. Positioning the client laterally ensures fluids drain out of the mouth rather than pooling in the oropharynx, effectively preventing aspiration. Preparation of the environment (towel/basin) follows to maintain hygiene. Opening the mouth safely with a padded tongue blade prevents bite injuries during the cleaning process. The actual cleaning occurs next, and applying lip moisturizer is the final basic care comfort measure.
Step-by-Step Solution
Key Concept
Oral hygiene and aspiration precautions for the unresponsive client