The patient has an endotracheal tube (ET) and is unresponsive to painful stimuli. Which action should the nurse implement while providing oral care?

Question

a. Use suction to remove oral secretions.
b. Test the gag reflex with squirts of water.
c. Clean the teeth with a medium toothbrush.
d. Prevent patient toothbrush biting with an airway.

Answer 1

A
Oral care is safely provided to patients without a gag reflex by using suction. As secretions build from brushing the teeth and rinsing, the nurse suctions them with a clean, blunt-tipped suction catheter because suctioning helps to prevent fluid buildup in the trachea, which can lead to aspi-ration. The gag reflex is not tested when a patient has an ET and is unresponsive to painful sti-muli. A soft toothbrush or toothette is preferred for cleaning teeth. The ET is the patient's airway. If the patient is biting the ET, the ventilator settings need to be changed, or the patient's condi-tion is changing. The pressure alarm on the ventilator will sound if the patient bites the tube; however, the nurse leaves the alarm on to prevent patient injury. An airway is used to prevent the patient from biting the tube.