An unconscious patient requires mouth care every 2 hours. Before attempting mouth care, the nurse should first do which of the following?
a. Assess the patient for a gag reflex.
b. Position the patient in a prone position.
c. Have an operational suction machine nearby.
d. Retract the upper and lower teeth with a padded tongue blade.
A
If the patient does not have a gag reflex he or she is at an increased risk of aspiration. If no gag reflex is present two people may be needed, one to perform oral care and the other to suction the patient's mouth to prevent aspiration of fluid. The prone position is face down, which is not the position of choice. After you check for the gag reflex, a suction machine is necessary to remove secretions. A padded tongue blade is used to hold the mouth open.
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