The client has an endotracheal tube and is unresponsive to painful stimuli. Which should the nurse implement while providing oral care?

Question

1. Use suction to remove oral secretions.
2. Test the gag reflex with squirts of water.
3. Clean the teeth with a medium toothbrush.
4. Prevent client toothbrush biting with airway.

Answer 1

1
1 and 2. Oral care is safely provided to clients without a gag reflex by using suction. As secretions build from brushing the teeth and rinsing, the nurse suctions secretions with a clean, blunt-tipped suction catheter because suctioning helps to prevent fluid buildup in the trachea. Any fluid buildup can lead to aspiration.
3. Everyone's teeth should be cleaned with a soft toothbrush to remove debris and plaque but to prevent erosion of the teeth and gums.
4. The endotracheal tube (ET) is the client's airway. If the client is biting the ET, the ventilator settings can need to be changed or the client's condition is changing. The ventilator's pressure alarm will sound if the client bites the tube; however, the nurse leaves the alarm on to prevent client injury. An airway is used to prevent the client from biting the tube.