The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?
a. Insert an oral airway.
b. Place the patient in a flat, supine position.
c. Use undiluted hydrogen peroxide as a cleaner.
d. Quickly proceed while not talking to the patient.
ANS: A
If the patient is uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, and then turn the airway sideways and over the tongue to keep the teeth apart. Do not use force. Position the patient on his or her side or turn the head to allow for drainage. Placing the patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is irritating to mucosa. Even though the patient is debilitated, explain the steps of mouth care and the sensations that he or she will feel. Also tell the patient when the procedure is completed.
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