The nurse assists the client who is 1 day postoperative after nasal reconstruction with oral care, Which is the most important intervention for the nurse to implement to maintain integrity of the oral cavity?

Question

1. Scrape the tongue to remove thick secretions.
2. Instruct the client to use a fluoride mouthwash.
3. Teach the client to brush the teeth twice daily.
4. Assist the client to maintain adequate hydration.

Answer 1

4
4. The most important intervention for this client to maintain integrity of the oral cavity is to provide adequate hydration because the mouth is a vital component of the body's innate defense against microorganisms. The client cannot breathe through the nose for several days after nasal reconstruction because of edema and nasal packing and the nose is integral to warming and humidifying inhaled air; so, the mouth dries out quickly as the client is forced to mouth breathe. If the mouth becomes dry, the mucous membranes become dry and stick to oral structures, the risk of oral lesions and erosion increases, and the mouth's ability to destroy harmful invaders to the body decreases. An oral care plan for hydration includes humidified oxygen, frequent sips of decaffeinated beverages and water, ice chips, hard candy, and frequent, gentle oral care. The remaining options are part of an oral care plan but are not as effective as maintaining hydration to preserve the oral mucous membranes.
1. Scraping the tongue removes accumulated and dehydrated oral secretions, de-creases the microorganism count in the mouth, and refreshes the client's breath.
2. Fluoride rinses help to maintain strength of tooth enamel.
3. Brushing the teeth twice daily helps to remove plaque and debris and stimulates the gums.