A nurse is providing oral care for a client who is immobile.
Which of the following actions should the nurse take?
A.
Use a stiff toothbrush to clean the client’s teeth.
B.
Turn the client on his side before starting oral care.
C.
Use the thumb and index finger to keep the client’s mouth open.
D.
Apply petroleum jelly to the client’s lips after oral care.
The Correct Answer and Explanation is:
The correct answer is:
B. Turn the client on his side before starting oral care.
Explanation:
When providing oral care for an immobile client, patient safety is the primary concern. Immobile clients, especially those who may be unconscious, sedated, or unable to control their swallowing reflex, are at a high risk for aspiration. Aspiration occurs when saliva or oral debris enters the airway, potentially leading to pneumonia or other respiratory complications.
Turning the client on his side (lateral position) is a critical action to prevent aspiration. This position allows any fluids, such as water, saliva, or cleaning solutions, to drain out of the mouth naturally rather than collecting in the back of the throat. It helps keep the airway clear and reduces the risk of fluid entering the lungs, which could cause aspiration pneumonia—a significant concern in immobile clients.
Why Other Options Are Incorrect:
- A. Use a stiff toothbrush to clean the client’s teeth: This option is incorrect because a stiff toothbrush can damage the client’s gums, especially if they are sensitive or vulnerable due to immobility. A soft-bristled toothbrush is recommended to gently clean the teeth and gums without causing trauma or bleeding.
- C. Use the thumb and index finger to keep the client’s mouth open: This method is inappropriate for keeping the mouth open during oral care. Instead, a padded mouth prop or tongue depressor is recommended to prevent injury. Using fingers can be unsafe, as the client might bite down reflexively, leading to injury for both the nurse and the client.
- D. Apply petroleum jelly to the client’s lips after oral care: While moisturizing the lips is essential, petroleum jelly should not be used. It poses a risk of aspiration if ingested, especially in immobile clients. A water-soluble moisturizer is a safer alternative.
By positioning the client on their side, nurses ensure safer oral care and prevent aspiration, maintaining both oral hygiene and respiratory safety.