LERT
If the patient has an impaired gag reflex, determine the type of suction apparatus needed at the bedside to protect the airway against aspiration.
Never place fingers into the mouth of an unconscious or debilitated patient. The normal response is to bite down.
Perform hand hygiene before patient contact.Verify the correct patient using two identifiers.Provide privacy for the patient.Explain the procedure to the patient, even if he or she is unconscious.Place paper towels on the over-bed table, and arrange supplies.If needed, turn on suction machine, and connect tubing to suction catheter.Raise bed to appropriate height for the nurse; lower side rail.Unless contraindicated, position the patient on side (Sims position) with head turned well toward dependent side and head of bed lowered.Place a towel under the patient’s head and an emesis basin under the chin.Perform hand hygiene and don gloves while remaining at the bedside.Remove the patient’s dentures or partial plates, if present.Insert an oral airway if the patient is unable to cooperate. Insert it when the patient is relaxed, if possible. Insert it upside down, then turn it sideways and position it over the tongue to keep the teeth apart. Do not use force.Clean the mouth/teeth using a small, soft-bristle toothbrush moistened in water if the patient can tolerate brushing. Use a water-moistened foam stick applicator if the patient has sensitive gums (Figure 1).Apply toothpaste or use antiinfective solution first to loosen crusts.Clean chewing and inner tooth surfaces first, outer surfaces next, using an up-and-down gentle motion.Use toothbrush or foam stick applicator to clean roof of mouth, gums, and inside of cheeks. Gently brush tongue but avoid stimulating gag reflex.Rinse with water and repeat as needed.Moisten toothbrush with antimicrobial mouth rinse and cleanse oral cavity, ensuring contact of the antimicrobial rinse with all oral cavity structures.Repeat antimicrobial rinsing several times if needed.Use toothbrush or foam stick applicator to apply water-based mouth moisturizer. Do not use lemon and glycerin swabs.Suction secretions as they accumulate, if necessary.Apply a thin layer of water-soluble moisturizer to the patient’s lips (Figure 2Inform the patient that the procedure is completed.Reposition the patient comfortably; return the bed and side rail to original positions.Clean equipment and return it to its proper place.Report any unusual findings to the practitioner.Assess, treat, and reassess pain.Discard supplies, remove gloves, and perform hand hygiene.Document the procedure in the patient’s record
LERTถ้าผู้ป่วยมีการสะท้อนความปิดปาก กำหนดชนิดของเครื่องดูดที่จำเป็นสำหรับข้างเตียงเพื่อป้องกันสินค้าจากความใฝ่ฝันไม่เคยใส่นิ้วมือเข้าไปในปากของผู้ป่วยมีสติ หรือ debilitated ตอบปกติจะกัดลงPerform hand hygiene before patient contact.Verify the correct patient using two identifiers.Provide privacy for the patient.Explain the procedure to the patient, even if he or she is unconscious.Place paper towels on the over-bed table, and arrange supplies.If needed, turn on suction machine, and connect tubing to suction catheter.Raise bed to appropriate height for the nurse; lower side rail.Unless contraindicated, position the patient on side (Sims position) with head turned well toward dependent side and head of bed lowered.Place a towel under the patient’s head and an emesis basin under the chin.Perform hand hygiene and don gloves while remaining at the bedside.Remove the patient’s dentures or partial plates, if present.Insert an oral airway if the patient is unable to cooperate. Insert it when the patient is relaxed, if possible. Insert it upside down, then turn it sideways and position it over the tongue to keep the teeth apart. Do not use force.Clean the mouth/teeth using a small, soft-bristle toothbrush moistened in water if the patient can tolerate brushing. Use a water-moistened foam stick applicator if the patient has sensitive gums (Figure 1).Apply toothpaste or use antiinfective solution first to loosen crusts.Clean chewing and inner tooth surfaces first, outer surfaces next, using an up-and-down gentle motion.Use toothbrush or foam stick applicator to clean roof of mouth, gums, and inside of cheeks. Gently brush tongue but avoid stimulating gag reflex.Rinse with water and repeat as needed.Moisten toothbrush with antimicrobial mouth rinse and cleanse oral cavity, ensuring contact of the antimicrobial rinse with all oral cavity structures.Repeat antimicrobial rinsing several times if needed.Use toothbrush or foam stick applicator to apply water-based mouth moisturizer. Do not use lemon and glycerin swabs.Suction secretions as they accumulate, if necessary.Apply a thin layer of water-soluble moisturizer to the patient’s lips (Figure 2Inform the patient that the procedure is completed.Reposition the patient comfortably; return the bed and side rail to original positions.Clean equipment and return it to its proper place.Report any unusual findings to the practitioner.Assess, treat, and reassess pain.Discard supplies, remove gloves, and perform hand hygiene.Document the procedure in the patient’s record
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