FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

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Fundamental of Nursing Procedure Manual
Care Action Rationale
7. Place the mackintosh and towel on the neck to
chest.
8. Put the kidney tray over the towel and
mackintosh under the chin.(Fig. 18)
9. Inspect oral cavity:
1) Inspect whole the oral cavity, such as teeth,
gums, mucosa and tongue, with the aid of
gauze-padded tongue depressor and torch.
2) Take notes if you find any abnormalities, e.g.,
bleeding, swollen, ulcers, etc.
10. Clean oral surfaces: (Fig.19)
1) Ask the client to open the mouth and insert the
padded tong depressor gently from the angle of
mouth toward the back molar area. You never use
your fingers to open the client’s mouth.
2) Clean the client’s teeth from incisors to molars
using up and down movements from gums to
crown.
3) Clean oral cavity from proximal to distal, outer
to inner parts, using cotton ball for each stroke.
The towel and mackintosh protect the client and
bed from soakage.
It facilitates drainage from the client’s mouth.
Comprehensive assessment is essential to
determine individual needs.
Some clients with anemia, immunosuppression,
diabetes, renal impairment, epilepsy and taking
steroids should be paid attention to oral condition.
They may have complication in oral cavity.
The tong depressor assists in keeping the client’s
mouth open. As a reflex mechanism, the client
may bite your fingers.
Friction cleanses the teeth.
Friction cleanses the teeth.
11. Discard used cotton ball into small kidney tray. To prevent the spread of infection.
12. Clean tongue from inner to outer aspect. Microorganisms collect and grow on tongue
surface and contribute to bad breath.
Fig.18 Placing a kidney tray on the mackintosh
covered a face towel
Fig. 19 Cleansing teeth with supporting padded
tongue depressor