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Student ______________________________________________________ Instructor ____________________________________________________

Date _________________________ Date _________________________

PERFORMANCE CHECKLIST SKILL 17-3 PERFORMING MOUTH CARE FOR THE UNCONSCIOUS OR DEBILITATED PATIENT

S
ASSESSMENT

NP

Comments

1. Performed hand hygiene. Applied clean gloves. 2. Assessed for presence of gag reflex. 3. Conducted physical assessment of oral cavity. 4. Removed gloves. Performed hand hygiene. 5. Assessed patients risk for oral hygiene problems.
NURSING DIAGNOSIS

1. Developed appropriate nursing diagnoses based on assessment data.


PLANNING

1. Identified expected outcomes. 2. Positioned patient on side with head turned toward dependent side and head of bed lowered. Unless contraindicated, raised side rail. 3. Explained procedure to patient. 4. Performed hand hygiene and applied clean gloves. 5. Properly arranged equipment and turned on suction device. 6. Closed curtain or room door for privacy.
IMPLEMENTATION

1. Raised bed and lowered side rail to have easy access to patient; raised side rail when patient was unattended. 2. Positioned patient on side of bed near student; kept patient positioned on side with head turned toward mattress unless contraindicated. 3. Removed dentures, if present. 4. Placed towel under patients face and positioned emesis basin under patients chin. 5. Placed oral airway if patient was uncooperative.
Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published.

S 6. Cleansed mouth. 7. Used toothette for patient without teeth. 8. Suctioned secretions as necessary. 9. Applied water-soluble jelly to lips. 10. Informed patient completed. that procedure was

NP

Comments

11. Raised side rail. Removed gloves and disposed of them in proper receptacle. 12. Repositioned patient safely and comfortably after procedure. 13. Disposed of equipment and soiled linen properly. 14. Performed hand hygiene.
EVALUATION

1. Applied gloves and inspected patients oral cavity. 2. Assessed patients level of comfort and cleanliness. 3. Assessed patients respirations on an ongoing basis. 4. Identified unexpected outcomes.
RECORDING AND REPORTING

1. Recorded procedure, including description of the condition of the oral cavity and patients ability to assist. 2. Reported any unusual findings to nurse in charge or physician.

Mosby items and derived items 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Some material was previously published.