Riverside College Inc.

College of Nursing

RLE114GEP

EYES, EARS, NOSE, AND THROAT (EENT)

PROCEDURES

Submitted To:
Ms. Ria Bisaya

Submitted By:
BSN 3 DODD GROUP 3
Lanas, Izzie
Llaguno, Christian
Lumayno, Isabella
Malvas, Micah Jay
Mariblanca, Mary Junielyn
Molina, Melody Nina
Mondejar, Cielo Marie
Morales, Darren Daniel
Olorvida, Frecy
Panes, Alexa
 Administration of Medications:

EYE INSTILLATION
Ophthalmic Ointment
Definition:
• An ophthalmic ointment is a semi-solid, greasy or creamy topical treatment for certain
eye conditions, whether mild or severe.
• Ophthalmic ointments are often recommended for eye infections, dry eyes, and
blepharitis, among many other issues of the eye.
Types:
1. Antibiotic ointment – kills the bacteria that caused an eye or eyelid infection.
examples: bacitracin, erythromycin, gentamicin
2. Lubricating ointment – aids in keeping the eyes moist when conditions such as dry eye
are present.
examples: Duratears, Stye

Indications:
Ophthalmic ointments are recommended to treat conditions such as:

• Eye infections, including conjunctivitis (pink eye)

• Eyelid infections
• Eyelid conditions such as blepharitis and meibomian gland dysfunction
• Dry eyes/dry eye syndrome
• Keratitis (inflammation of the cornea)
• Styes
• Chalazia

Contraindications:

• Before using this medication, tell your doctor or pharmacist if you are allergic to
neomycin, bacitracin, or polymyxin; or to aminoglycoside antibiotics (such as
gentamicin); or if you have any other allergies. This product may contain inactive
ingredients, which can cause allergic reactions or other problems. Talk to your
pharmacist for more details.
 • Before using this medication, tell your doctor or pharmacist your medical history,
especially of: other eye problems.
• After you apply this drug, your vision may become temporarily blurred. Do not drive,
use machinery, or do any activity that requires clear vision until you can do it safely.

Adverse Effects:

• Stinging/burning of eyes for more than 1-2 minutes.

• Prolonged blurred vision
• Allergic reactions: rash, itching, swelling (especially of the face/tongue/throat/eye/eyelid,
severe dizziness, trouble breathing

Assessment:
1. Assess the patient's ability to cooperate during administration, since medication is
instilled into the lower conjunctival sac.
2. Check medication expiration date.
3. Assess the condition of the eye and surrounding areas.

Objectives:
1. To provide direct route for local effect.
2. To decrease intra-ocular pressure.
3. To relieve irritation and pain.
4. To prevent infection.

Equipment:

• Medication Card
• Eye ointment
• Application stick (PRN)
• Cotton balls or tissue
• Clean gloves
Preparation:
1. Obtain the patient's Medication Administration Record (MAR). MAR may be a
medication card, medication sheet, or Kardex depending on the method of dispensing
medications in your facility.
2. Compare the medication record with the most recent physician’s order.
3. Wash hands.
4. Gather necessary equipment.
5. Remove the medication from the drug box or tray on the medication cart.
6. Compare the label on the medication bottle/tube against the medication record.
7. Observe the 12 Rights in giving medications or or other treatments.

PROCEDURE:
STEPS RATIONALE

1. Check patient's Medication

Administration Record (MAR) for the
drug name, dose and strength. Also
confirm the prescribed frequency of
the instillation and which eve is to be
treated.
2. Gather and assemble the equipment. To save time, energy, and effort.
3. Compare the label on the medication Patient safety is the priority when giving
tube or bottle with the MAR and medications.
check the expiration date.
4. Introduce yourself and verify the JCAHO recommends two patient identifiers
patient's identity using two identifiers. to reduce errors in drug administration.
Explain to patient what you are going Explaining the procedure to patient reduces
to do and how he/she can cooperate. anxiety and promotes cooperation.
5. Perform hand hygiene and observe To prevent spread or transfer of pathogenic
other appropriate infection control microorganisms.
procedures
6. Ensure patient’s privacy.
7. Prepare the patient by assisting Correct body position facilitates smooth flow
him/her to a comfortable position, of the procedure.
either sitting or lying.
8. Put on gloves.
9. With the use of sterile cotton balls
moistened with sterile irrigating
solution or sterile normal saline, wipe
from the inner canthus to the outer
canthus.
 10. If ointment is to be used, discard the
first bead.
11. Give the patient a dry, sterile,
absorbent sponge and instruct him/her
to look up to the ceiling
12. Expose the lower conjunctival sac by
placing the thumb or fingers of your
non dominant hand on the patient's
cheekbone, just below the eye, and
gently draw down the skin.
13. Hold the medication in the dominant
hand; place your hand on patient's
forehead to stabilize your hand.
14. For ointments: Hold the tube above
the lower conjunctival sac, squeeze 2
cm of ointment from the tube into the
lower conjunctival sac from the inner
canthus outward.
15. Instruct the patient to close eyelids but
not to squeeze them shut.
16. Clean and dry the eyelids as needed.
Wipe the eyelids gently from the inner
to the outer canthus to collect excess
medication.
17. Assess patient's response and Assessing patient's response determines if
document all relevant assessments and desired therapeutic effect has been achieved
interventions. or side effects have been manifested.
Documentation promotes communication to
the other members of the health team.

Charting:
• Appropriate medication form for facility used
• Name of drug
• Dosage
• Method of administration
• Time ordered
• Time administered
• Initials of the nurse who administered the drug
• Nurses' notes: condition of eye and surrounding tissue
Evaluation:
1. Patient cooperated with instillation of eye medication.
2. Desired therapeutic effect is obtained.
3. Eye surgery or evaluation is accomplished.
4. Intra-ocular pressure is reduced.

Ophthalmic Drops
Description:

• Ophthalmic solution is a term sometimes used to describe liquid eye drops.

Objectives:
Eye drops are most often saline solutions with medications in them to treat various conditions of
the eye. Sometimes, they contain no medication and are meant to lubricate the eyes or to rinse
out foreign bodies.

Types:

• Artificial tears
• Antihistamine eye drops
• Antibiotic eye drops
• Steroid eye drops
• Anti-redness eye drops
Ophthalmic tobramycin is an effective antibiotic used in the eye to treat bacterial infections of
the eye. Tobramycin works by killing bacteria. Specifically, it acts by inhibiting synthesis of
protein in bacterial cells.

Indications

• Redness-relieving drops.
• Lubricating drops for dry eye.
• Itch-relieving (anti-allergy) drops.
• Numbing drops before surgery.
• Antibiotic drops for some infections.
• Pressure-lowering drops for long-term treatment of glaucoma.
Contraindications:

• You should not use this medicine if you are allergic to tobramycin.
• Tobramycin ophthalmic can pass into breast milk and may cause side effects in the
nursing baby. You should not breast-feed while using this medicine.
• Tobramycin ophthalmic is not approved for use by anyone younger than 2 months old.

PROCEDURE:
STEPS RATIONALE
1.Check the opthalmic preparation for the
name, length, and number of drops, if a liquid
is to be used.
2.Expose the lower conjunctival sac by
placing the thumb or fingers of your non
dominant hand on the patient's cheekbone,
just below the eye, and gently draw down the
skin.
3.Hold the medication in the dominant hand;
place your hand on patient's forehead to
stabilize your hand."
4.For eyedrops: Instill the correct number of
drops into the outer third of the lower
conjuctival sac. Hold the dropper 1-2cm
above the sac.
5.For liquid medication, press firmly or have
the patient press firmly on the nasolacrimal
duct for atleast 30 seconds."
6.Clean and dry the eyelids as needed. Wipe
the eyelids gently from the inner to the outer
canthus to collect excess medication.
7.Assess patient's response and document all Assessing patient's response determines if
relevant assessments and interventions. desired therapeutic effect has been achieved
or side effects have been manifested.
Documentation promotes communication to
the other members of the health team.

Charting

• Appropriate medication form for facility used

• Name of drug
• Dosage
• Method of administration
• Time ordered
 • Time administered
• Initials of the nurse who administered the drug
• Nurses' notes: condition of eye and surrounding tissue.
Evaluation

• Patient cooperated with instillation of eye medication.

• Desired therapeutic effect is obtained.
• Eye surgery or evaluation is accomplished.
• Intra-ocular pressure is reduced.

EAR INSTILLATIONS

Otic Drops
I. Definition:
• Administration of the medication into the ear

II. Assessment:
• Assess patient's ability to cooperate with instillation
• Assess patient’s ability to be positioned on side

III. Objectives:
• To soften the earwax
• To relieve pain and obtain desired therapeutic effect
• To apply anesthetic agent
• To provide route for antibacterial medications

IV. Indication:
• Inner ear infection (otitis media)
• Outer ear infection (otitis externa)
• Ear pain
• Earwax blockage
• Itchy ears
• Ear drainage.
• Ear fullness.
 V. Contraindication:
• Perforated eardrum
• Allergic Reaction
• Severe Ear Infection

VI. Adverse Effects

1. Local Irritation

• May produce sensation like burning, itching, or redness in the ear creating local
irritation. Most often this is transient and minor.
2. Allergic Reaction

• Rarely, this medication might cause a very dangerous adverse reaction. However, if you
have any of the following signs of a significant allergic response, obtain medical attention
right away: rash, breathing difficulties, redness in the ears, extreme dizziness, and
itching/swelling (particularly of the face, tongue, or neck).

VII. Equipment:
• Medication card
• Dropper for instilling medication
• Cotton wick
• Medication
• Clean gloves and flashlight

VIII. Preparation:
1. Obtain patient’s medication record
2. Compare the medication record with the most recent physician’s order
3. Wash hands
4. Gather necessary equipment
5. Remove the medication from the drug box or tray on medication cart
6. Compare the label on the medication bottle to the medication record
7. Check that medication is to be administered via the right method “Note of rights”.
8. Before preparing medication for administration, warm medication bottle to body
temperature.
PROCEDURE:
STEPS RATIONALE

1. Place medication on a tray if not using For aesthetic purposes

medication cart.
2. Take medication to patient’s room and
check room number against
medication card or sheet.
3. Check patient’s identification band To ensure accuracy
and ask patient to state name.
4. Explain the procedure To gain cooperation
5. Wash your hands To prevent spread of microorganisms
6. Provide privacy and position patient To allow medication to enter external ear
on side, with ear to be treated in the canal
uppermost position.
7. Fill medication dropper with
prescribed amount of medication
8. Prepare patient for instillation of ear These positions straighten out the ear canal
medication as follows:
a. Infant: Draw the auricle gently
downward and backward to separate
the drum membrane from the floor of
the cartilaginous canal.
b. Adult: Lift the pinna upward and
backward.
9. Instill medication and insert a loose
cotton into the canal to maintain a
continuous application of the solution
(optional)
10. Instruct patient to remain on his side To prevent medication from escaping
for 15 minutes following instillation.
Insert a small piece of cotton fluff
loosely at the meatus of the auditory
canal.
11. Assess client's response.
12. Document all nursing assessment,
interventions and record the name of
the drug on irrigating solution. The
strength, the number of drops and the
response of the client.
Charting

• Appropriate medication form for facility used

• Name of drug
• Dosage
• Method of administration
• Times ordered
• Time administered
• Initials of nurse administering drug

Evaluation
1. Patient cooperates with instillation.
2. Desired therapeutic effect is obtained.

NOSE INSTILLATION

NASAL SPRAY

I. Definition:
• Nasal spray is a type of medication that is administered through the nostrils to treat nasal
congestion and other conditions.

II. Types:
• Decongestant Sprays – it shrinks swollen blood vessels and tissues to relieve congestion.
• Nasal Steroid Sprays – use to relieve stuffiness, irritation or discomfort associated with
other sinus problems.
• Saline Sprays – contains a mixture of water and salt. Used to lubricate and flush out
nasal passages.

III. Indications:
• Nasal Congestion
• Sinusitis infection
• Common cold
• Fever
IV. Contraindication
• High blood pressure
• Arrhythmias
• Thyroid problems
• Diabetes
• Glaucoma
• Hypersensitivity to azelastine
• Pregnancy

V. Adverse Effects
• Burning
• Stinging
• Dryness in the nose
• Runny nose
• Sneezing
• Bradycardia
• Tachycardia
• mood changes
• trouble sleeping

VI. Objectives:
• To relieve congestion and symptoms of seasonal allergies, sinus infections or common
colds.

VII. Equipment:
• Saline/Decongestant nasal spray
• Tissues or handkerchief
• Gloves
• Kidney basin
• Medication card
• Pillow
 VIII. Assessment:
1. Assess the patient's medical history, allergies, and current medications to identify any
potential contraindications or interactions.
2. Evaluate the patient's ability to correctly administer the nasal spray to ensure proper
medication delivery.

PROCEDURE

STEPS RATIONALE

Introduce self; verify patient’s identity using To reduce errors in drug administration.
two identifiers and explain the procedure. Explaining the procedure to patient reduces
anxiety and promotes cooperation.
Check the Medication Administration Record To ensure accuracy.
(MAR). Check the label on the medication
carefully against the medication card or the
MAR
Gather and assemble the equipment. To save time, energy, and effort.
Perform hand washing and observe To reduce transmission of pathogenic
appropriate infection control procedure. microorganisms.
Provide tissues and ask patient to blow their This clears the nose prior to medication
nose gently. instillation.
Prepare patient by positioning him/her on To allow medication to enter external ear
sitting position with his/her head tilted back, canal.
if patient is lying down, gently tilt his/her
head back with a pillow.
The head should be elevated forward slightly, Relaxation minimizes discomfort.
with the nose in line with the toes.
Spray sufficient amount of solution/ Breathing through the mouth will help
depending on the doctor’s order. Ask patient prevent aspiration of the medication.
to breathe through the mouth.
Close the nostril that is not receiving the
medication. Do this by gently pressing on the
other side of the nose.
Gently insert the bottle tip into the other
nostril. Ask patient to breathe in deeply
through the nostril as you squeeze the bottle.
Remove the bottle and ask patient to sniff
once or twice.
Have the patient remain in the position with Prevent the medication from escaping.
his head tilted back for 30- 60 second.
Remove gloves and assist patient to a To ensures patient safety and comfort.
comfortable and safe position.
Perform Hand hygiene. To prevent the spread of microorganisms
 Assess patient’s response and document all Assessing patient’s response determines if
nursing assessment and interventions. Record desired therapeutic effect has been achieved
the drug, the strength, number of drops or or side effects have been manifested.
spray, the time, and the response of the Documentation promotes communication to
patient. the other members of the health team.

Evaluation

• Patient cooperates with instillation.

• Desired therapeutic effect is obtained.
• Patent airway is established, and the patient is able to breathe after the procedure.

NASAL INSTILLATION

Introduction:
Nasal instillations are used to treat allergies, sinus infections, and nasal congestion. The nose is
normally not a sterile cavity, but because of its connection with the sinuses, medical asepsis
should be observed carefully when using nasal instillation.

Definition:

• A nasal installation is a medicine solution prepared for administration into the nose.
• Nasal medicine is given in the form of nose drops or nasal sprays.

Objectives:
1. Relief of Nasal Congestion
2. Provide a patent airway
3. To shrink swollen mucus membrane of nasal cavity (astringent effect)
4. To loosen secretion and facilitate drainage.
5. To treat infections of the nasal cavity or sinuses.

General Instructions:

• Caution the client to avoid the use of nasal decongestants for a prolonged period as it can
lead to a rebound effect in which the nasal congestion worsens.
• Medicines are instilled only on written order from doctor.
 • Avoid oil-based solutions as nasal drops since it interferes with the normal ciliary action
and causes aspiration pneumonia.
• The anterior nares should be clean and free from any discharge before installation.
• Medical asepsis should be followed carefully throughout the procedure.

Indications:

• Nasal Congestion
• Allergic Rhinitis
• Sinus Infections
• Nasal Dryness
• Nasal Polyps
• Postoperative Care

Contraindications:

• Hypersensitivity or Allergy
• Active Nosebleeds (Epistaxis)
• CVD or Hypertension
• Pregnant or Lactating Mothers

Side Effect:

• Temporary burning
• Stinging,
• Dryness in the nose
• Runny nose
• Sneezing

Assessment:
1. Review physician’s order and determine which sinus is affected by referring to a medical
record
2. Assess patient’s history of hypertension, heart diseases, diabetes mellitus, and
hyperthyroidism.
3. Assess and determine whether the patient has any known allergies to the medications for
nasal instillation.
Equipment:
Articles Rationale
Medication with a clean dropper For instillation drops
Medication Card To ensure accurate nasal instillation
Handkerchief / Facial Tissue / Small Towel To wipe the nose
Pillow For proper positioning
Kidney Tray To discard wet waste
Gloves To prevent cross infection
Preparation:
1. The nurse should wash his or her hands before instilling nasal medicine.
2. Each time the medicine is administered, the medication label should be checked to avoid
medication errors.
3. It should be confirmed that it is the right medicine, the correct dose (i.e., strength), the
proper time, the right patient, and the appropriate method.
4. The expiration date on the label should be checked to ensure that the medication is not
outdated.
5. Prior to administration of the medicine, the bottle or canister should be shaken.
6. The patient should blow his or her nose before nasal instillations. It is not unusual for
nasal instillations to stimulate a sneeze.
7. Tissues should be kept at hand so that residue can be wiped away and for the client to use
to cover the mouth and nose when sneezing.

Techniques in the Instillation of Nose Drops

1. Provide the patient with paper tissues for the expectoration of secretions.
2. Position the patient by having him sit up with his head tilted well back. Or if he is lying
down, tilt his head back over a pillow.
3. Draw sufficient solution into the dropper for both nares.
4. Hold up the tip of the nose, and place the dropper just inside the nares, about 1/3 of an
inch. Instill the prescribed number of drops in one nare and then into the others.
5. Avoid touching the nares with the dropper because it may cause the patient to sneeze. of
the solution.
6. Have the patient remain in position with his head tilted back for a few minutes to prevent
the escape.
Procedures:
Steps Rationale
1. Check on medication administration To ensure accuracy
record.
2. Organize the equipment. To save energy and effort
3. Perform hand washing and observe To reduce transmission of organisms
appropriate infection control
procedure
4. Prepare patient. Introduce self. Verify To gain cooperation
client’s identity
5. Position patient on sitting position Relaxation minimizes discomfort.
with his head tilted back, if he is
laying down tilt his head back with a
pillow.
6. Provide the patient with tissue paper To wipe off excess secretions and
for expectorant of secretions. medications
7. Draw enough solution into the dropper
for both nares. Hold up the tip of the
nose and place the dropper just inside
the nose about 1/3 of an inch.
8. Instill the prescribed number of drops
in one nares and then into the other.
9. Have the client remain in position Prevent medication from escaping
with his head tilted back for a few
minutes.
10. Assess client’s response and document Maintain continuity of care
all nursing assessment and
interventions. Record the drug, the
strength, number of drops or spray, the
time, and the response of the client.

After Care:

• Dispose of the soiled supplies in a proper container.

• Remove gloves and wash hands.
• Observe patient for onset of side effects 15-30 minutes after administration.
• Ask if patient is able to breathe through nose after decongestant administration.

Recording and Reporting:

• Record the procedure date, time and medicine’s name.

• Report to the physician for any side effects.
Evaluation
1. Patient cooperates with instillation.
2. Desired therapeutic effect is obtained.
3. Patent airway is established and the patient is able to breathe after installation.

NASAL IRRIGATION
Definition
Nasal irrigation is rinsing your nasal cavities by irrigating them with saline solution through the
nostrils. It can help relieve upper respiratory symptoms, allergies, nasal problems, and sinus
infections.

Objectives:

• Cleans mucus from the nose, so medication can be more effective.

• Cleans allergens and irritants from the nose, reducing their impact
• Cleans bacteria and viruses from the nose, decreasing infections
• Decreases swelling in the nose and increases airflow.
Assessment:
• Assess the individual's past and present medical history, including any allergies or past
nasal surgeries. Avoid nasal irrigation if ear infection, ear pressure, blocked nostril, or
ear/sinus surgery; immunocompromised individuals consult doctor before sinus rinse
device use
• Evaluate medication use and consider consulting a healthcare provider for chronic nasal
issues.
• Assess device suitability for the user's age. Some children as young as 2 with nasal
allergies may benefit, if recommended by a pediatrician, but very young children may not
tolerate it well.

Indication:
Nasal irrigation clears mucus and flushes out pathogens, allergens or other debris. Pathogens
include germs, like bacteria and viruses. Allergens include pollen, mold, dirt, dust and pet
dander. When these substances get trapped in your nose, they irritate your sinuses and cause
symptoms like:

• A stuffy or runny nose.

• Itchy feeling in your nose or sneezing.
• Trouble breathing.
 • Symptoms associated with allergies, sinus infections (sinusitis), colds, flu and COVID-
19, among other conditions.
• people who have sinus problems, nasal allergies, colds, and even flu symptoms.

Equipment:

• Saline solution or other irrigants as ordered

▫ Noniodized salt
▫ Baking soda
• Irrigating device (a neti pot, a nasal syringe, an irrigation bottle, waterpick)
• Clean basin or jar
• Distilled, sterile, boiled, or filtered water
Procedure
Steps Rationale
Introduce yourself to the patient and explain
the procedure
Wash hands. to avoid contaminating the treated water that
is to enter the nasal passages.
Fill the irrigation device with lukewarm
distilled water or boiled water that has cooled
If using a nasal rinse bottle, fill it with either a Plain water can irritate your nose. The saline
ready-to-use saline solution or prepare a allows the water to pass through delicate nasal
saline solution as instructed and shake it well. membranes with little or no burning or
- To create the saltwater solution, use a irritation.
clean basin or jar to mix one-half
teaspoon of non-iodized salt in an 8- Noniodized salt is preferred over iodized salt
ounce glass of water. Then, add a to prevent potential irritation over time.
pinch of baking soda, which is a small
amount that can be picked up between
two fingers. Use the entire 8 ounces of
saltwater during the nasal wash if
congested; otherwise, 4 ounces should
suffice. Remember to discard any
unused saltwater and prepare a fresh
solution before the next nasal wash.
Ask the patient to stand in front of a sink. To prevent aspiration, keep the patient's head
Position their body by bending forward and tilted forward.
flex the neck approximately 45 degrees,
facilitating observation or interaction with the
sink.
Then, place the tip of the rinse bottle into
patient’s nostril.
 Instruct the patient to breathe through the This allows for expelling some of the salt
mouth, then gently squeeze the bottle water from the mouth. It's not harmful if a
directing the stream towards the back of the small amount is swallowed.
head rather than the top. This will squirt the
solution into their nostril. The solution will
start to drain from the other nostril. Some
may drain from the mouth. This is normal.
. Ask the patient to gently blow their nose to remove remaining water or mucus.
Repeat steps 6 to 8 with the other nostril.
Mild irritation is typical initially and tends to
subside over time.
Do after care of the equipment
Wash hands thoroughly.
Record type of drainage returned

Evaluation:

• Mucus, pathogens, allergens, and irritants are removed from their nose and sinuses.
• Symptoms such as a runny or stuffy nose due to allergic rhinitis, sinusitis, common cold,
influenza, and COVID-19 are relieved.
• Their sinus passages are kept moisturized.
• The function of nasal cavity cell linings is improved, aiding in the clearance of excess
mucus in the nasal passageway.
MOUTH CARE

MOUTH CARE FOR CONSCIOUS PATIENTS

I. Definition
Mouth Care is the care given to maintain the tissue and structure of the mouth.

II. Indication
• Persistent bad breath
• Bleeding gums
• Tooth sensitivity

III. Assessment
1. Assess patient's knowledge of oral hygiene technique.
2. Assess/inspect integrity of lips, teeth, buccal mucosa, gums, palate and tongue.
3. Determine status of client's oral cavity and extent of need for oral hygiene.
4. Assess risk for oral hygiene problems. Certain conditions increase likelihood of
impaired oral cavity integrity and need for preventive care.
5. Determine client's oral hygiene practices. Allows nurse to identify errors in technique,
deficiencies in preventive oral hygiene and client's level of knowledge regarding
dental care.
a. Frequency of tooth brushing and flossing
b. Type of toothpaste and dentrifice used.
c. Last dental visit
d. Frequency of dental visits
e. Type of mouthwash or moistening preparation
6. Assess client's ability to grasp and manipulate toothbrush. Determine level of
assistance required.

IV. Objectives
1. To refresh the client.
2. To remove decomposing materials from the mouth and teeth preventing bad breath
3. To prevent Sordes formation.
4. To maintain the integrity of the mucous membrane, teeth, gums and lips.

V. Equipment
• Soft bristled toothbrush
• Nonabrasive fluoride toothpaste or dentrifice
 • Straw or drinking tube.
• Glass with water
• Kidney basin
• Face towel or paper towel
• Prescribed mouthwash (optional)
• Gloves
• Dental floss (optional)
• Denture- cleansing equipment (if necessary)
• Denture cup
• Denture cleaner
• 4 x 4 gauze
• Petroleum jelly (optional)

VI. General Considerations

1. Identify presence of common oral problems
a) Dental caries - chalky white discoloration of tooth or presence of brown or black
discoloration
b) Gingivitis - inflammation of gums
c) Periodontitis - receding gum lines, inflammation gaps between teeth
d) Halitosis - bad breath
e) Cheilosis - cracking of lips
f) Stomatitis - inflammation of the mouth
g) Plaque - an invisible soft film of bacteria, saliva, epithelial cells and leukocytes
h) Tartar - a visible, hard deposit of plaque that adhere to the enamel surface of the
teeth.
i) Glossitis - inflammation of the tongue
j) Sordes - accumulation of foul matter (food, microorganisms and epithelial elements)
on the guns and teeth
k) Parotitis - inflammation of the parotid salivary glands (mumps)
VII. Procedure

STEPS RATIONALE
Prepare equipment at bedside. To save time, effort and energy
Some clients feel uncomfortable about having the
Explain procedure to the client and discuss
nurse care for their basic needs. Client
preferences regarding use of hygiene aids.
involvement with procedure minimizes anxiety.
Place paper towels on over bed table and arrange
Organization facilitates performance of task.
other equipment within easy reach.
Raise bed to comfortable position. Raise head of
Raising bed and positioning client prevents nurse
bed (if allowed) and lower side rail. Move the
from straining muscles. Semi-fowler's position
client or help client move closer. Side lying
helps prevent client from choking or aspirating.
position can be used.
Place towel over client's chest. To prevent from getting wet.
Prevent contact with microorganisms or blood in
Apply gloves if assisting with oral care.
saliva.
Apply toothpaste to brush, holding brush over
Moisture aids in distribution of toothpaste over
ernesis basin. Pour small amount of water over
tooth surfaces
toothpaste.
Client may assist by brushing. Hold toothbrush
bristles at 45-degree angle to gum line. Be sure tips
Angle allows brush to reach all tooth surfaces and
of bristles rest against and penetrate under gum
to clean under gum line where plaque and tartar
line. Brush inner and outer surface or upper and
accumulate. Back and forth motion dislodges food
lower teeth by brushing from gum to crown of
particles caught between teeth and along chewing
each tooth. Clean biting surfaces of teeth by
surfaces.
holding top of bristles parallel with teeth and
brushing gently back and forth. Brush sides of
teeth by moving bristles back and forth.
Have client hold brush at 45-degree angle and Microorganisms collect and grow on tongue's
lightly brush over surface and sides of tongue. surface and contribute to bad breath. Gagging may
Avoid initiating gag reflex. cause aspiration of toothpaste.
Allow client to rinse mouth thoroughly by taking
several sips of water, swishing water across all Irrigation removes food particles.
tooth surfaces and spitting into emesis basin.
Reduces tartar on tooth surfaces. Aids in removal
Allow client to floss.
of plaque and promotes healthy gum tissue.
Allow client to rinse mouth thoroughly with cool
Irrigation removes plaque and tartar from oral
water and spit into emesis basin. Assist in wiping
cavity.
client's mouth.
Allow client to gargle to rinse mouth with
Mouthwash leaves pleasant taste in mouth.
mouthwash as desired.
Assist in wiping client’s mouth. Promote sense of comfort.
Assist client to comfortable position, remove
ernesis basin and bedside table, raise side rail, and Provides for client comfort and safety.
lower bed to original position.
Wipe off over bed table, discard soiled linen and
Proper disposal of soiled equipment prevents pread
paper towels in appropriate containers, remove
of infection.
soiled gloves and return equipment to proper place.
Remove gloves and wash hands. Reduce transmission of microorganisms.
Oral Care of Patient with Denture
• Follow steps 1 - 6 in mouth care to
conscious patient.
• Assist the patient with removal and
cleaning of dentures, if necessary.

a. Apply gentle pressure with 4 x 4 gauze to Rocking motion breaks suction between the
grasp upper denture plate and remove. denture and gum. Using 4 x 4 gauze prevents
Place it immediately in the denture cup. slippage and discourages spread of
microorganisms.
Lift the lower denture using slight rocking
motion, remove, and place in the denture
cup.

b. If the patient prefers, add denture cleanser Dentures collect food and microorganisms and
to the cup with water and follow directions require daily cleansing. Paper towels or washcloth
on preparation or brush all areas thoroughly in the sink protects dentures against breakage in
case they are dropped.
with toothbrush and toothpaste. Place paper
towels or washcloth in sink while brushing.

c. Rinse thoroughly with water and return

dentures to the patient. Water aids in removal of debris and acts as a
cleansing agent.
d. Offer mouthwash so patient can rinse his or
Mouthwash leaves a pleasant taste in the mouth
her mouth before replacing dentures. and removes food particles, thus permitting proper
fit.
e. Apply petroleum jelly to lips, if needed.
Petroleum jelly prevents cracking and drying of
lips.
 f. Remove equipment and assist the patient to This promotes oral hygiene and provides for oral
a position of comfort. Record any unusual assessment.
bleeding or inflammation.
g. Remove disposable gloves from inside out
and discard appropriately. Wast. your This protects the nurse from contact with any
hands. microorganisms. Hand washing deters spread of
microorganisms.

VIII. Evaluation

The oral health status of the client has been assessed and documented by the nurse.
 ORAL OINTMENT

I. Definition
- Are topical products designed for specific oral health purpose. These products
may contain ingredients like numbing agents, anti-inflammatories, antivirals,
antibiotics, or antifungals.

II. Indication
• Mouth Ulcers
• Teething discomfort
• Gum inflammation
• Cold sores

III. Routes of Administration

1. Buccal route-given between the gums and the inner lining of the mouth cheek.
Medicine is usually given in the buccal area when it is needed to take effect
quickly.
2. Sublingual route – It involves placing the drug beneath the tongue, to be
absorbed and dissolved into the bloodstream through the mucous membrane.

IV. Assessment
1. Assess condition of the patient’s oral cavity, teeth, gums, and month.
2. Check medication orders for completeness and accuracy.
3. Assess if 12 rights in medication administration are followed.
4. Check to make sure you have the correct medication for the patient.

V. Objective
1. To offer the most common, easiest, and least expensive route of administering
medication.
2. To prevent inflammation and pain
3. To preent infection

VI. Equipments
• Medication Card
• Oral Ointment
• Application Stick
• Clean gloves

VII. General Considerations

1. Determine patient’s physical ability to take medication as ordered.
• State of consciousness
• Signs of nausea and vomiting
• Cooperative behavior
2. Check the medication label and note the expiration date.
 3. Monitor reaction of the patient to medication administered and chart according to
the appropriate sheet.

VIII. PROCEDURE

STEPS RATIONALE
Check the patient’s Medication Administration
Record (MAR) for the drug name, dose and To ensure accuracy
strength.
Gather and assemble the equipment. To save time, energy and effort
JCAHO recommends two patient identifiers to
Introduce yourself and verify the patient’s identity reduce errors in drug administration.
using two identifiers. Explain to patient what you
are going to do and how he/she can cooperate. Explaining the procedure to patient reduces anxiety
and promotes cooperation.
Assist the patient to a comfortable position and put
on gloves.
Open the tube and discard the first bead.
With your dominant hand, squeeze out the
prescribed amount onto the application stick held by
your non dominant hand.
Apply the ointment on affected area. Allow it to
remain on the area for as long as possible.
Instruct pt to not eat or drink for about 30 minutes This helps to prevent the medicine from being
after applying the ointment. washed away too soon.
Assess patient’s response and document all relevant
assessments and interventions.
 MOUTH CARE FOR UNCONSCIOUS PATIENT

I. Definition
A special care of the teeth, gums, lips and tongue of an unconscious or debilated patient.

II. Assessment
1. Assess condition of patient’s oral cavity, teeth, gums, and mouth.
2. Assess for color, lesions, tenderness, inflammation, intactness of teeth and degree
of moisture or dryness of the oral cavity.
3. Observe the external and internal lips.
4. Assess the palate (roof and floor of mouth) and inspect under the tongue.
5. Assess the entire oral mucosa, noting the inside of the nasopharyngeal area.
6. Observe the tongue, note tip, sides, back position and underside.

III. Objectives

1. To remove plaque and bacteria producing agents from the oral cavity.
2. To allow the nurse to assess the patient’s oral health status, knowledgeable and
routine of oral care.
3. To decrease the possibility of irritation or infection of the oral cavity and prevent
sore formation.
4. To refresh and provide comfort to the patient.
5. To remove unpleasant tastes and odors from the oral cavity thereby preventing
bad breath (Halitosis)
6. To provide teaching when appropriate.

IV. Equipment

• Gloves
• Soft toothbrush or sponge toothette/Cotton applicator
• Tongue blade paddedd with a 4x4 gauze
• Water, mouthwash or hydrogen peroxide
• Towel
• Water-soluble lubricant for lips
• Suction catheter with suction for lips
• Emesis basin
Procedures
STEPS RATIONALE
Organization facilitates accurate skill
Gather equipment needed at bedside.
performance.
Allows debilitated client to anticipate procedure
Explain procedure to the client or significant
with anxiety; unconscious client may retain
others. Provide privacy.
ability to hear. Relaxes patient.
Reduces transmission of microorganisms; gloves
prevent contact with microorganisms; gloves
Wash hands and put on gloves.
prevent contact with microorganisms in blood or
saliva.
Raise the bed to a comfortable height. Lower the Proper positioning prevents back strain.
near side rail. Turn the client on the side toward
you, with the client’s head tilted down toward Tilting the head downward encourages fluid to
the mattress. drain out of the client’s mouth.
Place a towel and emesis basin under the client’s The towel protects the client and the bed. The
chin. Have a suction catheter and apparatus emesis basin and suction equipment facilitate
available if needed. drainage from the client’s mouth.
The tongue blade assists in keeping the client's
Open the client’s mouth and insert the padded
mouth open. As a reflex mechanism, the client
tongue blade toward the back molar area. Never
may bite down if fingers are placed in his or her
insert your fingers into the client’s mouth
mouth.
Dip a toothette sponge/soft toothbrush/cotton Friction cleanses the teeth. Cleaning solutions
applicator or another padded tongue blade in aid in removing residue on the client's teeth and
water, mouthwash, or diluted hydrogen peroxide. in softening encrusted areas.
Move it back and forth gently across the client's Toothpaste may foam and cause aspiration.
teeth and chewing areas. Cleanse the roof of the
mouth and the inner cheek area. Do not use
toothpaste.
Rinse the areas, using a clean toothette/cotton Rinsing or suctioning removes cleaning solution
applicator or padded tongue blade moistened in and debris.
water. Suction any drainage if necessary.
Apply water-soluble lubricant or moisturizer to Applying lubricant prevent lips from drying or
the client's lips. cracking.
Reposition the client. Lower the bed and raise Repositioning with the bed at the proper height
the side rail again. and side rails raised provides for the client's
comfort and safety.
Dispose any contaminated items in biohazard Promote proper disposal of contaminated
bag. materials.
Removes gloves and wash your hands. Hand washing prevents the spread of infection.
Document assessments on the health record. Documentation provides communication and
coordination of care.

V. General Considerations
1. Suction apparatus or bulb should be available at bedside for emergency use.
2. If mouthwash is used, always rinse the mouth with water following steps as in
cleaning to avoid mouth irritations.
3. A patient receiving chemotherapy medication may have bleeding gums and
extremely sensitive mucous membranes. Use a soft sponge toothette for cleaning
or substitute a salt-water rinse (1/2 teaspoon salt in one (1) cup of warm water) for
brushing teeth.

VI. Evaluation
1. Teeth are free of plaque.
2. Mucosa is moist, intact and has a uniform color.
3. Tongue is well hydrated as well as the lips are smooth and hydrated.
4. Bacteria producing agent is removed from oral cavity thereby preventing
halitosis.
5. Client experiences no oral discomfort.