When performing oral care on an unconscious resident, position the resident in the side-lying position

According to the CDC, aspiration pneumonia is a serious risk for unconscious patients, with mortality rates as high as 20–30%. When performing oral care on an unconscious resident, position the resident in a way that prioritizes safety and prevents this life-threatening complication.

Quick Summary

To perform oral care on an unconscious resident safely, position them in a side-lying position with their head turned to the side. This prevents aspiration by allowing fluids to drain from the mouth instead of into the airway.

Key Points

• Side-Lying Position: Always place the resident on their side with the head turned to prevent aspiration and allow fluids to drain.

• Protect the Airway: Never tilt the head back or perform oral care while the resident is flat on their back, as this increases the risk of aspiration.

• Minimize Fluid Use: Use only lightly moistened swabs or a minimal amount of water with a soft brush to avoid liquid pooling in the mouth.

• Never Use Fingers: A padded tongue blade is essential for safely holding the mouth open and protecting the caregiver from involuntary bites.

• Monitor for Complications: During and after oral care, watch for any signs of coughing, choking, or respiratory distress and seek help if needed.

• Maintain Dignity: Explain the procedure to the resident in a calm voice, even if they are unconscious, to show respect and maintain dignity.

The Critical Importance of Safe Positioning

When caring for an unconscious resident, seemingly simple tasks like oral hygiene carry significant risks. The most severe danger is aspiration, where fluids, saliva, or bacteria enter the lungs, potentially causing a serious and often fatal condition known as aspiration pneumonia. Because the gag reflex is diminished or absent in an unconscious individual, proper positioning is not merely a convenience but a life-saving procedure.

The Standard and Safest Position

The correct and universally recommended position is the side-lying position, with the resident's head turned to the side. This simple adjustment leverages gravity to your advantage, ensuring that any excess liquid or debris drains out of the mouth and onto a towel or basin, rather than back toward the throat and into the airway. This technique is a cornerstone of patient safety in all caregiving and clinical settings involving unconscious or semi-conscious individuals.

Step-by-Step Procedure for Oral Care

Providing oral care requires a careful, systematic approach to ensure resident safety and comfort. Following these steps can help minimize risk.

1. Gather Your Equipment: Assemble all necessary items beforehand. This includes a small, soft-bristle toothbrush (or foam swabs for sensitive mouths), a padded tongue blade, an emesis basin, a towel, water-based lip lubricant, and a cup of water with a minimal amount of mouthwash if permitted by the care plan. Crucially, avoid using acidic substances like lemon-glycerine swabs, which can dry out oral tissues.
2. Explain the Procedure: Even though the resident is unconscious, it is best practice to explain what you are doing in a calm, clear voice. This is a sign of respect and dignity.
3. Position the Resident Safely: Raise the bed to a comfortable working height. Gently turn the resident onto their side, positioning them away from you. Use pillows to support their back and head. Turn their head slightly towards the bed's surface to facilitate drainage.
4. Protect the Area: Place a towel under the resident's chin to protect their clothing and bedding. Position the emesis basin close to their mouth to collect any drained fluid.
5. Access the Mouth: Use the padded tongue blade to gently hold the resident's mouth open. Never use your fingers. Even an unconscious resident may involuntarily bite down. The tongue blade also helps keep the tongue safely out of the way.
6. Cleanse the Mouth: Using the moistened toothbrush or swab, clean the oral cavity systematically. Clean the chewing surfaces, inner and outer surfaces of the teeth, gums, and tongue. Use very little fluid and change swabs frequently. Squeeze excess moisture from swabs before use.
7. Rinse and Moisturize: Using a fresh, moist swab, gently wipe the mouth to rinse. Once finished, pat the face and mouth dry. Apply a water-based lip moisturizer to prevent chapping and cracking. Do not use petroleum jelly inside the mouth.
8. Ensure Comfort: Return the resident to a comfortable and safe position, lower the bed, and ensure the call light is within reach. Dispose of used equipment properly.

Comparing Safe vs. Unsafe Practices

Aspect	Safe Practice	Unsafe Practice
Positioning	Side-lying with head turned to the side.	Flat on the back (supine) or with head tilted back.
Fluid Usage	Minimal fluid, moistened swabs.	Rinsing or using cups of water.
Equipment	Padded tongue blade, soft brush, water-based moisturizer.	Using fingers to hold the mouth open, lemon-glycerine swabs.
Risk Management	Actively promotes drainage out of the mouth via gravity.	Creates a high risk of fluids or debris entering the lungs.
Patient Dignity	Explaining the procedure, gentle handling.	Rushing or rough handling.

Additional Best Practices for Enhanced Safety

While proper positioning is the most important step, there are other considerations that enhance resident safety and care quality.

• Regular Frequency: Unconscious residents often breathe through their mouths, leading to dryness and a higher risk of bacterial growth. Oral care should be provided at regular, frequent intervals, often every two hours, to keep the mouth moist and clean.
• Oral Health Monitoring: During each session, inspect the resident's mouth for any abnormalities. Look for signs of irritation, sores, bleeding gums, or changes in the tongue's appearance. These could indicate other health issues and should be reported to the appropriate medical staff.
• Post-Care Observation: After completing the procedure, observe the resident for a short period for any signs of respiratory distress, coughing, or difficulty breathing. While proper technique minimizes risk, vigilance is always necessary.

Conclusion: The Standard of Care

The highest standard of care for an unconscious resident demands meticulous attention to detail, with positioning being the paramount consideration. The American Dental Association provides guidance on proper infection control and patient care. By always placing the resident in the side-lying position with their head turned, caregivers can confidently perform oral hygiene while mitigating the severe risks of aspiration. This practice safeguards the resident's health and upholds the commitment to providing compassionate and safe senior care.

Frequently Asked Questions

Why is the side-lying position so important when performing oral care on an unconscious resident?

It is the single most important step to prevent aspiration, which is when liquid or debris is inhaled into the lungs. This positioning uses gravity to drain fluids safely out of the mouth.

What should I do if an unconscious resident starts coughing during oral care?

If a resident coughs or shows any sign of respiratory distress, stop the procedure immediately. Turn them further onto their side, clear their mouth of any fluid or debris, and call for medical assistance.

What equipment is needed for oral care on an unconscious resident?

You will need a soft-bristle toothbrush or foam swabs, a padded tongue blade, a towel, an emesis basin, and a water-based lip moisturizer.

Should I use toothpaste for an unconscious resident?

It is generally not recommended to use toothpaste, as the foaming and rinsing required can increase the risk of aspiration. Instead, use a moistened brush or swab.

How often should I provide oral care for an unconscious resident?

Oral care should be provided frequently, often every two hours, to prevent the build-up of bacteria and keep the mouth moist.

Can I use lemon-glycerine swabs?

No, these should be avoided. Despite a common misconception, they are acidic and can cause dry mouth and irritate the oral tissues.

How can I ensure the resident's dignity and comfort during this procedure?

Always explain the procedure to the resident, even if they are unconscious. Use a gentle touch, ensure their privacy, and maintain a calm and respectful demeanor throughout the process.

What is aspiration pneumonia and why is it a risk for unconscious residents?

Aspiration pneumonia is a lung infection caused by inhaling foreign material like saliva or oral bacteria. Unconscious residents are at high risk because their diminished gag reflex cannot prevent this from happening.