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By Root 2016 0

critically ill patients the mouth can become colonized within 48 hours of admission to hospital with bacteria that tend to be more virulent than those normally found in the mouth (Grap et al. 2003). The oropharynx can become colonized, as can an artificial airway. This can allow pathogens to travel to the respiratory tract, resulting in pneumonia (Cutler and Davis 2005). It is well recognized that good oral care is essential in critically ill patients to reduce the incidence of VAP. Other contributing factors to poor oral health in this group of patients include dry mouth related to use of oxygen, mouth breathing and the patient being nil by mouth. The presence of tubes or securing tapes can make it difficult to view and clean the oral cavity.

Further research is needed in this area as there is a lack of trial-based evidence to support practice (Munro and Grap 2004).

Procedure guideline 9.6 Mouth care

Essential equipment

Small torch

Plastic cups

Mouthwash or cleaning solutions

Appropriate equipment for cleaning

Clean receiver or bowl

Paper tissues/gauze

Wooden spatula

Small-headed, soft toothbrush

Toothpaste

Non-sterile disposable gloves

Denture pot

Preprocedure

Action Rationale

1 Explain and discuss the procedure with the patient. When possible, encourage patients to carry out their own oral care. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008a, C). To enable patients to gain confidence in managing their own symptom management (DH 2005, C).

2 Wash hands with bactericidal soap and water and dry with paper towel or use alcohol handrub. Put on disposable gloves. To reduce the risk of cross-infection (Fraise and Bradley 2009, E).

Procedure

3 Prepare solutions required. Solutions must always be prepared immediately before use to maximize their efficacy and minimize the risk of microbial contamination (Fraise and Bradley 2009, E).

4 If the patient cannot remove their own dentures, remove the lower denture first.

(a) Lower denture: grasp it in the middle and lift it, rotating it gently to remove from the mouth, and place in denture pot.

(b) Upper denture: remove the upper denture by grasping firmly in the middle and tilting the denture forward while putting pressure on the front teeth to break the seal with the palate. Rotate the denture from side to side to remove it from the mouth and place in denture pot.

The lower denture should be removed first to avoid the risk of aspiration (Sweeney 2005, R5).

Removal of dentures is necessary for cleaning of underlying tissues (Sweeney 2005, R5).

5 Carry out oral assessment using an oral assessment tool. Provides baseline to enable monitoring of mucosal changes and evaluate response to treatment and care (Eilers et al. 1988, R5; Sonis et al. 2004, R5).

6 Inspect the patient’s mouth, including teeth, with the aid of a torch, spatula and gauze, paying special attention to the lips, buccal mucosa, lateral and ventral surfaces of the tongue, floor of the mouth and the soft palate. Ask the patient if they have any of the following: taste changes, change in saliva production and composition, oral discomfort or difficulty swallowing. The mouth is examined for changes in condition with respect to moisture, cleanliness, infected or bleeding areas, ulcers, and so on. These areas are known to be more susceptible to cytoxic damage (Sonis et al. 2004, R5). To assess nutritional deficits, salivary changes and pain secondary to oral changes (Sonis et al. 2004, R5).

7 Using a soft, small toothbrush and toothpaste (or foam stick if the gingiva is damaged or susceptible to bleeding), brush the patient’s natural teeth, gums and tongue. Stand behind or to the side of the patient and support the lower jaw with your free hand. To remove adherent materials from the teeth, tongue and gum surfaces (Beck 2004, E). Brushing stimulates gingival tissues to maintain tone and prevent circulatory stasis (Clay 2000, E; Pearson and Hutton 2002, R1b). Foam stick reduces possibility of trauma (Cooley 2002, E).

8 Hold the brush against the teeth with