Skill 7-4

Providing Oral Care for the Dependent Patient

Adequate oral hygiene care is imperative to promote the patient's sense of well-being and comfort, and prevent deterioration of the oral cavity (Kisely, 2016; Riley, 2018). Diligent oral hygiene care can improve oral health and limit the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, community-acquired pneumonia, nonventilator health care-associated pneumonia (NV-HAP), and ventilator-associated pneumonia (VAP) (AACN, 2017; Chick & Wynne, 2020; Jenson et al., 2018; Quinn et al., 2020). Comprehensive oral care that includes thorough mechanical cleaning is an important part of care to achieve oral health outcomes for patients in all settings (Barbe et al., 2020; Chick & Wynne, 2020; Chicote, 2019; Gibney et al., 2019; Kisey, 2016).

Physical limitations, such as those associated with aging, often lead to less than adequate oral hygiene. The dexterity required for adequate brushing and flossing may decrease with age or illness. Older adults may be dependent on caregivers for oral hygiene. Patients with cognitive impairment, such as dementia and mental illness, are also at risk for inadequate oral hygiene (Brennan & Strauss, 2014; Jablonski et al., 2018; Kadia et al., 2014; Red & O'Neal, 2020). Refer to Box 7-2 in Skill 7-3 for suggestions to meet the oral hygiene needs for patients with cognitive impairments.

Teeth should be brushed and flossed twice a day; the mouth should be rinsed after meals. If the patient is unable to perform oral hygiene, make certain that the mouth receives care as often as necessary to keep it clean and moist, as often as every 1 or 2 hours, if necessary. This is especially important for patients who cannot drink or are not permitted fluids by mouth. Moisten the mouth with water, if allowed, and lubricate the lips often enough to keep the membranes well moistened.

Delegation Considerations

The implementation of oral care for a dependent patient may be delegated to assistive personnel (AP) after assessment by the registered nurse as well as to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Suction toothbrush (see Figure 4) or soft toothbrush
Suction swab
Suction catheter with suction apparatus
Toothpaste or other oral cleanser
Emesis basin
Glass with cool water
Disposable gloves
Additional PPE, as indicated
Towel
Mouth rinse (optional)
Dental floss in holder or other interdental cleaner
Mouth-prop or second toothbrush (Figure 1)
Denture-cleaning equipment (if necessary)
Denture cup
Denture cleaner
4 × 4 gauze
Washcloth or paper towel
Lip lubricant (optional)
Oral health assessment tool (see Figure 1 in Skill 7-3)
Additional care giver, as indicated

Assessment

Assess the patient's oral hygiene preferences: frequency, time of day, and type of hygiene products. Assess for any physical activity limitations. Assess the patient's level of consciousness and overall ability to assist with oral care and respond to directions. Assess the patient's risk for oral hygiene problems. Alterations in cognitive function and/or consciousness increase the risk for alterations in oral tissue and structure integrity. Assess the patient's gag reflex. Decreased or absent gag reflex increases the risk for aspiration. An oral assessment tool can assist with assessment of the status of the oral cavity, as well as help to determine the frequency and procedure for oral care (see Figure 1 in Skill 7-3). Assess the patient's oral cavity and dentition. Look for any inflammation or bleeding of the gums. Look for ulcers, lesions, and yellow or white patches. The yellow or white patches may indicate a fungal infection called thrush. Assess for signs of dehydration (dry mucosa) and dental decay. Look at the lips for dryness or cracking. If the patient is conscious and/or cognitively able to respond, ask the patient if they are having pain, dryness, soreness, or difficulty chewing or swallowing.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired ability to perform oral hygiene
Impaired oral mucous membrane
Aspiration risk

Outcome Identification and Planning

The expected outcome to achieve when performing oral care is that the patient's mouth and teeth are clean; the patient does not experience impaired oral mucous membranes; and the patient verbalizes, if able, an understanding about the importance of oral care.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient. Explain the procedure to the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors. Explanation facilitates engagement in care.
3. Assemble equipment on the overbed table or other surface within reach.	Organization facilitates performance of the task.
4. Close the room door or curtains. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016). Lower one side rail and position the patient on the side, with head tilted forward. Place towel across the patient's chest and emesis basin in position under chin. Depending on equipment in use, connect the suction toothbrush/swab or suction catheter to suction tubing and turn on suction. Put on gloves.	Closing the door or curtains provides privacy. Proper bed height helps reduce back strain while performing the procedure. The side-lying position with head forward prevents aspiration of fluid into lungs. Towel and emesis basin protect the patient from dampness. Suction provides means to remove oral hygiene products and saliva from oral cavity. Gloves prevent the spread of microorganisms.
5. Gently open the patient's mouth by applying pressure to the lower jaw at the front of the mouth. Do not use fingers to hold the patient's mouth open. Use another toothbrush or mouth prop (Figure 1) to keep the mouth open (Johnson, 2012). Remove dentures, if present. (Refer to Skill 7-5.)	Patients with altered cognition may inadvertently bite fingers inserted into the mouth. Removal of dentures allows for cleaning of dentures and oral cavity.
6. If using a regular toothbrush and suction catheter, one care giver provides oral cleaning and the other removes secretions with the suction catheter.	This allows for efficient care to reduce the risk of aspiration.
7. Brush the teeth and gums carefully with toothbrush and paste or other oral cleanser (Figure 2). Lightly brush the tongue.	The toothbrush provides friction necessary to clean areas where plaque and tartar accumulate.
8. Moisten toothbrush with water to rinse the oral cavity. Position the patient's head to allow for return of water. If using regular toothbrush, use suction catheter to remove the water and cleanser from oral cavity (Figure 3).	Rinsing helps clean debris from the mouth. Suction toothbrush removes fluids and cleansers.
9. Brush the tongue gently with toothbrush or tongue scraper (MFMER, 2019a).	This removes coating on the tongue. Gentle motion does not stimulate the gag reflex.
10. Using the suction swab, apply a therapeutic antiseptic mouth rinse as indicated. Apply oral moisturizer as indicated.	Therapeutic and antiseptic mouth rinses reduce bacteria and reduce plaque, gingivitis, tartar, and reduce the incidence of health care-associated pneumonia (AACN, 2017; ADA, 2019; Chick & Wynne, 2020). Oral moisturizers provide moisture to the mucosa.
11. Clean the dentures before replacing. (See Skill 7-5.)	Cleaning maintains dentures and oral hygiene. Plaque can accumulate on dentures and promote oropharyngeal colonization of pathogens.
12. Apply lubricant to the patient's lips.	This prevents drying and cracking of lips.
13. Remove equipment and return the patient to a position of comfort. Remove gloves. Perform hand hygiene. Raise the side rail and lower the bed.	Promotes patient comfort and safety. Removing gloves properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
14. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient's oral cavity has been cleaned and is free from complications, and, the patient, if able, has verbalized a basic understanding of the need for oral care.

Documentation

Guidelines

Record oral assessment, significant observations, and unusual findings, such as bleeding or inflammation. Document any teaching done. Document care provided and patient response.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient begins to bite the toothbrush: Do not jerk the toothbrush out. Wait for the patient to relax mouth before removing the toothbrush and continuing with care. Use distraction, gentle touch, or massage to divert the patient (Johnson, 2012).
Mouth is extremely dry with crusts that remain after oral care provided: Increase frequency of oral hygiene. Apply mouth moisturizer to oral mucosa. Monitor fluid intake and output to ensure adequate intake of fluid.

Special Considerations

Suction toothbrushes may be used with patients with dysphagia (Figure 4).
Use a soft bristled toothbrush with a small head even when the patient has no or few teeth. It is the only effective way to remove plaque and debris from the teeth, gums, and tongue.
Automatic toothbrushes, electric or battery operated, are simple to use and can be used to removing debris and plaque and clean the teeth effectively. Use of an electric toothbrush provide superior oral hygiene care when oral hygiene is provided by a caregiver (Vannah & Sammarco, 2019).
The use of chlorhexidine gluconate (CHG) as part of oral hygiene has been integrated into oral hygiene regimens and is available as an oral rinse, oral spray, and dental gel (AACN, 2017; de Camargo et al., 2019). The use of CHG as part of protocols for systematic oral care for critically ill patients has been shown to reduce risk of VAP (AACN, 2017; Chen et al., 2015).

EVIDENCE FOR PRACTICE

Caregiver-Assisted Oral Hygiene

Poor oral hygiene contributes to alterations in oral health, and is associated with increased risk for aspiration pneumonia, community-acquired pneumonia, and other health concerns (Hata et al., 2019; Jenson et al., 2018; Müller, 2015; Quinn et al., 2020). Poor oral health in older adults compounds dental problems associated with aging. Adequate oral hygiene is essential to promote a sense of well-being and comfort and prevent deterioration of the oral cavity (Kisely, 2016; Riley, 2018).

Related Research

Vannah, C. E., & Sammarco, V. R. (2019). Electric brushes improve outcomes in caregiver-assisted oral hygiene. Nursing, 49(8), 56-60. https://doi.org/10.1097/01.NURSE.0000569764.96290.70

This study investigated caregiver-assisted oral hygiene using an electric toothbrush compared with caregiver-assisted oral hygiene using manual brushing. The residents at a long-term care facility were divided into two groups, based on the side of the hallway in which they resided. Eight of the residents who were completely dependent on caregivers for oral hygiene were recruited for the study. An experienced registered dental hygienist measured the amount of plaque on participants' teeth pre- and postintervention using the Plaque Index, resulting in a PLI score; a score of 0 indicates no visible plaque and 3 indicates a large amount of plaque on the teeth and in the space between the tooth and surrounding gum tissue. Nursing staff received training in use of the electric toothbrush and in manual tooth brushing. Caregivers provided oral care to all hallway residents, using the electric toothbrush with one group (one side of the hallway, Group A) and manual brushing with the other group (other side of the hallway, (Group B) for 8 weeks. Caregivers were unaware of which residents were study participants. The intervention was implemented for a second time after a 2-week interval of regular oral care. After the 2 weeks, a second pre-intervention scoring of teeth was completed. Nursing staff then provided oral care to all hallway residents, this time providing care using the other type of toothbrush: manual brushing for Group A and oral care with the electric toothbrush for Group B. The mean pre- and postintervention PLI scores in both phases were compared to determine the difference. The mean differences between the electric and manual methods were compared. Electric brushing was associated with a decrease in PLI score, and manual brushing was associated with an increased PLI score, with a statistically significant difference between the scores (p = .011). The researchers concluded that, after proper training, electric brushing was superior to manual brushing for plaque control in residents in long-term care settings when oral care was provided by a caregiver.

Relevance for Nursing Practice

Poor oral hygiene can contribute to poor oral health and oral diseases, as well as other systemic health problems. Nurses should consider evidence-based interventions to improve patient outcomes. Use of an electric toothbrush as part of oral health protocols provides the potential to improve patient's oral care and support optimal oral health outcomes and prevention of oral diseases in older adults.

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Skill 7-4

EVIDENCE FOR PRACTICE