Mouth care-basic and essential

MOUTH CARECARE BASIC AND ESSENTIAL Mouth care, a basic Mouth of nursing care, ppart rt of can also be crucial can to length length of of stay. to ~RACE GRACE M. BLANEY

Mouth care considered considered to be a part part of of Mouth routine nursing care care is not always always ootine nursing performed routinely. This simple erformed routinely. procedure, increases appefocedure, however, however,increases tite, general comfort comfort of of re, adds to the general the patlent, patient, and and can prevent systemic the preventsystemtc illness. illrjess. purpose of of this discussion discussion For the purpose on the necessity of ofgood mouth care, o~a good mouth let's describe a patient patient who is reprerepret's describe sentative of many many older patients patients in r~tative of hospitals or nursing nursing homes. hospitals homes.Mr. Zee diagnosis of of is 70 years old with a diagnosis cerebral vascular vascular accident. accident. He has a cerebral of diabetes diabetes and has lO-year history history of 10.year Humulin NPH units been on Humulin NPH 25 units every morning. He is being treated treated verY morning. with Digoxin, and K-lor K-lar for ith Lasix, Digoxin, congestive heart heart failure. failure. He has lost coogestive feedings gag reflex and is on tube feedings his gag J Grace Bianey, Blaney, RN, RN, BSN, BSN, is a staff nurse nurse at G~ee at Winthrop University University Hospital Hospital in in Mineola, Mineola, winthrop New York. York. Nev¢

242 Geriatric Nursing September/October 1986

at 50 cc/hr. days ago, Mr. ccJhr. Two days Mr. Zee developed a fever fever of of 102 with chest developed congestion. An intravenous intravenous solution solution congestion. of Dextrose 5 percent, percent, started of was started normal saline at 50 one-halfstrength one-half strengthnormal cc/hr. His diagnosis diagnosis is pneumonia. pneumonia. cc/hr. An antibiotic antibioticwas given and he develrash. At that that point, the medioped a rash. changed to Benadryl, Benadryl, givcation was changed hours to treat treat the rash. en every eight hours therash. percent venti-mask venti-mask for for He is on 28 percent therapy and requires requires frefreoxygen therapy quent suctioning suctioning for thick yellow sequent cretions. cretions. has many problems problems that that Mr. Zee has health can affect the cleanliness and health of his mouth. mouth. A number number of ofstressors of stressors affect the oral mucosa and aIid lead to can affect conditions such as xerostomia, xerostomia, or conditions Candida albicans.* albicans. * Oxygen Oxygen therapy therapy Candida frequent suctioning and the need for frequent suctioning trauma of of the mucosa, mucosa, can lead to trauma while mouth breathing breathing and lack of of intake leads to dryness dryness ooff the oral intake mouth(I). Moreover, Moreover, the aging promouth(l). cess itself may lead to a decrease decrease in cess ofsaliva. the flow of saliva. medications affect affect the oral Many medications Antibiotics can destroy destroy normucosa. Antibiotics mal flora flora in in the mouth mouth and without without appropriate mouth mouth care can can lead to appropriate Candida albicans albicans infections. infections. AntiCandida histamines, such as Benadryl, Benadryl, and histamines,

anticholinergic agents, agents, such as AtroAtroanticholinergic decrease the secretion secretion of of pine, will all decrease effects of diuretics, diuretics, such saliva. The effects monitored freas Lasix, need to be monitored quently to to prevent prevent the patient from from quently thepatient dehydrated. This can hapbecoming dehydrated. elderly patient, patient, espen easily with an elderly profile pecially one with a clinical profile described. like the one we have described. of the recent recent nursing nursing literaliteraMuch of pertains to mouth mouth care are ture that pertains ture studies(2-9). This literature literature oncology studies(2-9). resource for providing providing can be a good resource mouth care, care, and S. Beck has effective mouth this information information and developtaken this Guidelines/or Care(l 0). ed Guidelines for Oral Care(10). conditions can also Other medical medicalconditions stressors on the health health and inact as stressors tegrity of of the mouth. mouth. Cancer Cancer detegrity immune system and thus presses the immune increases the risk risk of of infections, infections, inincreases mouth. Diabetes cludingthose in the themouth. Mellitus also depresses depresses the immune immune Mellitus thickening of of system and causes thickening decreases circucircublood vessels, which decreases ~o mucosa. mucosa. Leukemia, Leukemia, which lation to suppresses white white blood cell count suppresses platelet levels, leads ieads to a deand platelet creased ability ability to fight fight infection infection and creased -Candida albicans albicans isisa genus genus of yeastlike yeastlike imim*Candida perfect fungi fungi that that can can cause cause a variety variety ofinfecofinfecperfect usually thrush. tions. Inthe the mouth, mouth, it is usually lions. thrush.

greater risk for bleeding. Radiagreaterrisk for oral oral bleeding. Radiation therapy therapy and and chemotherapy chemotherapy mouth and cause ulcerations in the mouth cause ulcerations and lower white blood cell count lower white count and arid platelet levels. Renal platelet Renal dysfunction dysfunction can lead lead to increased increased ammonia ammonia buildup and saliva saliva and and buildup in the blood and thus can cause thus cause oral oral inflammation inflammation and ulcerations. and ulcerations. risk factors, In view of the above above risk factors, that Mr. prime we can see that Mr. Zee Zee is a prime candidate candidatefor for alterations alterationsin the oral oral mucosa related related to his overall mucosa overall clinical clinical status. past nustatus. We need to assess his past tritional status receiving tritional statusto see ifhe if he is receiving adequate nutrients for healing. The adequate nutrients for healing. tube feedings tube feedings will have to be increased creased as he shows tolerance tolerance to them them to provide provide proper propernutrition. nutrition. alcohol and and tobacco can Since both both alcohol tobacco can irritate past history history irritatethe mucosa, mucosa, his past of smoking smoking and and drinking drinking is imporimportant. Oral must be done tant. Oral assessment assessment must frequently past and frequentlyto evaluate evaluate his past and present oral hygiene. A nursing nursing care present oral hygiene. care plan needs needs to written and plan to be written and evaluated regular basis. ated on on a regular

According to one study According study by Wiley, Wiley, the effectiveness effectiveness of lemon glycerin glycerin point. Wiley Wiley swabs remained remained a moot point. recommended additional recommended additionalstudies studies be carriedout(1l). out(l 1). carried mouth with with liquids Irrigating Irrigatingthe mouth liquids under pressure pressure can be effective, under effective, and and used in many many instithis procedure procedureis used institutions. However, patient such tutions. However, a patient such as Mr. Mr. Zee, who is semi-alert semi-alertand and combative with with a weak weak gag reflex, reflex, has a bative potential for potential for aspiration. aspiration.Thus when method of cleansing this method cleansing is employed, the patient patient must must be posiployed, tioned on his side with with his head head eletioned vated. Irrigations with vated. Irrigationscan be done with an asepto power spray, water asepto syringe, syringe,power spray,water pick, douche, bag. pick, douche, or enema enema bag. Cleansing Solutions

into the person's person's mouth mouth to provide provide lubrication. lubrication. How Often is Care Given? The frequency mouth care frequencyof mouth care will patient. A depend depend on the individual individual patient. plan of care would inplan care for for MI. M~. Zee would mouth care clude clude mouth care at least least every every two hours around the clock. A study study by by hours around that a failure Ginsberg Ginsbergdemonstrated demonstratedthat failure mouth care to give mouth care for for an extended extended period of two to six hours hours nullifies nullifies period previously given oral benefits of previously the benefits oral care(l2). care(12). Breakdown Breakdown can occur occur in the oral oral mouth care mucosa if mouth mucosa care is inadequate inadequate for period of time. time. Stofor a significant significantperiod matitis or mucositis matitis mucositis may develop. develop. The tongue tongue and mucosa become and oral oral mucosa red, inflamed red, inflamed and and extremely extremely dry, dry, which leads which leads to cracking crackingof the mucosa, bleeding, bleeding, and and open lesions, and, and, 1n turn, can cause infection. in turn, infection.Your patient will be more more uncomfortable uncomfortable and tient and can become more more ill. Then Then even more aggressive nursing measures measures more aggressive nursing needed. will be needed. Although providing providing mouth mouth care Although care may not be the highest highest priority priority on may your list, it deserves your deserves attention attention because cause it is basic to the comfort comfortofyour ofyour patient and prevents further patient and can prevents further complications. complications.

Many Many solutions solutions are are available available for for rinsing the mouth. mouth. cleaning cleaning and and rinsing Commercial mouthwashes must must be Commercial mouthwashes carefully before they they are carefully evaluated evaluated before are used. Most contain used. contain alcohol alcohol and and could more dryness could lead lead to more drynessand and irritairritation. Normal Normal saline tion. saline solutions solutions are are probably the most universally universally availprobably availMouth Care Equipment able, able, effective, effective, and and least least likely likely to Normal saline cause irritation. irritation. Normal saline is If Mr. Mr. Zee has has fairly fairly clean clean and and cause plastic bottles bottles or can be available in plastic healthy oral tissue to begin begin with, with, prepre- available healthy oral tissue readily made made by adding teaspoon addingone teaspoon vention vention is the key. key. If he already alreadyhas readily water. quartof water. some oral problems, then then proper proper as- of salt to a quart oral problems, People like Mr. might have Mr. Zee Zee might sessment treatment is imperasessment and and treatment imperavery thick thick secretions mucus References secretions or dried dried mucus before more more severe problems problems de- very tive before References in the mouth. mouth. Sodium bicarbonate I. DeWalt, Sodium bicarbonate velop. DeWalt, E. Haines, A. F_ M., and and Haines, A. K. ICThe The effects effectsof velop, specified stressors stressors on healthy oral mucosa. mucosa. specified healthy oral normal saline) saline) Since Mr. Mr. Zee cannot cannot care care for for his his (10 cc. in 1000 ml. of normal Nurs.Res. 18:22-27, 18:22-27, Jan.-Feb. Jan.-Feb.1969. hydrogen peroxide peroxide solutions solutions(1f4 (1/4or 2. Yasko, own mouth, mouth, as his nurse nurse you will be or hydrogen Vasko, Joyce. SympJoyce.Guidelinesfor Guidelines for Cancer Care: Care:Symptom Management. Management. Reston, Reston, VA, VA, Reston Reston Publish· PublishI/2 H H202) responsible for performing his III responsible for performing 20 2) can be used to loosen the pp. 212-223. ing Co., 1983, 1983, pp. mucus and thin the secretions. and thin secretions. Hy- 3. ingCo., mouth care teaching his family mouth care or for for teaching family mucus Lane, Forgay, M. M. Upgrading Upgrading your your oral Lane,B., and and Forgay, oralhy. hyperoxide should drogen peroxide should not be used how to do so. Using dental dentalfloss and and a drogen giene the patient giene protocol protocol for for the patient with with cancer. cancer. Can.Nurs. 7:27·29, 7:27-29, Dec. 1981. 1981. tissue. It is also fresh granulation granulationtissue. soft-bristle toothbrush is the most ef- on fresh soft-bristletoothbrush Bersani, Gayle, for 4. Bersani, Gayle,and and Carl, Carl,William. William.Oral Oralcare care for necessary completely remove necessary to completely remove the fective remove debris fective way to remove debris and and Am.J.Nurs. 83:533-536, Apr. cancer cancer patients. patients. Am.J.Nurs. 83:533-536, Apr. bicarbonate or hydrogen hydrogen pesodium bicarbonate plaque. The toothbrush toothbrush can also be sodium 1983. plaque. Beck, Susan. Susan.Impact Impactora of a systematic systematicoral oralcare careproproroxide solution mouth with with 5. Beck, solution from from the themouth used· to stimulate used stimulate circulation circulation in the roxide Cancer tocol on stomatitis tocol stomatids after afterchemotherapy. chemotherapy. water or orsaline. saline. mucosa. Some patients, patients, however, however, water mucosa. Nurs. 2:185-199, Nuts. 2:i85-199, June June 1979. 1979. D. E., E., and and others. others. Relationship Relationshipof in· in6. Peterson, Peterson, D. cannot tolerate flossing tooth- Moisturizers cannot tolerate flossing and and a toothtensive oral oralhygiene hygieneto systemic systemiccomplications complicationsinin brush. Other mouth just brush. Other times timesif the mouth acute acute nonlymphocytic nonlymphocytic leukemia leukemia patients. patients. mouth is clean, Once the mouth clean, it needs needs needs to be moistened moistened or medication medication needs Clin.Res. 29:440A, 29:440A, Nov. 1981. Daemer. Reidun. measures forfor pa-paReidun.Oral Oralhygiene hygiene measures kept moist. moist. When When not contraincontrain- 7. Daefner, applied, toothbrush is not indi- to be kept applied, a toothbrush CancerNurs. 3:347-356, tients with with cancer. rents cancer.Pan PartI. I. dicated, encourage encouragefluid fluid intake. intake. The cated. using le- dicated, cated. Many Many institutions institutionsare are using Oct. Oct. 1980. 1980. mucosa can be moistened moistened with with water water 8.8 . . mucosa . Oral hygiene measures measures for pamon glycerin glycerinswabs. swabs. Oral hygiene for patients with cancer. cancer.Pan PartII. II. Cancer Nuts. 3:427tients with Nurs. 3:427Petroleum jelly and Q-Tip. Petroleum and Lemon, however, is an acid that that with a Q-Tip. Lemon, however, Dec. 1980. 432, Dec. mineral oil can be applied applied carefully carefully 9. sometimes causes discomfort discomfortto irriirri- mineral sometimes •. Oral hygiene measures measures for paOral hygiene for paIII. Nurs. 4:29-35. tients with tients withcancer. cancer,Pan Part nl. Cancer Nuts. 4:29-35, but could problems couldcause problems tated areas tated areas and and can lead lead to decalcifidecalcifi- to the lips but Feb. 1981. aspirated.Water-soluble Water-solublelubricant lubricant 10. Feb. teeth. Glycerin cation cation ofthe of the teeth. Glycerinis a form form if aspirated. Beck; S. Guidelines for Oral Care. Cary, Beck, Cary, II., IL,Sage Sage applied to the lips and and oral oral ofalcohol that can cause dryness. of alcohol that dryness.Le- can be applied Products, Products, 1984. Wiley, B. Why Glycerol 11. Wiley, B. Why Glycerol and and lemon lemon juice? juice? salivas, although although II. mucosa. Artificial Artificial salivas, mon glycerin glycerinswabs also have no me- mucosa. Am.J.Nurs. 69:342-344, Feb. 1969. 69:342-344, Feb. 1969. expensive, are are used in cases ofxeros- 12. Am.ZNurs. chanical chanical effect effect in cleaning cleaning the expensive, Ginsbell. M. K. Ginsber~,M. K. A study studyor of oral oral hygiene hygienenursing nursing tomia tomia and and can be sprayed sprayed directly directly mouth(lO). car~m.J.Nurs. care rJgm.J.Nurs. 61:67·69, 61:67-69, Oct. Oct. 1961. mouth(10).

Geriatric Nursing September/October Geriatric Nursing September/October1986243 1986 243