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The Effect of Oral Care Using an Oral Health Care Guide on Preventing Mucositis in Pediatric Intensive Care
Journal of Pediatric Nursing 36 (2017) 98–102
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Journal of Pediatric Nursing
The Effect of Oral Care Using an Oral Health Care Guide on Preventing Mucositis in Pediatric Intensive Care Duygu Sönmez Düzkaya, PhD, BSc, RN a,⁎, Gülzade Uysal, PhD, BSc, RN, Assistant Professor b, Gülçin Bozkurt, PhD, BSc, RN, Associate Professor c, Tülay Yakut, BSc d a
Istanbul University, Istanbul Faculty of Medicine, Directorate of Nursing Services, Education Nurse, Çapa-Fatih, 34053 Istanbul, Turkey Okan University, School of Health Sciences, Istanbul, Turkey Istanbul University, School of Health Sciences, Istanbul, Turkey d Istanbul University, Istanbul Faculty of Medicine, Pediatric Intensive Care Unit, Istanbul, Turkey b c
a r t i c l e
i n f o
Article history: Received 13 January 2017 Revised 27 May 2017 Accepted 28 May 2017 Available online xxxx Keywords: Oral mucositis Oral care Nursing care Pediatric intensive care
a b s t r a c t Objectives: To evaluate the effectiveness of standard-of-care oral care guides developed specifically for children in intensive care to prevent mucositis. Design and Methods: This prospective, interventional and single-group study design was performed in the pediatric intensive care unit of a university hospital in Istanbul between January and December 2014. Daily oral care was implemented to pediatric patients in the study group in line with an oral care guide developed by the researchers. Data were collected using the data collection form and oral mucositis assessment scale published by the World Health Organization (WHO). Results: Oral mucositis occurred in 16 (5.2%) patients in the pre-intervention group and 7 (2.5%) in the post-intervention group, 10 patients had grade 1, and 6 patients had grade 2 oral mucositis in the pre-intervention group, and in the post-intervention group, three patients had grade 1, and four patients had grade 2 oral mucositis. Although more patients in the pre-intervention group had mucositis than in the post-intervention group, the differences were not statistically significant (P = 0.067). Conclusions: Oral mucositis can be reduced through the practice of administering oral care in accordance with oral healthcare guidelines. Practice Implications: Oral care implemented in line with an evidence-based oral care guide and frequent observation of patients are the most important steps in preventing oral mucositis. © 2017 Elsevier Inc. All rights reserved.
Introduction Providing oral care hygiene for patients in the intensive care unit and protecting oral mucosa are important in the promotion of healthy nutrition, comfort, and increasing patients' quality of life, as well as preventing infections that might develop in the oropharynx and respiratory tract (Berry & Davidson, 2006; Berry, Davidson, Masters, & Rolls, 2007; Johnstone, Spence, & Koziol-McLain, 2011; Özveren, 2010; Thomson, Ayers, & Broughton, 2003). Although pediatric patients in intensive care require frequent oral care, this is commonly overlooked by nurses (Kearns, Brewer, & Booth, 2009). In a study performed in an adult intensive care unit in India, it was determined that the most frequently used technique for oral care was suctioning (AdibHajbaghery, Ansari, & Azizi-Fini, 2013).
⁎ Corresponding author. E-mail addresses: [email protected] (D.S. Düzkaya), [email protected] (G. Uysal), [email protected] (G. Bozkurt), [email protected] (T. Yakut).
http://dx.doi.org/10.1016/j.pedn.2017.05.010 0882-5963/© 2017 Elsevier Inc. All rights reserved.
Bacteria start to reproduce within 24–48 h of admission to intensive care units, which rapidly deteriorates the health of oral mucosa (Sebastian, Lodha, Kapil, & Kabra, 2012; Sönmez-Düzkaya, 2014). Nasogastric catheter/intubation tube can cause mechanical trauma related to the reduction of saliva and immunoglobulin A (IgA) secretion in the mucosa (Özveren, 2010; Sebastian et al., 2012). The mouth is constantly open because of endotracheal tube (ETT) use, and drugs for treatment such as steroids, sedatives, and opioids. Oxygen therapy, fever, and adhesive tape used for securing the endotracheal tube lead to deterioration of tissue integrity in the mouth, results in the development in the mouth such as halitosis, dry mouth, cracked lips, and stomatitis (Abidia, 2007; Grap, Munro, Brooke, & Bryant, 2003; Sebastian et al., 2012; Thomson et al., 2003). In addition to such problems, insufficient application of oral care leads to an increase in the formation of plaques in the mouth, bacterial colonization in the oropharynx, and frequency of hospital infections. The incidence of ventilator-associated pneumonia is a concern (Grap & Munro, 2004; Johnstone et al., 2011; Sönmez-Düzkaya, 2014). It has been found that insufficient oral care affects mortality and morbidity, and that strategies should be formed to
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develop oral care in patients who are in a critical condition (Chan, Ruest, Meade, & Cook, 2007; Munro et al., 2006; Stonecypher, 2010). For mechanical ventilator-dependent patients in intensive care, providing and sustaining oral hygiene, preventing pressure arising from biting and adhesive tape or trauma, and deterioration in skin/mucosa are important nursing care interventions that enhance good patient care (Abidia, 2007; Akdemir, 2013). Grap et al. (2003) detected that 72% of nurses performed oral care to intensive care patients 5 or more times per day but did not report it. To prevent oral mucositis and protect oral health in intensive care, it is important to evaluate the oral cavity (teeth, gum, tongue, mucosa membrane, and lips) and implement oral care with appropriate equipment (Berry et al., 2007; Fields, 2008; Garcia et al., 2009; Pearson, 1996; Uysal & Sönmez-Düzkaya, 2013). Studies related to oral care have mostly been conducted in adult patients; it was shown that mucosal integrity deteriorated and functional loss occurred at a serious level in 4.4% of patients, and at a medium level in 41% of patients 24 h after inserting an ETT (Mohammed & Hassan, 2015). Ullman, Long, and Lewis (2011) detected that mucosal integrity deteriorated and functional loss occurred at a medium level in 62.6% of children in intensive care. Nurses in intensive care units play an important role in the prevention or reduction of mucositis and increasing patients' quality of life because their role as health care providers is to continuously follow up patients and implement oral care. There is still no generally accepted standard treatment and care applications for preventing or managing mucositis. In accordance with standards of nursing practice and quality clinical care, nurses are encouraged to used evidence-based clinical guidelines (Çavuşoğlu, 2007; Grap et al., 2003; Yılmaz, 2007). A large number of studies are needed to determine the best oral care guide for patients in intensive care (Grap et al., 2003). Method Objectives The purpose of this study was to review the effect of standardized oral care, which was implemented in line with the oral health care guide in children in intensive care to prevent mucositis formation. Study Design Oral care for preventing mucositis in the pediatric intensive care unit (PICU) was implemented in line with an oral care guide (OCG) that was developed by the researchers after reviewing the literature. The effect of using the guide was evaluated using prospective, interventional and single-group study methods (Franklin, Senior, James, & Roberts, 1999; Stonecypher, 2010; Ullman et al., 2011). Study Period and Sample The study was conducted between January and December 2014 with 320 patients who were admitted to the PICU of a university hospital in Istanbul. Convenience sampling was used because all patients were admitted as part of the study. No sampling selection was made and the entire population was taken into consideration; 5 patients who had oral mucositis on admission to intensive care, and 31 patients who were discharged from intensive care within 48 h were excluded from the study. Over the study period, 284 pediatric patients who were admitted to the PICU for N48 h and had no oral mucositis on admission were included in the study; the participation rate in the study was 88.8%. To evaluate the guide's impact, a retrospective study was conducted of oral mucositis rates before the oral care guide's implementation between January and December 2013. A total of 310 patients were included.
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Study Setting The 6-bed PICU in which the study was conducted is staffed by 13 nurses. An average number of 250–350 children with acute respiratory diseases, sepsis, shock, multi-organ insufficiency, poisoning, or those who require close post-operative follow-up are admitted to the unit yearly. The nurse-to-patient ratio is one nurse per two patients. Study Stages The research was performed in three stages. Stage 1: We collected data retrospectively to evaluate the OCG's impact. Stage 2: Nurses who worked in the clinic were informed about the scope of the study followed by a 2-hour training session on the use of the OCG and additional training on the data collection tools (data collection form and oral mucositis assessment scale). The responsible nurse gave monthly feedback to nurses about oral mucositis rates on the unit. Interventions were performed for children who developed oral mucositis, in addition to methods for protecting their oral mucosa, i.e. changing ETT fixation position, applying moisturizer to lips, suction, and increasing the frequency of oral care (Akdemir, 2013; American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health, 2008; Uysal & Sönmez-Düzkaya, 2013). Oral Care Guidelines: (Akdemir, 2013; American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health, 2008; Berry et al., 2007; Fields, 2008; Johnstone et al., 2011; Thomson et al., 2003). • Evaluate/assess mouths daily • Perform oral care every 4 h each day (oral care should be applied every 2–4 h for high-risk patients such as those receiving chemotherapy, with fever, or using neuromuscular blocking medicine), • Use disposable sponge sticks and solutions containing 0.12% chlorhexidine in oral care, • Brush gums and teeth gently (with care if the patient is edentulous) • To keep the tissues moistened, the mucous membrane should be coated with a moisturizer gel • Apply moisturizer after oral care to prevent lips from drying, • Toothpaste or secretions should be removed by rinsing the mouth using an irrigation syringe or sponge, and if necessary, secretions may be removed using suction at low negative aspiration pressure (50–80 mm Hg), • Use soft fasteners in securing of the intubation tube, continuously watching the contact area of the skin, protect against damage to the skin when removing fasteners, and to sustain circulation by applying massage to the zones where tube securing is present. Stage 3: A data collection form was completed for each patient in the first 24 h. The patients' daily oral care was provided using the OGC. The World Health Organization (WHO) oral mucositis assessment scale (Ahmed, 2013; Cheng, Molassiotis, Chang, Wai, & Cheung, 2001; World Health Organization, 1979) was used to evaluate the patients' mouths every day. Stage 4: Retrospective data from before the OCG implementation were compared with the mucositis rates during the study period. Pilot Study A pilot study was conducted on nine patients to evaluate the conformity of the research forms. The patients in the pilot study were excluded from the research. Data Collection Data Collection Form A Data Collection Form was prepared by the authors after reviewing the relevant literature (Chan et al., 2007; Munro et al., 2006;
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Stonecypher, 2010; Ullman et al., 2011). The form comprised 25 sections in total, including personal characteristics such as the patient's date of admission, age, gender, diagnosis, additional disease, nutritional status, mechanical ventilation, and drugs used, as well as providing space to comment or record observations regarding oral mucositis risk factors such as fever, oxygen therapy, not feeding, dehydration, steroid treatment, and chemotherapy, and oral mucositis. The World Health Organization (WHO) Oral Mucositis Assessment Scale is a commonly used identification tool in the grading of oral mucositis in hospitals. In the scale, anatomic changes regarding oral mucosa and mucositis severity are graded between zero and four. A mouth with a healthy appearance and no mucositis was graded as zero (0) points, erythematous lesions observed in the oral cavity (1), red zones with increased mucosa, and lesions separated from each other (2), reddening of the entire oral mucosa with a large number of combined ulcers (3), and (4) if ulcers, hemorrhage and necrosis was present in the mouth (Can, 2010; Cheng et al., 2001; Çubukçu, 2005; World Health Organization, 1979). The oral mucositis assessment scale has been used for the clinical assessment of adult and pediatric patients receiving cancer therapy (Ahmed, 2013; Elad et al., 2011).
Ethical Approval This study was conducted after obtaining the required permissions were obtained from hospital management and ethics committee. The parents of the children included in the research were informed regarding the purpose, planning, and duration of the study, and how the data were to be used. Written consent was obtained from the parents based on the principles of willingness and voluntariness. All healthcare workers related with the PICU were briefed about the research. Data Analysis
Table 1 Baseline data of children. Features
Post-intervention (n = 284) n (%)
Pre-intervention (n = 310) n (%)
Pa
Age (month) average (min-max)
76.64 ± 5.29 (1–204)
69.78 ± 4.89 (1–204)
0.742
123(43.3) 161 (56.7)
152 (49) 158 (51)
90 (31.8) 52 (18.3) 51 (17.9) 33 (11.6) 30 (10.5) 18 (6.3) 10 (3.6)
118 (38) 62 (20) 48 (15.5) 31 (10) 25 (8) 14 (4.6) 12 (3.9)
110 (38.7) 174 (61.3)
126 (40.6) 184 (59.4)
22 (7.7) 38 (13.5) 32 (11.2) 192 (67.6)
19 (6.2) 42 (13.5) 39 (12.5) 210 (67.8)
182 (64) 102 (36)
198 (63.9) 112 (36.1)
0.848
222 (78.1) 62 (21.9)
234 (75.5) 76 (24.5)
0.750
57 (20) 227 (80) 5.43 ± 3.69 (0−20) 10.15 ± 0.48 (2−30)
68 (21.9) 242 (78.1) 5.19 ± 4.51 (0–24) 11.56 ± 1.45 (3–40)
0.983
Sex Female Male Diagnosis Respiratory system diseases Neurologic diseases Intoxication Metabolic diseases Post-op follow-up Septicemia Other diseases Additional diseases Yes No Nutrition status Oral Enteral feeding Parenteral feeding Enteral and parenteral feeding Intubation status Intubated Not intubated Treatment of antibiotic Used Did not use Neuromuscular-blocking-drugs Used Did not use Duration of ventilation mean/median/min-max (days) PICU length of stay mean/median/min-max (days) a
Data were analyzed using the SPSS.21.0 version (SPSS, Chicago, IL, USA).
0.162
0.934
0.839
0.764
0.621 0.393
χ2 = Chi-square test.
Oral Mucositis Features, Post- and Pre-intervention Results Baseline Data Pre- and Post-intervention The pre-intervention research group was composed of 310 patients who were admitted to the PICU between January and December 2013, and the post-intervention research group was comprised of 284 patients who were admitted to the PICU between January and December 2014. The baseline data of the post- and pre-intervention groups are shown in Table 1. No statistically significant difference was found between the pre-and post-intervention groups (P N 0.05).
Detailed descriptions of pre- and post-intervention findings regarding oral mucositis are shown in Table 4. No statistically significant difference between the pre-and post-intervention groups was found (P N 0.05). All of the patients with oral mucositis had been intubated, could not feed orally, had oxygen therapy, steroid therapy, and antibiotic treatment. When considered in terms of other characteristics, it was determined that 71.5% of the patients had fever and dehydration. Some 42.8% received chemotherapy treatment and 85.7% received neuromuscular block treatment (Fig. 1).
Risk Factors of Pre- and Post-intervention We reviewed risk factors related to oral mucositis in the pre- and post-intervention groups in terms of oral feeding, oxygen therapy, steroid therapy, fever, dehydration, and chemotherapy. The results are presented in Table 2.
Compared Oral Mucositis Rate Oral mucositis was detected in 5.2% (n = 16) of patients in the preintervention group, and 2.5% (n = 7) of patients the post-intervention group. Although more patients in the pre- intervention group had mucositis than in the post-intervention group, the differences were not statistically significant (P = 0.067) (Table 3).
Table 2 Comparison of risk factors for developing oral mucositis. Risk factors
Post-intervention (n = 284) n (%)
Pre-intervention (n = 310) n (%)
Pa
No oral feeding Oxygen therapy Treatment of steroid Fever Dehydration Chemotherapy
262 (92.2) 250 (88) 158 (55.7)
291 (93.8) 286 (92.2) 172 (55.4)
0.346 0.060 0.966
29 (10.2) 26 (9.2) 5 (1.8)
42 (13.5) 38 (12.2) 8 (2.6)
0.172 0.182 0.495
a
χ2 = Chi-square test.
D.S. Düzkaya et al. / Journal of Pediatric Nursing 36 (2017) 98–102 Table 3 Compared oral mucositis rate. Features Post-intervention (n = 284) Pre-intervention (n = 310) Pa Oral mucositis n (%) n (%) Occurred Did not occur a
7 (2.5) 277 (97.5)
16 (5.2) 294 (94.8)
– 0.067
χ2 = Chi-square (Fisher exact) test.
Discussion Pediatric patients are mostly admitted to intensive care units with diagnoses of respiratory, neurologic, and metabolic diseases, and for postoperative follow-up (Abramczyk, Carvalho, Carvalho, & Medeiros, 2003; Porto et al., 2012; Ullman et al., 2011). We also found that children in the study group mostly had respiratory, neurologic, and metabolic conditions. Approximately one third of the patients who were admitted to intensive care with serious conditions also had an additional disease. Many researchers reported that numerous interventions provided to children in the intensive care because of serious disease (e.g. nasogastric catheter/intubation tubes causing mechanical trauma; constant open mouth; drugs used for treatment, inability to take food and liquid by mouth, oxygen therapy, and adhesive tape used for endotracheal tube securing) and comorbidities were factors that increased the risk of oral mucositis (Grap et al., 2003; Özveren, 2010; Sebastian et al., 2012). The number of studies related to oral mucositis in children in intensive care is limited (Franklin et al., 1999; Ullman et al., 2011). In the literature, the general rate of oral mucositis is 5–15%, whereas this ratio is over 80% in patients who receive cancer treatment (Çavuşoğlu, 2007). In the study by Ullman et al. (2011), which was conducted in a PICU, the authors found that oral mucosal integrity was impaired in 62.6% of patients. The rate in the pre-intervention group in our PICU was 5.2%, and the post-intervention rate was 2.5% in our study group. When the results of Ullman et al. (2011) and our pre-intervention rate were compared with our post-intervention frequency, the rate of oral mucositis was quite low. Franklin et al. (1999) determined that children were at risk and routine mouth care was not effective in preventing plaque accumulation and protecting gum health due to local or systemic spread of microorganisms formed in the mouth during intensive care. In the literature, it is stated that one single intervention is not sufficient in mucositis management and the integration of multipurpose interventions for care is recommended (Çavuşoğlu, 2007). In the present study, it can be considered that oral care implemented in line with an OCG was effective in preventing mucositis and reducing oral health assessment scores. These results supported those of Abidia (2007), Handa, Chand, Sarin, Singh, and Sharma (2014), and Sazlina and Ong (2012), which showed
Table 4 Oral mucositis features, post- and pre-intervention. Features
Post-intervention (n = 7) n (%)
Diagnosis phase Grade 1 3 (42.9) Grade 2 4 (57.1) Exposure time of mucositis ≤7 day 3 (42.9) N7 day 4 (57.1) Mucositis at discharge No mucositis 5 (71.4) Grade 1 2 (28.6) Region of oral mucositis Lip edge 3 (42.9) Cheek 3 (42.9) Upper tongue 1 (14.2) a
χ2 = Chi-square test.
Pre-intervention (n = 16) n (%)
Pa
10 (62.5) 6 (37.5)
0.170
5 (31.2) 11 (68.8)
0.208
13 (81.2) 3 (18.8)
0.209
7 (43.7) 4 (25.0) 5 (31.3)
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that an oral care protocol could maintain the oral health status of hospitalized children. Regardless, there is a paucity of literature surrounding the effectiveness and appropriateness of oral hygiene practices in pediatric intensive care units. Due to the spread of microorganisms in the mouths of ventilator-dependent children in intensive care, it has been emphasized that the risk for deterioration of mouth integrity is high (Franklin et al., 1999; Özveren, 2010). In the literature, it was reported that antibiotic use, inability for eating orally, and steroid use (Jiggins & Talbot, 1999; Sixou, Medeiros-Batista, & Bonnaure-Mallet, 1996) had serious disease effects on oral health, accelerated mucositis formation (Thorburn et al., 2009), and intubation in particular caused injuries in the mucosa and cheek thus leading to patient discomfort (Ullman et al., 2011). In three (1.1%) children in the study group, oral mucositis development was identified on the side of the lips as a result of ETT fixation. Compatible with the literature, we found that all patients who developed oral mucositis were intubated, could not eat orally, and had oxygen therapy, steroids, and antibiotic treatment and 42.8% of the patients received chemotherapy treatment. As the time that patients stay in intensive care extends, it is reported that tissues in and around the mouth lose their integrity based on the increase in drugs used for treatment and extension of intubation time (Özveren, 2010; Sebastian et al., 2012). In the study group, it was observed that oral mucositis developed after the 7th day in four of the children after admission. No inference can be made regarding the effect of length of stay in intensive care to mucositis development because the number of patients in whom oral mucositis was detected was very low within the study period. In order to test this with randomized controlled studies, more studies are required with larger samples. As result of the interventions applied for oral mucositis, it was observed that the oral mucositis of five children totally recovered and two children were discharged from intensive care with grade 1 oral mucositis. In the literature, it is documented that replacing the ETT fixation point, applying moisturizer, and increasing the frequency of oral care, which are techniques performed in children with mucositis, are effective at both preventing and treating oral mucositis (Johnstone et al., 2011; Thomson et al., 2003). Clinical Implications Protecting oral mucosal integrity in the PICU is an important intervention for nurses. Risk factors for oral mucositis include being in the PICU, use intubation tube and intubation tube fasteners, and treatment such as steroids, sedatives, opioids, and oxygen therapy. Nurses should be aware of these risk factors and care for patients using evidence-based practice. The OCG can be used by nurses to prevent oral mucositis. Limitations of the Study This was a single institutional study and the results are not generalizable because there was no randomization. The major limitation of this study was sample size. The pre- and post-intervention findings of the study were collected by the same researcher, which could be a potential source of bias. This study did not describe oropharyngeal colonization. Conclusion
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It is important to prevent mucositis before it develops considering its burden to the individual and healthcare costs, because treatment of oral mucositis is intractable. Oral care implemented in line with an evidence-based OCG and frequent observation of patients are the most important steps in preventing oral mucositis. Oral care implemented in line with the OCG in this study decreased the frequency of oral mucositis.It can be considered that the OCG was effective in reducing the incidence of oral mucositis.
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Fig. 1. Features of children with oral mucositis (n=7). *NBG: Neuromuscular-blocking-drug.
The number of studies conducted towards preventing oral mucositis in children in intensive care is limited, and multicenter, randomized, controlled studies with greater sample sizes are needed. Acknowledgments The researchers gratefully thank all the nurses and physicians working in the PICU, and we would also like to thank Mr. David F. Chapman for his assistance in the language of the article. References Abidia, R. F. (2007). Oral care in the intensive care unit: A review. Journal of Contemporary Dental Practice, 8, 10–26. Abramczyk, M. L., Carvalho, W. B., Carvalho, E. S., & Medeiros, E. A. S. (2003). Nosocomial infection in a pediatric intensive care unit in a developing country. The Brazilian Journal of Infectious Diseases, 7, 375–380. http://dx.doi.org/10.1590/S141386702003000600004. Adib-Hajbaghery, M., Ansari, A., & Azizi-Fini, I. (2013). Intensive care nurses' opinions and practice for oral care of mechanically ventilated patients. Indian Journal of Critical Care Medicine, 17, 23–27. http://dx.doi.org/10.4103/0972-5229.112154. Ahmed, K. M. (2013). The effect of olive leaf extract in decreasing the expression of two pro-inflammatory cytokines in patients receiving chemotherapy for cancer. A randomized clinical trial. The Saudi Dental Journal, 25, 141–147. http://dx.doi.org/10. 1016/j.sdentj.2013.09.001. Akdemir, N. B. (2013). The identification of critical care experience and factors that affect patients. Graduate Thesis, Gazi University Institute of Health Sciences, Ankara. American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health (2008). A policy statement: Preventive intervention for pediatricians. Pediatrics, 122, 1387–1394. Berry, A. M., & Davidson, P. M. (2006). Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit. Intensive & Critical Care Nursing, 22, 318–328. http://dx.doi.org/10.1016/j.iccn.2006.04.003. Berry, A. M., Davidson, P. M., Masters, J., & Rolls, K. (2007). Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. American Journal of Critical Care, 16, 552–562. Can, G. (2010). Mucositis. In G. Can (Ed.), Evidence-based symptom management in oncology nursing (pp. 81–101) (1st ed.). İstanbul, 3P-Pharma Publication Planning. Çavuşoğlu, H. (2007). Evidenced based nursing in the management of oral mucositis: Review. Türkiye Klinikleri, 27, 398–406. Chan, E., Ruest, A., Meade, M., & Cook, D. (2007). Oral decontamination for prevention of pneumonia in mechanically ventilated adults: Systematic review and meta-analysis. British Medical Journal, 334, 889–900. http://dx.doi.org/10.1136/bmj.39136.528160.BE. Cheng, K. K. F., Molassiotis, A., Chang, A. M., Wai, W. C., & Cheung, S. S. (2001). Evaulation of an oral care protocol intervention of chemotherapy-induced oral mucositis in paediatric cancer patients. European Journal of Oncology Nursing, 37, 2056–2063. Çubukçu, Ç. E. (2005). Oral mucositis and oral health in the pediatric cancer patients. Güncel Pediatri, 3, 67–69. Elad, S., Luboshitz-Shon, N., Cohen, T., Wainchwaig, E., Shapira, M. Y., Resnick, I. B., ... Or, R. (2011). A randomized controlled trial of visible-light therapy for the prevention of oral mucositis. Oral Oncology, 47, 125–130. http://dx.doi.org/10.1016/j.oraloncology. 2010.11.013. Fields, L. (2008). Oral care intervention to reduce incidence of ventilator associated pneumonia in the neurologic intensive care unit. Journal of Neuroscience Nursing, 40, 291–298. Franklin, D., Senior, N., James, I., & Roberts, G. (1999). Oral health status of children in a paediatric intensive care unit. Intensive Care Medicine, 26, 319–324. Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing ventilator-associated pneumonia through advanced oral-dentalcare: A 48-month
study. American Journal of Critical Care, 18, 523–534. http://dx.doi.org/10.4037/ ajcc2009311. Grap, M. J., Munro, C., Brooke, A., & Bryant, S. (2003). Oral care interventions in critical care: Frequency and documentation. American Journal of Critical Care, 12, 113–118. Grap, M. J., & Munro, C. L. (2004). Preventing ventilator-associated pneumonia: Evidence based care. Critical Care Nursing Clinics of North America, 16, 349–358. http://dx.doi. org/10.1016/j.ccell.2004.03.005. Handa, S., Chand, S., Sarin, J., Singh, V. A., & Sharma, S. (2014). Effectiveness of oral care protocol on oral health status of hospitalised children admitted in intensive care units of selected hospital of Haryana. Nursing and Midwifery Research Journal, 10, 8–15. Jiggins, M., & Talbot, J. (1999). Mouthcare in PICU. Paediatric Nursing, 11, 23–26. Johnstone, L., Spence, D., & Koziol-McLain, J. (2011). Oral hygiene care in the pediatric intensive care unit: Practice recommendations. Pediatric Nursing, 36, 85–96. Kearns, R., Brewer, A., & Booth, M. (2009). Oral hygiene practices in Scottish intensive care units — A national survey. The Journal of the Intensive Care Society, 10, 155–158. Mohammed, H. M., & Hassan, M. S. (2015). Endotracheal tube securements: Effectiveness of three techniques among orally intubated patients. Egyptian Journal of Chest Diseases and Tuberculosis, 64, 183–196. http://dx.doi.org/10.1016/j.ejcdt.2014.09.006. Munro, C., Grap, M. J., Elswick, R. K., McKinney, J., Sessler, C. N., & Hummel, R. S. (2006). Oral health status and development of ventilator-associated pneumonia: A descriptive study. American Journal of Critical Care, 15, 453–460. Özveren, H. (2010). Oral care in patients receiving mechanical ventilator. Sağlık Bilimleri Fakültesi Hemşirelik Dergisi, 92–99. Pearson, L. S. (1996). A comparison of the ability of foam swabs and tooth brushes to remove dental plaque: Implications for nursing practice. Journal of Advanced Nursing, 23, 62–69. Porto, J. P., Mantese, O. C., Arantes, A., Freitas, C., Gontijo-Filho, P. P., & Ribas, R. M. (2012). Nosocomial infections in a pediatric intensive care unit of a developing country: NHSN surveillance. Revista da Sociedade Brasileira de Medicina Tropical, 45, 475–479. Sazlina, S. G., & Ong, L. (2012). Oral care practice for the ventilated patients in intensive care units: A pilot survey. Journal of Infection in Developing Countries, 6, 333–339. Sebastian, M. R., Lodha, R., Kapil, A., & Kabra, S. K. (2012). Oral mucosal decontamination with chlorhexidine for the prevention of ventilator-associated pneumonia in children—A randomized, controlled trial. Pediatric Critical Care Medicine, 13, 305–310. http://dx.doi.org/10.1097/PCC.0b013e31824ea119. Sixou, J., Medeiros-Batista, O., & Bonnaure-Mallet, M. (1996). Modifications of the microflora of the oral cavity arising during immunosuppressive chemotherapy. Oral Oncology: European Journal of Cancer, 32B, 306–310. Sönmez-Düzkaya, D. (2014). Nurse's role in preventing ventilator-associated pneumonia in pediatric intensive care unit. The Journal of Pediatric Research, 1, 54–61. Stonecypher, K. (2010). Ventilator-associated pneumonia: The importance of oral care in intubated adults. Critical Care Nursing Quarterly, 33, 339–347. http://dx.doi.org/10. 1097/CNQ.0b013e3181f649a6. Thomson, W. M., Ayers, K. M. S., & Broughton, J. R. (2003). Child oral health inequalities in New Zealand: A background paper to the public health advisory committee. National Health Committee, 2003, 30–94 Retrieved from http://www.nhc.govt.nz/publications/ PDFs/chldoralhth.Pdf. Thorburn, K., Jardine, M., Taylor, N., Reilly, N., Sarginson, R. E., & van Saene, H. K. (2009). Antibiotic resistant bacteria and infection in children with cerebral palsy requiring mechanical ventilation. Pediatric Critical Care Medicine, 10, 222–226. http://dx.doi. org/10.1097/PCC.0b013e31819368ac. Ullman, A., Long, D., & Lewis, P. (2011). The oral health of critically ill children: An observational cohort study. Journal of Clinical Nursing, 20, 3070–3080. http://dx.doi.org/10. 1111/j.1365-2702.2011.03797. Uysal, G., & Sönmez-Düzkaya, D. (2013). Evidence- based practice on children in intensive care. Yoğun Bakım Hemşireliği Dergisi, 17, 29–36. World Health Organization (1979). Handbook for reporting results of cancer treatment. Geneva, Switzerland: World Health Organization, 15–22. Yılmaz, M. (2007). Evidence-based practices for managing mucositis. Uluslararası Hematoloji-Onkoloji Dergisi, 4, 241–246.
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
The Effect of Oral Care Using an Oral Health Care Guide on Preventing Mucositis in Pediatric Intensive Care Duygu Sönmez Düzkaya, PhD, BSc, RN a,⁎, Gülzade Uysal, PhD, BSc, RN, Assistant Professor b, Gülçin Bozkurt, PhD, BSc, RN, Associate Professor c, Tülay Yakut, BSc d a
Istanbul University, Istanbul Faculty of Medicine, Directorate of Nursing Services, Education Nurse, Çapa-Fatih, 34053 Istanbul, Turkey Okan University, School of Health Sciences, Istanbul, Turkey Istanbul University, School of Health Sciences, Istanbul, Turkey d Istanbul University, Istanbul Faculty of Medicine, Pediatric Intensive Care Unit, Istanbul, Turkey b c
a r t i c l e
i n f o
Article history: Received 13 January 2017 Revised 27 May 2017 Accepted 28 May 2017 Available online xxxx Keywords: Oral mucositis Oral care Nursing care Pediatric intensive care
a b s t r a c t Objectives: To evaluate the effectiveness of standard-of-care oral care guides developed specifically for children in intensive care to prevent mucositis. Design and Methods: This prospective, interventional and single-group study design was performed in the pediatric intensive care unit of a university hospital in Istanbul between January and December 2014. Daily oral care was implemented to pediatric patients in the study group in line with an oral care guide developed by the researchers. Data were collected using the data collection form and oral mucositis assessment scale published by the World Health Organization (WHO). Results: Oral mucositis occurred in 16 (5.2%) patients in the pre-intervention group and 7 (2.5%) in the post-intervention group, 10 patients had grade 1, and 6 patients had grade 2 oral mucositis in the pre-intervention group, and in the post-intervention group, three patients had grade 1, and four patients had grade 2 oral mucositis. Although more patients in the pre-intervention group had mucositis than in the post-intervention group, the differences were not statistically significant (P = 0.067). Conclusions: Oral mucositis can be reduced through the practice of administering oral care in accordance with oral healthcare guidelines. Practice Implications: Oral care implemented in line with an evidence-based oral care guide and frequent observation of patients are the most important steps in preventing oral mucositis. © 2017 Elsevier Inc. All rights reserved.
Introduction Providing oral care hygiene for patients in the intensive care unit and protecting oral mucosa are important in the promotion of healthy nutrition, comfort, and increasing patients' quality of life, as well as preventing infections that might develop in the oropharynx and respiratory tract (Berry & Davidson, 2006; Berry, Davidson, Masters, & Rolls, 2007; Johnstone, Spence, & Koziol-McLain, 2011; Özveren, 2010; Thomson, Ayers, & Broughton, 2003). Although pediatric patients in intensive care require frequent oral care, this is commonly overlooked by nurses (Kearns, Brewer, & Booth, 2009). In a study performed in an adult intensive care unit in India, it was determined that the most frequently used technique for oral care was suctioning (AdibHajbaghery, Ansari, & Azizi-Fini, 2013).
⁎ Corresponding author. E-mail addresses: [email protected] (D.S. Düzkaya), [email protected] (G. Uysal), [email protected] (G. Bozkurt), [email protected] (T. Yakut).
http://dx.doi.org/10.1016/j.pedn.2017.05.010 0882-5963/© 2017 Elsevier Inc. All rights reserved.
Bacteria start to reproduce within 24–48 h of admission to intensive care units, which rapidly deteriorates the health of oral mucosa (Sebastian, Lodha, Kapil, & Kabra, 2012; Sönmez-Düzkaya, 2014). Nasogastric catheter/intubation tube can cause mechanical trauma related to the reduction of saliva and immunoglobulin A (IgA) secretion in the mucosa (Özveren, 2010; Sebastian et al., 2012). The mouth is constantly open because of endotracheal tube (ETT) use, and drugs for treatment such as steroids, sedatives, and opioids. Oxygen therapy, fever, and adhesive tape used for securing the endotracheal tube lead to deterioration of tissue integrity in the mouth, results in the development in the mouth such as halitosis, dry mouth, cracked lips, and stomatitis (Abidia, 2007; Grap, Munro, Brooke, & Bryant, 2003; Sebastian et al., 2012; Thomson et al., 2003). In addition to such problems, insufficient application of oral care leads to an increase in the formation of plaques in the mouth, bacterial colonization in the oropharynx, and frequency of hospital infections. The incidence of ventilator-associated pneumonia is a concern (Grap & Munro, 2004; Johnstone et al., 2011; Sönmez-Düzkaya, 2014). It has been found that insufficient oral care affects mortality and morbidity, and that strategies should be formed to
D.S. Düzkaya et al. / Journal of Pediatric Nursing 36 (2017) 98–102
develop oral care in patients who are in a critical condition (Chan, Ruest, Meade, & Cook, 2007; Munro et al., 2006; Stonecypher, 2010). For mechanical ventilator-dependent patients in intensive care, providing and sustaining oral hygiene, preventing pressure arising from biting and adhesive tape or trauma, and deterioration in skin/mucosa are important nursing care interventions that enhance good patient care (Abidia, 2007; Akdemir, 2013). Grap et al. (2003) detected that 72% of nurses performed oral care to intensive care patients 5 or more times per day but did not report it. To prevent oral mucositis and protect oral health in intensive care, it is important to evaluate the oral cavity (teeth, gum, tongue, mucosa membrane, and lips) and implement oral care with appropriate equipment (Berry et al., 2007; Fields, 2008; Garcia et al., 2009; Pearson, 1996; Uysal & Sönmez-Düzkaya, 2013). Studies related to oral care have mostly been conducted in adult patients; it was shown that mucosal integrity deteriorated and functional loss occurred at a serious level in 4.4% of patients, and at a medium level in 41% of patients 24 h after inserting an ETT (Mohammed & Hassan, 2015). Ullman, Long, and Lewis (2011) detected that mucosal integrity deteriorated and functional loss occurred at a medium level in 62.6% of children in intensive care. Nurses in intensive care units play an important role in the prevention or reduction of mucositis and increasing patients' quality of life because their role as health care providers is to continuously follow up patients and implement oral care. There is still no generally accepted standard treatment and care applications for preventing or managing mucositis. In accordance with standards of nursing practice and quality clinical care, nurses are encouraged to used evidence-based clinical guidelines (Çavuşoğlu, 2007; Grap et al., 2003; Yılmaz, 2007). A large number of studies are needed to determine the best oral care guide for patients in intensive care (Grap et al., 2003). Method Objectives The purpose of this study was to review the effect of standardized oral care, which was implemented in line with the oral health care guide in children in intensive care to prevent mucositis formation. Study Design Oral care for preventing mucositis in the pediatric intensive care unit (PICU) was implemented in line with an oral care guide (OCG) that was developed by the researchers after reviewing the literature. The effect of using the guide was evaluated using prospective, interventional and single-group study methods (Franklin, Senior, James, & Roberts, 1999; Stonecypher, 2010; Ullman et al., 2011). Study Period and Sample The study was conducted between January and December 2014 with 320 patients who were admitted to the PICU of a university hospital in Istanbul. Convenience sampling was used because all patients were admitted as part of the study. No sampling selection was made and the entire population was taken into consideration; 5 patients who had oral mucositis on admission to intensive care, and 31 patients who were discharged from intensive care within 48 h were excluded from the study. Over the study period, 284 pediatric patients who were admitted to the PICU for N48 h and had no oral mucositis on admission were included in the study; the participation rate in the study was 88.8%. To evaluate the guide's impact, a retrospective study was conducted of oral mucositis rates before the oral care guide's implementation between January and December 2013. A total of 310 patients were included.
99
Study Setting The 6-bed PICU in which the study was conducted is staffed by 13 nurses. An average number of 250–350 children with acute respiratory diseases, sepsis, shock, multi-organ insufficiency, poisoning, or those who require close post-operative follow-up are admitted to the unit yearly. The nurse-to-patient ratio is one nurse per two patients. Study Stages The research was performed in three stages. Stage 1: We collected data retrospectively to evaluate the OCG's impact. Stage 2: Nurses who worked in the clinic were informed about the scope of the study followed by a 2-hour training session on the use of the OCG and additional training on the data collection tools (data collection form and oral mucositis assessment scale). The responsible nurse gave monthly feedback to nurses about oral mucositis rates on the unit. Interventions were performed for children who developed oral mucositis, in addition to methods for protecting their oral mucosa, i.e. changing ETT fixation position, applying moisturizer to lips, suction, and increasing the frequency of oral care (Akdemir, 2013; American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health, 2008; Uysal & Sönmez-Düzkaya, 2013). Oral Care Guidelines: (Akdemir, 2013; American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health, 2008; Berry et al., 2007; Fields, 2008; Johnstone et al., 2011; Thomson et al., 2003). • Evaluate/assess mouths daily • Perform oral care every 4 h each day (oral care should be applied every 2–4 h for high-risk patients such as those receiving chemotherapy, with fever, or using neuromuscular blocking medicine), • Use disposable sponge sticks and solutions containing 0.12% chlorhexidine in oral care, • Brush gums and teeth gently (with care if the patient is edentulous) • To keep the tissues moistened, the mucous membrane should be coated with a moisturizer gel • Apply moisturizer after oral care to prevent lips from drying, • Toothpaste or secretions should be removed by rinsing the mouth using an irrigation syringe or sponge, and if necessary, secretions may be removed using suction at low negative aspiration pressure (50–80 mm Hg), • Use soft fasteners in securing of the intubation tube, continuously watching the contact area of the skin, protect against damage to the skin when removing fasteners, and to sustain circulation by applying massage to the zones where tube securing is present. Stage 3: A data collection form was completed for each patient in the first 24 h. The patients' daily oral care was provided using the OGC. The World Health Organization (WHO) oral mucositis assessment scale (Ahmed, 2013; Cheng, Molassiotis, Chang, Wai, & Cheung, 2001; World Health Organization, 1979) was used to evaluate the patients' mouths every day. Stage 4: Retrospective data from before the OCG implementation were compared with the mucositis rates during the study period. Pilot Study A pilot study was conducted on nine patients to evaluate the conformity of the research forms. The patients in the pilot study were excluded from the research. Data Collection Data Collection Form A Data Collection Form was prepared by the authors after reviewing the relevant literature (Chan et al., 2007; Munro et al., 2006;
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Stonecypher, 2010; Ullman et al., 2011). The form comprised 25 sections in total, including personal characteristics such as the patient's date of admission, age, gender, diagnosis, additional disease, nutritional status, mechanical ventilation, and drugs used, as well as providing space to comment or record observations regarding oral mucositis risk factors such as fever, oxygen therapy, not feeding, dehydration, steroid treatment, and chemotherapy, and oral mucositis. The World Health Organization (WHO) Oral Mucositis Assessment Scale is a commonly used identification tool in the grading of oral mucositis in hospitals. In the scale, anatomic changes regarding oral mucosa and mucositis severity are graded between zero and four. A mouth with a healthy appearance and no mucositis was graded as zero (0) points, erythematous lesions observed in the oral cavity (1), red zones with increased mucosa, and lesions separated from each other (2), reddening of the entire oral mucosa with a large number of combined ulcers (3), and (4) if ulcers, hemorrhage and necrosis was present in the mouth (Can, 2010; Cheng et al., 2001; Çubukçu, 2005; World Health Organization, 1979). The oral mucositis assessment scale has been used for the clinical assessment of adult and pediatric patients receiving cancer therapy (Ahmed, 2013; Elad et al., 2011).
Ethical Approval This study was conducted after obtaining the required permissions were obtained from hospital management and ethics committee. The parents of the children included in the research were informed regarding the purpose, planning, and duration of the study, and how the data were to be used. Written consent was obtained from the parents based on the principles of willingness and voluntariness. All healthcare workers related with the PICU were briefed about the research. Data Analysis
Table 1 Baseline data of children. Features
Post-intervention (n = 284) n (%)
Pre-intervention (n = 310) n (%)
Pa
Age (month) average (min-max)
76.64 ± 5.29 (1–204)
69.78 ± 4.89 (1–204)
0.742
123(43.3) 161 (56.7)
152 (49) 158 (51)
90 (31.8) 52 (18.3) 51 (17.9) 33 (11.6) 30 (10.5) 18 (6.3) 10 (3.6)
118 (38) 62 (20) 48 (15.5) 31 (10) 25 (8) 14 (4.6) 12 (3.9)
110 (38.7) 174 (61.3)
126 (40.6) 184 (59.4)
22 (7.7) 38 (13.5) 32 (11.2) 192 (67.6)
19 (6.2) 42 (13.5) 39 (12.5) 210 (67.8)
182 (64) 102 (36)
198 (63.9) 112 (36.1)
0.848
222 (78.1) 62 (21.9)
234 (75.5) 76 (24.5)
0.750
57 (20) 227 (80) 5.43 ± 3.69 (0−20) 10.15 ± 0.48 (2−30)
68 (21.9) 242 (78.1) 5.19 ± 4.51 (0–24) 11.56 ± 1.45 (3–40)
0.983
Sex Female Male Diagnosis Respiratory system diseases Neurologic diseases Intoxication Metabolic diseases Post-op follow-up Septicemia Other diseases Additional diseases Yes No Nutrition status Oral Enteral feeding Parenteral feeding Enteral and parenteral feeding Intubation status Intubated Not intubated Treatment of antibiotic Used Did not use Neuromuscular-blocking-drugs Used Did not use Duration of ventilation mean/median/min-max (days) PICU length of stay mean/median/min-max (days) a
Data were analyzed using the SPSS.21.0 version (SPSS, Chicago, IL, USA).
0.162
0.934
0.839
0.764
0.621 0.393
χ2 = Chi-square test.
Oral Mucositis Features, Post- and Pre-intervention Results Baseline Data Pre- and Post-intervention The pre-intervention research group was composed of 310 patients who were admitted to the PICU between January and December 2013, and the post-intervention research group was comprised of 284 patients who were admitted to the PICU between January and December 2014. The baseline data of the post- and pre-intervention groups are shown in Table 1. No statistically significant difference was found between the pre-and post-intervention groups (P N 0.05).
Detailed descriptions of pre- and post-intervention findings regarding oral mucositis are shown in Table 4. No statistically significant difference between the pre-and post-intervention groups was found (P N 0.05). All of the patients with oral mucositis had been intubated, could not feed orally, had oxygen therapy, steroid therapy, and antibiotic treatment. When considered in terms of other characteristics, it was determined that 71.5% of the patients had fever and dehydration. Some 42.8% received chemotherapy treatment and 85.7% received neuromuscular block treatment (Fig. 1).
Risk Factors of Pre- and Post-intervention We reviewed risk factors related to oral mucositis in the pre- and post-intervention groups in terms of oral feeding, oxygen therapy, steroid therapy, fever, dehydration, and chemotherapy. The results are presented in Table 2.
Compared Oral Mucositis Rate Oral mucositis was detected in 5.2% (n = 16) of patients in the preintervention group, and 2.5% (n = 7) of patients the post-intervention group. Although more patients in the pre- intervention group had mucositis than in the post-intervention group, the differences were not statistically significant (P = 0.067) (Table 3).
Table 2 Comparison of risk factors for developing oral mucositis. Risk factors
Post-intervention (n = 284) n (%)
Pre-intervention (n = 310) n (%)
Pa
No oral feeding Oxygen therapy Treatment of steroid Fever Dehydration Chemotherapy
262 (92.2) 250 (88) 158 (55.7)
291 (93.8) 286 (92.2) 172 (55.4)
0.346 0.060 0.966
29 (10.2) 26 (9.2) 5 (1.8)
42 (13.5) 38 (12.2) 8 (2.6)
0.172 0.182 0.495
a
χ2 = Chi-square test.
D.S. Düzkaya et al. / Journal of Pediatric Nursing 36 (2017) 98–102 Table 3 Compared oral mucositis rate. Features Post-intervention (n = 284) Pre-intervention (n = 310) Pa Oral mucositis n (%) n (%) Occurred Did not occur a
7 (2.5) 277 (97.5)
16 (5.2) 294 (94.8)
– 0.067
χ2 = Chi-square (Fisher exact) test.
Discussion Pediatric patients are mostly admitted to intensive care units with diagnoses of respiratory, neurologic, and metabolic diseases, and for postoperative follow-up (Abramczyk, Carvalho, Carvalho, & Medeiros, 2003; Porto et al., 2012; Ullman et al., 2011). We also found that children in the study group mostly had respiratory, neurologic, and metabolic conditions. Approximately one third of the patients who were admitted to intensive care with serious conditions also had an additional disease. Many researchers reported that numerous interventions provided to children in the intensive care because of serious disease (e.g. nasogastric catheter/intubation tubes causing mechanical trauma; constant open mouth; drugs used for treatment, inability to take food and liquid by mouth, oxygen therapy, and adhesive tape used for endotracheal tube securing) and comorbidities were factors that increased the risk of oral mucositis (Grap et al., 2003; Özveren, 2010; Sebastian et al., 2012). The number of studies related to oral mucositis in children in intensive care is limited (Franklin et al., 1999; Ullman et al., 2011). In the literature, the general rate of oral mucositis is 5–15%, whereas this ratio is over 80% in patients who receive cancer treatment (Çavuşoğlu, 2007). In the study by Ullman et al. (2011), which was conducted in a PICU, the authors found that oral mucosal integrity was impaired in 62.6% of patients. The rate in the pre-intervention group in our PICU was 5.2%, and the post-intervention rate was 2.5% in our study group. When the results of Ullman et al. (2011) and our pre-intervention rate were compared with our post-intervention frequency, the rate of oral mucositis was quite low. Franklin et al. (1999) determined that children were at risk and routine mouth care was not effective in preventing plaque accumulation and protecting gum health due to local or systemic spread of microorganisms formed in the mouth during intensive care. In the literature, it is stated that one single intervention is not sufficient in mucositis management and the integration of multipurpose interventions for care is recommended (Çavuşoğlu, 2007). In the present study, it can be considered that oral care implemented in line with an OCG was effective in preventing mucositis and reducing oral health assessment scores. These results supported those of Abidia (2007), Handa, Chand, Sarin, Singh, and Sharma (2014), and Sazlina and Ong (2012), which showed
Table 4 Oral mucositis features, post- and pre-intervention. Features
Post-intervention (n = 7) n (%)
Diagnosis phase Grade 1 3 (42.9) Grade 2 4 (57.1) Exposure time of mucositis ≤7 day 3 (42.9) N7 day 4 (57.1) Mucositis at discharge No mucositis 5 (71.4) Grade 1 2 (28.6) Region of oral mucositis Lip edge 3 (42.9) Cheek 3 (42.9) Upper tongue 1 (14.2) a
χ2 = Chi-square test.
Pre-intervention (n = 16) n (%)
Pa
10 (62.5) 6 (37.5)
0.170
5 (31.2) 11 (68.8)
0.208
13 (81.2) 3 (18.8)
0.209
7 (43.7) 4 (25.0) 5 (31.3)
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that an oral care protocol could maintain the oral health status of hospitalized children. Regardless, there is a paucity of literature surrounding the effectiveness and appropriateness of oral hygiene practices in pediatric intensive care units. Due to the spread of microorganisms in the mouths of ventilator-dependent children in intensive care, it has been emphasized that the risk for deterioration of mouth integrity is high (Franklin et al., 1999; Özveren, 2010). In the literature, it was reported that antibiotic use, inability for eating orally, and steroid use (Jiggins & Talbot, 1999; Sixou, Medeiros-Batista, & Bonnaure-Mallet, 1996) had serious disease effects on oral health, accelerated mucositis formation (Thorburn et al., 2009), and intubation in particular caused injuries in the mucosa and cheek thus leading to patient discomfort (Ullman et al., 2011). In three (1.1%) children in the study group, oral mucositis development was identified on the side of the lips as a result of ETT fixation. Compatible with the literature, we found that all patients who developed oral mucositis were intubated, could not eat orally, and had oxygen therapy, steroids, and antibiotic treatment and 42.8% of the patients received chemotherapy treatment. As the time that patients stay in intensive care extends, it is reported that tissues in and around the mouth lose their integrity based on the increase in drugs used for treatment and extension of intubation time (Özveren, 2010; Sebastian et al., 2012). In the study group, it was observed that oral mucositis developed after the 7th day in four of the children after admission. No inference can be made regarding the effect of length of stay in intensive care to mucositis development because the number of patients in whom oral mucositis was detected was very low within the study period. In order to test this with randomized controlled studies, more studies are required with larger samples. As result of the interventions applied for oral mucositis, it was observed that the oral mucositis of five children totally recovered and two children were discharged from intensive care with grade 1 oral mucositis. In the literature, it is documented that replacing the ETT fixation point, applying moisturizer, and increasing the frequency of oral care, which are techniques performed in children with mucositis, are effective at both preventing and treating oral mucositis (Johnstone et al., 2011; Thomson et al., 2003). Clinical Implications Protecting oral mucosal integrity in the PICU is an important intervention for nurses. Risk factors for oral mucositis include being in the PICU, use intubation tube and intubation tube fasteners, and treatment such as steroids, sedatives, opioids, and oxygen therapy. Nurses should be aware of these risk factors and care for patients using evidence-based practice. The OCG can be used by nurses to prevent oral mucositis. Limitations of the Study This was a single institutional study and the results are not generalizable because there was no randomization. The major limitation of this study was sample size. The pre- and post-intervention findings of the study were collected by the same researcher, which could be a potential source of bias. This study did not describe oropharyngeal colonization. Conclusion
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It is important to prevent mucositis before it develops considering its burden to the individual and healthcare costs, because treatment of oral mucositis is intractable. Oral care implemented in line with an evidence-based OCG and frequent observation of patients are the most important steps in preventing oral mucositis. Oral care implemented in line with the OCG in this study decreased the frequency of oral mucositis.It can be considered that the OCG was effective in reducing the incidence of oral mucositis.
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Fig. 1. Features of children with oral mucositis (n=7). *NBG: Neuromuscular-blocking-drug.
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