To p i c s i n

Progressive Care

Brush up on oral assessment and care

By Allan J. Schwartz, DDS, CRNA, and Sherry Powell, RDH

A
A CRITICALLY ILL PATIENT needs frequent oral
assessment and care to avoid complications caused
by oropharyngeal bacteria. Because the head and
neck command a large portion of the body’s blood
supply, infection can quickly spread throughout the
body, making early detection of possible problems
important to help keep your patient healthy. In this
article, we’ll take a look at how to perform oral
assessment and care.
ous infections. Aggregated bacteria excrete an
adhesive matrix and form a substance called
plaque that causes tooth decay.4
Oropharyngeal microorganisms are most thor-
oughly and effectively removed by mechanically
cleaning the teeth, gums, and tongue with a soft
toothbrush and using an antibacterial toothpaste
and oral topically applied antimicrobials. Patients
who are endotracheally intubated should have their
subglottic areas suctioned frequently because bacte-
Why is oral care important? rially contaminated oral secretions may leak around
Without properly performed oral assessment and the ET tube and find an environment that supports
care, a critically ill patient can experience complica- the growth of these pathogenic bacteria.
tions that may lead to a longer hospital stay, signifi- Patients who are endotracheally intubated are
cantly increased costs of care, and even death.1 A especially vulnerable to VAP. The ET tube is usual-
critically ill patient’s individual requirements for ly held in place with either tape or a commercial
oral care should be considered as part of the admis- ET securement device, which provides a breeding
sion assessment.2 Nurses may be reluctant to per- ground for potentially pathogenic bacteria and pre-
form oral care for various reasons, such as fear of vents easy access to the mouth for cleaning.
dislodging an oral endotracheal (ET) tube, but these Carried along by saliva, pathogens can migrate
barriers must be overcome to enable essential nurs- down the ET tube through the space between the
ing care.3 (See Barriers to proper oral care in critically ill tube and the vocal cords, down the trachea, and
patients.) into the lungs or directly down the ET tube. VAP is
The mouth is host to many bacteria, viruses, and most commonly caused by Gram-negative enteric
fungi, even in a healthy indi-
vidual. If left unchecked, these
potentially harmful pathogens
become opportunistic in the
oral cavity’s dark, warm, and
moist environment and can
cause both local and systemic
complications. Multiplying
quickly, they can cause caries,
halitosis, periodontal inflam-
mation and infection,
osteomyelitis of the maxilla
and mandible, ventilator-asso-
ciated pneumonia (VAP), and
septicemia if they’re not
removed properly. Critically
ill patients also have impaired
immune responses, making
them more vulnerable to seri-

www.nursing2009criticalcare.com November l Nursing2009Critical Care l 7

 Barriers to proper oral care in The BRUSHED oral
critically ill patients assessment tool8
• fear of dislodging the patient’s ET tube Use this mnemonic device to help you perform a thor-
• fear of aspiration ough and systematic assessment of your patient’s
• fear of adding to the patient’s discomfort mouth.
• the nurse’s time constraints B leeding (gingiva, oral mucosa, patient’s coagula-
• lack of knowledge of proper oral assessment and tion status)
care R edness (gingiva, tongue, dry mouth, antibiotic
• perception that oral care has a low priority for criti- stomatitis)
cally ill patients U lceration (size of ulcer, shape of ulcer, herpetic
ulcers, aphthous ulcers)
S aliva (thin/watery, thick, copious amounts, dry
bacteria and two species of normal oral flora, mouth)
Pseudomonas aeruginosa and Staphylococcus aureus.5 H alitosis (character, absence of)
E xternal factors (cracks and redness at corners of
Start with assessment the mouth, ET tape or commercial ET tube secure-
Assess the patient’s gingiva daily for signs of dis- ment device, cleanliness)
ease. Note the tissue’s color, size, shape, consis- D ebris (visible plaque, foreign substances, pres-
tency, and surface texture. Diseased gingiva may ence on ET tape or ET tube securement device)
appear bright red, enlarged, bulbous, spongy,
smooth, and shiny. Also look for ulcerations on To begin, explain to the patient that you’ll clean
the oral mucosa and assess the teeth, lips, and her mouth with toothpaste and mouth rinse and
tongue. (See The BRUSHED oral assessment tool for apply petroleum jelly to her lips. Carefully open
more details.) Document your findings. her mouth with gloved fingers.
Gently brush all surfaces of the teeth, gums,
Time for a cleaning and tongue in a circular motion, using an antibac-
Once you’ve completed your assessment and are terial toothpaste. If the patient doesn’t have teeth,
ready for cleaning, gather the following supplies: brush her gums and tongue gently. Rinse the
• clean gloves toothpaste from the patient’s mouth with an alco-
• protective face mask hol-free mouth rinse using an irrigation syringe
• protective eyewear for the patient and for you or swab and suction as needed. Apply a pea-sized
• 0.12% chlorhexidine gluconate (only for adult amount of oral moisturizing gel to a gloved finger
perioperative cardiac surgery patients) and gently massage it into the mucous mem-
• pediatric-sized or adult-sized toothbrush with branes of her mouth. Put petroleum jelly on a
soft bristles (foam swabs are ineffective for gloved finger and apply it to her lips.7
removing plaque) An oral chlorhexidine gluconate (0.12%) rinse
• antibacterial toothpaste should be used twice a day during the periopera-
• alcohol-free mouth rinse tive period for adult patients who undergo car-
• petroleum jelly diac surgery. Routine use in other populations
• oral moisturizing gel isn’t recommended.6
• roll of 1-inch (2.5-cm) tape
• flashlight Document carefully
• clean Yankauer suction tip and clean suction Once you’ve completed cleaning, document any
tubing. suspicious oral exudate, odors, red tissue, bleed-
Note the depth of the ET tube in relation to a ing, ulcerations, or other abnormalities you see in
facial landmark and secure it to the side of your the patient’s mouth. Record the frequency of oral
patient’s face with tape. Teeth, gums, and tongue care, differentiating between comprehensive oral
need to be brushed twice a day. In addition to care (including brushing) and oral moisturizing.
brushing, oral moisturizing should be provided to Providing frequent oral assessment and care will
oral mucosa and lips every 2 to 4 hours.6 help your patient avoid serious complications. ❖

8 l Nursing2009Critical Care l Volume 4, Number 6 www.nursing2009criticalcare.com

 Call for manuscripts
®

REFERENCES We’re looking for manuscripts for Nursing2009

1. Cason CL, Tyner T, Saunders S, Broome L. Nurses’ implementation
of guidelines for ventilator-associated pneumonia from the Centers
Critical Care. If you’d like to write about some practi-
for Disease Control and Prevention. Am J Crit Care. 2007;16(1):28-37. cal aspect of critical care that would interest other
2. Abidia FR. Oral care in the intensive care unit: a review. J Con- nurses in this field, or a short non-clinical article
temp Dent Pract. 2007;8(1):76-82. about a challenging or memorable patient or experi-
3. Jones H, Newton JT, Bower EJ. A survey of the oral care practices ence, please send us a topic query letter or e-mail.
of intensive care nurses. Intensive Crit Care Nurse. 2004;20(2):69-76.
Typically, we look for short, focused articles that read-
4. Haake SK, Newman MG, Nisengard RJ. Carranza’s Clinical Peri-
odontology. 9th ed. Philadelphia, PA: WB Saunders; 2002:96-99. ers can apply to their clinical practice or patient educa-
5. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guide-
tion. So if you’ve been thinking about trying your hand
lines for preventing health-care-associated pneumonia, 2003. http:// at having an article published, why not give it a try?
www.cdc.gov/ncidod/dhqp/pdf/guidelines/CDCpneumo_guidelines.pdf.
Start by getting a copy of our standard author
6. AACN Practice Alert: Oral care in the critically ill. http://www.
aacn.org/WD/Practice/Docs/Oral_Care_in_the_Critically_Ill.pdf.
guidelines. You can access them online at www.
nursing2009criticalcare.com (click on "About this
7. Fitch JA, Munro CL, Glass CA, Pellegrini JM. Oral care in the
adult intensive care unit. Am J Crit Care. 1999;8(5):314-318. publication") or request a copy by calling Barbara
8. Hayes JH, Jones C. A collaborative approach to oral care during
Miller at 215-628-7789 or by e-mailing her at
critical illness. Dent Health. 1995;34(3):6-10. barbara.miller@wolterskluwer.com.
Then send your topic query to Jan Corwin Enger,
managing editor, at jan.enger@wolterskluwer.com or
Allan J. Schwartz is a dentist at ProDental in Columbia, Mo., and a certified
registered nurse anesthetist with St. Elizabeth’s Hospital in Belleville, Ill. submit your manuscript to Nursing2009 Critical Care
Sherry Powell is a dental hygienist in Columbia, Mo. via www.lwwesubmissions.com. We look forward to
Adapted from Schwartz AJ, Powell S. Brush up on oral assessment and care. hearing from you!
Nursing. 2009;39(3):30-32.

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