Page 132 - ACCCN's Critical Care Nursing

Essential Nursing Care of the Critically Ill Patient 109

for pupil assessment and access for eye care. It is not neces-
sary to change the tape at each pupil assessment using this BOX 6.1 Characteristics of a healthy mouth
method. However, the use of tape may be inappropriate
for patients whose skin is very friable. Furthermore, if the ● Pink, moist oral mucosa and gums. Absence of coating,
eyelid becomes sore and inflamed, taping should be dis- redness, ulceration or bleeding
continued and an alternative method employed to close ● Pink, moist tongue. No coating, cracking, blisters or areas of
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the eyes, e.g. gel eye pads. When it is not possible to close redness
the eyes, artificial tear ointment has been shown to reduce ● Clean teeth/dentures; free of debris, plaque and dental
the incidence of corneal abrasion. 15 caries
● Well-fitting dentures
If it is difficult to maintain eye closure by taping the upper ● Adequate salivation
part of the eyelid, the entire eye can also be covered with ● Smooth and moist lips. No cracking, bleeding or
polyethylene film, which has been shown to reduce the ulceration
incidence of corneal abrasion. This should be changed ● No difficulties eating or swallowing (uncommon in ICU)
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4-hourly with eye care and assessment. Commercially
available eye-closing tape products are also available
along with gel eye dressings which may be used instead
of polyethylene film. 20,21 Current evidence indicates that
polyethylene film is the superior and most cost-effective caused by grinding of teeth or biting of the tongue, and
product for maintaining the ocular surface. 9,21 reduce bacterial activity that leads to local and systemic
infection. 22
ORAL HYGIENE Oral care for an un-intubated conscious patient with a

Poor oral hygiene is unpleasant, causing halitosis and healthy mouth generally involves daily observation of the
discomfort. Although mouth care is one of the most basic mucosa and twice-daily toothbrushing with a non-irritant
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nursing activities, in some cases lack of oral hygiene can fluoride toothpaste. In general, for unconscious patients
lead to serious complications or increase their risk, such oral care should be attended to 2-hourly, although the
as ventilator-associated pneumonia in the ventilated evidence is inconclusive and frequency ranges from 2- to
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patient. Attendance to oral hygiene including the removal 12-hourly. If the mouth is unhealthy, it may be neces-
of dental plaque which harbours pathogens is an imptant sary to provide oral hygiene as often as every hour.
component of nursing care. 23-26 Using a well-developed The basic method for oral care is to use a soft toothbrush
oral protocol can improve the oral health of ICU and toothpaste (even for intubated patients), as this will
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patients. However, the practice of mouth care is not assist with gum care as well as cleaning teeth. Tooth-
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always evidence-based, although evidence supports paste loosens debris and fluoride helps to prevent dental
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having a standardise oral care protocol to improve oral caries. However, if it is not rinsed away properly, tooth-
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hygiene. Factors associated with poor quality of oral paste dries the oral mucosa. The practice of using mouth
care include lack of education, insufficient time, non- swabs only for oral hygiene is ineffective, and tooth-
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prioritising of oral care, and the perception that it is brushes perform substantially better than foam swabs in
unpleasant. 29 removing plaque. 25,36,37 Mouth rinses have not conclu-
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Saliva produces protective enzymes, but absence of mas- sively shown benefit, however they may be comfortable
tication, for example, due to the presence of an endotra- for the patient to use. Toothbrushing every 8 hours was
cheal tube or deep sedation, leads to a reduction in saliva recommended in a recent study as being an adjunct to
production. An endotracheal tube (ETT) can cause pres- other ventilator associated pneumonia prevention prac-
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sure areas in the mouth (which may be exacerbated if the tices while use of chlorhexidine toothbrushing was
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patient is oedematous) and may thus need to be relo- found to be of benefit in another study.
cated regularly to a different position in the patient’s Although it is an effective saliva stimulant, practices such
mouth. as the use of lemon and glycerine are outdated, as glyc-
erine causes reflex exhaustion of the saliva process, result-
ORAL ASSESSMENT ing in a dryer mouth. 22,25 Lemon juice is to be avoided,
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Mouth care should be reviewed regularly based on a thor- as it can decalcify enamel. Commercial mouthwashes
ough assessment of the oral cavity. Several oral assess- moisten and soften the mucosa and help to loosen debris,
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ment tools have been designed specifically for intubated which can be washed away. They must be used with
patients. 30-32 Essentially, a healthy mouth is characterised caution in patients with oral problems, due to their
by several factors, as identified in Box 6.1, and all potential to cause irritation and hypersensitivity. 22
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of these areas should be assessed as a basis for good In addition to toothbrushing, regular sips of fluid or
oral care. mouthwashing with water is recommended. If the patient
is able to suck and swallow, small pieces of ice are very
ESSENTIAL ORAL CARE refreshing. Patients with clean mouths, who are febrile
Oral care aims to ensure a healthy oral mucosa, prevent and/or receiving antibiotics, should also have their
halitosis, maintain a clean and moist oral cavity, prevent mouths moistened often with water to prevent drying,
pressure sores from devices such as ETTs, prevent trauma coating and subsequent discomfort. Immunosuppressed