Page 133 - ACCCN's Critical Care Nursing

110 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

patients or those on high-dose antibiotics may also PATIENT POSITIONING AND
require antifungal treatment to treat oral thrush. MOBILISATION
There are many oral hygiene products and solutions avail-
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able to suit the needs of all patients. Commercial Positioning patients correctly is important for their
mouthwashes should be used as a comfort measure to comfort and the reduction of complications associated
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supplement toothbrushing. A range of other products with pressure areas and joint immobility. Lying in bed
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are available to treat oral problems, for example benzy- for long periods can be a painful experience. Several
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damine hydrochloride (anti-inflammatory), aqueous researchers describe neuromyopathy from critical
lignocaine (anaesthetic) and nystatin (antifungal). For illness and disuse atrophy from prolonged immobility
patients intubated for more than 24 hours, rates of noso- contributing to intensive care acquired weakness. This
comial pneumonia may be reduced by using twice-daily weakness may contribute to prolonged ventilation, inten-
chlorhexidine gluconate mouthwashes, 25,37,39,40 which sive care length of stay as well as delayed return to phy-
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also prevent plaque accumulation. This has the disad- sical normality. Cardiovascular stability, respiratory
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vantage of an unpleasant taste and can discolour teeth. function and cerebral or spinal function are all factors
For patients with crusty build-up on their teeth, a single that influence the positioning of patients in critical care
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application of warm dilute solution of sodium bicarbon- areas. Modern beds and pressure-relieving devices have
ate powder with a toothbrush is effective in removing helped considerably to enhance the care of critically ill
debris and causes mucus to become less sticky, although patients.
its use has not be definitively tested. However, it can cause The primary goals of essential nursing care for patient
superficial burns and its use should be followed immedi- positioning are:
ately by a thorough water rinse of the mouth to return
the oral pH to normal. Hydrogen peroxide has an anti- ● to position the patient comfortably
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plaque effect, but if incorrectly diluted it can cause pain ● to enhance therapeutic benefits
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and burns to the oral mucosa and a predisposition to ● to prevent pressure ulcers
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candida colonisation. It is not pleasant tasting and ● to ensure the limbs are supported appropriately and
sometimes rejected by patients although it is the sub- to maintain flexible joints
stance that impregnates some of the foam sticks available ● to facilitate patient activity to minimise muscle
for oral care. As a preventive measure, to reduce the atrophy
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incidence of fungal colonisation, natural yoghurt may be ● to implement early mobilisation as the patient’s con-
used. Normal oral hygiene is followed by coating the dition allows.
mouth and tongue with yoghurt. There is growing evidence that early mobilisation is an
important aim for critically ill patients 51-55 and an essen-
Plastic water ampoules (10 mL) can be used to drip water
into the mouth for convenient administration to patients tial goal of nursing care is to support the patient in main-
unable to easily open their mouths or swallow. A Yankauer taining or attaining a normal level of physical function
suction catheter facilitates rinsing of toothpaste from the for mobility. As with many other aspects of care for the
mouth, and a bite-guard device may be used temporarily critically ill, this is best achieved through multidisci-
to prevent patients from inadvertently biting on the plinary team members working together. Here, physio-
toothbrush or their tongue. They should not be used long therapists and occupational therapists have a lead role in
term due to the risk of pressure sores. Lanolin may be assessing patients and planning programs of care and
applied to help maintain integrity of the lips. activity to facilitate attaining the goals of normal physical
function, while nurses contribute by ensuring the pro-
grams of care are delivered when other personnel are not
available.
Practice tip

If the patient objects to the taste of the chlorhexidine gluconate
mouthwash, consider a follow-up rinse of water. Practice tip

Movement of the lower legs, ankles and feet can be achieved
in conjunction with a gentle massage or application of moistur-
iser. Family members may wish to undertake this, giving them
Practice tip an opportunity to provide the patient with care and touch.
Performing oral hygiene with toothbrush and toothpaste in an
intubated patient and ensuring the mouth is rinsed well may
be assisted by the use of a dental sucker, which is flexible. This ASSESSMENT OF BODY POSITIONING
disposable device attached to a continuous suction system can Body positioning assessment is based on the goals of
be positioned in the mouth to aid in the continual removal of nursing care. First, a risk assessment is made and those
fluids while brushing and rinsing is performed. The dental patients at highest risk of complications related to their
sucker can also be used for continuous oral suction in patients position are those who are unable to move for long
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with excessive saliva. periods, for whatever reason. For example, unstable
patients whose status is compromised when they are