Skill List > Mouth Care for a Dependent Patient
Clinical Alert
If the patient is unconscious, position them on their side and ensure that the suction equipment is working.

Unconscious patients should not wear their dentures.

‘Foam heads of oral swabs may detach from the stick during use, which may present a choking hazard for patients’ (MDA/2012/020). Therefore if local policy is to use this type of equipment, ‘care should be taken that the foam head is securely attached to avoid risk of aspiration.’ (Dougherty et al. 2015)

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Nicol: Essential Nursing Skills 4E
Adapted by: Yvonne Muldowney
BSc MSc PGDip(CHSE) RGN NT
Updated by: Chris Brooker SRN SCM RNT BSc MSc
Last updated: April 2017

 

The importance of oral competence to the process of feeding, chewing, and swallowing. (From Brooker C, Nicol M (eds) 2011 Alexander’s Nursing Practice, 4th edn. Churchill Livingstone Elsevier, Edinburgh.)
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of mouth care for a dependent patient.

Introduction

Mouth care involves regular oral assessment (see Oral Assessment skill). The frequency of mouth care is based on the patient's oral assessments, their general condition and their individual needs. Health promotion and education promotes self-care, independence, and autonomy for mouth care.

The mouth is an important structure for taking in food and fluids, communicating through vocalising and nonverbal communication, for example, smiling. The mouth and nose are involved in expiration and provide some defence against infection. The aim of mouth care is to maintain normal function and mucosal integrity, which promotes comfort, safety, and wellbeing. It involves the removal of food, debris, and dental plaque to keep the oral cavity clean, prevent build-up of plaque, and prevent oral infection. Potential problems include:

  • Dental decay.
  • Xerostomia (dry mouth).
  • Oral mucositis (inflammation).
  • Stomatitis (sore mouth).
  • Gingivitis (red, swollen, and bleeding gums).
  • Periodontal disease (inflammation around the tooth).
  • Gum friability.
  • Reduction in saliva production.
  • Bacterial pneumonia (Nicol et al. 2012).

For the patient, the profound and often underestimated effects of poor oral hygiene are pain, discomfort, decreased self-perception, poor nutritional intake, communication issues, infection, reduced quality of life, and even life-threatening illness; aspiration of oropharyngeal pathogens is a source of hospital-acquired pneumonia.

To provide effective mouth care the nurse requires knowledge and understanding of the anatomy and physiology of the mouth. The mouth is the start of the alimentary canal and is lined with mucous membrane. It consists of the oral cavity and vestibule that is surrounded by the lips and contains the cheeks, gums, teeth, tongue, and the hard and soft palate (Figure 1).

The bony hard palate and the muscular soft palate form the roof of the mouth. The walls are shaped by the muscles of the cheeks, which are known as the buccal region. The muscular tongue practically fills the entire floor of the oral cavity. The tongue is extremely mobile and sensitive containing nerve endings, including taste buds. The oropharynx, the posterior exit of the oral cavity, is under the border of the soft palate through two archways: the palatoglossal and the palatopharyngeal, which enclose the palatine tonsil.

The buccal mucous membranes assist in control of the location of food. The incisor and canine teeth bite off small pieces of food, the premolars and molars chew and grind the food, and the lips keep food within the oral cavity. The tongue is involved in taste, forming the food bolus, pushing the food bolus to the back of the mouth, and the formation of sounds. The hard palate and soft palate are involved in mastication, swallowing, and speech.

There are three pairs of salivary glands: parotid, submandibular and sublingual, producing saliva. Saliva (combined secretions from salivary glands and the small mucus secreting glands of the oral cavity) plays a key role. Approximately 1-1.5 L of saliva is produced daily, consisting mainly of water with electrolytes, the enzyme amylase, proteins, lysozymes and immunoglobin (IgA). It is crucial for mastication, taste, speech and defence against infection.

The amount of saliva is dependent on several factors; hydration, eating habits, age, some medications, and underlying disease (Stringer 2011). Several risk factors are associated with a reduction in the amount of saliva, causing drying of the mouth (xerostomia). These include oxygen therapy, mouth breathing, restriction of oral fluids and food, altered consciousness, confusion, critical illness, intermittent mechanical ventilation, suction of the airways, analgesics and anti-depressants. Older adults are at risk due to a natural decline of salivary gland function, and wear and tear of teeth. Antibiotics and corticosteroids change the activity of the salivary glands, resulting in thick, viscous saliva. The oral mucosa is replaced every 7–14 days and is thus vulnerable to chemotherapy and head and neck radiotherapy. Anaemia causes changes resulting in glossitis (inflammation of the tongue) and stomatitis (inflammation of the mouth). Dexterity and sight problems may also increase the risk due to inability to independently attend to mouth care. Through assessment and discussion the nurse will be able to determine how much assistance the patient will require with mouth care.

Effective mouth care is a crucial nursing skill yet there is evidence that it is not always considered a priority and not always evidence based. Effective nursing assessment should always precede actual care, and use of a  validated, standardised assessment tool is recommended (Stringer 2011, Heath et al. 2011).The use of a standardised assessment tool ensures that mouth care is given when required.

Initial assessment should be done on admission, and include an account of normal dental care and any oral problems. The initial assessment will provide baseline data and aid in the identification of actual or potential oral complications. An individualised care plan should be developed from the initial assessment and updated if and when potential or actual complications are identified.

The utilisation of a pen torch, tongue depressor, or a gloved finger may be recommended, but a risk assessment should be completed as biting injuries may occur (see local policy).

The moisture, colour, texture, debris, and any lesions should be noted. Frequency of care should be individualised and will be dependent on assessment and identified risk factors.

Various mouthwashes may be used, such as a weak solution of sodium chloride, or sodium bicarbonate and chlorhexidine gluconate mouthwash. Note that chlorhexidine gluconate mouthwash may be incompatible with some substances in toothpaste. Rinse the mouth with sufficient water between using the toothpaste and any chlorhexidine product (British National Formulary 73 (MarchSeptember 2017)). The mechanical effect of mouthwashes may prevent infection.

Sodium bicarbonate acts as a solvent on mucus, but must be made up correctly and rinsed thoroughly. Although glycerine swabs are effective as a salivary stimulant, they are not recommended due to risk of over-stimulation of salivary glands. Some patients might like to have unsweetened pineapple to help breakdown of debris and to refresh the mouth.

Individual preference, oral assessment, and tolerance of mouthwashes need to be considered when using chemical solutions.

Preparation and safety

  • Collect the required equipment. Rationale - Avoids the need to leave the patient during the procedure.
  • Wash and dry hands and put on a plastic apron.  Rationale - Reduces the risk of cross-infection.
  • Introduce yourself and check the patient's identity, using the patient's name-band or asking the patient's name, according to local policy.
  • Ensure privacy.  Rationale - To respect the patient and protect their dignity.
  • Provide a brief explanation of the purpose of the interaction, to obtain the patient's consent and cooperation.
  • Assist the patient into a safe, suitable, comfortable position, for example, sitting upright if their condition allows.
  • Encourage the patient to clean their own teeth if possible.
  • Note: If the patient is unconscious or their condition prohibits this position, position them on their side to allow free drainage from the mouth and cover the bed and pillow with a waterproof cover and a towel. Ensure suction equipment is working, if needed.
  • Note: Unconscious patients should not wear their dentures, as these may obstruct the airway. The dentures should be cleaned and stored in water in a labelled denture pot.
  • Raise the bed to a height suitable for working.
  • Additional protective clothing may be necessary if indicated by the patient’s condition.
  • If applicable, put on non-sterile gloves, remove patient's dentures and put in a pot of water.

Procedure

  1. Cover the patient’s chest with a towel.  Rationale – To preserve the patient’s dignity and to protect the patient's clothing and bedding.
  2.  Open the clinical waste bag and place in a convenient place that allows easy access. Rationale – For ease of access and to prevent cross-infection.
  3. Perform an oral assessment using a tongue depressor and pen torch. (See separate skill on Oral Assessment.) Rationale – The use of a standardised assessment tool ensures that mouth care is given when required. It provides a baseline for monitoring mucosal changes, evaluates required treatment and response to treatment, and allows you to note changes in the patient’s condition.
  4. Open mouth care tray and pour water into the mouth care tray. Rationale – To prepare solution. Solutions should be prepared immediately before use to reduce the risk of microbial contamination.
  5. Put on nonsterile gloves. Rationale – Standard precautions for the prevention of infection stipulate that gloves must be worn when dealing with body fluids such as saliva.
  6. Squeeze a small (small pea-sized) amount of toothpaste onto the brush. If battery-operated, set the brush at the lowest speed, to minimise the risk of traumatic injury. Rationale – Toothbrushes are the most effective tool to remove plaque. Soft-bristled toothbrushes are least likely to cause buccal mucosal damage. Too much toothpaste can result in excessive foaming and can be difficult to rinse away.
  7. Using small up and down or circular strokes, clean the inner and outer aspects of the teeth, gums, and tongue. Rationale – To remove debris and plaque between and from the surfaces of the teeth and from the surfaces of the gums and tongue; to reduce the risk of oral pathogenic microorganism formation; to maintain healthy soft tissue in the mouth. Gingival tissue is stimulated when brushing, which maintains tone and prevents circulatory stasis.
  8. The mouth should be rinsed with water to remove any food debris or remaining toothpaste. The patient should be advised to rinse vigorously and then spit the water into a vomit bowl/receiver (Nicol et al. 2012). Rationale  Removes any food debris and remaining toothpaste very effectively. 
  9. If the patient is unconscious, the mouth should be rinsed by using foam sticks wetted in water according to local policy. If oral foam sticks are used to remove toothpaste, ensure that the foam is securely attached to the stick (Dougherty et al. 2015). Dip foam sticks into the water and gently wipe around the patient’s mouth to remove the toothpaste. Discard the foam sticks into the waste bag. Rationale – Foam sticks may be useful to rinse the mouth to remove toothpaste and debris and to refresh the mouth. Foam sticks are for single use, and must be discarded once used. Foam sticks should not replace toothbrushes unless the use of a toothbrush is contraindicated.
  10. Gentle suction may be used to remove excess water or secretions (Nicol et al. 2012).
  11. If a conscious patient wears dentures, they should be cleaned with a denture brush and denture-cleaning paste and thoroughly rinsed before giving them back to the patient. Ordinary toothpaste should not be used on dentures, as it is too abrasive. If the dentures are not being replaced, they should be stored in water in a labelled denture pot. 
  12. Use the towel to dry around the patient’s mouth. Rationale – To maintain surrounding skin integrity and maintain patient dignity.
  13. If the lips are dry or cracked, apply a thin layer of lip balm or petroleum jelly. Rationale – Lip balm and petroleum jelly provide an occlusive barrier that helps retain moisture. Note: It should not be used if the patient is receiving oxygen therapy as it is flammable and traps microorganisms.
  14. Clean the toothbrush in the beaker of water and dry. Replace toothbrush and toothpaste in the locker. Rationale – To prevent the risk of contamination. Toothbrushes should be change regularly.
  15. Cover the mouth care tray and place on the locker. Rationale – To reduce the risk of contamination and maintain a safe environment. 
  16. Remove the gloves and apron and discard into the clinical waste bag. Rationale – As per standard precautions to reduce the risk of cross-infection.
  17. Wash and dry hands.
  18. Write the date and time on the cover of the mouth care pack so that it is clear when it must be changed; every 24 hours. Rationale – To reduce the risk of contamination and prevent infection.

Documentation and reporting

  • Document the mouth care (paper-based or electronically), noting and reporting on the condition of the oral cavity and teeth. 
  • Report any changes to the nurse in charge or the doctor. 
  • Update the patient's care plan as required.

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