Nursing Process Standard - Oral Care
Developed by LDSH (Latter Day Saints Hospital)
Salt Lake City, Utah
ARDSNetwork Center

PURPOSE

To standardize oral care for all ventilator-dependent, intubated or
recently extubated patients.

SUPPORTIVE DATA

The most common mechanism of acquiring nosocomial pneumonia is aspiration of oropharyngeal secretions. Patients who require long-term mechanical ventilation are at increased risk for colonization, aspiration, and infection. Studies have shown trachael colonization risk for colonization, aspiration, and infection. Studies have shown tracheal colonization eventually occurs in almost 90% of patients who receive long-term ventilation. Once extubated, dysphagia may pose a further risk for aspiration of colonized oropharyngeal secretions.

PRECAUTIONS

Requires RN supervision
1. Facial trauma
1. Broken or loose teeth
3. Bleeding or ulcerated gums
4. Coagulopathy

NURSING INTERVENTIONS
1. Suction oropharyngeal secretion every two hours while awake.

2. Assess oral cavity for inflammation, bleeding, candidiasis, secretions,
and salivary flow and document every shift.

3. Clean with a swab using oral hydrogen peroxide solution or an  antibacterial  mouthwash every 4 hours. Swab teeth, gums, roof of mouth, and tongue.

4. Brush teeth every shift
* Using a soft, pediatric toothbrush, brush the patient's teeth, gums, and tongue. If the patient has no teeth, brush his/her gums and tongue gently.

* If an oral airway (i.e., bit block) is present, remove, clean and replace it after mouth care is completed.

* Place tonsil suction in the back of mouth during oral care to prevent aspiration of cleaning solution.

* Rinse toothpaste from the patient's mouth with antibacterial alcohol-free mouthwash (use a swab) and suction the mouth with oral suction as needed.

* Apply moisturizing gel to gloved finger and gently massage it onto the mucous membranes of the patient's mouth.

* With gloved finger, apply petroleum jelly to the patient's lips.

DOCUMENTATION
1. Routine oral care per hygiene section of nursing documentation
2. Teeth brushed per hygiene section of nursing documentation.