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. |
