Oral Hygiene and Mouth Care - Essay Example

Oral Hygiene: Nursing Research Proposal June 2, 2006 [Insert [Insert [Insert Oral hygiene and mouth care are related to respiratory illnesses especially in ICU and seriously ill patients. This study will aim to recognize and make recommendations towards the knowledge base of nursing staff in ICU wards. The research design is a quantitative survey analysis distributed to a sample population of nursing staff within ICU hospital wards. The data will be collected and analyzed using analysis and hypothesis testing. This information will then be given to [INSERT SCHOOL] at a time frame specified by [INSERT INSTRUCTOR]. This research has an impact on nursing instruction and training as well as understanding what improvements have been made over previous research and what areas of mouth care need to be improved upon. Chapter 1: Introduction Oral care is imperative to promoting a healthy patient, especially in the seriously ill, geriatric and cancer patients. Good oral hygiene is linked to the prevention of somatological diseases in older residents (Ship 2002), as well as periodontal diseases and infections in diabetic patients (Nursing 1993), and oral care reduces pneumonia in older patients (Yoneyama, 2004). However, it stands to be shown that very often nursing staff is unaware of the importance and method of appropriate oral hygiene (Adams 1996). Oral care is very cost effective and when appropriately applied, it can prevent diseases and infections, yet there is very little information on oral care for the intensive care unit and seriously ill patient other than in the geriatric, cancer and diabetic related studies. Currently, the National Institutes of Health Clinical Center is sponsoring a study on Oral Care to Reduce Mouth and Throat Infections in Critically Ill Patients (ClinicalTrials 2005). Their research uses phase three longitudinal studies of one-thousand to three-thousand patients in intensive care units to evaluate a program of oral hygiene that may prevent respiratory infections in patients, which "occur five times more often in critically ill patients compared with patients in general hospital wards and result in longer hospital stays and an increased risk of death" (ClinicalTrials 2005). It stands to be noted that there is a higher likelihood of a patient leaving an intensive care unit with a mouth infection or respiratory infection because of inadequate oral hygiene. This rate of infection, according to ClinicalTrials.gov and Maryland Health Institute is due to the presence of disease causing bacteria in the patient population. Their study is planning to asses oral care effectiveness amongst seriously ill patients from Washington DC related areas, and the Maryland Health Institute study sponsored by the National Institutes of Health Clinical Center seeks to define the effectiveness of oral care in patients over the age of eighteen with a focus on: These hospitals have ICUs more representative of ICU's nation-wide. This study will test the effectiveness of a comprehensive and systematic oral care program to reduce the oral assessment scores, mucosal plaque scores, and the amount of pathogen inoculum present in the saliva and plaque. Incubated and non-incubated patients will be compared as well as meticulous care with or without the addition of the oral antiseptic, chlorhexidine. Consistency of practice performance will also be evaluated when nursing staff has dentist/hygienist instruction and monitoring versus the traditional nurse instruction. The following research proposal will come to a slightly different approach in developing mouth care for seriously ill patients. The proposal is to seek the manner in which ICU nurses give oral care and their understanding of method, procedures and guidelines as well as prevention techniques. It is obvious from previous studies that the health care industry as a whole is not entirely aware of preventative measures (Adams 1996) and that there are few studies devoted specifically to the seriously ill patients' mouth care (ClinicaTrials 2005). The nursing staff's perspective on oral hygiene for seriously ill patients will assist in the development and training of oral care in intensive care units. It is possible that because ICU patients do not generally have the same long-term stay as geriatric or cancer patients this area of the hospital is often overlooked for oral hygiene. However, it is also important to note that hospitals and nursing staff do not want patients to leave the facility with poorer oral hygiene than they came in with, and also that because oral care is such an easy preventative measure, seriously injured and ill patients should leave with better oral states than they entered the hospital with. To do this, nursing staff must have an understanding of the methodology behind oral hygiene and deployment of oral care. For nursing staff who work with seriously ill patients to have a better understanding in performing oral care, their current knowledge must be measured to create a process for training and development. The theory is that nursing staff in ICU units place an amount of importance on oral care, but are not adequately trained to deliver oral care to seriously ill and intensive care unit patients. In the following, literature reviews will show the importance of oral care and methods of oral care as a preventative measure against disease and illness, as well as the general consensus of nursing knowledge in this area. The methodology will be explored with a focus on the level of measurement, the reliability and validity of the survey, as well as scoring methods and rationale for data analysis. Chapter 2: Theoretical Framework The theory in this research proposal is that nursing staff who work with intensive care and seriously ill patients are often not aware of the importance and methods of oral care when dealing with prevention of oral inflammation, diseases and infections that result from inadequate oral hygiene, such as pneumonia. Stiefel et al (2000) initiated a research study with these characteristics: A research-based policy and procedure to improve the oral hygiene care of intubated and other seriously ill patients was developed, implemented, and evaluated. The project resulted in (a) improved oral hygiene for patients, (b) standardization and simplification of nursing practice, and (c) a reduction in supply costs. The project has implications for nursing practice and evidence-based practice protocol development (Steifel et al p 40. 2000) Their research shows that when oral hygiene is implemented by nursing staff in practice, patients had improved oral hygiene. This is also identified by Paulson et al (p 299 1999) who aimed to "describe how nurse managers perceive oral health in general and the oral health of the care-receiver in particular," and further research by Adams (1996) who noted that there is a "lack of knowledge about oral health among qualified nurses in district general hospital in Great Britain," and noted that this is directly a cause of "inadequacy of oral care of patients on medical wards," due to an "occurrence of gaps in knowledge of oral care procedures." The theoretical framework of this study is to define the gaps that occur between nursing practice and oral hygiene towards prevention of illnesses as shown in Diagram 1: ICU and Oral Hygiene Research Framework. Diagram 1: ICU and Oral Hygiene Research Framework The above framework focuses on the nursing staff's cognition of practice as it relates first to the ICU and seriously ill patient's needs relative to their illness or disease. Secondly, the framework is to determine the nursing understanding of qualitative techniques in oral hygiene methodology and guidelines for practice on the ICU and seriously ill patient. The third measurement is also important, as this will gauge the nursing development in prevention practices in regards to the links between oral care and illnesses and knowledge of special needs in mouth care and hygiene for ICU and seriously ill patients. Chapter 3: Literature Review The focus of this research is nursing staff who deal with seriously ill and intensive care unit patients. These patients often have special needs that are not covered by generally administered mouth care. In similar research, Furr et al (p 454 2004) explain that the "oropharynx of critically ill patients becomes colonized with potential respiratory pathogens," and that the colonization of respiratory pathogens in the mouth "may contribute to ventilator-associated pneumonia," and This is especially important in critical patients to prevent further illnesses because oral care protocols significantly reduce the colonization of pathogens which lease to a lessening of "nosocomial pneumonia risks" by the use of "chlorhexidine rinses and gels administered two or three times daily." Furr's research team's results lend to a better understanding of the factors that prevent oral care in ICU and seriously ill patients. These factors are outlined by Furr et al (2004) as having various qualities. They note that the nursing staff's education and experience in intensive care unit patients and mouth care needs has an effect on the practice of mouth care, also that nurses need sufficient timeframes to adequately complete oral hygiene practices, and furthermore, nurses noted oral care as being an unpleasant task (Furr 2004). These components have an effect on the way and amount of oral care that is given in a preventative manner. Geriatric patients have a more involved need for better oral hygiene, as Jonathan Ship (2002) explains, mechanisms of oral care help maintain health in the elderly patients to reduce risk in the development of diseases and infections can be accomplished by antimicrobial mouth rinses, xylitol and chlorhexidine gums. He (Ship 2002) notes that there are major impediments in maintaining oral health for prevention of somatological diseases in geriatric patients. Ship notes that while there are easier methods to prevent mouth diseases and bad oral hygiene, chewing gums require special monitoring by nursing staff, and there is a lack of emphasis on the importance of oral care in patients. This is further emphasized by Takeyoshi Yoneyama (2004) whose research in geriatric patients found that the risk of pneumonia was significantly reduced in patients receiving oral care, further accentuating that a health care provider should support and advocate for better health care for geriatric patients. Yoneyama's (p 165 2004) study used eleven nursing homes in Japan, with four hundred patients that were "were randomly assigned to an'oral care' group or a'no oral care' group and were investigated for 2 years," resulting that "the removal of latent oral infection and potential problems might be a way to reduce the incidence of lower respiratory tract infection." Further research leads to the consideration of oral hygiene as link to illness in already seriously ill patients. El-Soth et al (p 1575 2004) researched the link between poor dental hygiene and respiratory pathogen colonization by investigating "the association between dental plaque (DP) colonization and lower respiratory tract infection in hospitalized institutionalized elders using molecular genotyping." The method they employed was to assess "the dental status of 49 critically ill residents of long-term care facilities requiring intensive care treatment," where "Plaque index scores and quantitative cultures of DPs were obtained on ICU admission," by isolating respiratory pathogens recovered in fluids using pulsed-field gel electrophoresis" (El-Soth et al p 1575 2004). The following results were found: "Twenty-eight subjects (57%) had colonization of their DPs with aerobic pathogens," and "Staphylococcus aureus (45%) accounted for the majority of the isolates, Enteric Gram-negative bacilli (42%) and Pseudomonas aeruginosa (13%)" (El-Soth et al p 1575). The conclusion of the research suggests that institutionalized elders are more susceptible to aerobic respiratory pathogens due to colonizing dental plaques. Cancer patients also have special needs in the oral hygiene area. Larson and Nirenburg (2004) substantiate the importance of good oral care using chlorhecidine and antiseptics in cancer patients, especially those with neutropenia, greatly reduces microbial flora that causes infections. In patients, "mucositis, ulcerative lesions and other mouth problems are a frequent cause of morbidity among many patients with neutropenia and those undergoing radiotherapy and pose challenging nursing management problems." They identify the main interventions as being the chlorhexidine mouth rinse or a calcium phosphate mouth rinse, and in some cases the application of honey have all produced positive results. Diabetics have further need for special preventative oral care. More than half of all adults have at least the early stages of gum disease. The American Diabetic Association states that most adults have gum disease, but poor glucose control makes gum disease and infection more likely. Furthermore, it is noted that "periodontal disease is one of the most commonly reported oral conditions associated with diabetes, yet it doesn't receive the attention that other conditions, such as foot problems, do, it affects people with insulin dependant and non-insulin dependant diabetes mellitus-especially those with poorly controlled diabetes" (Nursing p 61 1993). This demonstrates the importance of good oral care to the diabetic population for prevention of mouth disease. The above researchers have determined that there is a lack of appropriate metrics-knowledge as well as time and practice-to deliver adequate oral hygiene to prevent complications resulting from bacterial collections in ICU and seriously ill patients. This is in correlation with the proposed research; however, this research proposal focuses on the nursing staffs understanding of their qualifications and needs to perform adequate oral care in a preventative method. Steifel et al (2000) researched the methods used by nursing staff in the care of seriously ill patients, identifying first that seriously ill patients have increased risk for antagonized oral complications, and that oral care of patients is inherently a nursing responsibility. They further noted that "While nursing studies identify appropriate tools, chemical agents, and frequencies for providing effective oral hygiene, nursing practice continues to be provided based on ritual, tradition, and the individual nurse's preferences" (Stiefel et al p 40 2000). This led to the research of methods used by nursing staff in oral care for seriously ill patients, where a "procedure to improve the oral hygiene care of intubated and other seriously ill patients was developed, implemented, and evaluated. The project resulted in (a) improved oral hygiene for patients, (b) standardization and simplification of nursing practice, and (c) a reduction in supply costs" (Stiefel et al p 40 2000). Stiefel's research specifically noted that there is a wide variety and methodology used by nursing staff in oral care, and that implementing a single oral care procedure is the best manner in which patients can receive care. This however, does not gauge the level of commitment and knowledge base nursing staff has on the methods, guidelines and importance of oral care for ICU and seriously ill patients. Paulson et al (1999) sought to determine how nursing managers view oral health care in importance and responsibility; again noting that in seriously ill patients mouth care is essentially a nursing responsibility. Paulson's team (1999) used a phenomenographical method to analyze interviews according to nursing management job role and discovered that nursing management staff has varying viewpoints on "how nurse managers perceive oral health: maintaining patients' well-being, having knowledge about oral health, behaviour towards the patient, feeling of being insufficient and creating the necessary conditions" (Paulson et all p 299 1999). In maintain patients well being, Paulson's study discovered two very different nursing manager responses where the responses show functional and aesthetic qualities: Interview 5: It affects the speech; it affects the nutrition, being able to eat. The mouth is the most important part of the face, so everything is affected by it. If one doesn't have a good oral status and oral health, one can't eat, because the mouth is sore and one can't drink, which makes one feel worse. So there are many factors that are affected by this. One's whole health deteriorates if one doesn't have good oral health. Interview 11: Yes, it's of course important, because you laugh, smile and talk and then your teeth show, which gives an impression of you as a person. (Paulson et al p 304 1999) The first nursing manager in Interview 5 noted the functional and health-related characteristics of the mouth, while the second nursing manager noted the aesthetic qualities. This shows that there is a variance in perception of mouth care; however, Paulson's study is based on qualitative and empirical-perception evidence, which does not lend to a quantitative description of the importance and understanding nursing staff places on oral hygiene in practice. Lastly, Rachel Adams (1996) investigated the lack of knowledge about oral health care among qualified nurses. This study was conducted ten years ago in Great Britain, and there has not been a published repeated study with the same quantitative goals in America. As such, Rachel Adams' study is highly parallel to this research proposal in regards to the nursing knowledge base of oral care. The study questionnaire was comprised of twenty questions to understand the nurse's personal history (length of time as a nurse), extent of knowledge and education and current practices regarding oral hygiene on patients. In her study, Rachel Adams found that 28 nurses had received instruction during their training in regards to oral hygiene, but twenty-nine nurses had not received instruction since qualifying, but five nurses had never received any instruction on delivering oral care, and Adams notes that the quality and quantity of oral care instruction was not measured by her study. Ninety-one percent of Adams sample nursing group state that trained and experienced nurses teach untrained or inexperienced nurses oral care, and "this has serious ramification if the trained nurses lack knowledge themselves" (Adams p 558 1996). Rachel Adams study does vary from this research proposal in that it was conducted nearly a decade past, and in Great Britain. Nursing instruction has taken amazing strides over the past decade, and this research will be America based. It will be interesting to see exactly how far nursing has come in regards to understanding and implementing preventative mouth care for seriously ill patients. Chapter 4: Methodology The research methodology selected was a distributed survey. This allows for empirical character evidence to be gathered and studied for defining relationships. The implication is to develop a better understanding of nursing perception and knowledge regarding oral mouth care in ICU and seriously ill patients. The study seeks to define the measurements of the nursing staff sampling using a survey research model. This model is used widely in quantitative research and is fundamentally considered a low cost and time effective method of gathering information from a sample population. The survey was chosen because it can be deployed to many recipients with low cost and analyzed within a relatively normal timeframe. Furthermore, the survey method allows for the participants to define their values regarding the variables within the survey, where other the other considered methods would have imposed the researcher's values onto the participants. While the survey method selected has many valuable qualities, it is also important to note that there exists a certain amount of criticism that survey research collects data based on variables and does not always denote theoretical value; however, because the research is stated with documented objectives, this is not seen as a barrier to effective survey research. The written questionnaire allows for a sample population to be easily reached with responses documented and easily dissected using data entry and statistical analyzing methods. Because of their widespread use, questionnaires are non-confrontational to the sample population and do not force opinions or options, allowing for accurate and viable responses to be gathered with little bias or influence from the researchers or complicated research equipment.. However it is important to note that the questionnaire does not directly identify ambiguous questions; it relies on the respondents' language comprehension and cognition. Likert Scale The Likert Scale is used to identify nursing staff responses to the above questionnaire. This is done in the common format of a numerical five point scale where one shows a strong disagreement; two is a disagreement; three is a neutral response; four is an agreement; five is a strong agreement to the statements in the questionnaire. The benefit of this scaled method is that it allows for easy quantitative analysis to be made from qualitative questions because it defines respondents' opinions with numerical responses. The disadvantage of the Likert scale is that it 'boxes' the opinions into specific categories, thus it does not allow for explanation or definition of the responses made. The following survey will be used: Nursing in ICU and Seriously Ill Patients: Mouth Care Survey Knowledge and Practice Strongly Disagree Disagree Neither Agree Strongly Agree Mouth Care is a Nursing Responsibility Incubated Patients have special oral needs Geriatric, Diabetic and Cancer have special oral needs I understand the oral care needs of patients I have enough time to deliver oral care I only deliver mouth care when a patient exhibits halitosis. I frequently give mouth care to all ICU patients I have experience giving mouth care to ICU patients I was taught how to give mouth care to ICU patients. I am given new information on mouth care regularly. I understand how to practice oral hygiene on ICU patients I practice delivering oral care to my patients regularly I know how to deliver mouth care to patients with special needs. Method and Guidelines Strongly Disagree Disagree Neither Agree Strongly Agree I have used and understand hydrogen peroxide rinse for mouth care of ICU patients. I use and understand chlorhexidine mouth rinse for ICU patients. I use and understand calcium phosphate mouth rinse for appropriate patients to reduce bacterial flora. Mouth swabs, toothpaste and toothbrushes are methods of mouth care that are understood and applied to appropriate ICU patients. I use and understand when to use isotonic sodium chloride solution. I know what the guidelines and methods in delivering oral hygiene are. Prevention and Illness Strongly Disagree Disagree Neither Agree Strongly Agree I know there are links between serious illness and good oral hygiene. Oral care is low cost and a preventative measure against illness. Oral hygiene can prevent mouth ulcers. Oral care can prevent upper respiratory infections Mouth care is important to help a patient feel comfortable. Mouth care affects nutrition. The study proposes to develop a quantitative analysis of ICU and seriously ill patient nursing staff with a sample size of forty based on the inclusion and exclusion criteria: Inclusion Exclusion Nursing Staff ICU Other hospital wards Non nursing staff (CNA, Administration) Nursing Management Staff The setting of the questionnaire will be direct distribution to nursing staff currently employed in ICU or seriously ill wards with the exclusion of nursing assistance, management and administrations staff. This will allow for an in-depth description of tactics, knowledge and perceptions of oral care for seriously ill patients as it relates to the nursing practice and prevention of illnesses. Chapter 5: Results Descriptive statistics will be used to analyze correlation between each title in the above survey as well as define standard deviation, especially in relation to nursing knowledge. Analysis of Variance will be used to validate the hypothesis and determine a significant difference between treatments, as well as check homogeneity of variance. This will allow for statistical inferences to be made from the raw data that determines the validity of the theory and tests the hypothesis. Chapter 6: Discussion ICU patients are often incapable of providing personal mouth care, and as noted in the literature, appropriate mouth care is an important preventative measure, both for aesthetic and physical reasons. The ability for ICU nursing staff to understand and deliver to oral care is a highly important factor in determining a patients well being, specifically because it is the nursing staff's responsibility to deliver mouth care to patients, and secondly because part of nursing is to ensure that self care needs are met in a medically viable manner. It is of the utmost importance to gauge nursing staff's knowledge and techniques in delivering mouth care to patients so that appropriate guidelines can be made and adjustments to current practices can be incorporated into the nursing procedures. The various methods of application in mouth care have separate guidelines, time frames and distinctive qualities, and so it becomes important to include the most common methods of reducing oral bacteria when developing an understanding of the frequency and understandings of the applications. The implications towards nursing and nursing practice are to understand the knowledge base in ICU and seriously ill patient mouth care. This is important for nursing so that appropriate recommendations towards education, practice and guidelines can be made. References Adams, Rachel (1996) Qualified Nurses Lack Adequate Knowledge Related to Oral Health, Resulting in Inadequate Oral Care of Patients on Medical Wards. Journal of Advanced Nursing; Sep96, Vol. 24 Issue 3, p552-560, 9p, 8 charts, 3 graphs El-Solh, Ali A. et al (2004) Colonization of Dental Plaques. CHEST; Nov2004, Vol. 126 Issue 5, p1575-1582, 8p Furr, L. Allen, Binkley, Catherine J., McCurren, Cynthia, Carrico, Ruth Factors affecting quality of oral care in intensive care units. Journal of Advanced Nursing; Dec2004, Vol. 48 Issue 5, p454-462, 9p, 3 charts, 2 diagrams Larson, Elaine Nirenberg, Anita Evidence-Based Nursing Practice to Prevent Infection in Hospitalized Neutropenic Patients With Cancer. Oncology Nursing Forum; Jul/Aug2004, Vol. 31 Issue 4, p717-723, 7p, 1 chart Nursing (1993) Heading off Periodontal Disease Nursing August 2002Vol. 23 Issue 8, p61, 1/2p Paulsson; Nederfors; Fridlund; Paulsson Conceptions of Oral Health Among Nurse Managers. A Qualitative Analysis. Journal of Nursing Management; Sep99, Vol. 7 Issue 5, p299-306, 8p Ship, Jonathan A. (2002) Improving Oral Health in Older People. Journal of the American Geriatrics Society; Aug2002, Vol. 50 Issue 8, p1454-1455, 2p Stiefel, Karen A. Damron, Sandra, Sowers, Nancy J. Velez, Laura (2000) Improving Oral Hygiene for the Seriously Ill Patient: Implementing Research-Based Practice. MEDSURG Nursing; Feb2000, Vol. 9 Issue 1, p40 Terpenning, Margaret Shay, Kenneth Oral Health is Cost-Effective to Maintain but Costly to Ignore. Journal of the American Geriatrics Society; Mar2002, Vol. 50 Issue 3, p584-585 Yoneyama, Takeyoshi (2004) Oral Care Reduces Pneumonia in Older Patients. Geriatrics & Gerontology International; Sep2004 Supplement 1, Vol. 4 Issue s1, pS165-S166, 1p Read More