Procedure: Oral Care in Intubated or Trached Patients

Ensure that patient and health care provider safety standards are met during this procedure including:

• Risk assessment and appropriate PPE
• 4 Moments of Hand Hygiene
• Procedural Safety Pause is performed
• Two patient identification
• Safe patient handling practices
• Biomedical waste disposal policies

INDEX

1. Supplies Required
2. Review Orders
3. Perform oral assessment
4. Brush Teeth
5. Apply Chlorhexidine
6. Provide PRN Care
7. Document

Supplies Required:

Paediatric toothbrush

Toothpaste (toothpaste is single patient use only)

Toothettes

Bottle of chlorhexidine 0.12% (supplied as ward stock, 100 ml bottles)

Plastic medicine cups

Oral mouth suction (yaunker or single use suction catheters)

Petroleum jelly (lip care)

PPE- non-sterile gloves, facemask and shield

PROCEDURE

 1.

Review Orders

• This oral care routine applies to all patients who are intubated or have a tracheostomy
• Verify that order has been obtained for chlorhexidine 0.12% mouth wash BID.
• Rule out contraindications including severe mucositis or allergy to chlorhexidine

 2.

Perform Oral Assessment:

• Perform hand hygiene and don non-sterile gloves, facemask and shield.
• To fully inspect oral cavity, use a flashlight and a 4 X 4 gauze to facilitate lifting/moving of the tongue
• Inspect top, sides and undersurface of tongue. Assess lips, back of throat and mucous membranes for any bleeding, odor, discharge or evidence of skin breakdown or ulceration
• Inspect teeth to observe for breakage, missing teeth, dental carries or recent trauma. Consider need for dentistry consult.
• Remove any partial or full plates or dentures.
• Palpate along cheeks, gum line and neck glands for signs of swelling, enlarged lymph nodes or abscess.
• Review ETT or NG tube placement and assess for associated ulcers/early pressures; discuss with RRT if tube repositioning is needed
• Document findings in AI record.

• Disruption of mucous membranes can be very painful and may increase risk for systemic infection.

  Dental caries increase risk for abscesses/oral infections.

 3.

Brush Teeth

• Use a new tooth brush for each oral care episode
• Brush the teeth using a small toothbrush and toothpaste q 12 h and prn.
• Hold brush at 45 degrees and brush away from the gumline.
• Rinse with water (use sterile water bottle) and suction
• Wait at least 2 hours following chlorhexidine or oral nystatin (if used) before brushing teeth with toothpaste or using mouth washes.
• Use a new tube of toothpaste for each patient (single use item)

Intubated patients are unable to maintain normal oral care hygiene. Accumulation of bacteria in the mouth can change the bacterial flora. Oral secretions are aspirated during intubation, even with intact endotracheal tube cuffs. Aspiration of oral secretions is associated with increased risk for Ventilator Associated Pneumonia (VAP). Tooth brushing loosens bacteria and enhances the ability to reduce the number of oral pathogens.

The small pediatric toothbrushes are soft and inexpensive. Reuse allows oral bacteria to multiply and may act as a fomite.

Flavoured toothpastes and mouth washes may interfere with the effectiveness of chlorhexidine.

Use a new tube of toothpaste for each patient to avoid potential cross contamination. The regular sized tubes cost less that the small tubes.

Sterile water is used for oral care and flushing of enteral feeding tubes to avoid potential introduction of pathogens from taps or sinks.

 4.

Apply chlorhexidine

• REMOVE ANY DENTURES. Place in denture cup and clean with polident. DO NOT use chlorhexidine on dentures (after removal, use chlorhexidine on natural teeth)
• Poor a small amount of chlorhexidine 0.12% into a medication cup
• Soak a toothette in chlorhexidine solution
• Scrub along teeth, tongue and gum line using small circular motions
• Ensure that toothette reaches above the gum line
• Suction any remaining chlorhexidine from mouth, but do not rinse.

Chlorhexidine creates a film that adheres and remains on the teeth to provide antibacterial activity against gram positive organisms.

Chlorhexidine can stain artificial teeth.

With prolonged use, chlorhexidine can stain natural teeth. Discoloration can be removed during the next dental cleaning and does not usually occur unless use exceeds several weeks.

The reason for chlorhexidine use should be explained to the patient/family and they should be advised that any discoloration of the teeth can be removed during the next dental cleaning.

 5.

PRN Care

• Cleanse mouth with toothette soaked in water q1-4 h and prn to maintain hydration
• Apply petroleum jelly to lips
• Do not use mouthwash within 2 hours of chlorhexidine
• Remove PPE and perform hand hygiene.

6.

Document

• Document oral assessment and oral care in the integumentary section of the EHR under Mucous Membranes.
• Document abnormal findings in the assess/reassess/comments.