Mouth care for proned COVID-19 patients - FEATURE - Nature
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
FEATURE
Mouth care for proned
COVID-19 patients
Zoe Holt1 is a dental nurse working Introduction
The Coronavirus pandemic 2019 (COVID-
in an acute setting as a mouth 19) caused by severe acute respiratory
care lead. During the pandemic syndrome coronavirus 2 (SARS-CoV-2)
reached the UK in late January 2020. The
Zoe helped develop guidance for number of hospital admissions reached
a high and our NHS was thrust into a
pressure sores in COVID-19 patients pandemic like nothing we had ever seen.
placed in the prone position. East Kent Hospital University Foundation
Trust (EKHUFT), one of the largest hospital
trusts in England made up of three acute
sites, started to notice an increase in
numbers of incidents reported by staff for
commissure (angle of mouth)/facial pressure
sores as more of our Intensive care unit
(ITU) patients needed to be nursed prone.
Proning or prone is the placement of
Author information
patients so that they are lying on their
1
Zoe first qualified as a dental nurse stomach, with their face to the side; this is
in 2005 while working in general used in the treatment of patients in ITU
practice. She then worked in a with Acute Respiratory Distress Syndrome
Maxillofacial Department before (ARDS). One of the most common
applying to become the Mouth complications of nursing patients in the prone
Care Matters nurse for her hospital position is the occurrence of pressure ulcers1
trust (https://mouthcarematters. as patients are repositioned far less frequently
hee.nhs.uk/). (generally only after 16 hours) and significant
facial oedema may develop.
28 BDJ Team www.nature.com/BDJTeam
© 2021 The Author(s), under exclusive licence to British Dental Association
FEATURE
• Cleanse face carefully with Senset foam, being careful not to
get it in the patient’s mouth
• Ensure mouth care is carried out following the Mouth Care Guideline
for COVID-19 patients, located on the Trust intranet page
Clean
• Apply Medi derma-s spray or Cavilon Lollipop to the cheek and
commissure (angle of mouth); this helps to prevent moisture
damage from any fluids that may collect
• Allow to dry
Prepare
• Protect lips with a balm/moisture gel (Oralieve gel)
• Place absorbent sheet under the head to collect any fluid
• Place appropriately sized Kerrapro Strip cut to size to cover the angle
of the mouth
• If dressing peels away, check to ensure moisture is not collecting
under the dressing which could cause moisture damage. If so remove,
Protect
©Juanmonino/iStock/Getty Images Plus
repeat clean and prepare stages, then apply new dressing
• Check dressings every 2 to 4 hours
Fig. 1 Mouth care guide for proned COVID-19 patients in the ITU
After seeing the damage to these vulnerable is an important part of patient care. The most Reduced access to the back of the mouth/
patients’ faces while going through this common complication of nursing patients dentition as patient is lying on stomach
rigorous treatment, multi-disciplinary team in the prone position is the occurrence of with face to the side and tubes in place
meetings were held and it was highlighted pressure ulcers. This can result in a decline Difficulty in keeping skin dry due to
that we had to try to reduce the number of in mental health and social functions when leaking secretions from the mouth as face
incidents and damage being reported. I sought weaned off the ventilator. to the side and patient has no functional
help from our tissue viability lead nurse to help On closer inspection of the incidents, we swallow as sedated
produce guidance for the ITU teams looking were faced with the following challenges when Pressure to face due to position
after these proned patients whilst maintaining patients were nursed in the prone position: Length of proning can be up to 18 hours
and providing the best care possible in line Limited mouth opening due to patient therefore reducing capability of some basic
with our trust’s values. being on ventilator and being somewhere care being carried out
A number of virtual meetings were held between awake and asleep, but most Patients over the age of 70 are at risk of
over Zoom (which we were still getting used patients with COVID-19 are more heavily skin damage through dehydration/other
to). It became apparent that we needed to sedated to help protect the lungs and factors
improve our practices in our ITUs and that they were unable to open their mouths Medical conditions that affect blood
the guidance we developed would be shared themselves supply eg kidney failure, Parkinson’s
trust-wide to allow for consistency in patients Limited space due to endotracheal tube disease and diabetes that have the ability
being treated proned. in place. The tracheal tube is a hollow to add additional complications with
plastic tube that is placed in the trachea healing and puts a strain on the heart’s
Background (windpipe/airway) through the mouth to pumping ability
Currently in our trust there is no guidance the lungs Reduced oral nutrition once weaned
in place for facial sores/damage to the Xerostomia (dry mouth) can be caused off ventilator due to sores at the angle
commissure (angle of mouth). We know due to patients receiving oxygen and of mouth, making opening the mouth
that when the teams are deciding to prone having the endotracheal tube in the oral painful, so there is a need for an alternative
a patient, appropriate care of the face and cavity, and no stimuli to the oral cavity to route for nutrition to be discussed so that
mouth should be undertaken to prevent help with saliva secretion. Some types of patients do not become malnourished and
pressure sores and wounds developing, as this medication can also cause dryness also to help with recovery and healing
www.nature.com/BDJTeam BDJ Team 29
© 2021 The Author(s), under exclusive licence to British Dental Association
FEATURE
The use of endotracheal tape (ET tape) day ideally with a disposable toothbrush. to help give guidance for any mouth related
to secure tube instead of anchorfast Try and brush all surfaces of the teeth issues the patients had sustained, and to be
device, this is so that this can be tied Avoid using electric toothbrushes as they able to advise on any additional resources
tightly to ensure no movement of the generate more aerosol spray patients may need to be able to carry out good
tube when being put in the prone Use a small headed toothbrush with a long mouth care.
position, but this also cuts into the angle handle for better access With looking at the practice in the ITU
of the mouth Use a smear of toothpaste or a non- department and considering the tissue
Possible infection or bacterial colonisation foaming toothpaste on a dry toothbrush to viability and mouth care knowledge we put
in broken skin from leaking secretions and prevent the build-up of secretions together the following guide (Fig. 1).
bacteria from the mouth Carry out gentle oral suctioning or use a We became aware that when patients
Trauma to the oral mucosa after having a single-use suction toothbrush were needing to be placed in the prone
tube placed: sometimes trauma can occur Try to stand to the side of the patient or position to support respiration it was
from equipment used and sometimes the behind them so your face is not directly in essential that we try to minimise damage.
force used to place the tube. front of their face This was especially important for patients
who had contributing factors that may
impinge on their healing, not just of the
‘This work highlights the need to look mouth and face. For example, the damage
sustained may also cause delayed recovery
once weaned off the ventilator, ie eating
for alternative ways to secure the tube and drinking, as the angle of mouth may be
sore and scabbed and this may cause pain/
in place in patients’ mouths, what we lack discomfort and limited opening. Our Speech
and Language Therapists (SLT) also noted
that it had an impact on communication due
in identifying these angle of mouth sores, to pain and discomfort.
This work has highlighted the importance
of the multidisciplinary team working
and how this impacts on our patients’ together at this pivotal time to deliver the
best care we can for our patients. It further
highlights the need to look for alternative
Considering the above challenges, we Carry out dry mouth care regularly by ways to secure the tube in place in patients’
felt that multi-disciplinary team discussions moistening the mouth with water or using mouth, what we lack in identifying the
with specialist input, to ensure that the a dry mouth gel on a toothbrush as needed potential hazards of developing these angle
patient’s proning plan was discussed ahead of Gently brush the tongue in a forward of mouth sores, and how this impacts on our
procedure with all the specialists involved in sweeping action patients who have already been through so
that patient’s care, would enable us to try to Make sure the lips are regularly lubricated much. We will continue to look into this to
reduce some of the above challenges, but also with a lip balm or water-based gel. find methods of further reducing/preventing
acknowledging that sometimes patients were these wounds.
proned as an emergency. The key difference for carrying out
mouth care for NON-ventilated patients is References
Oral care plan that patients are more likely to cough so it 1. Bloomfield R, Noble D W, Sudlow A.
An oral care plan was to be put in place and is important to go gently and take breaks to Prone position for acute respiratory failure
carried out before a patient was proned. allow the patient to rest and swallow. It was in adults. Cochrane Database Syst Rev
We followed the mouth care guidance from noted that COVID-19 affected patients’ ability 2015; CD008095. doi: 10.1002/14651858.
Public Health England for patients who are to swallow. CD008095.pub2.
COVID-19 positive and COVID-19 positive Patients who are enterally fed (intake of 2. Public Health England. Guidance.
and on a ventilator.2 This enabled us to make food via the gastrointestinal [GI] tract; enteral Mouth care for hospitalised patients
sure the oral cavity looked moist and clean feeding may mean nutrition taken through with confirmed or suspected COVID-
before being placed in a prone position for the mouth or through a tube that goes 19. 6 August 2020. Available at: https://
a long period of time as once proned, access directly to the stomach or small intestine) are www.gov.uk/government/publications/
to the oral cavity becomes difficult due to particularly at risk of aspiration pneumonia, covid-19-mouth-care-for-patients-
position and space. so regular mouth care on these patients is with-a-confirmed-or-suspected-case/
Before we carried out any mouth care it essential. mouth-care-for-hospitalised-patients-
was important to ensure that the endotracheal We asked that the mouth care assessment with-confirmed-or-suspected-covid-
tube cuff was inflated to prevent aspiration and skin assessment be carried out and 19#:~:text=When%20providing%20
(when material enters your airway or lungs), recorded regularly. The mouth care lead mouth%20care%20for,not%20an%20
and it was important to note how far the would follow up any patients who had aerosol%20generating%20procedure
endotracheal tube was in the mouth. received an angle of mouth sore whilst (accessed 30 March 2021).
The following recommendations were being in the prone position, until they were
made for mouth care for proned patients: discharged from hospital. This enabled us
Carry out tooth brushing at least once a to check that the sore had healed, but also https://doi.org/10.1038/s41407-021-0589-9:
30 BDJ Team www.nature.com/BDJTeam
© 2021 The Author(s), under exclusive licence to British Dental AssociationYou can also read
