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Ashleigh Windel

NURS 451
AACN Practice Alert Oral care in the critically ill
This American Association of Critical-Care Nurses practice alert states proper oral care in
critically ill patients (particularly those on a ventilator) is an important intervention in preventing
pneumonia as a hospital acquired infection. The main focus of this alert is on developing an oral hygiene
program for the patients in critical care that are at risk for ventilator-associated pneumonia. The
expected practice is to brush their teeth and gums twice a day with a soft toothbrush. Oral moisturizing
should be applied to the oral mucosa and lips every 2 to 4 hours. This can be done with wetted oral
swabs run along the gum lines and application of a lip balm to the lips. The next two recommendations
were surprising to me because I have never heard of oral chlorhexidine gluconate but it is expected
practice to use oral chlorhexidine gluconate rinse twice day in the perioperative period for adult patients
who undergo cardiac surgery. Upon further research that I did myself I discovered that this rinse is a
germicidal mouthwash that reduces the amount of bacteria in the mouth and is used to treat gingivitis.
Supposedly this is only recommended for patients that will be undergoing cardiac surgery because it can
prevent nosocomial respiratory infections in that population while reducing the use of nonprophylactic
systemic antibiotics.
The levels of evidence for these AACN practice alerts are starting to not surprise after doing this
third reflection. The level of evidence for using the chlorhexidine gluconate rinse on cardiac patients was
at level D. Level D has a very low quality of evidence and no direct research associated with it which
makes me wonder how they came up with that expected practice in the first place if there has not been
any quality research done on it. Very shockingly was that brushing the teeth, gums and tongue of
critically ill patients was at a level E which means it is only supported through expert consensus.
I think that this practice alert does not affect other disciplines so much as it affects nursing. The
nurses and nurse techs are the staff members that will be performing the oral hygiene programs on the
critically ill patients. Since it is the responsibility of nursing staff to maintain oral hygiene they would
have the responsibility of documenting the care provided and observing the patient for any changes
orally, as well as, in the direction of ventilator acquired pneumonia. This practice alert protects these
patients from possibly acquiring a nosocomial infection. By having these expected practices outlined in
facility policies the nursing staff is aware of their responsibility to maintain oral hygiene regimens on
their patients to protect them from infection. Overall, there should be less incidences of VAP and
possibly shorter hospital stays if these expected practices are followed.
From reading this practice alert I am now aware of the importance of oral hygiene for these
critically ill patients. I was unaware of the high risk critical patients on ventilators had of acquiring a
nosocomial infection just from lack of good oral hygiene care. In my future practice I will ensure that all
patients receive oral hygiene care regularly. For example, if I had a patient in the ICU that was on a
ventilator I would perform oral hygiene on them at least twice throughout my shift. With a soft
toothbrush I would gently brush their gums, teeth and tongue. Then I would use a wetted oral swab to
massage their gum line, as well as, remove any leftover rinse used. I am not sure how available the oral
chlorhexidine gluconate is but if that is readily available I will ensure that a cardiac patient has their
mouth rinsed out with it twice daily.