Version: / 1
Author: / Prepared by Nursing Matters and Associates.
Adapted for Local use by:
Issue Date: / September 2012
Review date: / September 2014
Authorised by:
1.0 Policy Statement:
Good oral health for all residents will be promoted through person centred assessment and care planning for oral hygiene needs on admission, routinely every three months or sooner where the resident’s condition indicates.
2.0 Purpose:
The purpose of this policy is to promote good oral health for residents in the Centre.
3.0 Objectives:
3.1 To ensure that nurses are knowledgeable in assessment and care planning for resident’s oral hygiene and dental care needs.
3.2 To ensure that residents’ oral hygiene and dental care are addressed in accordance with their needs, known preferences and wishes.
3.3 To ensure that all care staff are knowledgeable in the delivery of oral hygiene care.
4.0 Scope:
This policy applies to all nursing and care staff in the Centre.
5.0 Definitions:
5.1 Oral: refers to the mouth including natural teeth, gingival and supporting tissues, hard and soft palate, mucosal lining of mouth and throat, tongue, salivary glands, chewing muscles, upper and lower jaw, lips (Hartford Institute for Geriatric Nursing, 2008)
5.2 Oral Cavity: consists of the cheeks and the hard and soft palate (Hartford Institute for Geriatric Nursing, 2008)
5.3 Oral hygiene / Mouth Care: Mouth care is the use of a toothbrush and paste, a mouthwash or other mouth cleaning preparation to help the patient to maintain the cleanliness of his teeth or dentures and to encourage the flow of salvia to maintain a healthy oropharyngeal mucosa. ( Jameieson et al ,1998 cited in Midland Health Board, 2003)
6.0 Quick Reference Guide: Management of Oral Hygiene and Dental Care Needs.
Actions
/Responsible Person.
This policy will be disseminated to and read by all nursing personnel involved in assessment and care planning for resident.
/Person in Charge/Director of Nursing.
A record will be kept of all those who have signed the policy acknowledgement forms.
/Person in Charge/Director of Nursing.
Where a new version of this policy is produced, the previous version will be removed and filed away.
/Person in Charge/Director of Nursing.
Every new staff member who will have a role in assessment and care planning will be given an explanation of this policy as part of his/her induction.
/Person in Charge/Director of Nursing or delegated to another named nurse.
Each new resident will be screened for oral hygiene and dental care needs on admission.
/Admitting and/or designated nurse.
Resident will have an oral hygiene assessment using a validated screening tool within 48 hours or sooner if indicated by their admission assessment.
/Admitting or designated nurse.
Each resident who has a condition / disease affecting oral hygiene and / or dental care will have a written care plan developed in consultation with him/herself and /or the resident’s representative and other relevant healthcare personnel involved in the resident’s care.
/Admitting and/or designated nurse.
The resident’s plan of care to meet oral hygiene needs will be communicated to all those providing direct care to the resident.
/Designated nurse.
Nurses will maintain their competence in assessment for, care planning for and implementation of oral hygiene needs and communicate any competency / knowledge deficits to their line manager/Person in Charge.
/All registered nurses
Care given to residents will be in accordance with the plan of care developed and agreed by the resident and / or representative and other healthcare professionals involved in the resident’s care.
/All healthcare staff providing care to residents.
Changes in a resident’s condition will be reported to the senior nurse in charge and changes to care will be documented and communicated to all relevant healthcare professionals.
/All nurses, care assistants and other healthcare professionals involved in the resident’s care.
7.0 Protocol for Oral Hygiene Assessment and Care Planning.
7.1 Admission Assessment.
7.1.1 Every resident will have an assessment of their oral health commenced on admission.
7.1.2 The admitting nurse should identify the following as part of the admission assessment:
F Any known oral diseases or conditions affecting the resident’s oral health. These may be recorded in the resident’s discharge notes or referral forms.
F The resident’s ability to carry out oral hygiene care independently.
F The resident’s usual routine for oral hygiene.
F Level of assistance required for oral hygiene care.
F Presence or absence of natural teeth or dentures.
F Any known difficulty with swallowing or chewing ability.
F Any specific needs related to oral / dental care.
F The views and observations of the resident or his/her representative regarding current oral/dental status and oral hygiene care.
7.1.3 Based on the above information, the nurse should use his/her professional judgment as to whether or not a physical assessment of the resident’s oral cavity is required at this stage or can be completed as part of the comprehensive nursing assessment.
7.2 Comprehensive assessment
7.3 Comprehensive assessment of the resident’s oral health needs will continue over the first seven days following admission and include the following:
7.3.1 The admitting or designated nurse will complete an assessment of the resident’s oral cavity using the Oral Health Assessment Tool or The Kayser-Jones Brief Oral Health Status Examination (BOHSE) as outlined in 7.4.
7.3.2 The admitting or designated nurse will collaborate with the resident as far as he / she is able to ascertain needs and wishes related to oral / dental care.
7.3.3 The admitting or designated nurse will involve the resident’s family, where the resident is unable to participate, in order to ascertain the resident’s needs and known wishes for oral / dental care.
7.3.4 The admitting or designated nurse will gather information from other nurses and care staff to identify care needs and preferences.
7.3.5 The admitting or designated nurse will liaise with other relevant healthcare professionals to ensure a team based approach to assessment and care planning. This may include the resident’s general practitioner; dentist; dietician and so on.
7.4 Conducting an Oral Cavity Assessment.
7.4.1 The oral health assessment involves assessing the following eight areas:
- Lips.
- Tongue.
- Gums and Oral Tissue.
- Saliva.
- Natural Teeth.
- Dentures.
- Oral Cleanliness.
- Dental Pain.
7.4.2 The following equipment should be assembled for the assessment:
Ø Pen torch light.
Ø Disposable gloves.
Ø Tongue depressor/ bent toothbrush.
Ø Tissues or wipes.
Ø Oral Health Assessment Tool.
7.4.3 It is useful to have a second member of nursing present so as to free up the nurse to carry out the inspection of the oral cavity. A second person may be required if the resident has responsive behaviour.
7.4.4 For residents with cognitive impairment, it may be necessary to have a family member present.
7.5 Procedure.
7.5.1 The nurse should introduce him/herself to the residents and explain the procedure to the resident and seek their permission to continue.
7.5.2 Assist the resident into a comfortable position. The resident should be positioned in a semi reclined position (45 degree angle).
7.5.3 Wash hands and apply gloves.
7.5.4 Start with examining the lips. Lips should be pink, moist and smooth. Observe for dryness, swelling, lumps or ulcerated patches. Also look for cracks and soreness at the corners of the mouth.
7.5.5 Using the tongue depressor and pen torch, examine the tongue. It should be moist and pink. Observe for any signs of patchy, coated, ulcerated or fissured areas. The presence of these may indicate that the mouth is too dry or the colonization of bacteria or fungi.
7.5.6 Check the oral tissue using gloved fingers or the backwards bent toothbrush to gain access to a better view of the mouth. Mucosa should be pink, moist and smooth. Observe for redness, swelling, bleeding, patchy or ulcerated mucosa.
7.5.7 Check for the presence of saliva. Saliva should be clear and free flowing. Dry and / or sticky mucosa or the resident reporting a dry mouth may indicate problems with saliva production or flow.
7.5.8 Next, examine the resident’s teeth. Again the toothbrush can be used as a retractor to help see the inside of the mouth. Observe for broken teeth, roots, broken or excessively worn teeth. If the resident has a denture or partial denture this should be removed and inspected. Inspect dentures for any damage or excessive wear. Also check the gums and oral tissue under the dentures.
7.5.9 Assess general oral cleanliness. The mouth should be smooth and moist with no food particles or tartar build up on teeth and / or dentures.
7.5.10 Throughout the procedure, check for pain by asking the resident about the presence of any soreness or pain. If the resident cannot communicate verbally, observe for non verbal cues such as face pulling; chewing lips or changed behaviour.
7.5.11 Remove gloves and wash hands.
7.5.12 Make sure the resident is comfortable.
7.5.13 Complete the Oral Health Assessment Tool or The Kayser-Jones Brief Oral Health Status Examination (BOHSE).
7.5.14 Refer to resident’s general practitioner or dentist as appropriate.
Fig 1: Oral Health Assessment Source Australian Government Department of Health and Ageing (2009).
AREA
/Healthy
/See management protocol.
/* Indicates referral to dentist.
LIPS
/Smooth, pink and moist.
/Dry, chapped or red at corners
/Swelling or lump, red/white/ulcerated/bleeding. Bleeding/ulcerated at corners. *
TONGUE
/ Normal, moist roughness, pink. / Patchy, fissured, red or coated. / Patch that is red and / or white, ulcerated,swollen. *GUMS/ORAL TISSUE
/ Pink, moist, smooth, no bleeding. / Dry, shiny, rough, red, swollen, one ulcer/sore spot under dentures. / Swollen, bleeding, ulcers, white/red patches, generalised redness under dentures. *SALIVA
/ Moist tissues, watery and free flowing saliva. / Dry, sticky tissues, little saliva present, resident thinks they have a dry mouth. / Tissues parched and red, very little/no saliva present, saliva is thick, resident thinks they have a dry mouth. *NATURAL
TEETH / No decayed or broken teeth/roots. / 1-3 decayed or broken teeth/roots or very worn down teeth. / Decayed or broken teeth/roots, or very worn down teeth or less than 4 teeth. *DENTURES
/ No broken areas or teeth, dentures regularly worn, and labelled. / 1 broken area/tooth or dentures only worn for 1-2 hrs daily. / More than 1 broken area/tooth, denture missing or not worn. *ORAL
CLEANLINESS / Clean and no food particles or tartar in mouth or on dentures / Food particles/tartar/plaque in 1-2 areas of the mouth or on small area of dentures or halitosis (bad breath). / Food particles/tartar/plaque in most areas of the mouth or on most of dentures or severe bad breath. *DENTAL PAIN
/ No behavioural, verbal or physical signs of dental pain. / Verbal and / or behavioural signs of pain such as pulling at face, chewing lips, not eating, aggression. / Physical pain signs(swelling of cheek or gum, broken teeth, ulcers), as well as verbal and / or behavioural signs (pulling face, not eating, aggression. *
7.6 Care Planning.
7.6.1 The admitting nurse must commence the resident’s care plan for oral / dental on the day of admission based on information available. The care plan will be developed further over the next seven days based on additional information received from observation; referrals and additional assessments carried out as part of the comprehensive assessment.
7.7 Each nurse must add to the care plan based on additional information received during their shift.
7.8 Identifying the resident’s care needs for the care plan will involve reviewing the following resident information:
Ø Past medical history
Ø Past history of oral diseases or infections.
Ø Current medications.
Ø Nutrition and hydration status.
Ø Smoking history.
Ø Details of past dental treatments as far as is practicable.
Ø The resident’s knowledge and usual practice of oral and dental care.
Ø Preferences or wishes the resident may have regarding oral hygiene.
Ø Level of assistance required
Ø Presence or absence of natural teeth or dentures.
Ø Natural teeth in tact; broken; decayed; food particles; halitosis.
Ø Ability to function with or without natural teeth or dentures.
Ø Speaking chewing swallowing ability.
7.8.1 Care planning for oral hygiene and healthcare needs should be agreed with the resident and/or representative and other relevant healthcare staff involved in the resident’s care.
7.8.2 Residents who require referral to a dentist or general practitioner as indicated by their assessment should be referred for further assessment.
7.8.3 The care plan for each resident’s oral hygiene and healthcare needs should include the following information:
Ø Any illnesses/conditions affecting the resident’s oral/dental care.
Ø Any risks identified related to the resident’s oral status and measures to address these.
Ø What the resident can do himself/herself.
Ø What care needs /assistance the resident requires to perform oral hygiene care.
Ø Any care needs for oral / dental care to maintain oral health.
Ø Additional care needs that may be required if the residents has communication and behaviour management needs.
7.8.4 The care plan should identify frequencies and methods for monitoring the resident’s oral health according to their needs.
7.8.5 The resident’s care needs for oral hygiene and healthcare should be communicated to all relevant healthcare staff involved in the resident’s care at shift handovers.
7.8.6 Review and reassessment of needs will be carried out by the designated nurse every tree months or where there is a change in the resident’s health status affecting oral / dental needs.
7.9 Monitoring and Evaluation.
7.9.1 Resident’s oral hygiene and dental care should be reviewed and amended according to specific review schedule.
7.9.2 Changes to care / condition should be recorded in the resident’s progress notes.
8.0 Performing Oral Hygiene for Residents.
8.1 Care of Natural Teeth.
8.1.1 Brushing is the most effective way of physically removing plaque.
8.1.2 Residents should be encouraged to brush their teeth twice daily using a soft toothbrush.