Jamieson et al (2000) discusses the evaluation stage of the nursing process is continuous because the nurse should evaluate the intervention each time it has been performed. This should be documented to enable nursing interventions to be changed to meet the patient’s current condition and care needs. In relation to clinical practice Helen’s mouth was reassessed once during her ten day stay. However Helen’s mouth could have been assessed more than once, but this was not documented. Implications of the reassessment of Helen’s mouth not being documented are that staff on the opposite shift may not have the information to decide if treatment is being effective. Milligan et al (2002) believe accurate documentation of assessments is essential to maintain the efficiency of care, therefore it could be suggested that Helen’s mouth care was not implemented as well as it could have been because of a breakdown in communication between the different staff.
Xavier (2000) implies that nurses who are assessing patient’s mouths need to know what constitutes a healthy mouth. When assessing the patient’s mouth the nurse should be observing for a pink moist tongue and a healthy oral mucosa and question the patient regarding their normal oral hygiene pattern and if they have any problems chewing or swallowing (Hinchliff et al 2003). However it could be argued that the assessment of Helen’s mouth is subjective because an assessment tool was not used which would have made the assessment objective as Helen’s mouth would have a numerical score which could be verified by other nursing staff. Walsh (2002) reinforces the importance of assessing the patient’s mouth thoroughly because a poor nursing assessment can have consequences of poor nursing care because the nursing care can only be planned on information gained at assessment. Hinchliff et al (2003) state that an assessment tool such as an oral risk indicator tool should be used in practice.
Hinchliff et al (2003) implies that information gained from assessment is used to plan the patient’s individualised care plan. However it could be implied the planning stage of the nursing process should be continuous because the assessment stage of the nursing process is continuous. Walsh (2002) believes that nursing care has to be based upon the individual needs of each patient. This statement proposes the importance of utilising the information gained during the assessment process.
Walsh (2002) believes nursing goals are planned when the nurse and the patient identify activities to prevent reduce or correct the patient’s problems. Faull (2005) suggests oral hygiene goals should include cleanliness, comfort and prevention of infection and halitosis. In relation to clinical practice Helen’s goals of care were for her mouth to return to its normal condition, to prevent Helen from contracting an infection and for Helen to be pain free. The rationale for the nursing goals for Helen is to maintain comfort and ensure that her ulcerated areas respond to treatment.
Jamieson et al (2002) concludes that patients who have an oral infection should be given mouth care as well as patient’s who are experiencing nausea and vomiting because they could experience xerostomia. In relation to clinical practice Helen required mouth care because she had a suspected oral infection because her mouth was ulcerated, and she was also suffering from nausea and vomiting.
Thomson (2004) believes good oral hygiene is important in the prevention of infections which to some patients can be life threatening. However clinical practice illustrates the task of oral hygiene is often delegated to unqualified staff who have not had the required training to assess the condition of the patient’s mouth or if the treatment is being effective to achieve the goal. Therefore it could be argued that junior members of staff need to gain the skills and knowledge related to oral hygiene or registered nurses need to try to provide mouth care themselves instead of delegating the task to junior members of staff.
Walsh (2002) feels that to provide a patient with mouth care a soft paediatric toothbrush and toothpaste should be used. However observation from clinical practice it is apparent that foam sticks soaked in Chlorexhidene mouth wash were used to clean Helen’s mouth. Faull et al (2005) suggests foam sticks are ineffective at removing debris from the gums and teeth; however they are useful for refreshing the mouth. In clinical practice staff did not use a toothbrush on Helen even though her teeth were covered in debris because her mouth was ulcerated.
Mouth care needs to be administered regularly to have a significant impact (Thomson 2004). Clinical practice demonstrates mouth care is administered when the nurse has time or remembers to do so. Therefore it could be implied that mouth care carried out in clinical practice is of little significance because it may not be performed as often as required by nursing staff. Milligan et al (2002) state that mouth washing with Chlorexhidene should only take place once every twelve hours. This suggests the rationale for Helen only having her mouth cleaned twice a day with sponge sticks and Chlorexhidene.
Xavier (2000) believes nurses should try and promote independence whilst administering mouth care. In clinical practice this is often done poorly because the nurse administering the mouth care often performs the task for the patient as oppose to involving the patient in the procedure. This may be considered a degrading experience for the patient because many patients believe they can perform this simple task themselves. It could be recommended that patients who are able to perform this task themselves should be encouraged to, which would enable nursing staff to provide assistance to patients who cannot care for their own mouths. Helen could care for her own mouth in hospital because she normally cares for her own mouth at home. Helen still needs her mouth assessing daily by a qualified nurse to ensure treatment is being effective. Hinchliff et al (2003) feel patient’s should be continually assessed to monitor effects of treatment. Faull et al (2005) believes providing a patient with mouth care can reduce psychological distress, therefore it could be implied that the nursing intervention of mouth care is an holistic nursing intervention because it has a psychological impact as well as physiological impact. However it could be argued that the patient does not receive the psychological impact of mouth care if the nurse performs the procedure for them.
Xavier (2000) concludes that a mouth care regime should include a lip lubricant to prevent infection and soothe cracked lips. However, clinical experience does not follow the recommendations from nursing research because no lip lubricant was given to Helen. In relation to clinical practice the hospital treating Helen had no lip lubricant. Lip lubricant was not used on Helen’s lips at all. When the author asked nursing staff for lip lubricant for Helen the reason given was lip lubricant is not used in clinical practice due to costs and staff using it instead of patients.
Regnard et al (1997), conclude that if the mouth is unclean with food and debris sucking pieces of fresh pineapple chunks is thought to clean the oral mucosa naturally. Helen, sucking pineapple chunks was a nursing intervention which could have aided her mouth to recover quicker, however due to costs this intervention is not implemented in the hospital caring for Helen. If Helen had family living close by they could have brought some pineapple for her to suck on, however her family live over fifty miles away, therefore this was not an option.
Kenworthy et al (2002) concludes that evaluation is the most important part of the nursing process because it informs the nurse and the patient if the nursing goals have been achieved. In relation to clinical practice Helen informed nursing staff that her mouth was feeling healthier after five days of treatment. Helen did not have a time limit set for her goal to be achieved, however nursing staff knew her mouth was improving from reassessing it. Therefore it could be suggested that the nursing goals have been achieved because Helen’s mouth has returned to its normal condition following nursing intervention and she was no longer experiencing pain. When Helen was assessed she was assessed subjectively, therefore the achievement of Helen’s goal is not measurable.
When evaluating the patient’s mouth Walsh (2002), believes that examining the patient’s mouth should demonstrate evidence of regular hygiene. Helen’s mouth looked healthier with a pink intact oral mucosa and no white areas of ulceration.
Jamieson et al (2002) suggests that a mouth care pack should be covered, labelled with the patient’s details and thrown away after twenty four hours to prevent infection being introduced into the oral cavity. However clinical practice identifies that Helen’s mouth care pack was sat on top of her locker for three days and was not covered or labelled with her details.
From writing this assignment the author has learnt what mouth care actually entails and that it is an important clinical procedure which should ideally be carried out by a qualified nurse. The author has discovered that mouth care is not performed as well as it could be because it is often overlooked or delegated to unqualified members of staff who do not have the training to detect potential infections. The author has learnt that each patient’s mouth needs to be assessed which the literature suggests should be done using an assessment tool. Following assessment patient’s care needs to be planned accordingly. The author has realised that mouth care could cause a severe infection if infection control issues such as throwing away the mouth care pack after twenty four hours are not adhered to. The author has demonstrated that many options are available in relation to caring for patient’s mouths it could be conclude that due to staff training and cost effectiveness, many of these nursing interventions are not implemented. The author has highlighted mouth care contributes to the patient’s quality of life remarkably because it has physiological and psychological benefits. Therefore it could be suggested that it is the nurse’s job to ensure mouth care is provided correctly.
References
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