Studies show that stroke survivors with poor oral hygiene have a poor quality of life (Armstrong and Mosher 2011). (Lam et al. 2014) have explored the effect of clinical oral health and socio-demographic factors on oral health-related quality of life (OHRQoL) in patients following stroke. Oral health-related quality of life results were received before and after provision or oral health promotion interventions. Eighty-one patients faced a stroke rehabilitation ward. OHRQoL have also determined the outcomes after in-hospital oral health intervention programme. They observed a significant association between the absence of regular daily brushing and majority of measurement scale items (6 out of 8) with (p < 0.01) at baseline. Research showed improvements in OHRQoL over the course of trial for all patients as a whole (p<0.05). The study mentions that OHRQoL deteriorated after stroke and could possess a link with daily brushing or dental hygiene during the hospital stay.
Hence, the areas of practice must focus on re-establishing the oral hygiene protocol at the earliest opportunity for patients in stroke rehabilitation units in order to achieve clinical better outcomes in oral health and OHRQoL (Lam et al. 2014).
It is essential to know about the medical condition, Xerostomia which is very frequent among stroke survivors (Kerr et al. 2009). It is the result of low food intake that leads to salivary glands dysfunction.
In practice, healthcare professionals could overcome such reduced saliva production in patients and improve salivary secretion by recommending a) Chewing gum or artificial saliva and b) Salivary substitute such as moist film that supports the retention of (Gopal 2008)
Further, stroke survivors also require a regular monitoring of dehydration that contributes to dry mouth. Sana’s poor oral health clearly shows that she could have received intubation, which may have compromised her oral care. The reason for this compromise in effective oral health may be that patients on intubation, for instance have enteral tube feeding, encounter a disturbed oral ecosystem, all resulting in dry mouth. Patients receiving prolonged enteral tube feeding to maintain nutrition for the older adults alters oral microbiota (Takeshita et al. 2011) resulting in accelerated growth of microorganisms and consequently poor oral health.
It is essential for the medical team to reposition the tube to avoid any consequences. Tube that has been used to deliver feedings or medication can result in aspiration, pneumothorax, and sepsis (Simons & Abdallah 2012).
One of the common problems in such patients is aspiration. Where food or liquid materials are commonly inhaled (Armstrong and Mosher 2011). It results when a person swallowing a material reaches airway and lungs. Subsequently, that patient is at risk of pneumonia. The condition could occur without the awareness of stroke survivors. Thin liquids are often hard to swallow safely after a stroke because they move quickly through the mouth and throat. Adequate time is necessary for the voice box (larynx) to make adjustment to protect the airway; if this does not occur properly, as in the patient with dysphagia secondary to stroke, aspiration may result. Normally, aspiration would cause a violent cough; however, this may not occur in a stroke survivor due to a reduction in sensation (American Stroke Association 2013).
The guidelines of the National Stroke Association aim at focusing on the significance of oral healthcare in the rehabilitation of patients surviving on stroke, supporting the dental team in devising a framework to improve their oral healthcare, and offering help for recommending specific dental services for patients surviving on stroke (British Society of Gerontology 2010). Identifying the risk of stroke and applying all needed preventions will make the rehabilitation of survivors at its best. The nurse will take a major role in the prevention of stroke and making the survivors rehabilitation successful (Ireland S 2014).
Initially, the guidelines emphasize the basic biology of stroke and its impact on oral health. For example, individual has a stroke and it affects the tissues of the oral cavity and facial regions. The ultimate outcome would be a negative effect on nutrition, swallowing, quality of life, communication and general health. It could damage the seventh cranial nerve that results in functional impairment of voluntary muscles. The face may sag on the affected side (British Society of Gerontology 2010).
Sana’s condition reflects that she could be having one or more of the above-mentioned risk factors that resulted in the stroke. A stroke could affect oral and facial tissues resulting in impaired daily activities such as eating, drinking, swallowing and communicating. It refers to a condition that has no chronic facial and mouth pain, oral sores, birth abnormalities related to cleft lip and palate, oral and throat cancer, gum disease, tooth loss and other defects that badly impair the oral cavity (Who.int 2014).
Guidelines (British Society of Gerontology 2010) mention that the incidence of dysphagia in stroke survivors is 23%- 50. The main problem associated with dysphagia is that it could lead to aspiration and pneumonia. Sensational loss in the mouth affects the swallow reflex and leads to airway protection reduction. Poor lip seal is also a major problem and individual can struggle with keeping food and liquids inside the mouth. Many western hospitals insert a peg inside individual’s mouth to prevent this pool lip seal problem (Teismann et al. 2007). Dysphagia management requires through compensatory and rehabilitative strategies.
Compensatory strategies provide temporary solutions to dysphagia, but do not contribute the recovery of normal swallowing. This kind of strategy’s intend to change the consistency of food and fluids with thickening agents to support swallowing (British Society of Gerodontology 2010). Thickening agents contribute the reduced oral clearance. This agents are sugar-free, but may be added to sugar containing foods, increasing the caries risk of dentate individuals (British Society of Gerodontology 2010).
Rehabilitative strategies provide a permanent solution to dysphagia. They include exercises that enhance the integrity of suprahyoid muscles (British Society of Gerodontology 2010). Shaker R. said that such exercises are usually carried out in conjunction with speech and language therapist e.g. repeated raising and maintaining the head while lying flat. The oral impact mentions that a spectrum of communicative and cognitive problems linked with stroke. The communication becomes very slow and often results in the emotional outburst. It takes the individual more time to tell what he or she might think. It is also frustrating for the individual who knows what to say, but can’t express themselves. The solution is enabling communication through several aids and with the help of family care givers who understands the patient very well (British Society of Gerodontology 2010).
For dysphasia, medical or nurse professionals must seek the assistance of speech and language therapist (LST).
During its early stages, dental treatment may depend on emergency care, preventive suggestions and rehabilitation (Guidelines for the oral healthcare 2010). Some patients require more direct and intense rehabilitation strategies to improve impaired swallow functions (Sura et al. 2012). Patients in need of oral care who are dysphagic, dependent or severely ill must adhere to the guideline criteria followed by researchers. The presence of a strong relationship between swallowing ability, nutritional status, and health outcomes in the elderly suggests a role for dysphagia management in this population (Sura et al. 2012). Successful swallowing interventions not only benefit individuals with reference to oral intake of food/liquid, but also have extended benefit to nutritional status and prevention of related morbidities such as pneumonia (Sura et al. 2012).
For instance, the stroke patient must possess an oral/dental assessment involving signs of dental disorders, dentures, etc., immediately following hospital admission (van der Putten et al. 2010).
If the patient has a complete or partial denture, it must be determined if they possess the appropriate neuromotor skills to wear and utilize the device safely. A suitable oral care protocol must be employed the patient with stroke especially who use dentures. The protocol must address the areas such as oral care frequency, types of oral care products like mouthwash, floss, toothpaste and unique care for patients with dysphagia. If issues are recognized with oral hygiene and devices, then patients must be referred to a dentist for further investigation at the earliest (Prasad et al. 2011). When patient wears dentures normally, but has a NGT inserted and develops dry mouth it usually comes to oral care. The nutrition support should be reviewed regularly. Keeping the patient’s mouth moist by using web swabs and putting some petroleum jelly around their lips (Stroke.org 2014).
Certain issues could appear to affect the care of the patient, for example, if the health care professionals fail to properly consider underlying health problem, such as diabetes mellitus, the effects of medications and neurological diseases. People with diabetes can, over time, develop nerve damage throughout the body. Some people with nerve damage have no symptoms. Others may have symptoms such as pain, tingling, or numbness—loss of feeling—in the hands, arms, feet, and legs. Nerve problems can occur in every organ system, including the digestive tract, heart, and sex organs (Diabetes.niddk.nih.gov 2014).
The care of Sana was not well planned and delivered. Ms. Sana required a complete holistic assessment and a care plan that reflected her needs (Stein and Henry 2009). The community nurse started to offer holistic care to the patient by attempting to collaborate various healthcare professionals such as mental health experts, but not the dentist.
Hence, it appears that the care strategy provided to Ms. Sana did not consider any assessments associated with the oral hygiene. Such a flaw resulted in a plan where Ms. Sana received normal care with no dedicated medical attention. The care also might not have planned about providing improved mental health for the elderly patient due to ageing factor. Thus, the care was delivered with a no emphasis on long-term goals.
A team of investigators (Kikawada et al. 2005) mention that older individuals with cerebrovascular disease frequently have dysphagia that contributes to high incidence of aspiration. It was also apparent that patients with silent cerebral infarction that affects the basal ganglia were highly vulnerable to experiencing subclinical aspiration and a high incidence of pneumonia. Here, cascades of events appear to precipitate the aspiration. In fact, in some elderly people basal ganglia infarction results in an alteration of dopamine metabolism and, subsequently, a reduction in substance P production in the sensory vagal nerves and glossopharyngeal nerve. Thus, dysphagia and a reduced cough reflex could be produced due to altered dopamine metabolism in elderly patients with cerebrovascular disease (Kikawada et al. 2005). Therefore, tailored approaches that appear essential were not delivered. These could be swallowing rehabilitation, Swallow maneuver (Groher & Crary 2010) and Managing Oral Hygiene using threat reduction and avoidance of feeding dependence (Langmore et al. 1998).
Evaluation:
Nurses have a professional responsibility to provide basic oral health care to the patients. The poor oral care given to vulnerable patients in long-term care settings can have serious consequences, including increased risk of stroke, heart disease, and pneumonia. Oral care, like bathing, feeding and toileting are vital to the holistic care that nurses offer to the elderly who fail to take care of themselves (Stein and Henry 2009)
Training and education is the other area. (Stein and Henry 2009) Nursing schools must maintain collaboration with dental hygiene schools so that nurses become knowledgeable in offering oral care to the susceptible people. Programs must address oral examination, oral pathology, and severe oral impact of medications. It seems that community nurses require active involvement in training campaigns with resources and gain appropriate skills in offering the most reliable care that minimizes stroke and oral health complications.
In addition, continuing education could also offer practicing nurses and nursing assistants a similar level of knowledge (Stein and Henry 2009)
Community health is falling short of specific resources, according to (Thompson et al. 2008) they mention that community nurses must consider using validated screening tools for elderly patients with cognitive problems. Ms. Sana appears highly vulnerable to stroke driven cognitive problems. Geriatric oral assessment screening tools is needed in all settings to investigate and trial the more challenging oral health categories of saliva, oral cleanliness, and dental pain. For instance, oral health assessment tools (OHAT) (de Mello et al. 2012) could be of great help. This tool could collect information on categories such as lips, tongue, gums and tissues, oral cleanliness and dental pain and would provide scores based on their nature, healthy and in healthy factors (Johnson and Titler 2004). The Oral Health Assessment Tool was evaluated as being a reliable and valid screening assessment tool for use in residential care facilities, including those with cognitively impaired residents (Chalmers et al. 2014).
Swallowing rehabilitation is essential for the elderly population with stroke and dementia who have increased dysphagia (Sura et al. 2012). This approach relies on the severity of any nutritional defects and aspiration led pneumonia risks in the patient. In Sana’s case, the care providers could have chosen swallowing rehabilitation to manage poor oral health effects such as dysphagia and its impact on aspiration.
Next, Ms. Sana had aspiration, which could have been due to infection. Evidence has ruled out that elderly people with aspiration pneumonia possess the oral cavity harboured with microorganisms such as Streptococcus sobrinus, Porphyromonous gingivalis and Staphylococcus aureus. They contribute to dental plaque, periodontitis and dental plaques, respectively (Terpenning et al. 2001). Therefore, Sana did not receive proper antibiotic regimen that could have avoided oral infections and subsequent aspiration risk.
Hence, an overlook on the available literature evidence is more conspicuous. Next, multidisciplinary team is also a part in the oral care of elderly. However, its involvement is very poor in the community care of elderly individuals. The nurse experienced a disturbed environment as she was unable to offer a professional level of care in improving the oral hygiene of Ms. Sana. It is sure that that the community has no scarcity of healthcare professionals of various disciplines. The only limitation that prevented oral care of Sana is timely and efficient intervention.
In the near future, the community nurse administrators would develop a program that aims at providing recommendations to the overall nurse community members who engage in the oral care of elderly. Oral health assessment tools (OHAT) (de Mello, Zimmermann & Gonçalves 2012) and other tools could be of great help.
The recommendations include tooth brushing, toothbrush alternatives, cooperation through effective communication and positioning (Stein and Henry 2009).A recent survey of nursing assistants found that one of the greatest barriers to providing oral care to residents is a lack of supplies (Jablonski et al. 2009).
It is important to note that certain gaps in the community nurse practice appear to retard the progress of oral care management in elderly. The gaps noted are more prominent in the area of providing health education to the family members about oral hygiene and the importance of the multidisciplinary team. They appear to lack a focus on thorough evidence based recommendations, care of those who are, malnourished, underweight socially secluded or depressed (Stein and Henry 2009).
Therefore, this assignment on reflection suggests that nurses should be prepared for encountering the cases that are similar to Ms. Sana. Nurses have a professional duty to ensure basic oral health care for patients (Coleman PR 2004). The areas that need achievement are a continuous progress in the profession, better awareness of assessment tool applications, critical evaluation, assessing the effectiveness of stroke prevention measures and orodental appliances or dentures, making a precise physical examination, complete interaction with the family members of the patient and engaging them in care, recruiting multidisciplinary team and come up with a reliable guidelines for community based practices and implement all suitable care aspects in an evidence based approach. Oral care, like bathing, toileting, and feeding, is essential to the holistic care that nurses and nursing assistants provide to residents who can't care for themselves (Coleman PR 2004).
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