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Comparison between Effect of Using Cold Water Oral Swap and Cold Saline Oral Swab to Relieve Thirst Intensity and Oral Condition of Mechanically Ventilated Patient

Intessar Mohamed Ahmad

Critical Care Nursing Department, Faculty of Nursing, Damanhour University, Egypt

Abstract: Introduction: Thirst can be defined as a longing or desire to drink water, not necessarily generated by a physiological need, but also triggered by habit, taste, dry mouth or throat and the willing to consume fluids that provide a sensation of heating or cooling. In intensive care units, patients face conditions that predispose them to develop the symptom thirst. Like pain, thirst must be detected before it can be treated. Aim of the study: The aim of the study was to compare between effect of using cold water oral swap and cold saline oral swab to relieve thirst intensity and oral condition among mechanically ventilated patient. Material and method: Research design: A quasi – experimental design was utilized to study the effect of using oral swap with cold water and oral swab with cold saline on thirst relief and oral condition. Setting: This study was conducted at the general ICU of Damanhour Medical Institute having 15 beds. Sample: convenient sample of 60 mechanically ventilated patients were recruited in the current. Instrument: an assessment sheet was used to collect data including the following three tools: 1- Demographic and biomedical data tool which includes age, gender and variables relevant to disease as patient's diagnosis, date of admission, length of stay and days mechanically ventilated on the study. 2- Thirst intensity scale: it is a visual analogue scale (VAS) rates intensity of thirst on a 10-cm with 0 indicating no thirst at all, and 10 indicating the worst possible thirst. The VAS scores were classified into: mild (0-3), moderate (4-6) and severe (7-10). In addition, it includes the presence of thirst (yes/No). 3- Oral condition assessment tool: it measures change of oral condition including lips, mucosa, tongue and saliva. It includes items which scored on a 3- point scale from 1to 3. Lip has 1 if it is smooth, pink and moist, 2 if it is dry or cracked and 3 if it is ulcerated. As regards tongue has 1 if it is pink and papillae present 2 if it has loss of papillae and 3 if it is blistered or cracked. In relation to mucosa has 1 if it is pink & moist, 2 if it is red or white coated 3 if it is ulcerated with or without bleeding. Regarding saliva has 1 if it is watery, 2 if it is thick and 3 if it is absent. Method:- The patient received either the intervention cold saline oral swap or cold water oral swap according to randomization done by the researcher by a code drawn from an envelope. The first group received thirst relieving intervention using cold water oral swap. The procedure was done for 15 –minute sessions 3 times per day. There was a minimum of 30 minutes between each of the three sessions. The second group received thirst relieving intervention using cold saline oral swap. Also, this procedure was done during 15 minutes per session for 3 times a day and there was a minimum of 30 minutes between each of the three sessions. Before application of each method the patient asked about presence of thirst if the answer was yes, thirst intensity (TI) score was measured and oral assessment including lips, tongue, mucosa and saliva was done as a baseline then the patient received relieving method for 15 minutes, after 30 minutes of the first intervention the patient reassessed for TI and oral condition before and after the second and third interventions. Results: The mean values of thirst intensity score decreased significantly when cold saline oral swap was used (p=0.004) and it was lower than its values when cold water oral swap was used. Moreover, there was significant difference between 2 groups as p₁=0.001. As regard to condition of lips, tongue, mucosa and saliva there was no significant difference between two groups pre- procedures as p₁=0.458, 0.195, 0.577and 0.119 respectively. Also, this table shows that using cold saline oral swap improve oral condition as mean values of lips, tongue , mucosa and production of saliva decreased significantly. Moreover, there were significant differences between the 2 groups in relation to oral condition including lips, tongue, mucosa and saliva while p =0.001, 0.001, 0.002, 0.004 respectively. Conclusion: It can be concluded from the present study that using cold water oral swap decrease thirst intensity but, using cold saline oral swap to decrease thirst is better than using cold water oral swap and improve oral condition in mechanically ventilated patient. Repetition of using both methods did not have different effect on thirst and oral condition except mucosa and production of saliva when cold water oral swap used as they become drier.

Keywords: cold water, cold saline, oral swap, thirst, mechanically ventilated patients

Received October 11, 2018; Revised November 20, 2018; Accepted November 29, 2018

Citation: Intessar Mohamed Ahmad, Comparison between Effect of Using Cold Water Oral Swap and Cold Saline Oral Swab to Relieve Thirst Intensity and Oral Condition of Mechanically Ventilated Patient. American Journal of Nursing Research, 7 (1). 8-13. January 2019. doi:10.12691/ajnr-7-1-2

1. Introduction

Thirst can be defined as a longing or desire to drink water, not necessarily generated by a physiological need, but also triggered by habit, taste, dry mouth or throat and the willing to consume fluids that provide a sensation of heating or cooling. Different factors can influence the presence and intensity of thirst, including, age, comorbidity, nutrition and anxiety [1,2].

The hospitalized patient experiences stress situations and deprivation of fluid ingestion, often for prolonged periods, which cause the symptom of thirst [3,4]. In intensive care units, patients face conditions that predispose them to develop the symptom thirst such as hydroeletrolytic disturbances, dry mouth due to prolonged intubation and use of anticholinergic and opioid medications. In some cases, the communicating difficulty makes it impossible to report thirst, causing discomfort, stress, and irritability [5,6].

Thirst is poorly recognized in intensive care unit (ICU) practice. Yet, research has identified it as one of the most pervasive, intense, and under-treated symptoms in ICU patients [7,8]. Critically ill patients often experience intense thirst, 70.8% of 171 intensive care unit (ICU) patients rated thirst as having the greatest intensity, and thirst was the second most prevalent symptom. Moderate to severe thirst was similarly reported by 70% of 100 ICU patients and was experienced by more than 80% of 36 chronically ill patients who had tracheotomies [9,10]. Severe thirst with thirst scores of 7 or 8 persisted in 18% of 88 terminally ill cancer patients and thirst was reported intermittently in 36% of 36 patients until death occurred [11,12].

Like pain, thirst must be detected before it can be treated. Thirst is, therefore, a symptom that is present in clinical practice, but frequently undervalued, often unnoticed by the health team, although always recorded in the reports of individuals who experience it [13,14,15].

No previous study of ICU patients provides empirical guidance for thirst relief during critical illness. Mouth care is one of the most important cares in ICU and it is done repeatedly. Protocols for mouth care in ICU patients, including those for ventilator associated pneumonia (VAP) prevention, have eliminated the use of lemon-glycerin swabs because they produce an acid pH, dry oral tissues, cause irreversible softening and erosion of tooth enamel, exhaust salivary mechanisms, and worsen xerostomia. [16]

Artificial saliva substitutes are ineffective for relieving dry mouth [17]. There is no research basis for using swap with cold saline or water for mouth care also examines their effect to relief thirst or dry mouth therefore, the aim of this study was to compare between them

2. Aim of the Study

The aim of the study was to compare between effect of using cold water oral swap and cold saline oral swab to relieve thirst intensity and oral condition of mechanically ventilated patient.

Hypothesis 1: There is a difference between the effect of using cold water oral swap and cold saline oral swap to relieve thirst intensity and oral condition on mechanically ventilated patients.

Hypothesis 2: There is no difference between the effect of using cold water oral swap and cold saline oral swap to relieve thirst intensity and oral condition on mechanically ventilated patients.

3. Material and Methods

3.1. Research Design

A quasi – experimental design was utilized to study the effect of using oral swap with cold water and oral swab with cold saline on thirst relief and oral condition.

3.2. Setting

This study was conducted at the general ICU of Damanhour Medical Institute having 15 beds.

3.3. Sample

Convenient samples of 60 mechanically ventilated patients were recruited in the current study according to the following inclusion criteria:

• Adult with an age between 18-60 years.

• ICU stay ≥ 24 hours

• Mechanically ventilated patient with endotracheal or tracheostomy tube

• Fully conscious who had ability to communicate.

• Not sedated or agitated.

Exclusion criteria:

• Open sores or desquamation on the mouth or lips.

• Oral surgery

3.4. Instrument

- Data was collected by using an assessment sheet developed by the researcher including the following three tools:

1- Demographic and biomedical data tool which include age , gender and variables relevant to disease as patient's diagnosis, date of admission, length of stay and days mechanically ventilated on the study.

2- Thirst intensity scale: it is a visual analogue scale (VAS) rates intensity of thirst on a 10-cm with 0 indicating no thirst at all, and 10 indicating the worst possible thirst. The VAS scores were classified into: mild (0-3), moderate (4-6) and severe (7-10). In addition, it includes the presence of thirst (yes/No).

3- Oral condition assessment tool: it measures change of oral condition including lips, mucosa, tongue and saliva. It includes items which scored on a 3- point scale from 1to 3. Lip has 1 if it is smooth, pink and moist, 2 if it is dry or cracked and 3 if it is ulcerated. As regards tongue has 1 if it is pink and papillae present 2 if it has loss of papillae and 3 if it is blistered or cracked. In relation to mucosa has 1 if it is pink & moist, 2 if it is red or white coated 3 if it is ulcerated with or without bleeding. Regarding saliva has 1 if it is watery, 2 if it is thick and 3 if it is absent.

3.5. Method

- An official permission to carry out the study was taken from the head managers of the hospitals and managers of intensive care units to proceed with the study.

- Patients in the intensive care units who met the study inclusion criteria were approached individually and oral consent from patients who accepted to share in study was taken.

- Content validity of the research instruments was assessed by 5 experts in critical care nursing. To assess the reliability test retest method was done.

- A pilot study was carried out on 6 mechanically ventilated patients; they were chosen randomly to test clarity of the tools and in order to determine the approximate time needed for the tools to be completed. The necessary modifications were done.

- After obtaining patient's consent the patient received either the intervention cold saline oral swap or cold water oral swap according to randomization done by the researcher by a code drawn from an envelope.

- The first group received thirst relieving intervention using cold water oral swap. The second group received thirst relieving intervention using cold saline oral swap. Before application of each intervention the patient asked about presence of thirst if the answer was yes, thirst intensity (TI) score was measured and oral assessment including lips, tongue, mucosa and saliva was done as a baseline.

- The procedure was done for 15 –minute per session and 3 times a day. Before each time the patient was assessed for TI and oral condition then, this assessment was repeated after the intervention. There was a minimum of 30 minutes between each of the three sessions.

4. Results

Table 1 shows frequency distribution of studied patients according to socio-demographic characteristics and medical diagnosis. It can be noted that one third 30% of the studied group I which, used cold water oral swap and 33.3% of studied group II which, used cold saline oral swap had age ranges from 40 to 50 years with an equal percentage of male and female in both groups. Moreover, 33.3 % of group I and 30% of group II had neurological diseases. However, there was no statistical significant difference between both groups in relation to socio- demographic data and medical diagnosis.

Table 1. Frequency distribution of studied patients according to socio- demographic characteristics and medical diagnosis

Table 2. Comparison between the two studied groups according to thirst intensity score and oral condition:

Table 3. Comparison between pre and post procedure in the three times of intervention regarding thirst intensity and oral condition using cold water oral swap

Table 4.Comparison between pre and post procedure in the three times of interventions regarding thirst intensity and oral condition using cold saline oral swap

Table 2 reveals comparison between the two studied groups according to thirst intensity score and oral condition. It can be observed that mean values of thirst intensity score decreased significantly when cold saline oral swap was used (p=0.004) and it was lower than its values when cold water oral swap was used. Moreover, there was significant difference between 2 groups as p₁=0.001. As regard to condition of lips, tongue, mucosa and saliva there was no significant difference between two groups pre- procedures as p₁=0.458, 0.195, 0.577and 0.119 respectively. Also, this table shows that using cold saline oral swap improved oral condition as mean values of lips, tongue, mucosa and production of saliva decreased significantly. Moreover, there were significant differences between the 2 groups in relation to oral condition including lips, tongue, mucosa and saliva while p =0.001, 0.001, 0.002, 0.004 respectively.

Table 3 demonstrates comparison between pre and post procedure in the three times of intervention regarding thirst intensity score and oral condition using cold water oral swap. This table shows that mean values of the condition of mucosa and production of saliva slightly increased after second and third time of intervention. Moreover, there was significant difference between first and third time post procedure while, p= 0.0, 0.0 respectively.

Table 4 shows comparison between pre and post procedure in the three times of interventions regarding thirst intensity and oral condition using cold saline oral swap It can be noted from Table 4 there was a decreasing in intensity of thirst all over the three times of using wet swap with cold saline during pre and post procedure with significant difference p= 0.0. Moreover, there was slightly decreasing in mean values of oral condition including lips, tongue, mucosa and production of saliva. There was no significant difference between three times of intervention.

5. Discussion

Amelioration of thirst has not previously been a research focus on ICU patients despite documentation that thirst is a prevalent and intense symptom. In this study, 2 different interventions to relieve thirst were tested for ICU patients experiencing thirst. As regards to thirst intensity; the finding of this study indicates that using gauze with cold water reduce intensity of thirst. Similarly, with the finding of the study of Yoon Min [18], to identify the effects of gargling with cold water on thirst and the oral cavity condition, and throat pain in patients undergoing orthopedic surgery with general anesthesia, at 0, 2, 4 and 8 hours after surgery. The score of thirst intensity was lower. But, the finding of this study also, revealed that using gauze with cold saline decrease intensity of thirst more than using gauze with cold water with significant difference it may be related to that normal saline increase production of saliva. That is in the same line with previous study [19] who examined the effects of using gauze with a cold saline solution or ice to relieve thirst and oral condition in patients undergoing laparoscopic cholecystectomy, reported thirst score changes along the study; however, the difference was significantly higher in the experimental group who received frozen gauze with saline solution than the control group who received, ice or wet sponge.

In addition this study finding was on the same line with Moon, Lee [20], Lee compared between the effect of using cold saline wet gauze (experimental group) and cold water wet gauze (control group) on thirst of patients in the immediate postoperative period. Thirst in both groups improved with an increasing number of gauze applications. The reduction in thirst intensity was higher in the experimental group (p = 0.009). Similarly with Cho E [19] who examined the effects of using gauze with a cold saline solution or ice to relieve thirst in patients undergoing laparoscopic cholecystectomy, reported thirst score changes along the study; however, the difference was significantly higher in the experimental group who received frozen gauze with saline solution than the control group who received, ice or wet sponge.

Considering oral condition, it was found that there was no significant difference of between 2 groups pre- procedures in relation to the condition of lips, tongue, mucosa and saliva Moreover, the usage of wet gauze with cold saline improve oral condition as mean values of lips, tongue, mucosa, production of saliva decreased significantly. Moreover, there was significant difference between the 2 groups in relation to oral condition including lips, tongue, mucosa and saliva. In addition, increasing frequency of using both 2 methods did not improve oral condition, but it was found that using cold water oral swap increase mean values of mucosa and production of saliva which means they became drier.

These findings were in the contrary with the finding of Hur Y [21] this study compared the hydrating effect of gargling ice water and application of moist gauze versus humidification of the oral cavity on reduction of dryness of the mouth after nasal surgery. The intensity of dry mouth in the group's thirst which gargled with ice water was less, indicating more effective method than other strategies.

In the contrary with the finding of previous study which compared the effect between wet gauze with cold saline (experimental group) and wet gauze with cold water (control group) as there was no difference in the oral cavity condition between the groups.

In agreement with the current study findings Arai S. [22] found in their research entitled “The effects of oral care with normal saline on oral state of patients in intensive care unit” found a significant difference in the oral cavity state between the experimental group that had used normal saline and the control group that had used tantum solution. Similarly, Cho E. [19] found in their study about “Effects of frozen gauze with normal saline and ice on thirst and oral condition it was concluded that providing oral care using gauze frozen with normal saline and ice twice, improved the oral condition of tongue, saliva, mucosal membrane, and gingiva in patients. In a previous studies investigating “The effects of cold water gargling on thirst, oral cavity condition" [18,23] it was reported a lower score of thirst and oral cavity condition in the experimental group used cold water than in the control group.

In regard to the effects of mouth care with cold sterile normal saline, it was reported that mouth care using cold sterile normal saline reduced oral dryness, oral discomfort and severity of oral mucositis and emphasized that nurses could consider using it routinely as an intervention to improve oral discomfort of patients; thirst level, condition of tongue, saliva, mucosal membrane, and gingiva was improved as well [24]. In the contrary with the finding of a study entitled “A comparison of effect between cold saline wet gauze and cold water wet gauze on postoperative thirst, oral cavity condition, found that oral cavity condition except saliva was not significantly different between the groups [20]. As, it was found that after oral care was provided twice, there were significant differences in thirst level among the groups. When oral care was provided twice, the oral condition of tongue, saliva, mucosal membrane, and gingiva was improved in patients receiving gauze frozen with normal saline or ice.

6. Conclusion

It can be concluded from the present study that using cold water oral swap decrease thirst intensity but, using cold saline oral swap to decrease thirst is better than using cold water oral swap and improve oral condition in mechanically ventilated patient. Repetition of using both methods did not have different effect on thirst and oral condition except mucosa and production of saliva when cold water oral swap used as they become drier.

7. Recommendation

Based on the results of the study, the following recommendations are suggested:

1- Using cold saline oral swap is recommended to be used during routine oral care to relieve thirst and improve oral condition among mechanically ventilated patients.

2- ICU nurses have a pivotal role in managing patients' complaints of thirst so, In service training program for those nurses so, it should contain a protocol to deal with patients, thirst

3- Further research studies should be replicated on larger sample in different settings is recommended before generalization of the study findings.

References

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