Mouth Care Bundle update Velindre Cancer Centre. Sarah Owen June 2013

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1 Mouth Care Bundle update Velindre Cancer Centre Sarah Owen June 2013

2 Velindre Cancer Centre Velindre Hospital provides specialist non-surgical cancer services for the people of South East Wales, serving a population of 1.5 million. 50 in-patient beds divided over 2 wards Patients admitted for a variety of reasons elective chemotherapy, symptom control, infections and end of life care

3 Background work Audited 19 patients over both wards on their mouth care Breakdown by number of patients on daily assessment of mouths Mouth comfort 1 very uncomfortable - 5 very comfortable Nurse looked in mouth Nurse asked Not checked Review of 1000 lives mouth care bundle No inclusion of mucositis Feedback form staff that bundle is heavy and confusing VCC moving away from traditional care plans Positive start and identified the way to go forward

4 Mucositis Mucositis occurs when cancer treatments break down the rapidly divided epithelial cells lining the gastro-intestinal tract (which goes from the mouth to the anus), leaving the mucosal tissue open to ulceration and infection. The oral mucosa, is one of the most sensitive parts of the body and is particularly vulnerable to chemotherapy and radiotherapy to head and neck area. The oral cavity is the most common location for mucositis. Can result in hospitalisation for pain relief and enteral feeding Recommended that chlorhexidine gluconate is not use by patients at risk of, or with mucositis Other complications of cancer treatment painful ulcers and oral thrush

5 Taking forward Working group established patient safety nurse; head and neck CNS; review radiographer; chemotherapy specialist nurse; pharmacist; speech and language therapist Identified our priorities for staff to look in patients mouths each day for early identification of problems e.g. ulcers, thrush, dry mouth, excessive secretions, pain active prevention of mucositis Revised risk assessment, care plan and bundle to incorporate VCC needs Reviewed oral care policy and devised guidelines for patient receiving radiotherapy to head and neck area Reviewed patient leaflets and information Compiled an equipment and pharmacy list Identified training needs

6 Mouth Care Risk Assessment Form To Be Completed within 24 Hours of Admission and weekly thereafter All head and neck patients (+/- mucositis) to use Care Plan D only All other patients who have mucositis to use Care Plan D only after confirmation from doctor, head and neck CNS or review radiographer Consider any verbal, physical and behavioural signs of pain during assessment Assess all patients daily using the bedside mouth care bundle Patient Addressograph Ward: Admission date: Level of support needed for mouth care: Independent Mouth Comfort: Pain free Verbal/physical prompting needed Moderate/ intermittent pain Refer to SHO for pain relief Assistance needed Severe pain affecting eating and drinking Refer to SHO/ palliative care for pain relief Category Lips, Tongue, Gums, Soft Tissues and Pallet. Saliva Oral Cleanliness Natural Teeth Dentures Dentures lost in hospital report on Incident Form Record if patient has: Healthy Care Plan A Pink, smooth, intact and moist. No bleeding. Soft tissues moist, watery and free flowing saliva Mouth clean, no visible food or plaque. No decayed or broken teeth / roots or No natural teeth Dentures clean & intact or No Dentures Changes Care Plan B Any dry, coated, inflamed or broken areas. Localised ulcer or sore spot. Gums bleed on brushing +/- dry, shiny, swollen. Occasional dry mouth, little saliva present. Soft tissues dry & sticky, Visible food/plaque/tartar in 1 or 2 areas. Occasional bad breath. Decayed or broken teeth / roots - no signs of pain. Localised debris. 1 broken area. Patient reports some problem but not affecting health. Toothbrush Toothpaste Denture Pot None Relatives to supply Ward to supply within 24hrs Date when equipment supplied: Further changes Care plan C Signs of fungal infection white coated tongue, white spots on tongue and/or soft tissue. Redness and soreness in mouth and back of throat Multiple ulcers White/red area/lump longer than 3 weeks Constant dry mouth with little or no saliva present. Tenacious secretions Visible food/plaque/tarter in most areas. Severe bad breath. Decayed or broken teeth / roots / continuous pain & affecting health. Physical signs such as swelling of cheek or gum or ulcers. Loose teeth Generalised debris. Dentures very loose or painful. Patient unable to cope with dentures due to health problem e.g. stroke. Date: Mucositis Care Plan D Any bleeding, blisters, swelling, lumps, white or red patches. Ulcers. Pain or tenderness. Generalised inflammation. Soft tissues excessively dry, little or no saliva present. Saliva thick, ropy or tenacious secretions. Care Plan: Completed by: Care Plan Care Plan Care Plan Care Plan

7 Mouth Care Plan Always wear gloves for mouth care. Patients who are able to carry out their own mouth & denture care should be encouraged to do so. Carer / relative involvement should be encouraged if appropriate. CARE PLAN A (All patients will have as a minimum standard of care ) Patient with natural teeth Patient with dentures Acrylic (plastic) / Chrome Cobalt (metal): AM + PM. Brush teeth & gums thoroughly with 1,450 ppm fluoride toothpaste or patients own for 2 3 minutes. Encourage patient to spit out excess toothpaste. Ensure fluid intake/ unsweetened liquid to moisten mouth AM +PM Rinse denture in cold water and brush fit surface with liquid soap & water or denture cream. Rinse in cold water. Check for any cracks or chips. Brush tongue and inside of mouth / use fluoride toothpaste if any natural teeth with soft bristle toothbrush. Dentures should not be worn at night; store overnight in cold tap water in a named lidded pot. Ensure any dentures are moist when inserted in the mouth. CARE PLAN B Oral cleanliness Natural teeth / dentures Lips, soft tissue, tongue, saliva, gums and palate As Plan A plus Dry mouth Offer 2-hourly unsweetened fluids, crushed ice for a dry mouth.consider oral balance gel for inside mouth. Apply lip salve to dry lips. Bleeding gums persistent for longer than 7 days use Chlorhexidine Gluconate rinse 0.2% / Gel 1%/ or Spray 0.2% (30 minutes after tooth brushing) twice a day. Ulcer For a single painful ulcer due to denture rubbing, remove dentures and apply Chlorhexidine to the ulcer. Leave denture out as much as possible. If tongue is coated encourage patient to gently brush tongue. CARE PLAN C Encourage patient to brush teeth/ clean dentures twice daily Oral cleanliness As A plus advise patient to seek dentist on discharge If continuous dry mouth, advise patient to seek dentist on discharge Natural teeth / dentures Oral Candida Fluconazole 50mg for 7 days unless contrary indicated. If no response within 7 days follow VCC oral care policy. Rinse with Chlorhexidine Gluconate 0.2% 30mins after tooth brushing. Disinfect toothbrush - wipe toothbrush clean & dry, rinse with Chlorhexidine Gluconate 0.2% & allow to air dry. If patient wears dentures - soak in Chlorhexidine Gluconate 0.2% for 15 minutes twice daily and allow to air dry or soak in diluted Sodium Hypochlorite 1% - dilute 1:80 parts with water (3 min for acrylic and 1 min for metal denture) to kill fungal infection on the denture. Soak dentures overnight in cold tap water in a labelled lidded denture pot White/red area/lump/ swelling longer than 3 weeks refer to medical team, consider dental referral. Multiple/severe ulceration use soft bristle toothbrush (soften in warm water) non flavoured toothpaste. Refer to medical team for antimicrobials. Alcohol free Chlorhexidine Gluconate 0.2% to cleanse mouth. Gelclair and /or Difflam for pain relief (can be diluted 50:50 with water if not tolerated when mouth is severely ulcerated) Severe dry mouth. Moisten hourly or as required. Offer sips of water, if swallowing problems, encourage to patient to swill and spit. Lubricate the lips and inside of mouth with oral balance gel with a soft bristle toothbrush. Initiate hourly oral mucosa lubrication Use small soft bristle toothbrush to remove tenacious secretions safely. Continuous dry mouth advise patient to seek dentist on discharge Mouth Care Plan - Nursing and prescribing guidelines (Vers 4 April 2013) Gently brush teeth / gums to remove plaque. Use suction if needed. Clean tongue & wipe oral mucosa with water or Chlorhexidine Gluconate 0.2% using a soft toothbrush swept around the mouth. Increase mouth care up to 4 times a day or as tolerated. Apply oral balance gel to lips and around the inside of the mouth with a soft bristle toothbrush Refer to medical team and consider dental referral based at Whitchurch Hospital on If continuous pain & affecting health give prescribed analgesia. Dentures retained in the mouth may cause obstruction, remove from mouth, clean thoroughly and store overnight in cold tap water in a named lidded pot CARE PLAN D - Baseline mouth care for all head and neck patients. For more information please see Oral Care for Radiotherapy Guidelines Natural teeth and denture care follow Plan A. Dentures must be removed before using any mouth rinse. CHLORHEXIDINE GLUCONATE NOT TO BE USED IN ANY HEAD AND NECK PATIENTS. ORAL CAVITY treatment: Patients to use Caphosol to prevent and treat mucositis caused by radiotherapy. To be used 4 times a day and can be increased to 10 times a day as necessary. Rinse around the mouth for 1 minute and spit out, repeat until dose full taken ensuring whole of the mucosal lining is covered as the Caphosol works by direct contact with the mucosa PHARYNX / OROPHARYNX treatment: Patients to use Normosal sachets (Sodium Chloride 0.9%) 4 times a day. Swill around mouth, gargle for up to a minute and then spit out. To be repeated until whole sachet is used. This can be increased up 1-2 hourly if needed. Open the sachets and tip into a glass. Lipsalve to be used as needed. CARE PLAN D - Any changes For more information please see Oral Care for Radiotherapy Guidelines Mucositis Increase frequency of basic mouth care (it can t be done too often). DO NOT USE CHLORHEXIDINE GLUCONATE Benzydamine (Difflam) and Gelclair are indicated for pain relief of mucositis:- Benzydamine 10mls to be rinsed around the oral cavity every 2 hours if required. Can be diluted 50:50 with water if not tolerated Gelclair Should be mixed as directed and used 3 times a day. Gelclair can be used without diluting and can be applied directly inside lips or to deep ulcers in the oral cavity Continue with Caphosol if having radiotherapy to oral cavity Thick secretions Saline mouthwashes to be used 1-2 hourly. Steam inhalation and nebulisers may help to thin secretions. Carbocisteine (Mucodyne) suspension may help reduce the amount of secretions for some patients - start a 3 day trial if indicated. Encourage patient to clear secretions before eating to avoid nausea and vomiting. If secretions are causing nausea consider prescribing metoclopromide. Dry mouth Biotene Oralbalance gel may help with symptoms of dry mouth. Most artificial saliva products are not particularly helpful during radiotherapy. Encourage good fluid intake patients who are well hydrated are less likely to experience a dry mouth Oral Candida - Fluconazole 50mg for 7 days unless contrary indicated. If no response within 7 days follow VCC oral care policy. Ensure baseline mouth care continues and encourage use of mouthwashes.

8 Addressograph Mouth Care Bundle Care plan A/B/C/D Frequency of mouth care required Y If patient independent advise to brush teeth/ clean dentures twice daily If Care plan A check mouth once daily. If Care plan B or above check at least twice daily N Achievement (A) = care plan A. Variance (V) = care plan B or above. Details of this episode, the action taken and the outcome to be recorded on the variance sheet Level of support for mouth care: Independent pt; Prompting needed; Assistance 1-2nurses Mouth comfort: Ask patient to score their mouth comfort out of 5-1 not comfortable at all, 5 very comfortable Date Level of support for mouth care How comfortable is your mouth? Score out of 5 Advised Time Actual time Additional time of mouthcare Signature Teeth/ Dentures cleaned Mouthwash used (if applicable) Signature Lips, tongue, gums, soft tissue and pallet (A / V) Saliva (A / V) Oral cleanliness (A / V) Natural teeth (A / V/ NA) Dentures (A / V/ NA) Other (specify) (A / V) Variance (refer to guidelines to ensure patient on appropriate treatment)

9 Patient details Risk assessed within 24 hrs Care plan Compliance with bundle Level of support required How comfortable is your mouth score on admission How comfortable is your mouth score on day of audit

10 Rolling out in the next couple of weeks Staff feedback so far is positive Risk assessment much better than the current one Clear guidelines following on from the risk assessment Have found the additional training and education around mucositis very useful

11 THANK YOU ANY QUESTIONS?