I'm back again with more student questions. :) I hope it does not bother anyone. Still at my clinical in the LTC facility. My observations are that many of the patients have a lot of plaque and just plain nasties on their teeth and tongues (forgive my lack of technical terminology). There is a mixture of white buildup and mucous coating teeth, and oral mucosa, as well as darker colors about 1/3rd of the way up the teeth from the gumlines. This is the case on about 3 of the 8 that I have cared for (pretty much those who have tubes). We cannot use a toothbrush because they are all NPO once they get their g-tubes and not all of them even want to open their mouths, but the toothettes are just not getting all of it off. I'm also admittedly afraid they are going to swallow the foam of the toothette, either from falling apart or the patient clamping down (although that could just be my inexperience).
I assumed that the dentist would do a professional cleaning every 6 months, just as we are supposed to do ourselves, but when I asked last clinical, I was told that is not the case. The dentist makes rounds every monday but does not do any cleanings ever. Is that normal? How does plaque build up get removed without a dentist's tools? Or do they just give up on it at that point? Some of our residents have a lot of years ahead of them, and they must get cavities and gingivitis without more extensive cleanings than a toothette right? Perhaps I should read on it more, but we really just skimmed over oral care.
The way that my clinical is run, we don't interact with the nurses at all, or even our instructor. We have a selected "charge nurse" every week who we take our questions/comments/concerns/needs to, and she is the liason between us and the teacher and between us and the staff. I find I have learned more in the few instances where I have been able to view an actual CNA/LPN/RN have really helped me a hundred times more than the hands on I have,, but unfortunately, thats not really much of an option at our school.
Just wondering what your observations/input/thoughts are on oral care in LTC both on a daily basis and from a visit from the dentist? Are there ways that you can remove germs and bacteria from the mouth of an NPO patient (we're only allowed to use water on a toothette and it has to be completely squeezed out and it does not seem to be working very well for me).
Thank you all for your input. Your input on my last question was very enlightening to me. I am DEFINITELY not trying to judge anyone working in LTC. I know they have a huge workload here. I just want to know how *I* should approach this issue, both as a student now helping out, and down the road, when I am a nurse (and hopefully will still have the opportunity to help take care of my residents/patients atleast some of the time)
I have a lot of demented/combative patients, not nessecarily NPO, but they swallow the water if I tell them to swish/spit (along with the yucky paste, plaque etc) . So my alternative is to wet the toothbrush, put just a little bit of paste on (enough to lather up) and brush them as best I can. After that I use a few wet toothettes to wipe away as much of the toothpaste as possible. It may not be the 'by the book' way, but I just can't feel I did a good job cleaning those teeth with those crummy toothettes alone.
Specializes in med-surg 5 years geriatrics 12 years.
Having a dentist who will actually come in and then accept Medicare/Medicaid sounds wonderful. Unfortunately not all areas have dentists who will do either. Know what you mean about TF residents and nasty mouths....it's a bad situation all the way around.
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
Many dentists are unwilling to come to nursing homes due to the low reimbursement rates.
I know of a mobile dentist who travels to different nursing homes in my area. She is paid only $20 per tooth extraction, whereas a dentist in private practice can fetch over $100 per tooth. She gets paid $45 per scaling (deep cleaning), whereas a dentist in private practice can get paid a whole lot more to do the same thing.
Unless sedation is being used, I have no idea how a dentist or hygienist can adequately clean or do most dental work on a demented patient. Not to mention the risks to the dentist.
Specializes in LTC, ER, ICU, Psych, Med-surg...etc....
No one can fault you as long as you make a real effort and document and care plan it. I know you all probably get sick of hearing me say over and over document and care plan, but that is your evidence that you are aware, you are trying, and you have a plan. Also, some days a demented person may let you do oral care, some days not, maybe not ever. If the family knows, the MD knows and you have it charted, then you are on the right track. It is hard to get a dentist to come into alot of facilities, or to even see some residents because many dentists do not accept Medicaid. And you are right, how in the world can some dentists examine some demented residents? Just make sure you try everyday and document your successes or failures....
I'm into results not excuses- I in- service my staff once a year on dental hygiene and follow up PRN if teeth are being brushed. However plaque can still build up and there is terrible noncompliance with patients who are confused and bite - (not placing blame here). I simply write a note to the SW to ask the family to bring a dentist in (there is a charitable org that provides this for a nominal fee- using volunteer or student dentists). If the families don't care- than I cant do more than this- I wish we could organize something better. When the families complain about halitosis- again I ask them to bring in a dentist to deal with the plaque.
When all fails- I write another note to our CEO- a request from him almost always gets respected. I keep copies of these notes in the patients charts and care plan it all!!
Again- good for you for noticing this potentially uncomfortable and dangerous problem.
I actually work for HealthDrive and although I am not working directly with the patients on a daily basis, we, the office, know the dilemma the nursing staff has with oral care. I know that our Hygienists often persuade the ADON/DON's to allow us to have an inservice on oral health. The state has begun to really crack down on dental care and I just hope that you give us a call and ask for an inservice if you have questions. Our dentists provide initial exams, problem focused exams, dentures, simple extractions, restoratives, relines, adjustments, (i hope I'm not forgetting anything), and our hygienists complete annual exams, prophy's, POE's and fluoride treatments. Medicaid will pay for 100% of these procedures. I read some of the previous responses and again, I really urge you to contact your local HealthDrive to set up some type of inservicing. We have terrific Providers whose number one priority is to provide these patients the care they need. I have heard some really horrifying stories... it is really sad!
I can understand how some patients are not able to comply, and sometimes some of them just won't open there mouths, and for them I totally get the lack of oral care. I wouldn't want to pry their mouths open against their will if they really did not want it. Its just the general "only a toothette with slight moisture for anyone with a tube" rule that confuses me. I hate toothettes with a passion.
I know that plaque wont come off, but when an almost comatose patient who cannot speak or cry or do anything more than slight head movement and opening her eyes, makes faces like (forgive this comparison its the only one that I can think of based on my equestrian history) like a horse when you give them meds they dont like... it just really seemed that something was causing her distress at the moment, and seeing the thick white film and grayish green material coating her tongue/teeth/general oral mucosa seemed the first possible reason for it. (she generally lays very quietly)
In my LTC facility, we do oral care 1x a shift on residents, 2x a shift for tube feeding. I work day shift 6-2 and for the tube feeders we use toothbrushes. That is how we were instructed in CNA class. We either roll them to their side and brush, use a towel underneath to drain and a washcloth to wipe up any excess fluid. Or we sit them up, lean them forward and proceed. We use toothettes afterwards that are dry to also soak up any excess fluid. Then we use wet ones wrung out for a final cleaning. I find that odd that it varies since we were taught this in class unless careplans say otherwise.
In my LTC facility, we do oral care 1x a shift on residents, 2x a shift for tube feeding. I work day shift 6-2 and for the tube feeders we use toothbrushes. That is how we were instructed in CNA class. We either roll them to their side and brush, use a towel underneath to drain and a washcloth to wipe up any excess fluid. Or we sit them up, lean them forward and proceed. We use toothettes afterwards that are dry to also soak up any excess fluid. Then we use wet ones wrung out for a final cleaning. I find that odd that it varies since we were taught this in class unless careplans say otherwise.
clemmm78, RN
440 Posts
At the place I just started working at, a dentist and hygienest come in once a week and the residents are seen, I believe, every six months.