Pain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU
(IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management. We conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst. Evidence-based methods to assess pain are the enlarged 0–10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0–10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs. Relief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.

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Palliative care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board

Background. Few nursing studies have aimed to determine the effectiveness of different mouth care tools to remove plaque which is associated with the tooth/ gingival margin and, therefore, with gingivitis and chronic inflammatory perio- dontal disease. Findings from a previous case study of two people that compared the ability of foam swabs and toothbrushes to remove plaque at the gum/tooth margin (gingival crevice) and plaque from between teeth (approximal plaque) suggested that the success of a toothbrush is affected by user technique and that foam swabs are not able to remove plaque from someshelteredareas of teeth. Methods. A time-series, cross-over controlled trial with 34 volunteers was used to determine the ability of foam swabs and toothbrushes to remove dental plaque which had been allowed to accumulate overnight. Plaque accumulations were scored at each approximal and crevice site for the buccal surfaces of the eight upper and eight lower teeth after each treatment of either toothbrushing or swabbing. Results. Plaque frequency distributions in the form of boxplots, together with results from summary statistics demonstrate that toothbrushes performed substan- tially better than foam swabs in the ability to remove plaque from the sites studied in this larger sample of people. Conclusions. The trial verified the findings from the previous study. The conclu- sions can be generalized to a wider population because of the magnitude and direction of the differences measured. The implications for nurse education and the development of nursing in practice settings include the need to teach effective toothbrushing skills to nurses, and to support clinical staff in developing mouthcare practice, particularly in relation to the use of assessment strategies that include the choice of effective tools.

A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque.

To test an intervention bundle for thirst intensity, thirst distress, and dry mouth, which are among the most pervasive, intense, distressful, unrecognized, and undertreated symptoms in ICU patients, but for which data-based interventions are lacking. This was a single-blinded randomized clinical trial in three ICUs in a tertiary medical center in urban California. A total of 252 cognitively intact patients reporting thirst intensity (TI) and/or thirst distress (TD) scores ≥3 on 0–10 numeric rating scales (NRS) were randomized to intervention or usual care groups. A research team nurse (RTN#1) obtained patients’ pre-procedure TI and TD scores and reports of dry mouth. She then administered a thirst bundle to the intervention group: oral swab wipes, sterile ice-cold water sprays, and a lip moisturizer, or observed patients in the usual care group. RTN#2, blinded to group assignment, obtained post-procedure TI and TD scores. Up to six sessions per patient were conducted across 2 days. Multilevel linear regression determined that the average decreases in TI and TD scores from pre-procedure to post-procedure were significantly greater in the intervention group (2.3 and 1.8 NRS points, respectively) versus the usual care group (0.6 and 0.4 points, respectively) (p < 0.05). The usual care group was 1.9 times more likely than the intervention group to report dry mouth for each additional session on day 1. This simple, inexpensive thirst bundle significantly decreased ICU patients’ thirst and dry mouth and can be considered a practice intervention for patients experiencing thirst.

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A Randomized Clinical Trial of an Intervention to Relieve Thirst and Dry Mouth in Intensive Care Unit Patients

Oral care of the critically ill: a review of the literature and guidelines for practice.

This study aimed to assess the impact which the use of a toothbrush and the use of foam swabs had on the removal of dental plaque over a 6-day period Three experiments were completed and duplicated using the author's mouth and one of these experiments was completed a third time on a volunteer's mouth A plaque scoring system which quantified the amount of plaque on teeth in areas adjacent to periodontal tissue, and therefore capable of initiating inflammation, was used after plaque had been disclosed Plaque at the gum/tooth margin (gingival crevice plaque) and plaque between teeth (approximal plaque) was measured At the end of each 6-day period, which commenced with all tooth surfaces clean, the ability of the toothbrush to remove plaque was consistently better than that of swabs, and usually achieved complete visible plaque removal from all sites In contrast, plaque remained in all sites which had been cleaned using foam swabs (after using a ‘swabbing’or ‘scrubbing’technique) However, it was possible to remove plaque from a number of gingival crevice sites with a swab when a varied‘any technique’was used on the visible disclosed plaque The plaque in all approximal sites still remained after this technique An experiment to measure the effect of using foam swabs on plaque which had been allowed to accumulate over a 6 day period produced similar results The results from this study suggest that the success of a toothbrush in removing plaque is affected by user technique (total visible plaque removal was not achievable), and that foam swabs are not able to remove plaque from some ‘sheltered’areas of teeth (total visible plaque removal was not achievable) The implications of these findings to nursing practice are discussed

Susan B. Wiley

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