International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU

Shikha Gulia1, Vinay Kumari2, Neetu Khatri3

1Nursing Tutor (Medical Surgical Nursing), 2Professor (Medical Surgical Nursing), 3Assistant Professor ( and Gynaecological Nursing), M.M College of Nursing, M.M Deemed to be University, Mullana, Ambala, Haryana

Corresponding Author: Shikha Gulia

ABSTRACT

Background: Thirst and dry mouth are frequent impelling desire or need to drink water or any fluid. Intensive care unit (ICU) patients are exposed to many sources of distress. “Intensive care patients report thirst intensity as one of the most distressful of 10 symptoms; thirst is rated as the second prevalent symptom among patients. Thirst and Dry mouth are being the most neglected stressors during nursing care in ICU. There are multiple factors which drive the sensation of thirst in ICU: fasting, drugs used during anesthesia, endo tracheal intubation, surgical intra operative bleeding, , patients' age, treatments with drugs like , sedatives, high dose antibiotics, analgesics which stimulate the physiology of thirst and enhance it. With this background, systematic literature search was carried out. Objective: To collect the data and review various studies. Methodology: The study design was systematic review. The study includes the studies those which are related to occurrence of thirst and dry mouth among patients, predictors of thirst and dry mouth among patients and interventions to reduce thirst and dry mouth among patients. Analysis: Studies were identified through searches of MEDLINE, PUBMED, Elsevier and Google Scholar. Abstracted information is about the study design, interventions and outcomes. Conclusion: This systematic review has concluded that intervention bundle consisting of more than one intervention is significantly effective in reducing thirst and dry among patients admitted in ICU.

Key words: Thirst, Dry Mouth, Intervention Bundle

INTRODUCTION sensation of thirst in ICU: fasting, drugs Thirst and dry mouth are frequent used during anesthesia, endo tracheal compelling desire or need to drink water or intubation, surgical intra operative bleeding, any fluid. [1] Intensive care unit (ICU) dehydration, patients' age, treatments with patients are exposed to many sources of drugs like diuretics, sedatives, high dose distress. [2] “Intensive care patients report antibiotics, analgesics which stimulate the thirst intensity as one of the most distressful physiology of thirst and enhance it. [3] of 10 symptoms; thirst is rated as the second During stay in an Intensive care unit prevalent symptom among patients. Thirst the patients often report their desire to drink and Dry mouth are being the most neglected fluids, but most of the time it remains stressors during nursing care in ICU. There undocumented by nurses, patients feel more are multiple factors which drive the distress and discomfort during their stay due

International Journal of Health Sciences & Research (www.ijhsr.org) 397 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU to thirst intensity. Most of the nurses do not patients. Total 50 studies were selected for assess the patients for thirst and dry mouth, review out of which 20 were found which by and large lead to some severe appropriate for systematic review. Data was complications like: increase in intensity of divided into three different sections. and dyspnea. are LITERATURE RELATED TO present in the mouth and the OCCURRENCE OF THIRST AND DRY respond to chemical, tactile, pressure and MOUTH temperature stimuli and ingestion of cold A Prospective study was done to liquid in the mouth can reduce the characterize Self-reported symptom of thirst. The fact indicates that experience of critically ill cancer patients cold fluids reduce thirst with more receiving intensive care with a present or effectiveness than hot or warm fluids. [4] past diagnosis of cancer and was Nurses and usually carry consecutively admitted to a medical ICU the perception that nothing can be done to during an 8-month period. This study was overcome thirst and dry mouth. Also, it done at tertiary-care, urban medical center. remains undocumented by and neglected in A sample size of One hundred cancer critical areas of hospital. [5] As far by now, patients treated in a medical ICU was taken. no permanent assessment strategies are Data was collected by using the Edmonton being carried off to assess thirst and dry Symptom Assessment Scale (ESAS). The mouth. This highlights the fact that there is ratings of pain or discomfort associated with a lack of database interventions in hospitals ICU diagnostic/therapeutic procedures and to reduce the intensity and distress of thirst of stress associated with conditions in the and dry mouth. [6] There is an alarming need ICU were assessed. The results of the study to view and observe thirst and dry mouth as revealed that Hospital mortality for the distressful symptoms and by keeping that as group was 56%. Fifty patients had the one important factor. capacity to respond to the ESAS, among whom 100% provided symptom reports. MATERIALS AND METHODS Between 55% and 75% of ESAS responders Research Design: Systematic Review reported experiencing pain, discomfort, Inclusion Criteria: The study includes the anxiety, sleep disturbance, or unsatisfied studies those which are related the or thirst that they rated as moderate assessment of thirst and dry mouth among or severe, whereas depression and dyspnea ICU patients, predictors which increases at these levels were reported by thirst and dry mouth and interventions to approximately 40% and 33% of responders, relieve thirst and dry mouth. respectively. The study also suggested that Data Analysis: The data was grouped and Significant pain, discomfort, or both were analyzed in terms of Meta analysis. associated with common ICU procedures, Relevant articles based on thirst and dry but most procedure-related symptoms were mouth among ICU patients and controlled adequately for a majority of interventions were identified by search of patients and Inability to communicate, sleep significant articles. PubMed/Medline, disruption, and limitations on visiting were SCOPUS, CINAHL, PsychoINFO, Elsevier particularly stressful among ICU conditions and Google Scholar with the following key for patients. The study suggests more words: thirst, dry mouth, intervention effective strategies for symptom control and bundle. direct decisions about appropriate use of ICU . [7] RESULTS A Prospective, observational study A systematic review was done to on symptoms experienced by intensive care assess effectiveness of intervention bundle unit patients at high risk of dying was done. on thirst and dry mouth among ICU The study was conducted in two intensive

International Journal of Health Sciences & Research (www.ijhsr.org) 398 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU care units in a tertiary medical center in the themes relating to the patients' experiences western United States. The sample size of of thirst during MV: a paramount thirst, a One hundred seventy-one intensive care unit different in the mouth, deprivation of patients who were at high risk of dying. The the opportunity to quench thirst and data was collected by interview technique difficulties associated with thirst. The study by interviewing patients every other day for also concluded that Patients associate up to 14 days. Patients were asked to rate feelings of desperation, anxiety and the presence, intensity (1 = mild; 2 = powerlessness with the experience of thirst. moderate; 3 = severe), and distress (1 = not These feelings have a negative impact on very distressing; 2 = moderately distressing; their psychological well-being. A strategy in 3 = very distressing) of ten symptoms (that the ICU that includes no sedation for is, pain, tired, short of breath, restless, critically ill patients in need of MV anxious, sad, hungry, scared, thirsty, introduces new demands on the nurses who confused). The Confusion Assessment must care for patients who are struggling Method–Intensive Care Unit was used to with thirst. [8] ascertain the presence of delirium. A total of A qualitative study was conducted to 405 symptom assessments were completed assess of the nursing team by 171 patients. The study measured the regarding thirst in surgical patients at large results that Patients' average age was 58 ± university hospital in southern Brazil. The 15 yrs and 64% were males. Patients were study assessed the perception of the nursing mechanically ventilated (34%) of the 405 team in patient units with respect to thirst in assessments, and 22% died in the hospital. surgical patients and the factors that Symptom prevalence ranged from 75% interfere with the implementation of (tired) to 27% (confused). Thirst was management strategies. Qualitative moderately intense, and shortness of breath, descriptive study design was used with scared, confusion, and pain were moderately sample size of 12 nursing technicians of a distressful. Delirium was found in 34.2% of university hospital. The selection of the the 152 patients who could be evaluated. sample considered participants’ willingness Delirious patients were more acutely ill and to participate in the survey and the data received significantly higher doses of saturation in the discourses collected. Data opioids. Delirious patients were collection was performed using a significantly more likely to report feeling semistructured interview with the questions confused (43% vs. 22%, p = .004) and sad for e.g. What are the greatest discomforts (46% vs. 31%, p = .04) and less likely to that the patients feel during the pre-and report being tired (57% vs. 77%, p = .006) postoperative period? How do you detect than non delirious patients. The Study that the patients are thirsty? What makes findings suggest that unrelieved and surgical patients feel thirsty? What is your distressing symptoms are present for the behavior in the face of the discomfort majority of intensive care unit patients, caused by thirst reported by the patients? including those with delirium. and How do you feel about providing care A qualitative study was done to to surgical patients who are thirsty? The explore patients' experience of thirst while Discourse of the Collective Subject method being conscious and mechanically ventilated was used for the analysis and the categories at Denmark. This hermeneutic study used established were: thirst – a little valued qualitative interviews of 12 patients. The discomfort; perceiving patients’ thirst; and data were analyzed based on content performing in the face of thirst. The study analysis. Interviews were conducted concluded that the nursing technicians did between September and October 2014 in not regard thirst as a primordial discomfort, two large ICUs in Denmark. The results of making it an undervalued, underreported the study suggested identification of Four and unsystematically assessed symptom.

International Journal of Health Sciences & Research (www.ijhsr.org) 399 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU

For the management of thirst, they did not reuptake inhibitors, and low use evidence-based strategies due to the lack ionized calcium and Thirst intensity was of knowledge about the topic and fear of increased by patients not receiving oral fluid possible complications. The study also and having a gastrointestinal (GI) diagnosis focused on need of continuing education whereas Thirst distress was predicted by actions aimed at sensitizing the mechanical ventilation, negative fluid professionals for intentional assessment and balance, antihypertensive medications, and a intervention in surgical patients who suffer GI or “other” diagnosis. Predicted from thirst without being cared. The study probabilities of thirst presence from the final also stated that Thirst is an important model correlated with thirst presence (r = discomfort usually undervalued from the 0.306) and predicted 9.4% of the variance in perspective of nursing care. Within the work the presence of thirst. The study concluded routine, the nursing technicians identified that Thirst presence is initiated by selected visible and objective discomforts in the medications (e.g., opioids). Thirst intensity surgical patients, such as pain, hypothermia and/or thirst distress is initiated by other and nausea. However, subjective treatments (e.g., mechanical ventilation) and discomforts, such as thirst, were often medical diagnoses (e.g., GI). The study unnoticed. According to study, thirst is concludes that it is one of the first studies regarded as a common that the describing predictors of the patients had to undergo within an multidimensional characteristics of thirst. [20] institutional routine strongly characterized A cross-sectional observational by the culture of prolonged and total fasting. study was performed on terminally ill The staff nurses are able to recognize the cancer patients receiving inpatient hospice severity of thirst as discomfort in the care at Seirei Mikatabara Hospital, patients, despite of that they did not record Hamamatsu, Shizuoka, Japan. A sample size nor assessed thirst. The nursing technicians was 88 patients admitted for used management strategies in an empirical were taken. Patients were asked to report manner but there was no updating intensity of thirst on a visual analogue scale management done. It also has been (VAS). The researchers prospectively concluded that thirst produced compassion evaluated factors that might potentially be in the nursing just like pain but valued less. contributing to the symptom. The results of [9] the study showed that the mean VAS score LITERATURE RELATED TO for thirst was 5.0+/-2.8, and 18% of the PREDICTORS OF THIRST AND DRY patients complained of severe thirst with a MOUTH VAS score of > or = 8. Researchers didn’t A descriptive cross-sectional study find significant relationship between the was conducted to identify predictors of the VAS score for thirst and the values of total presence, intensity, and distress of thirst in protein, blood urea nitrogen (BUN), ICU patients at university of California San creatinine, , osmolality, hematocrit, Francisco, USA. The sample size was of atrial natriuretic peptide (ANP), and 353 patients taken from three ICUs biochemical dehydration defined by the (medical-surgical, cardiac, and levels of BUN, creatinine, sodium and neurological). The data was collected by osmolality. Whereas dehydration defined by using numeric rating scales. The Predictor ANP level (< or = 15 pg/ml), variables in study were demographic (e.g., hyperosmolality (> or = 300 mosmol/kg), age), treatment-related (e.g., opioids), and gastrointestinal cancer, survival, biological (e.g., total ). The study performance status, oral intake, vomiting, results revealed that Thirst presence was and stomatitis were significantly associated increased by high opioid doses (≥50 mg), with the severity of thirst. The study also high furosemide doses (>60 mg), selective concluded that mouth breathing and opioids

International Journal of Health Sciences & Research (www.ijhsr.org) 400 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU were determined to be a potential clinical maintenance hemodialysis (MHD) patients cause of severe thirst. The findings of the Fudan University, Shanghai, China. The study states that the sensation of thirst is sample consisted of Forty-two MHD associated with dehydration, patients and eleven patients were enrolled hyperosmolality, poor general conditions, for crossover trial. Data was collected by stomatitis, oral breathing, and opioids. using 100-mm visual analog scales (VAS) Therefore, there is a need for careful and dialysis thirst inventory (DTI) for assessments and treatment of underlying assessment of thirst, whereas xerostomia causes is important to alleviate patients' was assessed by VAS and xerostomia thirst distress. [10] inventory (XI). Depression, disease A descriptive study was done to quality of life (KDQOL), salivary flow rates determine the prevalence of xerostomia and and inter dialytic weight gain (IDWG) were hyposalivation in Haemodialysis (HD) also measured. The data were analyzed by patients in Spain. The sample size for the ANOVA and correlation coefficient was study was 50 Haemodialysis patients. The used to assess the correlations between data were collected by a questionnaire continuous variables. The results of containing demographic and clinical crossover trial showed significant positive variables, a visual analogue scale (VAS) relationship among DTI, VAS thirst score, for xerostomia, IDWG (intra dialytic weight XI and VAS xerostomia score were gain) and an oral health impact profile (P=0.000). Daily IDWG had significant questionnaire (OHIP-14). Unstimulated positive relationship with VAS thirst score whole saliva (UWS) and stimulated whole (r=0.315, P=0.042) and DTI saliva (SWS) were also collected by (r=0.391, P=0.010). UWS (unstimulated researchers. The results of the study whole saliva) was negatively correlated with concluded that around 56% patients VAS xerostomia score (r=-0.308, P=0.048). suffered xerostomia and it was associated Residual output had negative with hypertension (OR, 5.24; 95% CI, 1.11- relationship with DTI (r=-0.402, P=0.008), 24.89) and benzodiazepine consumption VAS xerostomia score (r=-0.461, P=0.002) (OR, 5.96; 95% CI, 1.05-33.99). The and XI (r=-0.403, P=0.008). In the crossover mean xerostomia VAS and OHIP-14 scores trial, DTI, XI, IDWG2d, IDWG3d, VAS were 31.74±14.88 and 24.38±11.98, thirst and xerostomia score were respectively. No significant relationship was significantly reduced by the use of chewing observed between IDWG% and VAS and gum (P=0.000, 0.001, 0.009, 0.017, 0.038, OHIP total score. However , a positive 0.001). The VAS thirst score, DTI and significant relationship between VAS level IDWG3d were significantly reduced by of thirst and IDWG% was found (r=0.48 receiving straw (P=0.016, 0.003, p=0.0001). The study revealed that 0.049). The study concluded that Thirst Xerostomia in Haemodialysis has a and xerostomia might affect the quality of multifactorial aetiology due to accumulative life in MHD patients and use of chewing risks as advanced age, systemic disorders, gum and straw could decrease thirst and drugs, fluid intake restriction, and salivary IDWG among patients. [12] parenchymal fibrosis and atrophy. LITERATURE RELATED TO Therefore, it is important to detect INTERVENTIONS TO REDUCE OF possible xerostomia risk factors to treat it in THIRST AND DRY MOUTH haemodialysis patients and to avoid A randomized clinical trial study systemic complications. [11] was done to assess the effectiveness of An observational study was done to intervention bundle to decrease thirst analyse the clinical significance and related intensity and dry mouth among ICU patients factors of thirst and xerostomia and to find at University of California, USA. A total of methods to alleviate thirst and xerostomia in 252 cognitively intact patients were asked to

International Journal of Health Sciences & Research (www.ijhsr.org) 401 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU report thirst intensity or thirst distress and (p< 0.001), but frequency thirst increased dry mouth on numeric rating scales (NRS), from 12.2±3.7 to 16.5±5.4(p<0.00). The patients with scores ≥3 on 0-10 scale were study concluded that Ice chips had no effect randomized to intervention or usual care on the intensity of thirst in patients groups. Intervention bundle administered to undergoing hemodialysis despite increasing the intervention group: oral swab wipes, the frequency of thirst but result in reducing sterile ice-cold water sprays, and a lip fluid intake. [13] moisturizer, and thirst intensity and dry A randomized clinical trial was done mouth scores were observed among patients to investigate the effect of chewing gum or a in the usual care group. Multilevel linear saliva substitute on xerostomia, thirst and regression determined that the average interdialytic weight gain among patients decreases in TI and TD scores from pre- undergoing haemodialysis. A sample size of procedure to post-procedure were sixty-five Haemodialysis patients (42 men, significantly greater in the intervention 54.6+/-14.1 years; 23 women, 54.7+/-16.3 group (2.3 and 1.8 NRS points, years) was taken in the study. The tools respectively) versus the usual care group used to assess Xerostomia and thirst were (0.6 and 0.4 points, respectively) (p < 0.05). validated questionnaires as xerostomia The usual care group was 1.9 times more inventory (XI) and dialysis thirst inventory likely than the intervention group to report (DTI), at baseline and after each treatment dry mouth for each additional session on period, as were IWG and salivary flow rates day 1. . After the use of chewing gum or saliva An experimental study was substitute for 2 weeks, a wash-out period of conducted to evaluate the effectiveness of 2 weeks was introduced and thereafter the ice chips on intensity of thirst and fluid other regimen was carried out. The results intake in patients undergoing hemodialysis of the study suggested that Chewing gum at Mashhad University of Medical Sciences, decreased XI from 29.9+/-9.5 to 28.1+/-9.1 Mashhad, Iran. Cross-over study design (P<0.05). Chewing gum as well as a saliva with sample size of 49 patients was taken. substitute reduced DTI significantly Patients were randomly divided into two (P<0.05), but no differences occurred for the groups of A and B. Both groups were average IWG or salivary flow rates. The trained on how to complete the check lists, study concluded that use of chewing gum measurement of liquids and fluid intake at and, to a lesser extent, a saliva substitute intervals between sessions. Afterward, may alleviate thirst and xerostomia in some group A was trained about the use of HD patients. [14] alternating liquid and ice and registered in An experimental and cross sectional the check List and group B only about study to evaluate simple and safe strategies taking up the liquids and registered in the to mitigate thirst in the immediate check List. In addition, the intervals postoperative period (IPO) at large between two dialysis sessions were university hospital, a regional reference reminded to patients by researcher by SMS center for burns and trauma, Lodrina, for intervention and completion of the check Brazil. The sample size consisted of 133 List. Sixth week, intervention between two patients in the Post- Anesthesia Care Unit groups was moved. In all these sessions, (PACU) who underwent surgical procedures intensity of thirst measured before and after during the research period. The inclusion and at the middle of each dialysis criteria for the composition of the sample session. The results of the study revealed included: patients aged between 18 and 70 that there was no significant differences years, with ASA I, II or III, undergoing any between the use of ice chips with severity of surgical procedure; patients were alert / thirst (p=0.806). Ice chips decreased fluid oriented, with localized pain, glottal reflex intake from 2375.4±654.2 to 2112.9±656.4 was present, spontaneous breathing on room

International Journal of Health Sciences & Research (www.ijhsr.org) 402 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU air with O2 saturation greater than 94%; significant difference of this magnitude patients who were able to verbalize thirst in between the two (p = 0.56). The study the immediate postoperative period (IPO) concluded that Thirst is a real discomfort and authorization was obtained from the and causes great suffering in the patient. [7] responsible anesthesiologist to administer A Randomized Clinical Trial was water or ice; patients accepted and signed done to determine the effect of an early the Terms of Free and Informed Consent liberal regimen of ice chips and water on preoperatively. Data Collection was done by adverse events and thirst after using an instrument developed by the cardiothoracic . A sample of 149 authors based on the objectives proposed in patients from an 18-bed CTICU was taken. this study, which was divided into three Patients were randomized to usual care parts: the first, to understand demographics group (6-hour fast post-extubation) and and hospitalization of the patient, followed liberal regimen during the pre-operative by the questionnaire with data relevant to visit. The researchers assessed patients after the IPP (surgery date, time of entry into the fasting 1 hour post-extubation, patients in operating room (OR), type of surgery, type the liberal regimen with a 6-item protocol of anesthesia, use of medications that for oral intake readiness, and administered interfere with the sensation of thirst, ice chips and advanced to water. The results complications during surgery, and departure of the study shows that mean age was time from the OR). The third included the 66±12.4 years and majority of patients were period of recovery from anesthesia and male(73.8%), two groups were equivalent determination of the verbalization of thirst except for the post-operative mean dose of and its measurement, authorization by the ketorolac that was higher in the UC group anesthesiologist for the administration of (p=.04). The result shows no differences in water or ice, and the consequent nausea, vomiting, or dysphagia between the administration of these to the patient. In UC vs. liberal group, and no aspiration order to measure the intensity of thirst in pneumonia. Thirst levels were higher in surgical patients, numeric rating scale was usual care group after extubation. In used from range of 1 to 10.The results of the analysis adjusted for relevant demographic study suggested that 96 (75%) patients and clinical variables (logistic regression), reported thirst. The preoperative fasting patients in the liberal group were less likely period varied from 8 to 37 hours, and there to report high thirst levels, compared with was no association between the type of UC patients (B=-.299, OR=.273, 95% CI anesthesia, bleeding, fasting time and thirst. .118-.630). Patients in the liberal group The intensity of initial thirst was 5.1 for the reported high thirst levels, compared with water group, and 6.1 for the ice group. The UC patients (B=-.299, OR=.273, 95% CI methods tested were effective in relieving .118-.630).The study also concluded that thirst in the Immediate Post Operative early initiation of ice chips and water post- period.. The ice group had a final intensity extubation after CT surgery was not of 1.51, as compared to 2.33 in the water associated with adverse events, but was group. Two (2.2%) patients experienced associated with significantly less thirst. In vomiting during the study. And also there appropriate patients, early oral intake can was a significant difference in the first reduce thirst. [15] moment, before the administration of water A quasi-experimental study was or ice, when the sensation of thirst was conducted to compare the effectiveness higher in the Ice Group than in the Water between wet gauze with cold normal saline Group (p = 0.2344). After the first dose of and wet gauze with cold water on post water or ice, there was an important and operative thirst and oral cavity condition significant fall in intensity of thirst of both experienced by patients at Dong A the Water and Ice groups, with no university, Korea. The sample sie of 56

International Journal of Health Sciences & Research (www.ijhsr.org) 403 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU participants and data were collected using intervention for alleviating thirst and visual analog scale for thirst, oral improving oral condition for patients with assessment guide for oral cavity condition after general anesthesia. and acidity tape for saliva pH. The scores [17] were taken before applying the gauze and at A quasi-experimental study was 15min, 30min, and 45min after applying done to examine the effects of using gauze gauze. The experimental group received wet frozen with normal saline or ice on thirst- gauze with cold normal saline, and control relief and oral condition of laparoscopic group received wet gauze with cold water cholecystectomy patients at Chosun for three times at 15 minute intervals. Data University Hospital, Gwangju, Korea. The were analyzed using repeated measured design of the study was nonequivalent ANOVA. Thirst, oral cavity condition, and control group, pretest-posttest design and saliva pH improved in both groups with sample size was 53. Patients received either increasing number of gauze application. gauze frozen with normal saline (n=17), ice Thirst for the experimental group improved (n=18) or wet gauze (n=18) for thirst-relief. more than for the control group (F=4.29, The subjective thirst level and oral condition p=.009), oral cavity condition except saliva, of the participants were assessed before the and saliva pH were not significantly intervention, 15 min after the first different between the groups. The study intervention and 15 min after the second concluded that nurses can apply wet gauze intervention. The results of the study with cold normal saline to reduce thirst and showed significant differences in thirst level saliva acidity, and also to improve the oral among the groups. When oral care was cavity condition for postoperative patients. provided twice, the oral condition of tongue, [16] saliva, mucosal membrane, and gingiva was An experimental study was done to improved in patients receiving gauze frozen identify the effects of cold water gargling on with normal saline or ice. The study also thirst, oral cavity condition and sore throat concluded that Gauze frozen with normal in orthopedics surgery patients who saline and ice can be effective for oral care underwent general anesthesia at Dong in reducing the thirst level and improving University, Korea. The study was done in the condition of the oral cavity. [18] post operative unit. The design for the study A quasi experimental study was was Pretest-posttest non-synchronized done which compared the effectiveness of design with a nonequivalent control group. oral care with ice cold saline versus room The sample size of 52 participants was temperature saline on thirst and oral selected conveniently and assigned condition among post-operative patients randomly to experimental and control undergone abdominal at GGS group. The experimental group gargled hospital, Faridkot, Convenience sampling hourly with cold water for 8 hours after technique has been used to allocate the operation. The control group received wet study subjects. A sample of 60 patients who gauze as needed. The thirst, oral cavity had undergone abdominal surgeries was condition and sore throat was assessed and taken. Subjective thirst scoring and compared at 0, 2, 4 and 8 hours after objective oral assessment (with room operation. The study revealed that the score temperature saline in group I and ice cold of thirst and oral cavity condition was lower normal saline in group II), pre and post in the experimental group than in the control intervention was done. The tool used was a group. The study concluded that there were structured questionnaire enquiring no significant differences in the levels of demographic and bio physiological profile, sore throat between the experimental and numeric rating scale (NRS) for thirst control group. The findings also suggest that assessment and objective oral assessment cold water gargling can be a useful nursing tool for assessing oral conditions. The study

International Journal of Health Sciences & Research (www.ijhsr.org) 404 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU findings revealed that the mean score of the An experimental study was done to thirst levels of the subjects in the ice cold evaluate the effectiveness of acupuncture in saline group experienced less thirst after the minimizing the severity of radiation-induced intervention as compared to the subjects in xerostomia in patients with head and neck room temperature saline group. The paired t cancer at University of São Paulo, São test value 5.37 of the subjective thirst Paulo, SP, Brazil. A total of 24 consecutive assessment was found to be statistically patients receiving > 5000 cGy radiotherapy significant at 0.00 level. The study focused (RT) involving the major salivary glands on the need for adopting modified oral care bilaterally were assigned to either the procedures such as use of ice cold saline for preventive acupuncture group (PA, n = 12), effective thirst management in post treated with acupuncture before and during operative patients. [19] RT, or the control group (CT, n = 12), A Randomized clinic trial was done treated with RT and not receiving to determine the safety and tolerability of acupuncture. After RT completion, clinical early oral rehydration compared with response was assessed in all patients by delayed oral rehydration after general syalometry, measuring the resting (RSFR) anesthesia at West China Hospital, Sichuan and stimulated (SSFR) salivary flow rates, University, China. One thousand and by the visual analogue scale (VAS) (ASA) I to III adult patients regarding dry mouth-related symptoms. The undergoing non-gastrointestinal surgery results shows that all patients exhibited with general anesthesia were randomly some degree of impairment in salivary gland assigned into two groups: DOH (n=500, functioning after RT, significant differences patients were given water 4 h after general were found between the groups. Patients in anesthesia), EOH (n=500, patients were the PA group showed improved salivary given 0.5 ml/kg water once recovered from flow rates (RSFR, SSFR; p < 0.001) and general anesthesia.) in the postanesthesia decreased xerostomia-related symptoms care unit (PACU). Patients were evaluated (VAS, p < 0.05) compared with patients in for nausea, vomiting, drink desire, thirsty the CT group. Although PA treatment did scale, oropharyngeal discomfort scale, and not prevent the oral sequelae of RT satisfaction scale. The results of study completely, it significantly minimized the showed data for 983 patients (EOH=488, severity of radiation-induced xerostomia. DOH=495) and revealed that twenty The results suggest that acupuncture minutes after receiving water the incidence focused in a preventive approach can be a of vomiting in EOH group was very low. useful in the management of And there was no significant difference patients with head and neck cancer between the two groups at the same time undergoing RT. [21] point (p > 0.05). Compared with DOH A randomized double-blind clinical group, after receiving water there was a trial was conducted to assess the clinical significant decrease of patients’ thirsty effectiveness of a topical sialogogue on scales (p < 0.0001) and oropharyngeal spray (malic acid, 1%) in the treatment of discomfort scales (p < 0.0001) in EOH xerostomia induced by antihypertensive group. Significantly more patients’ drugs at University of Granada, Granada, satisfaction were reported in EOH group Spain. The sample sie consisted of 45 (p < 0.001). The study concluded that for patients suffering from hypertensive drugs- patients undergoing non-gastrointestinal induced xerostomia and were were divided surgery, early oral hydration after recovery into 2 groups. The first group (25 patients) from general anesthesia was safe, with received a topical sialogogue on spray lower thirsty scale and oropharyngeal (malic acid, 1%) whereas the second group discomfort scales, and higher satisfaction. (20 patients) received a placebo. Both of the [20] groups were administered on demand for 2

International Journal of Health Sciences & Research (www.ijhsr.org) 405 Vol.9; Issue: 5; May 2019 Shikha Gulia et.al. Effectiveness of an Intervention Bundle on Thirst Intensity and Dry Mouth among Patients Admitted in ICU weeks. The data was collected by Dry washes per day for 3-4 minutes. The Mouth Questionnaire (DMQ) in order to participants of control group received the evaluate xerostomia levels before and after routine nursing care. The results of the study product/placebo application. Unstimulated shows that, In the study group, nine and stimulated salivary flows rates, before (45.00%) were between the age of 21-30 and after application, were measured by the years, nine (45.00%) in the study group researcher. The results of the study shows were male. The study group had decreased that DMQ scores increased significantly levels of thirst distress when compared to (clinical recovery) from 1.21 to 3.36 points the control group in the posttest which was (p<0.05) after malic acid (1%) application statistically significant at the level of whereas DMQ scores increased from 1.18 to p<0.01. Thirst distress and interdialytic 1.34 points (p>0.05) after placebo weight gain (IDWG) was reduced in the application. After two weeks of treatment study group after nursing intervention. with malic acid, unstimulated salivary flow There was no significant association increased from 0.17 to 0.242 mL/min between the thirst distress and sample whereas the stimulated one increased from characteristics. The finding of the study 0.66 to 0.92 mL/min (p<0.05). After suggests the importance of specific nursing placebo application unstimulated flow interventions that is Sucking ice cubes ranged from 0.152 to 0.146 mL/min and reduced thirst distress and improves stimulated flow increased from 0.67 to 0.70 compliance among patients with CKD mL/min (p>0.05). Therefore, study subjected to hemodialysis. [23] concludes that use of Malic acid 1% spray improved antihypertensive-induced CONCLUSION xerostomia and stimulated the production of The studies concluded that thirst and saliva among patients. [22] dry mouth are not assessed as stressors but An experimental study was done to cause distress among ICU patients. Multiple assess effectiveness of nursing interventions factors increases thirst and dry mouth like on thirst and interdialytic weight gain of drugs, \episodes of vomiting, hematocrit, patients with chronic kidney disease creatinine, sodium level, intake output of subjected to hemodialysis in the dialysis patient, glucose levels. A bundle consisted unit at a tertiary care teaching hospital in more than one intervention is effective in Chennai. The study also assessed relieving thirst and dry mouth among ICU relationship between thirst distress and patients interdialytic weight gain; association between selected variables and thirst REFERENCES distress. Pretest posttest control group 1. N., & Puntillo, K. (2013). Thirst in design was utilized in the study. The sample Critically Ill Patients: From Physiology to size consisted 40 patients with CKD Sensation. American Journal of Critical Care, 22(4), 328–335. subjected to haemodialysis in the dialysis http://doi.org/10.4037/ajcc2013533 unit at a tertiary care teaching hospital in 2. Arai, S., Stotts, N., & Puntillo, K. (2013). Chennai. The patients were selected Thirst in Critically Ill Patients: From conveniently and they were assigned to the Physiology to Sensation. American Journal study and control group using lottery of Critical Care, 22(4), 328–335. method. The Thirst Distress Scale was used http://doi.org/10.4037/ajcc2013533 to measure the intensity of thirst. The study 3. So, H. M., & Chan, D. S. K. (2004). group participants were given specific Perception of stressors by patients and nursing interventions of sucking ice cubes nurses of critical care units in Hong Kong. of 5ml each with a maximum allowance of International Journal of Nursing Studies, 10 cubes per day and mouthwash of 100 ml 41(1), 77–84. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14670 of water, with a maximum of 5 mouth 397

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How to cite this article: Gulia S, Kumari V, Khatri N. Effectiveness of an intervention bundle on thirst intensity and dry mouth among patients admitted in ICU. Int J Health Sci Res. 2019; 9(5):397-408.

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