Data Collection And Analysis: dependent variable(s) and the instrument(s) used to measure them…
Data Collection And Analysis
Identify and discuss the following:
- dependent variable(s) and the instrument(s) used to measure them.
- Were the measurement instruments reliable and valid? Why or why not?
Innovative Approaches
©2019 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ajcc2019400
Background Thirst is a common, intense symptom reported by hospitalized patients. No studies indicate frequency of use of ice water and lip moisturizer with menthol to ameliorate thirst and dry mouth. In an audit of 30 intensive care unit patients at a 580-bed commu- nity teaching hospital, 66% reported dry mouth with higher thirst distress and intensity scores than in pub- lished studies. Objectives To evaluate the effectiveness of scheduled use of ice water oral swabs and lip moisturizer with menthol compared with unscheduled use in relieving thirst and dry mouth for intensive care unit patients. Methods In a quasi-experimental design, adult patients admitted to 2 intensive care units at a community hos- pital were provided with ice water oral swabs and lip moisturizer with menthol upon request. The intervention was unscheduled in 1 unit and scheduled in the other unit. The scheduled intervention was provided hourly during a 7-hour period (n = 62 participants). The unsched- uled intervention consisted of usual care (n = 41 partici- pants). A numeric rating scale (0-10) was used to measure thirst intensity, thirst distress, and dry mouth before and after 7 hours in both groups. Results The scheduled-use group had significant lessen- ing of thirst intensity (P = .02) and dry mouth (P = .008). Thirst distress in the scheduled-use group did not differ from that in the unscheduled-use group (P = .07). Conclusion Scheduled use of ice water oral swabs and lip moisturizer with menthol may lessen thirst intensity and dry mouth in critical care patients. (American Journal of Critical Care. 2019; 28:41-46)
EFFECT OF A SCHEDULED NURSE INTERVENTION ON THIRST AND DRY MOUTH IN INTENSIVE CARE PATIENTS By Michelle VonStein, BSN, RN, CCRN, Barbara L. Buchko, DNP, RN, Cristina Millen, BSN, RN, PCCN, Deborah Lampo, DNP, RN, NE-BC, Theodore Bell, MS, and Anne B. Woods, PhD, MPH, RN
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2019, Volume 28, No. 1 41
This article is followed by an AJCC Patient Care Page on page 47.
42 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2019, Volume 28, No. 1 www.ajcconline.org
T hirst can be defined as “a perception that provokes the urge to drink fluids”1 and “is a prevalent, intense, distressing, and underappreciated symptom in intensive care patients.”2 Dry mouth, or xerostomia, can be associated with thirst.1 Thirst and dry mouth are common symptoms and may affect patients’ experience in intensive care unit (ICUs).3 In a study of 171 ICU patients by Puntillo et al,4 thirst was one of the
most common and intense symptoms reported.
Patients receiving mechanical ventilation experience powerless-
ness and frustration because of the inability
to satisfy thirst.
A more recent retrospective, descriptive study5
of patients who had cardiac surgery and received
mechanical ventilation confirmed that dry mouth
and thirst cause discomfort. The researchers5 sug-
gested that these symptoms could be addressed by
nursing staff, but studies were needed to identify
interventions. In a phenomenological study, Kjeld-
sen et al6 found that patients treated with mechani-
cal ventilation experienced powerlessness and
frustration because of the inability to satisfy thirst.
Patients in ICUs are predisposed to thirst and
dry mouth for a variety of reasons, including mechan-
ical ventilation, receiving nothing by mouth, specific
classes of medication, and certain medical conditions.7
Little research has been done
on nonpharmacological
interventions to manage
and minimize thirst and
dry mouth in hospitalized
adults, especially ICU
patients, resulting in a lack
of solid evidence for prac-
tice. Cold water was the
most common approach,
with a variety of application
techniques.1,3,8,9 Menthol
was also cited as an intervention for its cooling sen-
sation.10 Puntillo et al1 used a menthol lip moistur-
izer as part of an intervention bundle to prevent thirst
and dry mouth. No evidence-based recommendations
for a standardized frequency of use were reported.
A thirst intervention bundle consisting of ice water
spray, oral swab wipes, and menthol lip moisturizer
was tested in a randomized control study in 252 ICU
patients.1 Overall, use of the bundle resulted in a
statistically significant decrease in thirst intensity,
thirst distress, and dry mouth. These findings are
strengthened by the randomized control design of
the study and assessment of potential confounders.
In a quality improvement audit, we assessed for
thirst distress, thirst intensity, and dry mouth in 30
patients who were not receiving mechanical ventila-
tion and whose status was nothing by mouth. Mean
scores for thirst distress and thirst intensity were 5.5
and 6.1 (on a numeric rating scale [NRS] of 1-10),
respectively. Dry mouth was reported by 66% of
patients. Usual care consisting of oral swabs moist-
ened with ice water and lip moisturizer containing
methyl lactate (a derivative of menthol) are provided
to patients upon request at this facility. More than
half of the patients reported using these interven-
tions to relieve thirst and dry mouth.
Our aim in this study was to compare the effec-
tiveness of scheduled use of ice water oral swabs and
lip moisturizer with menthol with the effectiveness
of unscheduled, as-needed use of the same interven-
tions (usual care) at relieving thirst intensity, thirst
distress, and dry mouth in ICU patients. We hypoth-
esized that providing patients with regularly scheduled
applications of ice water oral swabs and lip moistur-
izer with menthol would decrease the patients’ per-
ception of thirst intensity, thirst distress, and dry
mouth more than would providing these interven-
tions upon patients’ request.
Methods Design, Setting, and Sample
We used a quasi-experimental study design with
a convenience sample of patients admitted to 2 medi-
cal ICUs at WellSpan York Hospital, York, Pennsyl-
vania, a 580-bed acute care community teaching
hospital. One unit provided the scheduled-use inter-
vention and the other unit provided usual care to
patients as needed. Both units provide care for ICU
patients with a variety of medical diagnoses. The
study was approved by the appropriate institutional
review board.
About the Authors Michelle VonStein and Cristina Millen are clinical nurses, and Deborah Lampo is a nurse manager, WellSpan York Hospital, York, Pennsylvania. Barbara L. Buchko is direc- tor, Evidence-Based Practice and Nursing Research, and Theodore Bell is a research program manager, WellSpan Health, York, Pennsylvania. Anne B. Woods is adjunct faculty, Messiah College, Mechanicsburg, Pennsylvania.
Corresponding author: Barbara Buchko, Director of Evidence-Based Practice and Nursing Research, Well- Span Health, 1001 S George St, York, PA 17405 (email: bbuchko @wellspan.org).
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2019, Volume 28, No. 1 43
The intervention group received hourly ice water oral swabs and lip moisturizer with menthol.
Patients were eligible if they were more than 18
years old, spoke English, were able to provide informed
consent, had an ICU stay of 12 hours or more, had
a score of -1, 0, or +1 on the Richmond Agitation-
Sedation Scale, and had a baseline thirst intensity or
thirst distress score of 3 or greater (on a 0-10 NRS).
The exclusion criteria mirrored those of the study of
Puntillo et al1: a history of dementia; open lesions
or desquamation on the mouth or lips; or a medical
condition, such as recent oral surgery, that contrain-
dicated the intervention. We did an a priori power
analysis for a paired t test with an of .05, a power
of 0.80, and an effect size of 0.35 (small-moderate).
The results indicated that 66 patients would be needed
for each group.
A total of 296 patients were evaluated for eligi-
bility from February through September 2017. Of
these patients, 219 met eligibility criteria, and 134
(61%) were enrolled in the study. The Figure is a
flowchart of enrollment in the study. A total of 31
participants were lost to follow-up because of trans-
fer from the unit before completion of data collec-
tion. The 2 groups did not differ significantly ( 2 1 = 0.3;
P = .59) in the number who were lost to attrition:
22% in the intervention group (n = 17) and 26% in
the control group (n = 14). The final sample consisted
of 103 patients who completed the study: 62 in the
intervention group and 41 in the control group.
Participants who completed the study (n = 103)
and those who were lost because of attrition (n = 31)
did not differ significantly in age; sex; ventilator sta-
tus; or scores for thirst intensity, thirst distress, and
dry mouth obtained before the start of the study.
Procedures Five research nurses were trained to enroll patients
and collect data. These nurses used a researcher-
developed data collection tool to ensure precision
in collection. Potential participants were identified
each morning by a research nurse in collaboration
with the unit charge nurse. Baseline data were col-
lected to determine eligibility. Patients who agreed
to participate completed an informed consent form.
Intervention. The research nurses informed par-
ticipants in the intervention group that clinical staff
members would provide freshly obtained ice water
oral swabs and would apply lip moisturizer with
menthol every hour with the first application at 10 AM
and the last application at 5 PM. The research nurses
informed the unit charge nurse and each patient’s
primary nurse of the patient’s enrollment in the study.
Participants in the intervention group received a
packet containing 8 swabs and lip moisturizer with
menthol. A reminder card was placed at each par-
ticipant’s bedside to ensure completion of sched-
uled treatments. Clinical staff in the intervention
unit were provided education about the interven-
tion and its frequency for participants.
Control (Usual Care). Providing ice water oral
swabs and lip moisturizer with menthol when
requested by a patient was the usual care. Study
participants within the ICU that provided usual
care were notified that they could ask the clinical
staff for ice water oral swabs
and lip moisturizer with men-
thol when needed. The charge
nurse and each participant’s
primary nurse in the usual-care
ICU were notified that the par-
ticipant was enrolled in a study.
No additional education was
provided to the nursing staff
because no change in usual care
was required. A research nurse returned to the
usual-care unit to evaluate the study participants’
thirst intensity, thirst distress, and dry mouth 7 hours
after enrollment (between 5:30 PM and 6 PM)
Instruments Construct validity of the NRS was established
through factor analysis.11,12 Concurrent validity was
evidenced by strong correlations between scores on
the NRS and scores on a visual analog scale, current
pain intensity word scales, and simple descriptive
scales.11,12 We chose an NRS rather than a visual
Figure Flowchart of participants enrolled in the study.
A n
a ly
si s
Fo ll o
w -u
p E n
ro ll m
e n
t A
ll o
ca ti
o n
Assessed for eligibility (n = 296)
Nonrandom assignment by unit
(n = 134)
Intervention unit (n = 79)
Usual care unit (n = 55)
Lost to follow-up (n = 17)
Lost to follow-up (n = 14)
Analyzed (n = 62) Analyzed (n = 41)
Excluded (n = 162)
Not meeting inclusion criteria (n = 77)
Declined participation (n = 85)
44 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2019, Volume 28, No. 1 www.ajcconline.org
analog scale (as used by Puntillo et al1) because
patients are familiar with the 0 to 10 NRS. Measures
for thirst intensity and thirst distress mirrored those
used by Puntillo et al.1 Thirst intensity was scored
as 0 (no thirst) to 10 (worst possible thirst); thirst
distress as 0 (no distress) to 10 (worst possible dis-
tress); and dry mouth as 0 (no dryness) to 10 (worst
possible dryness). Participants who were unable to
communicate verbally because of endotracheal intu-
bation were shown a paper copy of the NRS and asked
to point to the number that corresponded to their
thirst intensity, thirst distress, and dry mouth or to
nod affirmatively when the research nurse pointed
to the numbers, as done in an earlier study.1
Data Analysis We used IBM SPSS Statistics for Windows, version
24.0, (IBM Corp) to maintain and analyze data. To
evaluate differences between the scheduled-use group
and the control group for demographics (sex, venti-
lator status, and nothing by mouth status), we used
the Pearson 2 test or the Fisher exact test as appropri-
ate. Differences in age between the 2 groups were eval-
uated by using an independent samples t test. The
outcome variables (number of ice water swabs used
and number of times lip moisturizer with menthol
was used), along with scores for thirst intensity, thirst
distress, and dry mouth, were examined to assess
assumptions for parametric testing. These data violated
the assumptions of normality (kurtosis ≥ 1.0; Shapiro
Wilk test < .05), so nonparametric analyses were used.
The Wilcoxon signed rank test was used to identify dif-
ferences in scores before and after the intervention in
both the intervention and the control groups. The
Mann-Whitney test was used to detect significant dif-
ferences in the mean use of ice water oral swabs and
lip moisturizer with menthol between the intervention
and control groups and to detect differences in mean
difference scores before and after the intervention in
the intervention and control groups for thirst intensity,
thirst distress, and dry mouth. Statistical significance
was established as P less than .05.
Results Sample Characteristics
A total of 103 patients completed the study, 62
in the scheduled-use group and 41 in the control
group. The 2 groups did not differ significantly in
sex (P = .60), ventilator status (P > .99), nothing by
mouth status (P > .99) or age (P = .41; see Table 1).
Findings In the total sample, thirst intensity, thirst dis-
tress, and dry mouth were reported as substantial
symptoms, with mean NRS scores of 6.73 (SD, 2.4),
5.46 (SD, 3.1), and 6.68 (SD, 2.7), respectively. Mean
use of ice water oral swabs and lip moisturizer with
menthol was significantly greater in the intervention
group than in the control group: oral swabs, 5.4 vs
1.7 (P < .001); lip moisturizer with menthol, 4.4 vs
0.5 (P < .001). The 2 groups did not differ significantly
in the mean preintervention scores obtained within
1 hour of the time the study began for thirst inten-
sity (P = .22), thirst distress (P = .22), or dry mouth
(P = .68). Although both the intervention and the
control group had significant decreases in all 3 out-
comes (Table 2), the magnitude of the differences
was greatest in the intervention group (Table 3), with
Characteristic
Table 1 Group demographics
Male sex
Ventilator status
Nothing by mouth status
Age, mean (SD), y
.60
> .99
> .99
.41
24 (59)
1 (2)
6 (15)
62.8 (11.3)
33 (53)
1 (2)
10 (16)
60.3 (17.1)
P value Control groupa
(n = 41) Intervention
groupa (n = 62)
a Values are No. (%) of patients unless otherwise indicated in first column.
Group
Table 2 Paired samples results for intervention and control groupsa
Intervention
Control
< .001 < .001 < .001
.001 .01
.008
-5.10 -4.57 -5.36
-3.29 -2.57 -2.66
6.48 (2.45) 5.21 (2.95) 6.63 (2.57)
7.10 (2.41) 5.83 (3.20) 6.76 (2.95)
3.65 (2.84) 2.73 (3.03) 3.48 (2.84)
5.42 (2.87) 4.18 (3.40) 5.20 (2.97)
Thirst intensity Thirst distress Dry mouth
Thirst intensity Thirst distress Dry mouth
P valuebBefore
Score, mean (SD)
After ZOutcomes
a Scores were on a numeric rating scale. b Wilcoxon signed rank test.
Outcomes
Table 3 Comparison of mean difference scores for thirst intensity, thirst distress, and dry moutha
Thirst intensity
Thirst distress
Dry mouth
.02
.07
.008
-2.84 -1.68
-2.48 -1.65
-3.15 -1.56
6.48 7.10
5.21 5.83
6.63 6.76
3.65 5.42
2.73 4.18
3.48 5.20
Intervention Control
Intervention Control
Intervention Control
P valueBefore
Score
After Mean
differenceGroup
a Mann-Whitney test.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2019, Volume 28, No. 1 45
Implementing a simple scheduled protocol to reduce symptoms of thirst and dry mouth can increase patient comfort.
Thirst intensity, thirst distress, and dry mouth were reported as substantial symptoms.
significant statistical differences for thirst intensity
(-2.84 vs -1.68, U = 941.5, Z = -2.24, P = .02) and dry
mouth (-3.15 vs -1.56, U = 877.5, Z = -2.66, P = .008).
These findings were also clinically significant, with
medium-effect sizes for thirst intensity (Cohen d = 0.4)
and dry mouth (Cohen d = 0.5).
Discussion Thirst and dry mouth are substantial symptoms
experienced by patients in ICUs. Our preinterven-
tion mean scores for thirst intensity, thirst distress,
and dry mouth are similar to those reported by Wang
et al,5 who used a visual analog scale to measure
thirst and dry mouth associated with discomfort in
patients receiving mechanical ventilation. The mean
value for thirst and dry mouth in their multiple
regression analysis was 5.789 (P = .04), indicating
that these 2 symptoms were significant predictors of
discomfort in patients treated with mechanical ven-
tilation. Wang et al5 recognized thirst and dry
mouth as a problem and recommended further
research for interventions.
Puntillo et al1 investigated interventions. Of note,
Puntillo et al1 measured thirst intensity and thirst
distress by using a 0 to 10 NRS as we did but measured
dry mouth by using a dichotomous (yes-no) mea-
sure, whereas we used an NRS. Our preintervention
findings for thirst intensity and thirst distress scores
were higher than those of Puntillo et al1; however,
both their study and ours indicated improvement
in each group. Puntillo et al1 found significant
improvement with use of interventions in thirst
intensity, thirst distress, and dry mouth, whereas
we found significant improvement in thirst inten-
sity and dry mouth only. This difference may be
due to participants’ difficulty in understanding the
concept of thirst distress. Data collectors in our
study reported the need to explain and use various
terms for clarification.
A strength of our study is that the clinical staff
who provided the intervention could readily incor-
porate these practices with hourly rounding, a situa-
tion that supports the feasibility of implementing
these interventions in the clinical setting. Our study
has limitations. Because of challenges with staffing
and patient enrollment, the sample did not meet
the recommended size of 66 for each group as
determined by the a priori power analysis. Although
power was sufficient to detect a significant difference
for thirst intensity and dry mouth in both the inter-
vention and control groups, the lack of statistical
significance for thirst distress may be due to a type
II error related to insufficient power. Variations occurred
in clarifying thirst distress to participants, a situation
that may have affected the participants’ rating of
thirst distress. In addition, possible underlying dif-
ferences between the 2 units could have inadvertently
confounded the findings. Randomization to groups
was not done; clear separa-
tion of the intervention group
and the control group ensured
intervention fidelity. Also,
some study participants might
have received cold water swabs
rather than ice water swabs;
we did not require measure-
ment of water temperature to confirm use of ice
water. Our study was limited to 2 ICUs in a single
hospital; therefore, our findings cannot be general-
ized to other types of acute inpatient units. Our
study sample had few patients receiving mechanical
ventilation. Puntillo et al1 also had few patients
receiving mechanical ventilation and suggested
that interventions for thirst intensity, thirst distress,
and dry mouth may be beneficial to these patients.
Therefore, additional research is needed to generalize
our interventions for other populations of patients.
Conclusions Thirst and dry mouth are the result of illness,
medications, and other interventions that patients
receive in ICUs. These symptoms are uncomfortable
and distressing, but they are not routinely assessed
or treated. Thirst must compete with a cadre of other
symptoms that have greater potential to adversely
affect patient outcomes. Our findings confirm that
thirst intensity, thirst distress, and dry mouth are
common distressing symptoms among patients in
ICUs. Nurses play a pivotal role in the assessment
and identification of these symptoms. Compared
with as-needed interventions, implementation of a
simple, scheduled protocol
to reduce these symptoms
can increase patient com-
fort. Scheduled, hourly
applications of ice cold
water oral swabs and lip
moisturizer with menthol
are simple interventions
that can easily be incorpo-
rated with other hourly
rounding interventions. These interventions can be
used to engage patients and patients’ families to
participate more actively in the plan of care. Further
research with larger sample sizes is needed to gener-
alize our findings to other populations of patients.
46 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2019, Volume 28, No. 1 www.ajcconline.org
ACKNOWLEDGMENTS This research was performed at WellSpan York Hospital.
FINANCIAL DISCLOSURES Funding for this study was provided through a grant from the George L. Laverty Foundation.
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