Chapter 18: Dental Hygiene Diagnosis and Care Planning

Transcription

Chapter 18: Dental Hygiene Diagnosis and Care
Planning
By Dianne L. Sefo, RDH, BA, and Lisa B. Stefanou, RDH, BS, MPH
Learning Objectives
The student dental hygienist and dental hygiene professional will learn the following key objectives from this
chapter:
1. Identify and define the dental process of care model and describe each phase.
2. Discuss the purpose and determining factors of a dental hygiene diagnosis.
3. Determine the various periodontal disease classifications.
4. Identify components and define the important uses of the dental hygiene care plan.
5. Determine various alternatives for an individualized dental hygiene care plan.
6. Identify various patient and clinical considerations when developing an individualized dental hygiene care
plan.
7. Discuss principles that will enable patients to make informed decisions.
Overview
Oral health care should be based on a process that includes: assessment, diagnosis, planning, implementation and
evaluation. All phases in the dental hygiene process of care are essential to help the patient acquire and maintain
good oral health. The dental hygiene diagnosis allows for the identification of appropriate treatment options with
the use of evidence-based decision making. These interventions are arranged and sequenced in a formal written
care plan to provide a guideline for care, an educational tool for patients, communication within the dental team
and a legal document for informed consent prior to treatment.
Dental Hygiene Process of Care
The Dental Hygiene Process of Care Model1 includes (for reference, see Diagram 18.1 on page 45):
• Assessment – Full review of the patient’s systemic and oral health.
• Dental Hygiene Diagnosis – Identification of oral health needs that can be treated with dental hygiene
interventions.
• Planning – Sequential care plan that is based on the patient’s specific dental hygiene oral needs.
• Implementation – Educational, preventive and therapeutic interventions.
• Evaluation – Determination of effectiveness.
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Achieving Professional Excellence and Career Satisfaction in the Dental Hygiene Profession
Volume II: Patient Care
© 2012 Christine Hovliaras. All Rights Reserved.
Over time, evaluation is ongoing, altering each phase in the process of care as the conditions of the patient’s oral
health needs change.1
Integration with Comprehensive Dental Hygiene Diagnosis and Care Plan
The dental hygiene diagnosis and care plan are integral parts of the dental hygiene process of care. This ensures
accurate identification of patient needs and interventions that are within the proper scope of dental hygiene
practice using professional clinical judgment.
Evidence-Based Decision Making
Healthcare professionals such as dental hygienists must be able to derive valuable information from scientific
literature and use quality evidence from current research to help make the best possible decision(s) when
providing care for specific clinical circumstances. A well defined clinical question is developed by the dental
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hygienist that is related to diagnosis, prognosis, cause/problem or treatment. There are four elements of an
evidence-based question, referred to as PICO:
1. Patient or problem
2. Intervention, cause or prognosis
3. Comparison or control
4. Outcome or outcomes
Evidence-based decision making is an approach to treatment that relies on the role of individual professional
judgment. It integrates clinical and patient factors with thorough, unbiased clinical research reviews and current
scientific evidence to make quality clinical decisions for individual patients. It is important to critically evaluate
research evidence in scientific literature to determine validity and clinical applicability. 2
Analysis of Assessment Data
The gathering of information in regard to the patient’s overall health status and the analysis of the objective and
subjective assessment data must occur before the dental hygiene diagnosis can be formulated. Assessment
findings include:
• Medical, physical and psychological status;
• Chief complaint;
• Periodontal, dental caries and oral cancer status;
• Periodontal, dental caries and oral cancer risk factors;
• Oral habits (e.g. tobacco use, bruxism);
• Oral hygiene status, knowledge and ability; and
• Patient expectations of oral health.
Identification of Oral Health Needs
After careful collection and study of the assessment data, the dental hygienist is able to identify the oral health needs
of the patient. These needs are specific to each patient and the foundation for the dental hygiene diagnosis.
Dental Hygiene Diagnosis
The importance of use of the dental hygiene diagnoses may be defined as an analysis of the cause and nature of
an existing or potential health problem or situation that a dental hygienist is qualified, educated and licensed to
treat. The dental hygiene diagnosis provides the following functions:
• Classifies dental hygiene priorities.
• Coordinates dental hygiene interventions to meet highest priority needs of the patient.
• Provides a common language and creates a basis for communication and understanding between the
dental hygienist and other dental team members.
• Guides the formulation of the dental hygiene care plan.
• Basis for evaluation of expected outcomes of interventions.
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It is the professional responsibility of the dental hygienist to formulate a dental hygiene diagnosis. This provides
the foundation for the development, implementation and evaluation of the dental hygiene care plan to provide
comprehensive quality oral health care.1,3-6
Dental Hygiene Diagnostic Statements
The dental hygiene diagnosis is made up of one or more diagnostic statements depending on the number of
conditions the patient is present with. Components of a diagnostic statement are determined by the diagnostic
model that is being followed.
Dental Hygiene Diagnostic Models
Dental hygiene diagnostic models provide an objective guideline for the formulation of diagnosis and intervention.
These models have emphasis on the patient’s overall health, which is also the basis for nursing diagnostic models.
Medical and dental models tend to have a narrower focus on disease and pathology (for reference, see Table 18.1
Dental Hygiene Diagnostic Models on page 48).
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Periodontal Diagnosis
A guide to periodontal disease classification is shown in Table 18.2 is shown below and on pages 49-52.7
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Determining Current Periodontal Status
The current periodontal status is not limited to current periodontal conditions, such as pocket depths, gingival
tissue conditions, mobility, furcation involvement or exudate. The periodontal status is also determined by
previous conditions and risk factors for onset or progression of disease.
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Dental Hygiene Prognosis
Determining Factors:
•
•
•
•
Systemic and oral health status.
Causative and contributing risk factors.
Patient motivation and commitment to oral hygiene care and preventive regimen (e.g. keeping recare
appointments, practicing home care educational techniques, refraining from tobacco use, etc.).
Available interventions and chosen treatment.
Expected Outcomes:
There are expected outcomes that the dental hygienist should either hope to see in a first-time patient or hope to
see in patients on a care regimen specific to their oral health condition. The hygienist should expect a reduction
in dental plaque, no bleeding upon probing, reduced pocket depths, stable level of attachment, decrease or
no change in mobility, decreased swelling and edema and pink, firm and stippled free gingiva. It is ideal for no
demineralization or carious lesions to be present. 8
In order to maintain good oral health, dental sealants should be placed and iatrogenic factors (calculus, restoration
overhangs) should be eliminated. The patient should be encouraged to reduce the intake of sugary foods and beverages,
obtain a tobacco free status, achieve remineralization by daily fluoride use and comply with a daily care regimen to
improve plaque score. Regular or suggested recare appointments should also be reinforced by the dental team.
Dental Hygiene Care Plan
Importance of Use:
The dental hygiene care plan is used in today’s office to identify and prioritize current and potential dental hygiene
care needs of individualized patients. It aids in the establishment of goals, nature of treatment, cost and patient
commitment to ensure success. The care plan also determines interventions and outcomes to meet the dental
hygiene care needs. It is recommended to provide a checklist to ensure all planned interventions are completed
(for reference, see Form 18.1 Dental Hygiene Care Plan on pages 54 - 55 and Table 18.3 Integration with Dental
Care Plan on page 56. 9
Components:
•
•
•
•
•
•
•
•
Demographic data (patient name, clinician name, date of written plan, etc.);
Assessment findings;
Dental hygiene diagnosis;
Periodontal status;
Planned interventions (clinical treatment, preventive measures, patient education, oral hygiene
instructions, cost of treatment);
Oral hygiene care goals;
Appointment plan; and
Re-evaluation.
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When dental treatment extends over a long period of time, periodic dental hygiene care should occur to monitor
and maintain the success of the patient’s oral hygiene.
When determining the sequence of dental hygiene care, first determine the area of pain that requires the highest
priority for patient care and identify the severity and extent of the oral care condition. Additionally, oral hygiene
care must be controlled for effective dental hygiene interventions, the dentist must consult with the patient if
antibiotic prophylaxis premedication needs to be prescribed and if the patient has a physical disability and how
to handle their appointment.
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Considerations for Dental Hygiene Care
Patient Considerations:
Patient motivation helps determine the success of treatment. Patients that express eagerness or ability to actively
participate in the development of goals, priorities, interventions and appointment planning will more likely comply
with recommendations. It is important to educate patients of their critical role in their oral health. Those with a
lower socio-economic background tend to lack access to care, a basic level of health literacy and are less likely
to be aware of prevention and intervention options. Barriers of care may include cost, pain, fear, language and
physical ability.
Clinical Considerations:
When implementing dental hygiene care, pre-procedural bacterial reduction is recommended and can be
accomplished by patient brushing and flossing prior to dental procedures. If this is not feasible, vigorous rinsing
for one minute with an antibacterial mouthwash is beneficial. Water will have some effect on bacteria, but
chlorhexidine gluconate has the highest substantivity of the antimicrobial rinses. The removal of loose debris and
lowering the bacteria in aerosols reduces the potential for bacteremia.
Use of anxiety and pain control medications can be considered to control patient discomfort during treatment
procedures. Greater patient comfort encourages patient compliance with recommended interventions and future
appointments.
Case Presentation
Purpose:
Before the dental hygiene care plan is implemented, it must first be discussed with the dental team and explained
to the patient. The dental hygiene care plan is integrated with the dental care plan for complete intervention to
meet all the patient’s oral health needs. It is important for the patient to understand the care plan in its entirety
to help reinforce the patient’s role in reaching oral health goals and to give informed consent for treatment.
Principles to Follow:
As mentioned in Chapter 13: Business Etiquette in Dental Hygiene Practice, helping a patient to understand the
care plan requires the patient to be in an upright position, face to face with the clinician. Place patients in an
upright position with the clinician facing them directly. Use positive voice modulation and facial expression, be
clear and present important information regarding their dental health in an accurate and concise manner, using
terminology that patients should understand. The dental hygienist should let patients know that he or she is
interested in improving their oral health needs.
The development of the dental hygiene care plan should include existing systemic and dental health conditions
and related causative and contributing factors, planned interventions and appointment sequence, desired
outcomes of treatment and provisional prognosis, risks and benefi ts of all treatment options the patient’s role
and responsibility in care, potential risks if part or all of recommended treatment is not completed, treatment
alternatives, the patient’s right to decline care, treatment cost, and recommendations for referral to other
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healthcare providers if necessary. Use visual aids (e.g. pictures from intraoral camera, models, etc.) to help
patients participate in the planning and setting of goals. Then give the opportunity for questions and be prepared
to answer. Assess the patient’s understanding and re-educate as often as needed. It is important to obtain the
signed informed consent.
Informed Consent
Purpose:
Informed consent is a process by which a patient agrees to the proposed treatment after given the knowledge
that will allow shared decision making from a complete case presentation. Patients have the right to be informed
about the risks and benefi ts of planned procedures. The purpose of an informed consent is to satisfy legal and
ethical responsibilities for care and as an agreement for therapy. Informed consent that is obtained orally may be
proved by “habit” testimony, but this does not provide record of the patient’s signature, making it more difficult to
establish validity than written consent. Implied consent applies to assessment procedures, assessment analysis
and care planning when a patient is present in the dental chair.
Principles of Informing:
In order to obtain informed consent, the clinician must first assess the patient’s ability to give informed consent.
Forms should be written in large print or in the patient’s primary language if necessary. Use terminology that
can be understood by the patient and re-educate as often as needed. Give the opportunity for questions and be
prepared to answer. Document all relevant information and keep the signed form in the patient’s records.
The informed consent form should include date and signature by patient or guardian and clinician on the care
plan before the implementation of care. Give the patient a copy to take home. It is necessary to be familiar with
informed consent laws that apply as the statutes governing vary from state to state.10-12
Informed Refusal Form Content:
Informed refusal form is completed when a part or entire care plan is declined by the patient. It should include
the proposed dental and dental hygiene care plan, risks that may occur without treatment, procedures that are
being refused, date and signature.
Considerations for Communication Impairments:
As discussed earlier, it is advised to use simpler terminology, large print, and/or patient’s primary language. Be
culturally aware by researching potentially conflicting beliefs or values before communicating with the patient.
Again, assess the patient’s ability to give informed consent. If a cognitive impairment is present, which may be
due to age or disability, consult and obtain consent from the caregiver or legal guardian.
Summary
Dental hygiene care plan is based on a process that includes assessment, dental hygiene diagnosis, planning,
implementation and evaluation. Due to the various treatment options, evidence can be used as guidance to tailor
to the patients’ individual needs. The care plan should be discussed with other members of the dental team before
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presenting to the patient to keep the team coordinated. The evidence-based literature provides sound scientific
principles as guidance in all the phases in the process of care. All of these concepts must be used from inception
to commencement of treatment.
References
1. Mueller-Joseph L, Petersen M. Dental Hygiene Process: Diagnosis and Care Planning. Albany: Delmar;
1995:9-14.
2. Forest JL, Miller SA. Evidence-based decision making in action: Part 1 – Finding best clinical evidence.
J Contemp Dent Pract. 2002; 3(3):10-26.
3. American Dental Hygienists’ Association. Position Paper: Dental Hygiene Diagnosis. June 2005. Available
at: http://www.adha.org/downloads/DHDx_position_paper.pdf. Accessed June 5, 2009.
4. Gurenlian JR. Diagnostic decision making, in Woodall, I.R., ed. Comprehensive Dental Hygiene Care. 4th
ed. St. Louis: Mosby; 1993:361-370.
5. Darby ML, Walsh MM. Application of the human needs conceptual model to dental hygiene practice. J
Dent Hyg. 2000 Summer; 74:230.
6. Williams KB, Gadbury-Amyot CC, Bray KK, Manne D, Collins P. Oral health-related quality of life: a model
for dental hygiene. J Dent Hyg. 1998 Spring; 72:19-26.
7. Armitage GC. Developments of a classification system for periodontal diseases and conditions. Am
Periodontal. 1999;4:1-6.
8. Wilkins EM, Dental hygiene diagnosis and care planning, Clinical Practice of the Dental Hygienist. 10 th ed.
Philadelphia: Lippincott Williams and Wilkins; 2009: 364.
9. Weinberg MA, Westphal C, Froum SJ, Palat M. Comprehensive Periodontics for the Dental Hygienist. 2nd
ed. New Jersey: Pearson Prentice Hall; 2006:317-325.
10. Odom JG, Bowers BD. Informed consent and refusal, in Weinstein, B.D. Dental Ethics. Philadelphia: Lea
& Febiger; 1993:65-80.
11. Pape T. Legal and ethical considerations of informed consent, AORN. J. 1997;65:1122.
12. Fitch P. Cultural competence and dental hygiene care delivery: Integrating cultural care into the dental
hygiene process of care. J Dent Hyg. 2004 Winter; 78:11.
Recommended Reading
1. American Academy of Periodontology. Position paper: Periodontal maintenance. J Periodontol. 2003; 74:
1395-1401.
2. American Academy of Periodontology. Treatment of plaque-induced gingivitis, chronic periodontitis and
other clinical conditions. J Periodontol. 2001; 72: 1790-1800.
3. Anderson JD. Applying evidence based dentistry to your patients. Dent Clin North Am. 2002; 46: 157.
4. Calley KH. Dental hygiene process of care, in Darby ML, ed. Mosby’s Comprehensive Review of Dental
Hygiene, 6 th ed. St. Louis: Mosby; 2006: 613-663.
5. Forest JL, Miller SH. Evidence-based decision making in dental hygiene education, practice and research.
J Dent Hyg. Winter 2001; 75: 50.
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Critical Thinking Exercises
Using the case scenario given, complete the following exercises in groups of three (one person as the recorder,
one as the RDH and one as the patient):
1. Discuss the needs of Mr. Bennett. Identify three possible dental hygiene diagnoses, correlating
interventions and expected outcomes. Share and discuss the findings with the class.
2. Develop a complete and effective dental hygiene care plan and perform a case presentation for Mr.
Bennett to the class. Include sequence of interventions.
Case Scenario
Mr. Peter Bennett is a 71-year-old male who has retired from the advertising business. He is married, lives with
his wife and has four children who no longer live at home. Mr. Bennett came into the clinic because ”some of
his teeth are loosening up and because his gums have started to bleed when he brushes.” The medical history
indicates that nine months ago he had a stroke, which left him with loss of muscle tone on the right side of
his face, diminished mobility in his right arm, hand and leg. He is on anticoagulants, and his blood pressure is
154/88. Mr. Bennett’s dental history indicates regular treatment until he retired at age 67. Previous treatment
included restorative work, periodontal surgery and visits for prophylaxis and exam twice a year. His oral hygiene
instruction has been brushing with the Modified Bass technique, flossing daily and using a fluoride rinse (the
water is not fluoridated in his community). The Intra/Extra oral exam reveals all structures are within normal
limits, loss of muscle tone on the right side of the tongue and cheek. His periodontal exam indicated moderate
marginal and papillary inflammation, severe edematous tissue exists buccally and lingually in the postertior areas,
of the right side. There is adequate attached gingiva, and 5mm recession on teeth #3 and #14. Radiographs and
probe readings indicate approximately 5-7mm of horizontal bone loss. The oral hygiene examination indicates
moderate subgingival generalized calculus, moderate supragingival calculus right side lingual max and mandible,
poor oral hygiene on the right side since the stroke, loss of mobility and muscle tone since the stroke, heavy plaque
and light coffee stain. The dental exam presents new caries on # 5, #12, #13 and #14.
Key Concepts
1. The dental hygiene diagnosis and care plan are integral parts of the dental hygiene process of care.
2. After a complete assessment the dental hygiene diagnosis, prognosis and recommended treatment are
developed and tailored to an individual’s needs.
3. In order for the diagnosis, prognosis and recommended treatment to be valid, current scientific research
must be utilized.
4. The dental hygiene care plan provides a variety of purposes to aid in the success of treatment.
5. Patient motivation, socio-economic background and barriers such as cost, pain, fear, language or physical
ability should be considered when developing the care plan.
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6. All possible treatment alternatives for the individual care plan must be considered.
7.
Patients must understand the care plan in its entirety before giving informed consent and committing to
their role and responsibility of care.
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Chapter 18: Dental Hygiene Diagnosis and Care Planning

Transcription

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