Effect of Implementing Nursing Measures on Thirst Perception among Patients in Chest Intensive Care Unit

Background: Thirst is one of the main stressors that reduce the comfort of critically ill patients connected with a noninvasive laryngeal mask. It can cause significant distress and stress, which can increase oxygen consumption and the metabolic burden of their organs, and may even induce delirium, thus affecting recovery. Aim: The current study aimed to evaluate the effect of implementing nursing measures on thirst perception among patients in chest intensive care units. Design: A quasi-experimental study design . Setting: This study was conducted at the Chest Intensive Care Unit in Tanta University Chest Hospital affiliated to Tanta University Hospitals. Subjects : A purposive sample of 60 adult patients admitted to the previously mentioned setting. Tools: three tools were used in order to obtain the necessary data for this study: Tool I: Patient’s Interview Schedule, tool II: Subjective Thirst Perception Scale and tool III: Objective Thirst Assessment Sheet. Results : there was a statistical significant decrease in thirst perception in both control and study group on the third day in which p = 0.049* and 0.045* respectively. Additionally, there was statistical significant decrease in thirst perception in control versus study group on the third day in which p =0.043*. Conclusion: The results of the current study concluded that there was a significant decrease of thirst perception among critically ill patients after implementing nursing measures in ICU. Recommendations: It can be recommended that using nursing measures as a part of the daily care in managing patients' complains of thirst in ICU is essential.


Introduction
Thirst is one of the main stressors that reduce the comfort of critically ill patients connected with a noninvasive laryngeal mask.It can cause significant distress and stress, which can increase oxygen consumption and the metabolic burden of their organs, and may even induce delirium, thus affecting recovery.(Doi et al., 2021) According to an interesting study, in the intensive care unit (ICU), thirst is reported as the highest source of stress, with a prevalence in ICU patients of 70.8%.However, thirst is often undetected and remains untreated.Particularly in critically ill patients with a noninvasive laryngeal mask, it is difficult to detect patients' thirst perception because they cannot express thirst perception under sedation or intubation.(Schittek et al., 2020& Kawahara et al., 2020) Thirst can be defined as a perception that provokes the urge to drink fluids and is a prevalent, intense, distressing, and underappreciated symptom in intensive care patients.Additionally, dry mouth refers to a condition in which the salivary glands in the mouth don't make enough saliva to keep the mouth wet.Thirst and dry mouth are common symptoms and may affect patients' experience in the intensive care unit.It usually occurs due to the adverse effect of some medications, oxygen therapy, and intubation.

(VonStein et al., 2019&Aoki et al., 2018)
According to etiology, thirst can be osmotic or hypovolemic.Osmotic thirst derives from a slight increase of 1% to 2% in plasma osmolality, which can stimulate the release of the antidiuretic hormone.When the compensatory mechanism provided by the osmotic changes is not effective, thirst is activated, prompting the body to seek water.In turn, hypovolemic thirst is associated with the need for hydric ingestion to restore plasma volume, and its regulatory mechanism depends both on the renin-angiotensin-aldosterone system and the adrenergic action.On the other hand, a dry mouth is the result of inadequate saliva secretion, which may reflect hypovolemia.Although thirst perception and dry mouth may be associated, these relationships have not been investigated.(Doi et al., 2021&Nascimento et al., 2018) The critically ill patients are exposed to a confluence of factors that lead to an increase in the thirst incidence and patient distress such as extended fasting times both preoperatively and postoperatively, intraoperative bleeding, anxiety, intubation, blood loss, electrolyte imbalance, and effect of anesthetic drugs and prolonged oxygen therapy.(Nascimento et al., 2018) Management of thirst in critically ill patients on the non-invasive laryngeal mask is challenging; there is a great reduction in oral fluid intake due to the disturbing level of consciousness from both the anesthetic drugs and the presence of nausea and vomiting that might lead to the development of pulmonary aspiration.Therefore, finding easy and safe ways to alleviate thirst among patients postoperatively is a major challenge and crucial issue for health care professionals.(Lee et al., 2020) Several nursing measures have been proposed to quench thirst including declining body temperature, use of menthol in association with cold strategies, use chewing gums, applying acupressure, early fluid ingestion, substitute saliva, and the use of a thin straw (Garcia et al., 2016).The choice among such strategies is at least in part dependent on the type of critical care units.For example, declining body temperature seems suitable in the chest intensive care unit serving the dual purpose of limiting the ingested volume while stimulating cold-sensitive receptors.There is growing clinical interest in improving the ability to quench thirst for patient with noninvasive laryngeal mask and in optimizing thirst management.(Lee et al., 2020. Garcia et al., 2016&Gulia et al.,2019) Significance of study: Oral fluid intake may be restricted in ICU due to intubation and fasting which might lead to increased mouth dryness and thirst intensity.Nurses and physicians usually carry the perception that nothing can be done to overcome thirst and dry mouth.Also, it remains undocumented and neglected in critical care units.As far as now, no permanent assessment strategies are being carried out to assess thirst and dry mouth.This highlights the fact that there is a lack of database interventions in hospitals to reduce the intensity and distress of thirst and dry mouth.(Aoki et al., 2018) Thus, the study aims to evaluate the effect of implementing nursing measures on thirst perception among critically ill patients.The aim of the study was to: Evaluate the effect of implementing nursing measures on thirst perception among patients in chest intensive care units.

Research hypothesis:
Patients in the study group who will receive mouth care, ice water swabs, and acupressure exhibit relieving thirst and dry mouth compared to the control group.

Subjects and Method Research design:
A quasi-experimental research design was utilized in this study.

Setting:
The study was conducted at the Chest Intensive Care Unit in Tanta University Chest Hospital.This unit is prepared and equipped with 4 words (the first ward equipped with 10 beds, the second word equipped with 3beds, the third word equipped with 2beds, and the reception word equipped with 2 beds).The total number of beds is 17.

Subjects:
A purposive sample of 60 adult patients was collected from the previously mentioned settings.

Inclusion criteria:
The subjects were selected according to the following criteria:  2018) and adapted by the researchers to assess the oral condition as regards lips, tongue, mucosa, and saliva.The OAG scale consists of eight assessment categories: voice, swallowing, lips, tongue, saliva, mucous membrane, gingiva, and teeth/dentures.Each category was expressed in three stages.

Scoring system:
The OAG score was the sum of the scores for each category; each category was scored from 1 to 3-point Likert scale as the following: -Score (1) for normal findings (pink and moist) = no thirst and healthy oral mucosa.
-Score (2) for moderate abnormality without compromise of either mucosal integrity or loss of function (dry, reddened or crackled) = moderate thirst.

IV. Evaluation phase:
In this phase, the researcher observed each patient before implementing each nursing measures and after 15 minutes' post implementing nursing measure for 3 consecutive days to evaluate thirst perception thirst intensity level, and oral condition using tool II and III.

Results
Table (1) represents the percent distribution of the studied patients according to their sociodemographic characteristics.In relation to age, it was reported that, more than half (60.00 % and 67.67 %) of the studied patients in both control and study groups were in the age group (50-60) years respectively, with mean age of (51.17±7.096) in control group and (51.87±6.021) in study group.In relation to sex, the majority (80.00%) of the studied patients in control group were male and more than two-thirds (73.33%) of the studied patients in study group were male.Additionally, more than two-thirds (70.00%) of the studied patients in control group employee and the majority (80.00%) of the studied patients in study group employee.As regards to their marital status, the majority (86.67% and 83.33%) of the studied patients in both control and study groups were married respectively.Table (2) Represents the percentage distribution of the studied patients of both groups according to their clinical data.Regarding current diagnosis.It was noticed that the vast majority (90.00% and 96.67%) of the studied patients in both control and study groups were diagnosed as respiratory disorders respectively.Additionally, the most common (43.33% and 50.00%) comorbid disease among the control and study groups respectively was respiratory disease while, the least one (13.33%)was gastrointestinal disease.Concerning current medication, It was observed that more than half (53.33% and 56.67%) of the studied patients in control and study groups were received opioids medication and near half (46.67% and 43.33%) of the patients in control and study groups received diuretics respectively.Figure 1: Illustrates Distribution of the studied patients of both groups regarding the causes of thirst.It showed that more than two-thirds (70%) of the studied patients in control group and the vast majority (90.67%)of the patients in study group were suffered from thirst related to prolonged oxygen therapy.While more than half (66.67%and 63.33%) of the studied patients in control and study groups were suffered from thirst related to previous intubation respectively Table (3): Shows the distribution of the studied patients according to subjective thirst perception.This table represents that near half (40.00%) of the studied patients in control group on the first day after nursing measures were at level 5 (thirst) on thirst categorical scale while more than half (60.00%) were at level 5 (thirst) on the third day.on the other hand, near one quarter (23.33%)of the studied patients in study group on the first day were at level 6 (very thirst) after nursing measures while more than one third (33.33%) were at level 3(not very thirsty) on thirst categorical scale.Also it was observed that, there was statistical significant decrease in thirst perception in both control and study group on the third day in which p = 0.049* and 0.045* respectively.Additionally, there was statistical significant decrease in thirst perception in control versus study group on the third day in which p =0.043*.

Table (4): Illustrates the distribution of the studied patients at Chest
Intensive Care Unit regarding indicators of thirst assessment.It was found that more than two-thirds (73.33%) of the studied patients in the control group has dry mouth on the third day after implementing nursing measures.Compared to only minority (13.33%) of patients in the study group.It was observed that there were statistical significant improvement among the studied patients in the study group during the first and the second days of intervention P<0.05.Additionally, it was found that there were statistical significant improvement among the studied patients of the study group during the 3 rd day regarding light headedness, pain and vomiting P<0.05.

Table (5): Illustrates distribution of the studied patients of both groups regarding total level of oral assessment guide (OAG)
. This table reported that there was significance increase good oral health among patients in control group on third day in which p= 0.049*.On the other hand, there was significance increase good oral health among patients in study group on first day in which p=0.032* Also, there was significance increase oral health status between control and study group on first and third day after nursing measures in which p= 0.027* and p=0.025* respectively.

Discussion
Thirst is one of the most intense symptoms reported by intensive care unit patients.(Negro et al., 2021).There are several methods to manage thirst in ICU generally, include cold water sprays or swabs, menthol lip moisturizer and use of humidification.However, a review of these interventions concluded low quality of evidence due to insufficient studies (Clark & Archer, 2022).There for the main aim of this study was to evaluate the effect of implementing nursing measures on thirst perception among patients at chest intensive care units.

Part
(1): Assessment of sociodemographic characteristics and medical data of the studied patients.Regarding age of the studied patients, the current study reported that, more than half of the studied patients in both control and study groups were in the age group (50-60) years, with mean age of (51.17±7.096) in control group and (51.87±6.021) in study group.This may be attributed to that increase in age associated with chronic diseases, long term malnutrition, lowering their immune function and making them more vulnerable to ICU admission than young individuals.This finding was in agreement with, AlNoah et al., 2024 who showed that the most common age among both groups was in age between 51-60 years old of patient admitted to ICU.Concerning sex and marital status, the present study reported that the majority of the studied patients in control group were male and more than two-thirds of the studied patients in study group were male this may be interpreted that male was admitted to the Intensive Care Unit due to the nature of their work and massive accident.Additionally, the majority of the studied patients in both control and study groups were married.From the researcher point of view, this might because most of the studied patients ranged between 50-60 years old.This finding was matched with Vincent et al., 2020 who revealed that the patients admitted to ICU were mostly males.Also, Doi et al., 2021who showed that the majority of patients admitted to ICU were males However, AlNoah et al., 2024 who showed that more than two-thirds of the intervention group and more than half of the control group were females of patient admitted to ICU.Regarding medical diagnosis, it was noticed that the vast majority of the studied patients in both control and study groups were diagnosed as respiratory disorders.This finding was in agreement with, Celik & Eser, 2017 who showed that respiratory disorders were the most common cause of ICU admission among about 95% of patients.Also, Madkour et al., 2022 who showed that respiratory infections are known to be the most common cause of ICU admission in almost all the healthcare facilities all over the world.Regarding comorbidities, the most common comorbid disease among the control and study groups was respiratory disease while, the least one was gastrointestinal disease.The incidence and proportion of respiratory disease in the community has been increasing in recent years because of the increasing aging population, excessive body weight due to westernization, increased morbidity of chronic pulmonary disorders, and long-term air pollution exposure The current study was in line with, Simpson et al., 2021 who showed that nearly half of patients admitted to intensive care unit had at least one comorbidity, moreover the presence of comorbidities was associated with worse prognosis.
Concerning the current medication, It was observed that more than half of the studied patients in control and study groups were received opioids medication and near half of the patients in control and study groups received diuretics.This result clarified the explanation for used opioid in critical care for sedation and pain management.there are numerous sources of pain such as surgery, endotracheal intubation, placement of invasive catheters, or other painful conditions.The current study was in agreement with, Lin et al., 2023 and Stotts et al., 2015 who revealed that diuretics and opioids were the most commonly used medications among patients admitted to ICU, they also showed that the use of certain medications, such as opioids and diuretics, were predictors of thirst in ICU patients.Regarding the causes of thirst among the studied groups, It showed that more than two-thirds of the studied patients in control group and the vast majority of the studied patients in study group were suffered from thirst related to prolonged oxygen therapy.While more than half of the studied patients in control and study groups were suffered from thirst related to previous intubation.This due to Oxygen therapy has also been reported as one of the causes of thirst in ICU patients.Patients who receive conventional oxygen therapy frequently complain of dry mouth due to dry or under-humidified oxygen.The current study was in line with (Garcia et al., 2016& Carey et al., 2015).Who reported that the patients who receive prolonged oxygen therapy have high prevalence of thirst.Also, Sato et al., 2022who revealed that prolonged oxygen therapy was significantly associated with high thirst intensity among ICU patients.Additionally, Negro et al., 2022 stated that thirst was associated with xerostomia, endotracheal tubes, tracheostomies, oxygen therapy, solid and liquid fasting, electrolyte alterations, and hypovolemia.Regarding Subjective thirst perception, the current study showed that near half of the studied patients in control group on the first day after nursing measures were at level 5 (thirst) on thirst categorical scale while more than half were at level 5 (thirst) on the third day.on the other hand, near one quarter of the studied patients in study group on the first day were at level 6 (very thirst) after nursing measures while more than one third were at level 3(not very thirsty) on thirst categorical scale.Also, it was observed that there was statistical significant decrease in thirst perception in both control and study group on the third day.Additionally, there was statistical significant decrease in thirst perception in control versus study group on the third day.The current study suggested that the thirst intervention has positive effect on Subjective thirst perception, effective in improving salivary flow rates and decrease thirst among patients admitted to ICU.Regarding indicators of thirst assessment, the current study revealed that more than two-thirds of the studied patients in the control group have dry mouth on the third day after implementing nursing measures.Compared to only minority of patients in the study group.It was observed that there were statistical significant improvement among the studied patients in the study group during the first day of intervention.Additionally, it was found that there were statistical significant improvement among the studied patients of the study group during the 3 rd day regarding light headedness, pain and vomiting.The current study showed that the nursing measures resulted in significant decrease in dry mouth related to increase the salivary flow rate, sense of light headiness, pain and vomiting among ICU patients.This comes in agreement with VonStein et al., 2019 who revealed that scheduled use of ice water oral swabs and lip moisturizer with menthol resulted in significant reduction dry mouth (P= .008) in critical care patients.Similarly, a randomized controlled trial by Zhang et al., 2022 concluded that interventional bundle including vitamin C sprays, peppermint water mouthwash, and a lip moisturizer was shown to be a promising approach that can relieve thirst intensity and dry mouth, which are pervasively distressful to critically ill patients.The study also revealed that the intervention bundle significantly reduced thirst intensity by 1.27 points and there was a reduction of around two points in the pain intensity NRS score.Regarding total OAG scale, the current study showed that there was significance increase good oral health among patients in control group on third day.on the other hand, there was significance increase good oral health among patients in study group on first day.Also, there was significance increase good oral health status between control and study group on first and third day after nursing measures.The current study in agreement with Doi et al., 2021 who revealed that the oral care intervention resulted in significant improvement in oral health assessed by oral assessment guide score.Also, Al Sebaee & Elhadary, 2017 who showed that effective oral care reduces oral health issues and alleviates thirst and dry mouth in ICU patients.

Conclusion
The results of the current study concluded that there was a significant decrease of thirst perception among critically ill patients after implementing nursing measures in ICU.

Recommendations
It can be recommended that using nursing measures as a part of the daily care in managing patients' complains of thirst in ICU is essential.

Limitation of the study
This study had some limitations as follows: -The current study is a single center study.

Figure 1 :
Figure 1: Distribution of the studied patients of both groups regarding the causes of thirst.

Adams et al,2020. Zengin et al ,2020) Tool (II): Subjective Thirst Perception Scale This tool was developed by Millard- Stafford et al. (2012) to
Tool (I): Patient's Interview Schedule: This tool was developed by the researcher after reviewing the related literature (Kathleen, 2016.Zengin et al,