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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