In clinical experience, it is found that many patients in the intensive care unit (ICU) are under mechanical ventilation. These patients range from head injuries to heart surgeries and respiratory problems, but there are no clear, concise, standard oral care procedures noted across the various floors of the hospital. Oral care is a basic nursing activity that can provide relief, comfort, and prevention of microbial growth but is not prioritized over other critical practices in critically ill patients. The Center for Disease Control reveals that ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection affecting approximately 27% of critically ill patients (Koeman, Van der Ven & Hak, 2006). The purpose of this article is to explore Lewin's theory of change in the clinical setting by implementing standard oral care to prevent VAP, thereby improving patient care. According to the American Association of Critical Care Nurses, ventilator-associated pneumonia leads to high mortality rates, increases the number of days on mechanical ventilation, increases the number of additional days in the hospital and intensive care unit by 4 to 9 days and costs approximately $40,000 per case of VAP (Ames, Sulima, Yates, McCullagh, Gollins, Soeken, Wallen, 2011). Munro, Grap, Jones, and McClish & Sessler conducted a study in 2009 that collected data on nurse-reported oral interventions, frequency, and documentation and found that despite evidence demonstrating that sponge teeth are ineffective for eliminate dental plaque, they remained the main tool for oral intervention. care in intubated patients while the use of toothbrushes was used more in non-intubated patients. Nurses were also found to report frequent oral care, y...... middle of article......J., McCurren, C., Carrico, R. (2004) Factors affecting the quality of oral care in intensive care units. Journal of Advanced Nursing, 48(5), 454-462. Institute for Healthcare Improvement (2011). Implement the IHI fan set. Retrieved from http://www.ihi.org/knowledge/pages/changes/implementtheventilatorbundle.aspx.Koeman, M., Van der Ven, A., Hak, E. (2006). Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. American Journal of Respiratory and Critical Care Medicine, 173, 1348-1355. Munro, CL, Grap, MJ, Jones, DJ, McClish, DK, Sessler, CN (2009). Chlorhexidine, toothbrushing, and prevention of ventilator-associated pneumonia in critically ill patients. American Journal of Critical Care, 18(5), 428-437. Yoder-Wise, P. S. (2010). Direct and manage nursing care. Philadelphia, Pennsylvania: Mosby, Inc..