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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Oral Mucous Membrane, Altered - Stomatitis; Mucositis
Meg Gulanick, RN, PhD
Christa Schroeder, RN, MS
Marina Bautista, RN, BSN

NANDA: The state in which an individual experiences disruptions in the tissue layers of the oral cavity

Minor irritations of the oral mucous membrane occur occasionally in all persons and are usually viral-related, self-limiting, and easily treated. Patients who have severe stomatitis often have an underlying illness. Patients who are immunocompromised, such as the oncology patient receiving chemotherapy, are often affected with severe tissue disruption and pain. Infections such as candidiasis, if left untreated, can spread through the entire gastrointestinal (GI) tract causing further complication and sometimes perineal pain. Oral mucous membrane problems can be encountered in any setting, especially in home care and hospice settings.

Related Factors

Defining Characteristics

Expected Outcomes

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess oral hygiene practices.
Provides information on possible causative factors, and provides guidance for subsequent education.
(i) Assess status of oral mucosa; include tongue, lips, mucous membranes, gums, saliva, and teeth.
Home caregivers also need to be informed of the importance of these assessments.
(i) Assess for extensiveness of ulcerations involving the intraoral soft tissues, including palate, tongue, gums, and lips.
Sloughing of mucosal membrane can progress to ulceration.
(i) Observe for evidence of infection and report to physician or home health nurse. Severe mucositis may manifest as any of the following:
(i) Assess nutrition status
Malnutrition can be a contributing cause. Oral fluids needed for moisture to membranes.
(i) Assess for ability to eat and drink.
Inability to chew and swallow may occur secondary to pain of inflamed or ulcerated oral and/or oropharyngeal mucous membranes.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
For hospitalized or home care patients:
(i) Implement meticulous mouth care regimen after each meal and every 4 hours while awake
To prevent buildup of oral plaque and bacteria. Patients with oral catheters and oxygen may require additional care.
(See Education/Continuity of Care in this care plan for description of oral care.)
Caregivers need to be taught these procedures.
(c) If signs of mild stomatitis occur (sensation of dryness and burning; mild erythema and edema along the mucocutaneous junction):
(i) For severe mucositis infection:
(i) For eating problems:
(c) Refer patient to dietitian for instructions on maintenance of a well-balanced diet.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
Instruct patient/caregiver to:
(i) Gently brush all surfaces of teeth, gums, and tongue with a soft nylon brush.
To loosen debris.
(i) Brush with a nonirritating dentrifice such as baking soda.
(i) Remove and brush dentures thoroughly during and after meals and as needed.
To reduce risk of infection and improve appetite.
(i) Rinse the mouth thoroughly during and after brushing.
Removing food particles decreases risk of infection related to trapped decaying food.
(i) Avoid alcohol-containing mouthwashes.
As these may dry oral mucous membranes, increasing risk for disruption of mucous membrane.
(i) Use recommended mouth rinses:
(i) Keep lips moist.
To prevent drying and cracking.
Use a lip product or a water-soluble lubricant
(K-Y jelly, Aquaphor Cream)
To minimize risk of aspirating non-water-soluble agent.
(i) Include food items with each meal that require chewing.
As this stimulates gingival tissue and promotes circulation.
(i) Minimize trauma to mucous membranes. Avoid use of tobacco and alcohol.
As these are irritating and drying to the mucosa.
(i) Avoid extremely hot or cold foods. Avoid acidic or highly spiced foods.
(i) Have loose-fitting dentures adjusted.
Rubbing and irritation from ill-fitting dentures promotes disruption of the oral mucous membrane.

NIC

Oral Health Restoration; Oral Health Maintenance

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