O
Impaired Oral Mucous Membrane
Defining Characteristics
Bleeding; cheilitis; coated tongue; desquamation; difficult speech; difficulty eating; difficulty swallowing; diminished taste; edema; enlarged tonsils; fissures; geographic tongue; gingival hyperplasia; gingival pallor; gingival recession; halitosis; hyperemia; macroplasia; mucosal denudation; mucosal pallor; nodules; oral discomfort; oral lesions; oral pain; oral ulcers; papules; pocketing deeper than 4 mm; presence of pathogens; purulent drainage; purulent exudates; red or bluish masses (e.g.; hemangiomas); reports bad taste in mouth; smooth atrophic tongue; spongy patches; stomatitis; vesicles; white curd-like exudates; white patches/plaques; xerostomia
Related Factors (r/t)
Barriers to oral self-care; barriers to professional care; chemotherapy; chemical irritants (e.g., alcohol, tobacco, acidic foods, drugs, regular use of inhalers or other noxious agents), cleft lip; cleft palate; decreased platelets; decreased salivation; deficient knowledge of appropriate oral hygiene; dehydration; depression; diminished hormone levels (women); ineffective oral hygiene; infection; immunocompromised; immunosuppression; loss of supportive structures; malnutrition; mechanical factors (e.g.; ill-fitting dentures; braces); tubes (endotracheal/nasogastric); surgery in oral cavity; medication side effects; mouth breathing; NPO for more than 24 hours; radiation therapy; stress; trauma
Client Outcomes
Client Will (Specify Time Frame)
• Maintain intact, moist oral mucous membranes that are free of ulceration, inflammation, infection, and debris
• Demonstrate measures to maintain or regain intact oral mucous membranes
Nursing Interventions
Inspect the oral cavity/teeth at least once daily and note any discoloration, presence of debris, amount of plaque buildup, presence of lesions such as white lesions or patches, edema, or bleeding, and intactness of teeth. Refer to a dentist or periodontist as appropriate.
• If the client does not have a bleeding disorder and is able to swallow, encourage the client to brush the teeth with a soft toothbrush using fluoride-containing toothpaste at least twice per day.
• Recommend the client use a powered toothbrush if desired for removal of dental plaque and prevention of gingivitis.
• Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous client. Do not use foam sticks to clean the teeth unless the platelet count is very low and the client is prone to bleeding gums. Foam sticks are useful for cleansing the oral cavity of a client who is edentulous.
• If the client does not have a bleeding disorder, encourage the client to floss once per day or use an interdental cleaner.
• Use an antimicrobial mouthwash as ordered or tap water or saline only for a mouth rinse. Do not use commercial mouthwashes containing alcohol or hydrogen peroxide. Also, do not use lemon-glycerin swabs.
• If the client is unable to care for him- or herself, oral hygiene must be provided by nursing personnel. The nursing diagnosis Bathing/Hygiene Self-Care deficit is then applicable.
• If the client is unable to brush own teeth, follow this procedure:
Position the client sitting upright or on side.
Use a soft bristle baby toothbrush.
Use fluoride toothpaste and tap water or saline as a solution.
• Monitor the client’s nutritional and fluid status to determine if it is adequate. Refer to the care plan for Deficient Fluid Volume or Imbalanced Nutrition: less than body requirements if applicable.
• Encourage fluid intake of up to 3000 mL/day if not contraindicated by the client’s medical condition.
• Determine the client’s usual method of oral care and address any concerns regarding oral hygiene.
If the client has a dry mouth (xerostomia):
Recognize that more than 500 medications may cause xerostomia, and at times the medication can be discontinued to increase the client’s comfort.
Provide saliva substitutes as ordered.
Suggest the client chew sugarless gum or sugarless sour candy to promote salivary flow.
Provide ice chips frequently to keep the mouth moist.
Examine the oral cavity for signs of mucositis ulceration and oral candidiasis.
• Recommend the client decrease or preferably stop intake of soft drinks.
• If client has halitosis, review good oral care with the client including brushing teeth, using floss, and brushing the tongue.
• Instruct the client with halitosis to clean the tongue when performing oral hygiene; brush tongue with tongue scraper or toothbrush and follow with a mouth rinse.
Assess the client for underlying medical condition that may be causing halitosis.
• Keep the lips well lubricated using a lip balm that is water- or aloe-based.
Client Receiving Chemotherapy/Radiation
• Ensure that the client receives a comprehensive oral examination before initiation of chemotherapy or radiation, with aggressive preventive dental care given as needed.
• Provide instructions both verbal and written about the need for and method of providing frequent oral care to the client before radiation therapy or chemotherapy.
• Assess the condition of the oral cavity daily in the client receiving radiation or chemotherapy.
• For measurement of presence or severity of mucositis, use the Oral Mucositis Assessment Scale (OMAS).
• Use a protocol to prevent/treat mucositis that includes the following:
Use of a soft toothbrush that is replaced on a regular basis
Use of a validated tool to assess condition of the oral cavity
Client teaching of the need for and method of performing oral care
Use of a bland rinse to remove debris and moisten the oral cavity
Use of a pain assessment tool and treatment of pain as needed.
• Use cryotherapy with ice chips dissolving in client’s mouth before, during, and after bolus administration of fluorouracil (5-FU) to reduce the severity of mucositis.
• Help the client use a mouth rinse of normal saline or salt and soda every 1 to 2 hours for prevention and treatment of stomatitis. A typical mixture is 1 teaspoon of salt or sodium bicarbonate per pint of water. Clients are directed to take a tablespoon of the rinse and swish it in the mouth for 30 seconds, then expectorate.
If the mouth is severely inflamed and it is painful to swallow, contact the physician for a topical anesthetic or analgesic order. Modification of oral intake (e.g., soft or liquid diet) may also be necessary to prevent friction trauma. The nursing diagnosis Imbalanced Nutrition: less than body requirements may apply.
• If the client’s platelet count is lower than 50,000/mm3 or the client has a bleeding disorder, use a specially made toothbrush designed for sensitive or diseased tissue, or a toothette that is not soaked in glycerin or flavorings; if the client cannot tolerate a toothbrush or a toothette, a piece of gauze wrapped around a finger can be used to remove plaque and debris.
Critical Care—Client on a Ventilator
• Use a pediatric-sized soft toothbrush to brush teeth; use suction to remove secretions. Recognize that good oral care is paramount in the prevention of ventilator-associated pneumonia (VAP).
Apply chlorhexidine gluconate in the oral cavity by swab or spray early after intubation, and at intervals if ordered.
• Determine the functional ability of the client to provide his or her own oral care. Refer to Bathing/Hygiene Self-Care deficit.
• Provide appropriate oral care to the elderly with a self-care deficit, brushing the teeth after breakfast and in the evening.
• If the client has dementia or delirium and exhibits care-resistant behavior such as fighting, biting, or refusing care, utilize the following method:
Ensure client is in a quiet environment such as own bathroom, sitting or standing at the sink to prime memory for appropriate actions.
Approach the client at eye level within his or her range of vision.
Approach with a smile, and begin conversation with a touch of the hand and gradually move up.
Use mirror-mirror technique, standing behind the client, and brush and floss teeth.
Use respectful adult speech, not elderspeak—sing-song voice, calling dearie, honey, and so forth.
Promote self-care where client brushes own teeth if possible.
Utilize distractors when needed, singing, talking, reminiscing, or use of a teddy bear.
• Carefully observe the oral cavity and lips for abnormal lesions such as white or red patches, masses, ulcerations with an indurated margin, or a raised granular lesion.
• Ensure that dentures are removed and cleaned regularly, preferably after every meal and before bedtime.
• The interventions described previously may be adapted for home care use.
Instruct the client in ways to soothe the oral cavity (e.g., cool beverages, Popsicles, viscous lidocaine).
If necessary, refer for home health aide services to support the family in oral care and observation of the oral cavity.
Client/Family Teaching and Discharge Planning
• Teach the client how to inspect the oral cavity and monitor for signs and symptoms of infection or complications, and when to call the health care practitioner.
• Recommend the client not smoke, use chewing tobacco, or drink excessive amounts of alcohol.
• Teach the client and family if necessary how to perform appropriate mouth care. Utilize the Motivational Interviewing Technique.