O
Impaired Oral Mucous Membrane
NANDA-I
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
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
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. Systematic inspection can identify impending problems. White lesions are often leukoplakia, which is a precursor to squamous cell carcinoma. If the lesion is cancerous, prompt treatment is needed (Engelke & Pravikoff, 2010).
• 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. CEB: A systematic review found that the toothbrush is the most important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling periodontal disease (McGuire et al, 2006).
• Recommend the client use a powered toothbrush if desired for removal of dental plaque and prevention of gingivitis. EB: A Cochrane review found the powered/oscillating toothbrush to be safe for use on both hard and soft dental tissues (Robinson, 2011).
• 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. CEB: Foam sticks are not effective for removing plaque; the toothbrush is much more effective (Pearson & Hutton, 2002).
• If the client does not have a bleeding disorder, encourage the client to floss once per day or use an interdental cleaner. EB: Floss is useful to remove plaque buildup between the teeth (ADA, 2012a).
• Use an antimicrobial mouth wash 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. Some antimicrobial mouthwashes have demonstrated effective action in decreasing bacterial counts in plaque and decreasing gingivitis (ADA, 2012a). CEB: Hydrogen peroxide can cause mucosal damage and is extremely foul-tasting to clients (Tombes & Gallucci, 1993). Use of lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel (Foss-Durant & McAffee, 1997; Poland, 1987).
• 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.
Each client must receive oral care including toothbrushing two times every day to maintain healthy teeth and mouth and to prevent complications associated with periodontitis (the advanced form of gum disease that can cause tooth loss), which is associated with health problems such as cardiovascular disease, stroke, and bacterial pneumonia (ADA, 2012a).
• 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. Dehydration and malnutrition predispose clients to impaired oral mucous membranes.
• Encourage fluid intake of up to 3000 mL/day if not contraindicated by the client’s medical condition. Fluids help increase moisture in the mouth, which protects the mucous membranes from damage.
• 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 (Schub, Grose, & Pravikoff, 2010).
Provide saliva substitutes as ordered. Saliva substitutes are helpful to decrease the discomfort of dry mouth and may help prevent stomatitis (ADA, 2012c).
Suggest the client chew sugarless gum or sugarless sour candy to promote salivary flow. Both sugarless gum and candy stimulate the formation of saliva (ADA, 2012c; Schub, Grose, & Pravikoff, 2010).
Provide ice chips frequently to keep the mouth moist. CEB: There is some evidence that ice chips help prevent mucositis (Clarkson, Worthington, & Eden, 2003).
Examine the oral cavity for signs of mucositis ulceration and oral candidiasis. Untreated xerostomia may result in these conditions (Schub, Grose, & Pravikoff, 2010).
• Recommend the client decrease or preferably stop intake of soft drinks. Sugar-containing soft drinks can cause cavities, and the low pH of the drink can cause erosion in teeth (ADA, 2012a). EB: A study demonstrated a much higher incidence of caries in children who drank soft drinks, as well as increased processed foods (Llena & Forner, 2008).
• If client has halitosis, review good oral care with the client including brushing teeth, using floss, and brushing the tongue. Halitosis can be a beginning sign of gingivitis and can be eradicated by a good program of dental hygiene (ADA, 2012a).
• 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. EB: A Cochrane review found that tongue cleaning was effective for short-term control of halitosis (Van der Sleen et al, 2010).
Assess the client for underlying medical condition that may be causing halitosis. Causes of halitosis can be subdivided into three categories: oral origin where good mouth care can help prevent, halitosis from the upper respiratory tract including the sinuses and nose, and halitosis from systemic diseases that is blood-borne, volatilized in the lungs, and expelled from the lower respiratory tract. Potential sources of blood-borne halitosis are some systemic diseases, metabolic disorders, medication, and certain foods such as onions and garlic (ADA, 2012b).
• Keep the lips well lubricated using a lip balm that is water- or aloe-based. This is a comfort measure.
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 (Weikel, 2008).
• 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 (Harris et al, 2008).
• Assess the condition of the oral cavity daily in the client receiving radiation or chemotherapy (Harris et al, 2008).
• For measurement of presence or severity of mucositis, use the Oral Mucositis Assessment Scale (OMAS). EBN: This is an instrument that has two components: clinician’s assessment of presence and severity of mucositis, and client report about pain, difficulty swallowing, and ability to eat (Harris et al, 2008).
• 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.
CEB & EB: Use of an oral care protocol helps to decrease oral mucositis in clients receiving treatment for cancer (Harris et al, 2008; Keefe et al, 2007).
• 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 (Keefe et al, 2007). EBN: Katranci et al (2011). Also use cryotherapy for clients receiving bolus edatrexate (Bensinger et al, 2008; Keefe et al, 2007) and melphalan (Bensinger et al, 2008; Keefe et al, 2007). EB: A Cochrane review found evidence of the effectiveness of cryotherapy to prevent mucositis (Worthington et al, 2011).
• 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. Rinses are helpful to remove debris and hydrate the oral mucous membranes; sodium bicarbonate can discourage yeast colonization (Harris et al, 2008; Schub, Schub, & Pravikoff, 2010). CEB: A study demonstrated that there was no difference in the rate of cessation of symptoms of stomatitis when different mouthwashes were used: chlorhexidine, lidocaine, Benadryl and Maalox, and salt and soda (Dodd et al, 2000).
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). EBN & EB: Increased plaque on the teeth is associated with increased contamination of the mouth and incidence of VAP (Munro et al, 2006). Many studies have demonstrated the effectiveness of good oral care to decrease the incidence of VAP (Coffin et al, 2008; Fields, 2008; Hutchins et al, 2009).
Apply chlorhexidine gluconate in the oral cavity by swab or spray early after intubation, and at intervals if ordered. EB & EBN: The use of chlorhexidine gluconate administered early after intubation and at intervals decreased positive cultures of bacteria and has been shown to decrease VAP (Munro et al, 2009; Roberts & Moule, 2011).
Geriatric:• Determine the functional ability of the client to provide his or her own oral care. Refer to Bathing/hygiene Self-Care deficit. Interventions must be directed toward both treatment of the functional loss and care of oral health.
• Provide appropriate oral care to the elderly with a self-care deficit, brushing the teeth after breakfast and in the evening. EBN: Oral care is often poor for clients with dementia in long-term facilities (Jablonski et al, 2009). CEB & EB: Several studies have shown that the rate of pneumonia was decreased by providing oral care (Sarin et al, 2008; Watando et al, 2004).
• 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 elder speak—sing-song voice, calling dearie, honey, and so forth. Elder speak is a documented trigger for care-resistant behavior (Herman & Williams, 2009).
Promote self-care where client brushes own teeth if possible.
Utilize distractors when needed, singing, talking, reminiscing, or use of a teddy bear. EBN: Use of specific techniques can decrease the fear-evoked response to nursing care and increase the effectiveness of nurses providing oral care to clients (Jablonski, Therrien, & Kolanowski, 2011).
• 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. Malignant lesions are more common in elderly persons than in younger persons, especially if there is a history of smoking or alcohol use (Engelke & Pravikoff, 2010).
• Ensure that dentures are removed and cleaned regularly, preferably after every meal and before bedtime. Dentures left in the mouth at night impede circulation to the palate and predispose the client to oral lesions. EB: A Cochrane review found a lack of evidence about the effectiveness of the different denture cleaning methods considered, including chemical and mechanical methods of cleaning (de Souza et al, 2009).
Home Care:• 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 (Harris et al, 2008).
• Recommend the client not smoke, use chewing tobacco, or drink excessive amounts of alcohol. Tobacco use, either smoking or chewing, is a common cause of leukoplakia. Also, alcohol and HPV have been associated with squamous cell carcinoma in the oral cavity (Engelke & Pravikoff, 2010).
• Teach the client and family if necessary how to perform appropriate mouth care. Utilize the Motivational Interviewing Technique. EB: A study demonstrated improved dental hygiene with decreased amount of plaque when motivational interviewing was used as compared to a usual teaching session on dental care (Godard, Dufour, & Jeanne, 2011). A systematic review found motivational interviewing more effective in changing oral health than usual care (Watt, 2010). See Motivational Interviewing on Evolve webiste.
References
American Dental Association (ADA), Cleaning your teeth and gums, 2012 Retrieved January 24, 2012, from http://www.ada.org/3072.aspx?currentTab=1
American Dental Association (ADA), Halitosis, 2012 Retrieved January 24, 2012, from http://www.ada.org/3044.aspx?currentTab=1
American Dental Association (ADA), Dry mouth, 2012 Retrieved February 12, 2012, from http://http://www.ada.org/3014.aspx?currentTab=1
Bensinger, W., et al. NCCN Task Force Report. Prevention and management of mucositis in cancer care. Natl Compr Cancer Netw. 2008;6(Suppl 1):S1–S21. [quiz S22-S24].
Clarkson, J.E., Worthington, H.V., Eden, O.B. Interventions for preventing oral mucositis or oral candidiasis for patients with cancer receiving chemotherapy. Cochrane Database Syst Rev. (3):2003. [CD000978].
Coffin SE, et al: Strategies to prevent ventilator-associated pneumonia in acute care hospitals, Infect Control Hosp Epidemiol 29(1):S31–S37.
de Souza, R.F., et al. Interventions for cleaning dentures in adults. Cochrane Database Syst Rev. (4):2009. [CD007395].
Dodd, M.J., et al. Randomized clinical trial of the effectiveness of three commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(1):39.
Engelke, A., Pravikoff, D., Leukoplakia, oral. Nursing Reference Center. CINAHL Nursing Guide Oct 29, 2010.
Fields, L.B. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. J Neurosci Nurs. 2008;40(5):291–298.
Foss-Durant, A.M., McAffee, A. A comparison of three oral care products commonly used in practice. Clin Nurs Res. 1997;6:1.
Godard, A., Dufour, T., Jeanne, S. Application of self-regulation theory and motivational interview for improving oral hygiene: a randomized controlled trial. J Clin Periodontol. 2011;38(12):1099–1105.
Harris, D.J., et al. Putting evidence into practice: evidence-based interventions for the management of oral mucositis. Clin J Oncol Nurs. 2008;12(1):141–152.
Herman, R.E., Williams, K.N. Elderspeak’s influence on resistiveness to care: focus on behavioral events. Am J Alzheimers Dis Other Demen. 2009;24(5):417–423. [Epub Aug 19, 2009].
Hutchins, K., et al. Ventilator-associated pneumonia and oral care: a successful quality improvement project. Am J Infect Control. 2009;37(7):590–597.
Jablonski, R.A., et al. Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants. Geriatric Nurs. 2009;30(2):99–107.
Jablonski, R., Therrien, B., Kolanowski, A. No more fighting and biting during mouth care: applying the theoretical constructs of threat perception to clinical practice. Res Theory Nurs Pract. 2011;25(3):163–175.
Katranci, N., et al. Evaluation of the effect of cryotherapy in preventing oral mucositis associated with chemotherapy—a randomized controlled trial. Eur J Oncol Nurs. 2012;16(4):339–344.
Keefe, D.M., et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Am Cancer Soc. 2007;109(5):820–831.
Llena, C., Forner, L. Dietary habits in a child population in relation to caries experience. Caries Res. 2008;42(5):387–393.
McGuire, D.B., et al. The role of basic oral care and good clinical practice principles in the management of oral mucositis. Support Care Cancer. 2006;14(6):541–547.
Munro, C.L., et al. Chlorhexidine, tooth brushing, and preventing ventilator associated pneumonia in critically ill adults. Am J Crit Care. 2009;18(5):428–437.
Munro, C.L., et al. Oral health status and development of ventilator-associated pneumonia: a descriptive study. Am J Crit Care. 2006;15(5):453–461.
Pearson, L.S., Hutton, J.L. A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. J Adv Nurs. 2002;39:5.
Poland, J.M. Comparing Moi-Stir to lemon-glycerin swabs. Am J Nurs. 1987;87(4):422.
Roberts, N., Moule, P. Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates. Nurs Crit Care. 2011;16(6):295–302.
Robinson, P.G. The safety of oscillating-rotating powered toothbrushes. Evid Based Dent. 2011;12(3):69.
Sarin, J., et al. Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. J Am Med Dir Assoc. 2008;9(2):128–135.
Schub, T., Grose, S., Pravikoff, D., Xerostomia. Nursing Reference Center: CINAHL Nursing Guide Sept 3, 2010.
Schub, E., Schub, T., Pravikoff, D., Stomatitis (oral mucositis) therapy. Nursing Reference Center: CINAHL Nursing Guide Oct 29, 2010.
Tombes, M.B., Gallucci, B. The effects of hydrogen peroxide rinses on the normal oral mucosa. Nurs Res. 1993;42(6):332.
Van der Sleen, M.I., et al. Effectiveness of mechanical tongue cleaning on breath odour and tongue coating: a systematic review. Int J Dent Hyg. 2010;8(4):258–268.
Watando, A., et al. Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest. 2004;126(4):1066.
Watt, R.G. Motivational interviewing may be effective in dental setting. Evid Based Dent. 2010;11(1):13.
Weikel, D.S. Oral health maintenance guideline. In: Ackley B., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Worthington, H.V., et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2(4), 2011. [CD000978].