Nursing Diagnosis: Oral Mucous Membrane, impaired
May be related to
- Immunologic deficit and presence of lesion-causing pathogens, e.g., Candida, herpes, KS
- Dehydration, malnutrition
- Ineffective oral hygiene
- Side effects of drugs, chemotherapy
Possibly evidenced by
- Open ulcerated lesions, vesicles
- Oral pain/discomfort
- Stomatitis; leukoplakia, gingivitis, carious teeth
Desired Outcomes
- Display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
- Demonstrate techniques to restore/maintain integrity of oral mucosa.
| Nursing Interventions | Rationale |
| Assess mucous membranes/document all oral lesions. Note reports of pain, swelling, difficulty with chewing/swallowing. | Edema, open lesions, and crusting on oral mucous membranes and throat may cause pain and difficulty with chewing/swallowing. |
| Provide oral care daily and after food intake, using soft toothbrush, nonabrasive toothpaste, nonalcohol mouthwash, floss, and lip moisturizer. | Alleviates discomfort, prevents acid formation associated with retained food particles, and promotes feeling of well-being. |
| Rinse oral mucosal lesions with saline/dilute hydrogen peroxide or baking soda solutions. | Reduces spread of lesions and encrustations from candidiasis, and promotes comfort. |
| Suggest use of sugarless gum/candy or commercial salivary substitute. | Stimulates flow of saliva to neutralize acids and protect mucous membranes. |
| Plan diet to avoid salty, spicy, abrasive, and acidic foods or beverages. Check for temperature tolerance of foods. Offer cool/cold smooth foods. | Abrasive foods may open healing lesions. Open lesions are painful and aggravated by salt, spice, acidic foods/beverages. Extreme cold or heat can cause pain to sensitive mucous membranes. |
| Encourage oral intake of at least 2500 mL/day. | Maintains hydration; prevents drying of oral cavity. |
| Encourage patient to refrain from smoking. | Smoke is drying and irritating to mucous membranes. |
| Obtain culture specimens of lesions. | Reveals causative agents and identifies appropriate therapies. |
| Administer medications, as indicated, e.g., nystatin (Mycostatin), ketoconazole (Nizoral).
TNF-alpha inhibitor, e.g., thalidomide.
| Specific drug choice depends on particular infecting organism(s), e.g.,Candida.
Effective in treatment of oral lesions due to recurrent stomatitis.
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| Refer for dental consultation, if appropriate. | May require additional therapy to prevent dental losses. |
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