This guide is about Impaired Oral Mucous Membrane, Impaired Oral Mucous Membrane Nursing Assessment, Impaired Oral Mucous Membrane Nursing Interventions, and 2 Impaired Oral Mucous Membrane Nursing Care Plans. It can be used to prepare educational nursing care plans for Impaired Oral Mucous Membrane.
Impaired Oral Mucous Membrane
What is Impaired Oral Mucous Membrane?
impaired oral mucous membrane a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as disruptions of the lips and soft tissue of the oral cavity.
The oral cavity has seldom been described as a mirror because it reflects the health of a person. Alterations indicative of disease are seen as changes in the oral mucosa lining the mouth can reveal systemic conditions, such as minor irritations. These changes occasionally occur in all people and are usually viral-related, self-limiting, and easily treated. Impaired oral mucous membrane is the alteration of the lips or soft tissue of the oral cavity that may be caused by drying or being NPO for more than 24 hours.
Patients can develop impaired oral mucous membranes for several reasons involving NPO for 24 hours or more, prolonged use of steroids, immunosuppressants, or anti-neoplastic drugs, mechanical irritation, malnutrition, trauma, mouth breathing, inadequate oral hygiene, or decreased salivation.
Oral mucous membrane problems can be encountered in any setting, particularly in-home care and hospice settings. Prevention of oral disease and careful treatment planning is necessary to reduce oral disease and the need for and potential conflicting outcomes of, operative intervention.
What are the Causes of Impaired Oral Mucous Membrane?
There are several other reasons patients may develop impaired oral mucosa, which may include:
- prolonged use of steroids
- neoplastic medications
- poor oral hygiene
- decreased salivation
There are three classifications of trauma or injuries that occur in the mouth: mechanical/ physical, chemical. or thermal. This classification is usually used during dental procedures, but even common occurrences such as ill-fitting dentures, accidental biting, or a burned tongue etc. are all considered trauma.
What are the Factors related to Impaired Oral Mucous Membrane?
Despite these changes can be seen in all people of all ages, there are some studies that show prevalence is higher among women and among the old. These are also more common in confined patients, as well as those that need assistance in daily activities. Other related factors are more socio-economic in nature as people in lower income brackets tend to have poor access to oral health services. Other factors, such as smoking and alcohol intake have been linked to impaired oral mucosa.
What are the Signs and Symptoms of Impaired Oral Mucous Membrane?
There are several signs and symptoms a patient may display with an impaired oral mucosa. Which may include:
- dryness – “xerostomia ” may simply be a reaction to certain medications, or lifestyle; however, this is a symptom of many systemic diseases. It may be a simple, often quick nuisance, but in its prolonged state, it is advised to consult with the doctor.
- tongue discoloration – the tongue should be pink with a thin sheen of white; thus, discoloration of the tongue is often an immediate concern. From vitamin deficiencies to more serious concerns such as diabetes, heart problems etc.
- inflammation of the tongue or “glossitis” – may cause discomfort, but if left untreated may cause difficulty in breathing, swallowing and talking. Often enough the patient’s tongue will appear smooth when it’s inflamed. One may also experience burning or painful sensation and changes in size and shape of the papillae or the little bumps on the patient’s tongue.
- lesions, or ulcers in the mouth – can also be a sign of something more serious. More than often, these are canker sores, which might be due to trauma, reaction to acidic food, hormonal fluctuation or vitamin deficiency.
- changes in the usual saliva characteristics, such as its color, thickness etc.
The proper oral health is needed in the prevention, treatment and management of possible oral diseases, especially complications that may need surgical interventions.
Impaired Oral Mucous Membrane Nursing Assessment
How Can a Nurse Access for Impaired Oral Mucous Membrane?
The following are the comprehensive assessments for Impaired Oral Mucous Membrane:
|Assess oral cavity at least once daily and note any discoloration, lesions, edema, bleeding, exudate, or dryness. Refer to a physician or specialist as appropriate.||Oral examination can show signs of oral disease, symptoms of systemic disease, drug side effects, or trauma of the oral cavity.|
|Inspect for any indication of infection, and culture lesions as needed. Refer to a physician, nurse, or specialist as appropriate.||Early evaluation promotes immediate treatment. Specific manifestations direct accurate treatment.|
|Severe mucositis may manifest as any of the following:|
||Fungal infection due to any type of Candida (a type of yeast); cottage cheese-like white or pale yellowish patches on tongue, buccal mucosa, and palate|
||Common viral infection; painful itching vesicle (typically on upper lips) that ruptures within 12 hours and becomes encrusted with a dried exudate|
||Dry, raised, wartlike yellowish-brown, round plaques on buccal mucosa|
||creamy to yellow-white, shiny, nonpurulent patches often seated on painful, red, superficial mucosal ulcers and erosions|
|Evaluate nutritional status.||Malnutrition can be a contributing cause. Oral fluids are needed for moisture to membranes.|
|Observe ability to eat and drink.||Difficulty or inability to chew or swallow may occur secondary to pain of inflamed or ulcerated oral and/or oropharyngeal mucous membranes.|
|Note patient’s oral hygiene practices.||Information gives direction on possible causative factors and guidance for subsequent education.|
|Check for mechanical agents such as ill-fitting dentures or chemical agents such as constant exposure to tobacco that could create or develop trauma to oral mucous membranes.||Irritative and causative agents for stomatitis should be eliminated.|
|Inspect the status of the oral mucosa; include the:
Examine after removal of dental appliances. Use a moist, padded tongue blade to gently pull back the cheeks and tongue.
|A well-organized assessment should be performed of listed sites using a tongue blade to show areas of the oral cavity.
Denture removal is necessary because lesions may be underlying and further irritated by the appliance. Caregivers also need to be informed of the importance of these assessments.
|Assess the severity of ulcerations involving the intraoral soft tissues, including the palate, tongue, gums, and lips.||Sloughing of mucosal membrane can progress to ulceration.|
|Monitor patient’s fluid status to determine if adequate.||Dehydration predisposes patients to impaired oral mucous membranes.|
|Determine patient’s mental status. If patient is unable to care for self, oral hygiene must be provided by nursing personnel.||The nursing diagnosis Bathing/Hygiene Self-care deficit is then also applicable.|
Impaired Oral Mucous Membrane Nursing Interventions
What are the Interventions and Rationales for Impaired Oral Mucous Membrane?
The following are the therapeutic nursing interventions for Impaired Oral Mucous Membrane:
|Plan and implement a meticulous mouth care regimen after each meal regularly and every 4 hours while awake.||Mouth care prevents formation of oral plaques and bacteria. Patients with oral catheters and oxygen may require additional care.|
|Increase the frequency of oral hygiene by rinsing with one of the suggested solutions between brushings and once during the night especially if signs of mild stomatitis (dryness and burning; mild erythema and edema along mucocutaneous junction) occur.||This will reduce further damage and may promote comfort.|
|Provide systemic or topical analgesics as prescribed.||This will provide comfort and relieve pain.|
|Discontinue flossing if it causes pain.||Increased sensitivity to pain is a result of thinning of oral mucosal lining.|
|Explain that topical analgesics can be administered as “swish and swallow” or “swish and spit” 15 to 20 minutes before meals, or painted on each lesion immediately before mealtime.||Each treatment must be performed as prescribed for optimal results.|
|Instruct patient to hold solution for several minutes before expectoration.||This measure enhances therapeutic effect.|
|Explain the use of topical protective agents.||A variety of more protective agents are available to coat the lesions and promote healing as prescribed.|
||This medicated gel contains benzocaine for pain and is painted on the lesion and allowed to dry to form a protective seal and promote healing of mouth sores.|
||This is a bioadherent oral gel that covers the oral cavity and forms a protective barrier to relieve pain.|
||The substance is prepared by allowing antacid to settle. The pasty residue is swabbed onto the inflamed areas and after 15 to 20 minutes, rinsed with saline or water. The residue remains as a protectant on the lesion.|
||This agent decreases the incidence and duration of severe oral mucositis in patients with hematological cancers undergoing high-dose chemotherapy followed by bone marrow transplantation.|
|For severe mucositis infection:|
||Mycostatin, nystatin, and Mycelex Troche are commonly prescribed.|
||Brushing could increase damage to ulcerated tissues. A disposable foam stick (Toothette) or sterile cotton swab is a way to gently apply cleansing solutions.|
|If patient does not have a bleeding disorder and is capable to swallow, encourage to brush teeth with a soft pediatric-sized toothbrush using a fluoride-containing toothpaste after every meal and to floss teeth daily.||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.|
|Use tap water or normal saline to provide oral care; do not use commercial mouthwashes containing alcohol or hydrogen peroxide. Also, do not use lemon-glycerin swabs.||Alcohol dries the oral mucous membranes Hydrogen peroxide can injure oral mucosa and is remarkably foul-tasting to patients. Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel.|
|Maintain the use of lubricating ointment on the lips.||Lubrication prevents drying and cracking.|
|For eating problems:
||Dietary modifications may be needed to facilitate healing and tissue integrity.|
|Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous patient. Do not use to clean the teeth or else the platelet count is very low, and the patient is prone to bleeding gums.||Studies have revealed that foam sticks are apparently not effective for removing plaque from teeth.|
|Maintain inside of the mouth moist with frequent sips of water and salt water rinses.||Moisture promotes the cleansing effect of saliva and helps avert mucosal drying, which can result in erosions, fissures, or lesions.|
|Provide scrupulous oral care to critically ill patients.||Cultures of the teeth of critically ill patients have produced notable bacterial colonization, which can cause nosocomial pneumonia.|
|If whitish plaques are evident in the mouth or on the tongue and can be rubbed off readily with gauze, leaving a red base that bleeds, suspect a fungal infection and contact the physician for follow-up.||Oral candidiasis (moniliasis) is remarkably common secondary to antibiotic therapy, steroid therapy, HIV infection, diabetes, or immunosuppressive drugs and should be treated with oral or systemic antifungal agents.|
|Refer the patient to the dietitian for instructions on the maintenance of a well-balanced diet.||Nutritional expertise may be necessary to optimize the therapeutic diet needed to facilitate healing.|
|Instruct patient to avoid alcohol or hydrogen peroxide-based commercial products for mouth care and to avoid other irritants to the oral cavity (e.g., tobacco, spicy foods).||Oral irritants can further break and infect the oral mucosa and increase the patient’s discomfort.|
|For continuity of care, instruct the patient or caregiver to perform the following:|
||Careful mechanical cleansing and flossing loosens debris, stimulates circulation, and reduces risk of infection.|
||Baking soda promotes further cleansing of teeth.|
||Dental care is a key to reducing risk of infection and improving appetite.|
||Rubbing and irritation from ill-fitting dentures promote breakage and injury of the oral mucosa.|
||Removing food particles decreases risk for infection related to trapped decaying food.|
|Include food items with each meal that require chewing.||Chewing stimulates gingival tissue and promotes circulation.|
|Educate patient on how to inspect the oral cavity and monitor for signs and symptoms of infection, complications, and healing.||Build on patient’s existing knowledge to develop an individualized plan of care.|
|Educate patient on how to implement a personal plan of oral hygiene including a schedule of care.||Encouragement and reinforcement of oral care are significant to oral outcomes.|
2 Impaired Oral Mucous Membrane Nursing Care Plans
What are Some of the Available Care Plans for Impaired Oral Mucous Membrane?
Nursing Care Plan 1
Chronic Renal Failure (CRF)
Nursing Diagnosis: Impaired Oral Mucous Membranes related to the loss of the maxillary and lamina dura secondary to Chronic Kidney Disease (CKD) as evidenced by mouth lesions and mouth pain.
- The patient and family will be able to identify lesions and abide by the proposed treatment plan.
- The patient and family will be able to assess the patient’s oral health and maintain a record of findings.
- The patient with the help of the family will start with interventions for promoting healthy oral mucosa.
|Educate and demonstrate the patient and family how to inspect the oral cavity.||This will help with early identification to provide necessary intervention and prevention of any possible infection. Along with taking these down, it will track any changes and progress.|
|Instruct the family to provide fluids as prescribed||Prevents excessive dryness|
|Teach the patient to practice frequent mouth care by rinsing mouth with a 0.25% acetic acid solution and providing breath fresheners (such as mints) in between meals.||The oral cavity may have been dry for too long and may have cracked. Providing this oral rinse will help lubricate, freshen and soothe the mouth. The acetic acid will help neutralize the ammonia produced from urea conversion (which also affects mouth taste)|
|Encourage oral hygiene, especially the use of floss||This helps prevent and reduce growth of bacteria that may cause infection in the mouth. The floss will help in between the gums|
|If the patient is smoking, recommend cessation and avoid any product with alcohol and lemon. The family should also be counselled and try to guide the patient||These are known irritants and may cause drying and further discomfort|
|Introduce artificial saliva to the patient.||If necessary this will help with the dryness, and acts as a buffer to acids.|
- Both the patient and family are more confident in identifying changes observed in the mouth.
- The patient shared the active participation of the family in his care, even checking the ingredients in the family’s oral care products.
- The patient has been using artificial saliva in times when fluids aren’t enough to keep his mouth moist.
- The patient reported a sustained oral care routine for the last two weeks.
Nursing Care Plan 2
Nursing Diagnosis: Impaired Oral Mucous membranes secondary to mouth cancer as evidenced by oral lumps/bumps, inflammations, lesions/cracks that seems to never heals.
- The patient will practice recommended before, during, and after care plan for each treatment.
- The patient and family will be aware of causative agents found in dental/oral care products.
- The patient and family will promote maintenance and restoration of the oral mucosa.
- The patient and family will be able to assess the patient’s oral health and maintain a record of findings.
- The patient will improve diet, and nutrient intake to improve healing of oral lesions.
|Educate the family and the patient the importance of regular periodic assessments of dental and oral health||This helps establishing baseline data of the patient and it is ideal to have possible prophylactic treatments before any therapy|
|Encourage patient and family to practice self-assessment and awareness of any changes||Consistent good care is essential in controlling possible stomatitis (inflammation of mouth and throat) complications|
|Provide guidance to family and the patient on areas that needs improvement or awareness||This will help the patient bee more aware about irritants such as alcohol, phenol, (which may be present in some mouth wash) and tobacco use|
|Encourage the family and the patient to visit a dentist request a detailed oral care plan.||Oral care before treatment may include fluoride treatments to strengthen possible areas that may be affected by therapy used in cancer treatment. During treatment, a patient is more likely to be experiencing the side effects, the dentist may be able to prescribe topical medication to help with the pain. In addition to this, if the patient is taking anti-coagulant, bleeding may also affect the patient’s current practices. Lastly, treatment may have affected the patient’s enamel, causing mild to severe tooth decay. Some may opt to have dental procedures to repair decay, such as filling, root canals etc.|
|Help the patient establish a dental hygiene routine.||Consistency is important especially when undergoing several rounds of treatment. Thus, even just brushing the teeth twice a day, rinsing the mouth without astringents, flossing daily will alleviate possible side effects.|
|Educate the family the importance promoting a healthier lifestyle with the patient.||Improve the patient’s diet to include nutrients needed to improve healing and discourage the patient from partaking in drinking and smoking.|
- Since a consult to the dietician, the patient’s nutrient intake improved.
- The family and patient are undergoing counselling for adjustments needed for the patient’s care.
- The patient is currently undergoing the first round of treatment but had fluoride treatments done to lessen possible decay.
- The patient and family are both aware of periodic check-ups and treatment plan with the dentist.