Nursing Diagnosis: Risk for Altered Oral Mucous Membranes
Risk factors may include
- Side effect of some chemotherapeutic agents (e.g., antimetabolites) and radiation
- Dehydration, malnutrition, NPO restrictions for more than 24 hr
- Display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
- Verbalize understanding of causative factors.
- Demonstrate techniques to maintain/restore integrity of oral mucosa.
13 Cancer Nursing Care Plan (NCP)
- Anticipatory Grieving — Cancer Nursing Care Plan (NCP)
- Situational Low Self-Esteem — Cancer Nursing Care Plan (NCP)
- Acute Pain — Cancer Nursing Care Plan (NCP)
- Altered Nutrition: Less Than Body Requirements — Cancer Nursing Care Plan (NCP)
- Risk for Fluid Volume Deficit — Cancer Nursing Care Plan (NCP)
- Fatigue — Cancer Nursing Care Plan (NCP)
- Risk for Infection — Cancer Nursing Care Plan (NCP)
- Risk for Altered Oral Mucous Membranes — Cancer Nursing Care Plan (NCP)
- Risk for Impaired Skin Integrity — Cancer Nursing Care Plan (NCP)
- Risk for Constipation/Diarrhea — Cancer Nursing Care Plan (NCP)
- Risk for Altered Sexuality Patterns — Cancer Nursing Care Plan (NCP)
- Risk for Altered Family Process — Cancer Nursing Care Plan (NCP)
- Fear/Anxiety — Cancer Nursing Care Plan (NCP)
Risk for Altered Oral Mucous Membranes — Cancer Nursing Care Plan (NCP)
|Assess dental health and oral hygiene periodically.||Identifies prophylactic treatment needs before initiation of chemotherapy or radiation and provides baseline data of current oral hygiene for future comparison.|
|Encourage patient to assess oral cavity daily, noting changes in mucous membrane integrity (e.g., dry, reddened). Note reports of burning in the mouth, changes in voice quality, ability to swallow, sense of taste, development of thick/viscous saliva, blood-tinged emesis.||Good care is critical during treatment to control stomatitis complications.|
|Discuss with patient areas needing improvement and demonstrate methods for good oral care.||Products containing alcohol or phenol may exacerbate mucous membrane dryness/irritation.|
|Initiate/recommend oral hygiene program to include:Avoidance of commercial mouthwashes, lemon/|
Use of mouthwash made from warm saline, dilute solution of hydrogen peroxide or baking soda and water;
Brush with soft toothbrush or foam swab;
Floss gently or use WaterPik cautiously;
Keep lips moist with lip gloss or balm, K-Y Jelly, Chapstick;
Encourage use of mints/hard candy or artificial saliva (Ora-Lube, Salivart) as indicated.
|May be soothing to the membranes. Rinsing before meals may improve the patient’s sense of taste. Rinsing after meals and at bedtime dilutes oral acids and relieves xerostomia.|
Prevents trauma to delicate/fragile tissues. Note: Toothbrush should be changed at least every 3 mo.
Removes food particles that can promote bacterial growth. Note: Water under pressure has the potential to injure gums/force bacteria under gum line.
Promotes comfort and prevents drying/cracking of tissues.
Stimulates secretions/provides moisture to maintain integrity of mucous membranes, especially in presence of dehydration/reduced saliva production.
|Instruct regarding dietary changes: e.g., avoid hot or spicy foods, acidic juices; suggest use of straw; ingest soft or blenderized foods, Popsicles, and ice cream as tolerated.||Severe stomatitis may interfere with nutritional and fluid intake leading to negative nitrogen balance or dehydration. Dietary modifications may make foods easier to swallow and may feel soothing.|
|Encourage fluid intake as individually tolerated.||Adequate hydration helps keep mucous membranes moist, preventing drying/cracking.|
|Discuss limitation of smoking and alcohol intake.||May cause further irritation and dryness of mucous membranes. Note: May need to compromise if these activities are important to patient’s emotional status.|
|Monitor for and explain to patient signs of oral superinfection (e.g., thrush).||Early recognition provides opportunity for prompt treatment.|
|Refer to dentist before initiating chemotherapy or head/neck radiation.||Prophylactic examination and repair work before therapy reduce risk of infection.|
|Culture suspicious oral lesions.||Identifies organism(s) responsible for oral infections and suggests appropriate drug therapy.|
|Administer medications as indicated, e.g.:Analgesic rinses (e.g., mixture of Koatin, pectin, diphenhydramine [Benadryl], and topical lidocaine [Xylocaine]);|
Antifungal mouthwash preparation, e.g., nystatin (Mycostatin), and antibacterial Biotane;
Opioid analgesics: e.g., hydromoph (Dilaudid), morphine.
|Aggressive analgesia program may be required to relieve intense pain. Note: Rinse should be used as a swish-and-spit rather than a gargle, which could anesthetize patient’s gag reflex.|
May be needed to treat/prevent secondary oral infections, such as Candida, Pseudomonas, herpes simplex.
When given before beginning mouth care regimen, may prevent nausea associated with oral stimulation.
May be required for acute episodes of moderate to severe oral pain.