O
Impaired Oral Mucous Membrane
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.
Brush teeth in an up-and-down manner.
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).
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