Nursing Diagnosis: Impaired Oral mucous membrane Application of NANDA, NOC, NIC

Nursing Diagnosis: Impaired Oral mucous membrane
Betty J. Ackley

NANDA Definition: Disruptions of the lips and soft tissues of the oral cavity

Defining Characteristics: Purulent drainage or exudates; gingival recession, pockets deeper than 4 mm; enlarged tonsils beyond what is developmentally appropriate; smooth atrophic, sensitive tongue; geographic tongue; mucosal denudation; presence of pathogens; difficult speech; self-report of bad taste; gingival or mucosal pallor; oral pain/discomfort; xerostomia (dry mouth); vesicles, nodules, or papules; white patches/plaques, spongy patches, or white curd-like exudate; oral lesions or ulcers; halitosis; edema; hyperemia; desquamation; coated tongue; stomatitis; self-report of difficult eating or swallowing; self-report of diminished or absent taste; bleeding; macroplasia; gingival hyperplasia; fissures, cheilitis; red or bluish masses (e.g., hemangiomas)

Related Factors: Chemotherapy; chemical (e.g., alcohol, tobacco, acidic foods, regular use of inhalers); depression; immunosuppression; aging-related loss of connective, adipose, or bone tissue; barriers to professional care; cleft lip or palate; medication side effects; lack of or decreased salivation; chemical trauma (e.g., acidic foods, drugs, noxious agents, alcohol); pathological conditions—oral cavity (radiation to head or neck); NPO for more than 24 hours; mouth breathing; malnutrition or vitamin deficiency; dehydration; infection; ineffective oral hygiene; mechanical (e.g., ill-fitting dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity); decreased platelets; immunocompromised; impaired salivation; radiation therapy; barriers to oral self-care; diminished hormone levels (women); stress; loss of supportive structures

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Oral Health

·         Tissue Integrity: Skin and Mucous Membranes

Client Outcomes

·         Maintains intact, moist oral mucous membranes that are free of ulceration and debris

·         Describes or demonstrates measures to regain or maintain intact oral mucous membranes

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Oral Health Restoration

Nursing Interventions and Rationales

·         Inspect 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 inspection can reveal signs of oral disease, symptoms of systemic disease, drug side effects, or trauma of the oral cavity (White, 2000).

·         Assess for mechanical agents such as ill-fitting dentures or chemical agents such as frequent exposure to tobacco that could cause or increase trauma to oral mucous membranes. Irritative and causative agents for stomatitis should be eliminated (Rhodes, McDaniel, Johnson, 1995).

·         Monitor client's nutritional and fluid status to determine if 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 up to 3000 ml per day if not contraindicated by client's medical condition (Rhodes, McDaniel, Johnson, 1995). Fluids help increase moisture in the mouth, which protects the mucous membranes from damage and helps the healing process.

·         Determine client's mental status. If client 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.

·         Determine client's usual method of oral care and address any concerns regarding oral hygiene. Whenever possible, build on client's existing knowledge base and current practices to develop an individualized plan of care.

·         If client does not have a bleeding disorder and is able 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 (Buglass, 1995; Stiefel et al, 2000; Roberts, 2000).

·         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 damage oral mucosa and is extremely foul tasting to clients (Tombes, Gallucci, 1993; Winslow, 1994). Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel (Crosby 1989, Stiefel et al, 2000; Roberts, 2000).

·         Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous client. Do not use to clean the teeth or else the platelet count is very low, and the client is prone to bleeding gums. Studies have shown that foam sticks are probably not effective for removing plaque from teeth (Roberts, 2000). However, they are useful for cleaning the mouth of the edentulous client (Curzio, McCowan, 2000).

·         If client's oral cavity is dry, the keep inside of the mouth moist with frequent sips of water and salt water rinses (1/2 tsp salt in 8 oz of warm water) or artificial saliva. Moisture promotes the cleansing effect of saliva and helps avert mucosal drying, which can result in erosions, fissures, or lesions (Rhodes, McDaniel, Johnson, 1995). Sodium chloride rinses have been shown to be effective for the prevention and treatment of stomatitis (Feber, 1994).

·         Keep lips well lubricated using petroleum jelly or a similar product (Yeager et al, 2000).

·         For clients with stomatitis, increase frequency of oral care up to every hour while awake if necessary. Increasing the frequency of oral care has been shown to be effectively decrease stomatitis (Armstrong, 1994).

·         Provide scrupulous oral care to critically ill clients. Cultures of the teeth of critically ill clients have yielded significant bacterial colonization, which can cause nosocomial pneumonia (Scannapieco, Stewart, Mylotte, 1992).

·         If mouth is severely inflamed and it is painful to swallow, contact the physician for a topical anesthetic agent 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 whitish plaques are present 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 extremely common secondary to antibiotic therapy, steroid therapy, HIV infection, diabetes, or immunosuppressive drugs and should be treated with oral or systemic antifungal agents (Fauci et al, 1998; Epstein, Chow, 1999).

·         If client is unable to swallow, keep suction nearby when providing oral care.

·         Refer to Impaired Dentition if the client has problems with the teeth.

Geriatric

·         Carefully observe 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), and many elderly persons rarely visit a dentist (Aubertin, 1997).

·         Ensure that dentures are removed and scrubbed at least once daily, removed and rinsed thoroughly after every meal, and removed and kept in an appropriate solution at night. This is an evidence-based protocol for denture care (Curzio, McCowan, 2000). Denture plaque-containing candidiasis can cause denture-induced stomatitis, which is more common with unhealthy lifestyles and poor oral hygiene than otherwise (Sakki et al, 1997; Nikawa, Hamada, Yamamoto, 1998).

Home Care Interventions

·         Instruct client 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 damage the oral mucosa and increase the client's discomfort.

·         Instruct client in ways to soothe the oral cavity (e.g., cool beverages, Popsicles, viscous lidocaine) (Jaffe, Skidmore-Roth, 1993).

·         If client often breathes by mouth, add humidity to room unless contraindicated.

·         If necessary, refer for home health aide services to support family in oral care and observation of the oral cavity.

Client/Family Teaching

·         Teach client how to inspect the oral cavity and monitor for signs and symptoms of infection, complications, and healing.

·         Teach how to implement a personal plan of oral hygiene including a schedule of care. Encouragement and reinforcement of oral care are important to oral outcomes (Armstrong, 1994).