Impaired Oral Mucous Membrane NCLEX Review Care Plans
5 Nursing Care Plans on Impaired Oral Mucous Membrane
The mouth is extremely vital for receiving nutrients through eating and drinking, and for other functions such as breathing, (verbal and non-verbal) communication, and taste.
In addition to this, the production of saliva also happens in the mouth. Saliva is known to have antibacterial properties, serving as one of the body’s first layers of defense. Not only does poor oral hygiene lead to oral diseases like gingivitis, halitosis (chronic bad breath), dental caries, and more recently, it has been linked to chest infections and pneumonia.
The oral cavity may be described as a mirror to one’s health, as some changes in the oral mucosa may be a symptom of a disease or indicative of a more systemic problem. These are often viral, and easily treatable due to its self-limiting nature.
Impaired mucosa in the oral cavity commonly presents as drying, and alteration of the lips with the most common cause as the patient being NPO (do not eat/drink) for more than 24 hours.
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.
Related Factors 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.
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.
Nursing Care Plan 1
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.
Nursing Care Plan 3
Hand, Foot, and Mouth Disease
Nursing Diagnosis: Impaired Mucous Membrane related to oral dehydration secondary to Hand, Foot, and Mouth Disease as evidenced by mouth sores and mouth pain.
- The patient and family will be well-aware about the disease and its effects.
- The patient and family will be aware how to prevent further infection and transmission
- The family will be able to help the patient until sores are healed as there are no cure, only therapeutic assistance.
|-The family should encourage the patient to eat small amounts of soft food and drink plenty of fluids.|
– The family should be aware that the patient not to take anything too hot.
– Implement a meticulous routine for mouth care.
|This will help improve mucosal membranes and hasten healing|
|-Tell the family and patient to monitor lesions in and around the mouth.|
– Educate the family and patient to only use gentle cleansers, review the ingredients if possible.
|This will help restore skin integrity|
|– Refer the patient and family to a dietician if unsure how to ascertain the needed caloric and nutritional intake needed by the patient.|
– Ask the patient to consider eating small portions throughout the instead of the usual three portions.
|Improve nutrition and help the body in fighting until sores are healed/|
| – Encourage the family to help the patient adhere to advised personal hygiene. |
– Demonstrate to the family and patient to practice minimum safety protocols.
– Encourage the patient to follow the diet prescribed.
– Educate the family or caregivers proper disinfection.
|Prevent further infection in the patient, and transmission among family and care givers.|
|– Encourage an environment conducive for healing.|
– Encourage the significant others to remove possible stressors.
– Recommend the patient analgesics or topical ointment to help with pain.
|This will help with the patient’s pain.|
- After two weeks of following suggested treatment plan, and interventions, the patient reported majority of the sores are fully healed.
Nursing Care Plan 4
Nursing diagnosis: Impaired Mucous Membrane related to ongoing chemotherapy secondary to Wilms tumor as evidenced by mouth sores and mouth pain.
- The family will be able to assist the patient through treatments and recovery and alleviate pain the patient experiences.
- The family and patient will practice utmost care and minimum safety protocols as suggested.
|– Assess any sites that may have possible bleeding. |
– Monitor any changes in blood chemistry
|Inform the patients and their parents or caregivers about frank bleeding (rectal), the bone marrow suppression and immunosuppression that may induce bleeding.|
|– Perform minimum safety protocols and infection control.|
– Instruct family and caregivers to stay distant from anyone displaying symptoms of infectious diseases
|To prevent transmission of other infectious diseases during treatment|
|Provide counselling for the family on how to approach the children in changes s/he might need to change some habits/hobbies||Preventing any trauma will help lessen bleeding caused by the platelet and clotting factor during chemotherapy.|
|Check on the parents if the patient has experienced any changes in behavior, exposure to communicable diseases, and fatigue etc.||Report this to your physician, as it can be a sign of abnormal levels in the blood.|
|Teach and demonstrate to the caregiver/family how to do dipstick and hema test.||This will help them to monitor and identify bleeding in the gastrointestinal and/or urinary tract.|
|Administer blood transfusion as needed.||Replace blood loss when symptoms of anemia appears.|
- The patient needed two bags of blood due to signs of anemia.
- The family expressed difficulty of performing dipstick test; the nurse aided and re-demonstrated it.
- The patient has been reported to have extreme mood swings after the last round of chemotherapy.
Nursing Care Plan 5
Nursing diagnosis: Impaired Mucous Membrane related to the progressive deterioration of cell-mediated (T-cell) immunity secondary to AIDs/ HIV infection as evidenced by mouth lesions and mouth pain.
- The patient and family are aware of ideal oral health and how to maintain it.
|Educate the importance of having regular assessment of the oral cavity and take note of any swelling, difficulty and pain.||Edema, open lesions, crusting may cause pain and difficulty I chewing, swallowing, talking.|
|Demonstrate ideal oral care daily, maintain it before and after meals with the use of soft-bristle toothbrush, mild mouthwash, floss, and lip moisturizer.||This will help alleviate discomfort, prevent acid formation associated to food-particle build-up and improve patient well-being.|
|Educate the patient and family how to maintain proper wound care for any lesions.||To reduce spread of lesions and promote comfort.|
|Recommend to exercise the tongue.||This will stimulate flow of saliva to help protect mucous membranes, and neutralize acids.|
|Remind the patient to always drink fluids.||Prevents drying of the mouth.|
|Tell the family to check the patient’s diet, avoid any harsh or abrasive food and beverages. Check the temperature as well.||These foods may aggravate new lesions and open healing lesions. Extreme temperature may also cause pain to sensitive membranes.|
|Encourage the family to help the patient maintain a better lifestyle, cessation from alcohol and tobacco use.||These are irritants and will prevent healing.|
|Administer medications as needed and prescribed.||These will prevent any undue pain, and discomfort.|
|Refer to dentist if possible.||If case is better managed by dentist, refer as there might be additional therapy to prevent dental losses|
- The patient had expressed relief provided by recent routine they established with the dentist.
- There have been lesser mouth sores present than last visit.
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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