Minor irritations of the oral mucous membrane occur occasionally in

all persons and are usually viral-related, self-limiting, and easily treated. Patients who have severe stomatitis often have an underlying illness. Patients who are immunocompromised, such as the oncology patient receiving chemotherapy, are often affected with severe tissue disruption and pain. Infections such as candidiasis, if left untreated, can spread through the entire gastrointestinal (GI) tract causing further complication and sometimes perineal pain. Oral mucous membrane problems can be encountered in any setting, especially in home care and hospice settings.

Nursing Diagnosis: Oral Mucous Membrane, Altered Stomatitis; Mucositis & Risk for infection
Nursing interventions: 1. Assess oral hygiene practices. 2. Provides information on possible causative factors, and provides guidance for subsequent education. 3. Assess status of oral mucosa; include tongue, lips, mucous membranes, gums, saliva, and teeth. 4. Remove dentures.
Lesions may be underlying and further irritated by the dentures.

5. Use a moist, padded tongue blade to gently pull back the cheeks and tongue.
In order to expose all areas of oral cavity for inspection.

6 Assess for extensiveness of ulcerations involving the intraoral soft tissues, including palate, tongue, gums, and lips.
Sloughing of mucosal membrane can progress to ulceration.

7. Observe for evidence of infection and report to physician or home health nurse. >Severe mucositis may manifest as any of the following:
Candidiasis: Cottage cheese-like white or pale yellowish patches on

tongue, buccal mucosa and palate Herpes simplex: Painful itching vesicle (typically on upper lips) that ruptures within 12 hours and becomes encrusted with a dried exudate Gram-positive bacterial infection, specifically staphylococcal and streptococcal infections: Dry, raised wart-like yellowish-brown, round plaques on buccal mucosa Gram-negative bacterial infections: Creamy to yellow-white shiny, nonpurulent patches often seated on painful, red, superficial, mucosal ulcers, and erosions Fevers, chills
moisture to membranes.

8. Assess nutrition status

Malnutrition can be a contributing cause. Oral fluids needed for

9. Assess for ability to eat and drink.

Inability to chew and swallow may occur secondary to pain of inflamed

or ulcerated oral and/or oropharyngeal mucous membranes.

Candidiasis

HERPES

10. Implement meticulous mouth care regimen after each meal and every 4 hours while awake To prevent buildup of oral plaque and bacteria. 11. Provide additional care If signs of mild stomatitis occur (sensation of dryness and burning; mild erythema and edema along the mucocutaneous junction) such as: Increasing frequency of oral hygiene by rinsing with one of the suggested solutions between brushings and once during the night. 12. Discontinue flossing if it causes pain. 13. Provide systemic or topical analgesics as ordered. Increased sensitivity to pain is a result of thinning of oral mucosal lining.

14. Instruct patient that topical analgesics can be administered as "swished and swallow" or "swish and spit" 15 to 20 minutes before meals, or painted on each lesion immediately before mealtime. Topical analgesics include the following: Dyclone 1% Viscous lidocaine (10 ml per dose up to 120 ml in 24 hours). These provide a "numbing" feeling. Xylocaine (viscous 2%) Benadryl elixir (12.5 mg per 5 ml) and an antacid mixed in equal proportions. 15. Instruct patient to hold solution for several minutes before expectorating, and not to use solution if mucosa is severely ulcerated or if drug sensitivity exists. 16. Caution client to chew or swallow after each dose As numbness of throat may be experienced.

17. Explain use of topical protective agent: To coat the lesions and promote healing as prescribed Zilactin or Zilactin-B Has benzocaine for pain and is painted on lesion and allowed to dry to form a protective seal. Substrate of an antacid and Kaolin preparations. This 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. 18. For severe mucositis infection:Administer local antibiotics and/or antifungal agents as ordered. Mycostatin, nystatin, are commonly prescribed. 19. Discontinue use of hard bristle toothbrush and flossing As this will increase damage to ulcerated tissues. A disposable foamstick or sterile cotton swab are gentle ways to apply cleansing solutions. 20. Continue use of lubricating ointment on the lips. 21. For eating problems: Encourage diet high in protein and vitamins To promote healing and new tissue growth.

22. Serve foods and fluids lukewarm or cold As this may feel soothing to the oral mucosa. 23. Serve frequent small meals or snacks spaced throughout the day To maintain fluid balance and nutrition. 24. Encourage soft foods (mashed potatoes, puddings, custards, creamy cereals) To avoid tissue trauma and pain. 25. Encourage use of a straw To make swallowing easier. 26. Encourage peach, pear, and fruit drinks instead of citrus juices As these are not irritating and are easier to swallow.

Instruct patient/caregiver to:

1. Gently brush all surfaces of teeth, gums, and tongue with a soft nylon brush. To loosen debris. 2. Brush with a nonirritating agent such as baking soda. 3. Remove and brush dentures thoroughly during and after meals and as needed. To reduce risk of infection and improve appetite. 4. Rinse the mouth thoroughly during and after brushing. Removing food particles decreases risk of infection related to trapped decaying food 5. Avoid alcohol-containing mouthwashes. As these may dry oral mucous membranes, increasing risk for disruption of mucous membrane.

6. Use recommended mouth rinses: Hydrogen peroxide and saline or water (1:2 or 1:4). Peroxide solutions should be mixed immediately before use and held in mouth for 1 to 1.5 minutes. Follow with a rinse of water or saline.
To maintain oxydizing property

7. Keep lips moist. Use a lip product or a water-soluble lubricant (K-Y jelly, Aquaphor Cream)
To prevent drying and cracking.

8. Include food items with each meal that require chewing.As this stimulates gingival tissue and promotes circulation.(i) 9. Minimize trauma to mucous membranes. Avoid use of tobacco and alcohol.As these are irritating and drying to the mucosa.(i) 10. Avoid extremely hot or cold foods. Avoid acidic or highly spiced foods. 11. Have loose-fitting dentures adjusted.
Rubbing and irritation from ill-fitting dentures promotes disruption of

the oral mucous membrane.

To further prevent infection:

Evaluate Laboratory results frequently
Check the pt.s temp. Every 4-8hrs Protect skin from any trauma

Provide an aseptic technique when changing dressing

Check for any signs of wound infection Such as redness, swelling drainage and tenderness Use topical antibiotics as prescribed

Expected Outcomes
Patient has intact oral mucosa. Patient demonstrates appropriate oral hygiene. Patient verbalizes relief from stomatitis. Patient reduces risk for infection