Oral Mucous Membrane, Altered - Stomatitis; Mucositis
Meg Gulanick, RN, PhD
Christa Schroeder, RN, MS
Bautista, RN, BSN
NANDA: The state in which an individual experiences disruptions
in the tissue layers of the oral cavity
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.
- Pathological conditions--oral cavity (radiation to head or
- Trauma: chemical (e.g., acidic foods, drugs, noxious agents,
alcohol); mechanical (e.g., ill-fitting dentures, braces, tubes [endotracheal
or nasogastric]), surgery in oral cavity
- Nothing by mouth for more than 24 hours
- Ineffective oral hygiene
- Mouth breathing
- Lack of or decreased salivation
- Oral pain or discomfort
- Coated tongue
- Xerostomia (dry mouth)
- Oral lesions or ulcers
- Lack of or decreased salivation
- Oral plaque
- Hemorrhagic gingivitis
- Carious teeth
- Patient has intact oral mucosa.
- Patient demonstrates appropriate oral hygiene.
- Patient verbalizes relief from stomatitis.
- (i) independent
- (i) Assess oral hygiene practices.
- Provides information on possible causative factors, and
provides guidance for subsequent education.
- (i) Assess status of oral mucosa; include
tongue, lips, mucous membranes, gums, saliva, and teeth.
- Home caregivers also need to be informed of the importance
of these assessments.
- Use adequate source of light.
- Remove dental appliances.
- Lesions may be underlying and further irritated by the
- Use a moist, padded tongue blade to gently pull back the cheeks
- In order to expose all areas of oral cavity for
- (i) Assess for extensiveness of ulcerations
involving the intraoral soft tissues, including palate, tongue, gums, and lips.
- Sloughing of mucosal membrane can progress to
- (i) 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
- 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, rigors
- (i) Assess nutrition status
- Malnutrition can be a contributing cause. Oral fluids
needed for moisture to membranes.
- (i) 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.
- (i) independent
- For hospitalized or home care patients:
(i) Implement meticulous mouth care regimen after each
meal and every 4 hours while awake
- To prevent buildup of oral plaque and bacteria. Patients
with oral catheters and oxygen may require additional care.
- (See Education/Continuity of Care in this care plan for
description of oral care.)
- Caregivers need to be taught these procedures.
- (c) If signs of mild stomatitis occur
(sensation of dryness and burning; mild erythema and edema along the
- Increase frequency of oral hygiene by rinsing with one of the
suggested solutions between brushings and once during the night.
- Discontinue flossing if it causes pain.
- Provide systemic or topical analgesics as ordered.
- Increased sensitivity to pain is a result of thinning
of oral mucosal lining.
- 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.
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
- 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.
- Caution client to chew or swallow after each dose
- As numbness of throat may be experienced.
- Explain use of topical protective agent
- To coat the lesions and promote healing as
- 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
- (i) For severe mucositis infection:
- Administer local antibiotics and/or antifungal agents as
- Mycostatin, nystatin, and Mycelex Troche are commonly
- Discontinue use of toothbrush and flossing
- As this will increase damage to ulcerated tissues. A
disposable foamstick ("Toothette") or sterile cotton swab are gentle ways to
apply cleansing solutions.
- Continue use of lubricating ointment on the lips.
- (i) For eating problems:
- Encourage diet high in protein and vitamins
- To promote healing and new tissue growth.
- Serve foods and fluids lukewarm or cold
- As this may feel soothing to the oral mucosa.
- Serve frequent small meals or snacks spaced throughout the day
- To maintain fluid balance and nutrition.
- Encourage soft foods (mashed potatoes, puddings, custards,
- To avoid tissue trauma and pain.
- Encourage use of a straw
- To make swallowing easier.
- Encourage peach, pear, or apricot nectars and fruit drinks
instead of citrus juices
- As these are not irritating and are easier to
- (See Fluid Volume Deficit, Chapter 3.)
- (c) Refer patient to dietitian for
instructions on maintenance of a well-balanced diet.
Education/Continuity of Care
- (i) independent
- Instruct patient/caregiver to:
- (i) Gently brush all surfaces of teeth, gums,
and tongue with a soft nylon brush.
- To loosen debris.
- (i) Brush with a nonirritating dentrifice such
as baking soda.
- (i) Remove and brush dentures thoroughly
during and after meals and as needed.
- To reduce risk of infection and improve appetite.
- (i) Rinse the mouth thoroughly during and
- Removing food particles decreases risk of infection related
to trapped decaying food.
- (i) Avoid alcohol-containing mouthwashes.
- As these may dry oral mucous membranes, increasing risk for
disruption of mucous membrane.
- (i) 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
- Baking soda and water (1 tsp in 500 ml).
- Salt (.5 tsp), baking soda (1 tsp), and water (100 ml).
- (i) Keep lips moist.
- To prevent drying and cracking.
- Use a lip product or a water-soluble lubricant
- To minimize risk of aspirating non-water-soluble
- (i) Include food items with each meal that
- As this stimulates gingival tissue and promotes
- (i) Minimize trauma to mucous membranes. Avoid
use of tobacco and alcohol.
- As these are irritating and drying to the mucosa.
- (i) Avoid extremely hot or cold foods. Avoid
acidic or highly spiced foods.
- (i) Have loose-fitting dentures adjusted.
- Rubbing and irritation from ill-fitting dentures promotes
disruption of the oral mucous membrane.
Oral Health Restoration; Oral Health Maintenance
~ Care Plan Index ~
Outcomes Index ~
~ Care Plan Constructor Home ~