Impaired Oral Mucous Membrane | Nursing Care Plan for Ventilatory Assistance

Nursing diagnosis: Impaired Oral Mucous Membrane

Risk factors may include

Inability to swallow oral fluids

Presence of tube in mouth

Lack of or decreased salivation

Ineffective oral hygiene

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Tissue Integrity: Skin and Mucous Membrane

Report or demonstrate a decrease in symptoms.

Caregiver Will

Identify specific interventions to promote healthy oral mucosa as appropriate.

Nursing intervention with rationale:

1. Routinely inspect oral cavity, teeth, gums for sores, lesions, and bleeding.

Rationale: Early identification of problems provides opportunity for appropriate intervention and preventive measures.

2. Administer mouth care routinely per protocol and as needed, especially in client with an oral intubation tube; for example, cleanse mouth with water, saline, or preferred alcoholfree mouthwash. Brush teeth with soft toothbrush, WaterPik, or moistened swab.

Rationale: Prevents drying and ulceration of mucous membrane and reduces medium for bacterial growth. Promotes comfort.

3. Change position of ET tube and airway on a regular and prn (as necessary) schedule as appropriate.

Rationale: Reduces risk of lip and oral mucous membrane ulceration.

4. Apply lip balm; administer oral lubricant solution.

Rationale: Maintains moisture and prevents drying.