Risk for Impaired Oral Mucous Membrane

Nursing diagnosis: risk for impaired Oral Mucous Membrane

Risk factors may include
Lack of or decreased salivation, fluid restrictions
Chemical irritation, conversion of urea in saliva to ammonia

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

Desired Outcomes/Evaluation Criteria—Client Will
Oral Health
Maintain integrity of mucous membranes.
Identify and initiate specific interventions to promote healthy oral mucosa.

Nursing intervention with rationale:
1. Inspect oral cavity: note moistness, character of saliva, presence of inflammation, ulcerations, and leukoplakia.
Rationale: Provides opportunity for prompt intervention and prevention of infection.

2. Provide fluids throughout 24-hour period within prescribed limit.
Rationale: Prevents excessive oral dryness from prolonged period without oral intake.

3. Offer frequent mouth care or rinse with 0.25% acetic acid solution. Provide gum, hard candy, or breath mints between meals.
Rationale: Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea.

4. Encourage good dental hygiene after meals and at bedtime. Recommend avoidance of dental floss.
Rationale: Reduces bacterial growth and potential for infection. Dental floss may cut gums, potentiating bleeding.

5. Recommend client stop smoking and avoid lemon and glycerin products or mouthwash containing alcohol.
Rationale: These substances are irritating to the mucosa and have a drying effect, potentiating discomfort.

6. Provide artificial saliva as needed, such as Ora-Lube.]
Rationale: Prevents dryness, buffers acids, and promotes comfort.