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.

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.