Nurse's Pocket Guide

impaired ORAL MUCOUS MEMBRANE
• Note use of tobacco (including smokeless) and alcohol which
may predispose mucosa to infection, cell damage, and cancer.
• Assess for dry mouth, thick or absent saliva, and abnormal
tongue surfaces.
• Observe for chipped or sharp-edged teeth. Note fit of dentures
or other prosthetic devices when used.
• Assess medication use and possibility of side effects affecting
health or integrity of oral mucous membranes.
• Determine allergies to food/drugs, other substances.
• Evaluate client’s ability to provide self-care and availability of
necessary equipment/assistance. Client’s age, as well as current
health status, affects ability to provide self-care.
• Review oral hygiene practices: frequency and type (brush/
floss/Water Pik); professional dental care.
NURSING PRIORITY NO. 2. To correct identified/developing
problems:
• Routinely inspect oral cavity and throat for inflammation,
sores, lesions, and/or bleeding. Determine if client is experiencing
pain or painful swallowing.
• Encourage adequate fluids to prevent dry mouth and
dehydration.
• Encourage use of tart, sour, and citrus foods and drinks;
chewing gum; or hard candy to stimulate saliva.
• Lubricate lips and provide commercially prepared oral lubricant
solution.
• Provide for increased humidity, if indicated, by vaporizer or
room humidifier if client is mouth-breather.
• Provide dietary modifications (e.g., food of comfortable texture,
temperature, density) to reduce discomfort/improve intake,
and adequate nutrients and vitamins to promote healing.
• Avoid irritating foods/fluids, temperature extremes. Provide
soft or pureed diet as required.
• Use lemon/glycerin swabs with caution; may be irritating if
mucosa is injured.
• Assist with/provide oral care, as indicated:
Offer/provide tap water or saline rinses, diluted alcohol-free
mouthwashes.
Provide gentle gum massage and tongue brushing with soft
toothbrush or sponge/cotton-tip applicators (limits
mucosal/gum irritation).
Assist with/encourage brushing and flossing when client is
unable to do self-care.
Review safe use of electric or battery-powered mouth care
devices (e.g., toothbrush, plaque remover, etc.), as indicated.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
496 Cultural Collaborative Community/Home Care