Altered Oral Mucous Membranes: Stomatitis

Altered
Oral Mucous Membranes: Stomatitis

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Immunosupression from chemotherapy
(_) Nutritional depletion
(_) Radiation to head and neck

(_) Improper fitting dentures
(_) Excessive dry mouth
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(Must be
present
)

(_)
Disruption of mucous membrane tissue.
(_) Lesion
Minor:

(May be
present
)

(_)
Coated tongue (_) Dry mucous membranes
(_) Edema (_)Erythema (_) Leukoplakia

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date
Achieved:
  The
patient will:

(_)
Be free of oral mucosa irritation.

(_) Exhibit signs of
healing with decrease inflammation.

(_) Other:

  (_)
Obtain history of radiation or chemotherapy regimen.

(_) Check for oral burning,
pain, or change in tolerance to temperature.

(_) Do oral exam
noting evidence of lesions within the mouth and tongue
q____.

(_) Oral hygiene q____
hours using:
________________________

(_) Teach patient to:

  • avoid commercial
    mouth washes, citrus fruit juices, spicy foods,
    extremes in food temperature, crusty or rough
    foods
  • use straw to
    facilitate fluids bypassing inflammed lesions (if
    indicated)
  • use soft tooth
    brush or toothettes for oral care
  • check for proper
    fit of dentures

(_)
Other:________________

________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature