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:________________
________________________
________________________
________________________

 

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Patient/Significant other signature

 

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RN signature