NOC Tissue Integrity Skin and Mucous Membrane


Assess mouth daily for oral ulcers, To effectively treat oral ulcers pain, ability to ingest foods; and to promote healing; to provide meticulous oral hygiene, to prevent bacterial and Candida prevent oral breakdown and to infections; to prevent trauma promote healing (start as soon as a to oral mucosa. drug is used that causes oral ulcers): use a soft sponge toothbrush or toothette, administer frequent mouth rinses, at least every 4 hours and after meals; mouth rinses commonly used include Peridex, normal saline with or without sodium bicarbonate solution.

Administer nystatin mouthwashes as ordered after mouth rinses; restrict oral intake for 30 minutes after taking this mouthwash.

Administer Acyclovir (topically or IV) for oral herpes lesions as ordered.

Apply local anesthetics to ulcerated areas before meals and as needed to relieve pain; topical agents include: Ora-base; can be applied directly to oral lesions as ordered or swished and spit.

Apply lip balm (daily).

Encourage a bland, soft diet and selection of foods by child.

Avoid using lemon glycerin swabs.

Avoid juices containing ascorbic acid, hot, cold, or spicy foods.

Avoid use of hydrogen peroxide as a mouth rinse.

Avoid use of milk of magnesia.

Provide education to parents and child: 1) chemotherapy and radiation may cause oral ulcers; 2) effective oral hygiene strategies to prevent and treat oral ulcers; 3) child may require hospitalization (for hydration, parental nutrition, pain control of oral ulcers) if stomatitis interferes with food or fluid intake

NIC: Surveillance Evaluation

To maintain oral integrity; to treat bacterial and fungal infections.

To prevent or treat herpetic infections.

To relieve pain associated with oral ulcers.

To prevent cracking and fissuring of lips; to maintain lip integrity.

To minimize oral discomfort and irritation; enhances sense of control, independence, decreases sense of helplessness; may increase child's level of nutrition.

To prevent irritation of mouth ulcers decay of teeth.

To prevent discomfort to oral ulcers.

It will delay healing of oral ulcers by breaking down protein.

To prevent drying of oral mucosa.

Promotes understanding of oral stomatitis, significance of daily oral hygiene, and pain control for oral ulcers.

(Date/time of evaluation of goal)

(Has goal been met? Not met? Partially met?)

(Is there any evidence of mucous membrane impairment or new lesions?) (Revisions to care plan? D/C care plan? Continue care plan?)

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