PNEUMONIA

Nursing Diagnosis: Imbalanced Nutrition:

less than body requirements
Carroll A. Lutz
NANDA Definition: Intake of nutrients insufficient to meet
metabolic needs

Defining Characteristics: Body weight 20% under ideal

weight; pale conjunctival and mucus membranes; weakness
of muscles required for swallowing or mastication; sore,
inflamed buccal cavity; satiety immediately after ingesting
food; reported or evidence of lack of food; reported
inadequate food intake less than RDA (Recommended Dietary
Allowance); reported altered taste sensation; perceived
inability to ingest food; misconceptions; loss of weight with
adequate food intake; aversion to eating; abdominal
cramping; poor muscle tone; abdominal pain with or without
pathology; lack of interest in food; capillary fragility; diarrhea
and/or steatorrhea; excessive loss of hair; hyperactive bowel
sounds; lack of information; misinformation

Related Factors: Inability to ingest or digest food or absorb

nutrients because of biological, psychological, or economic
factors

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
 Nutritional Status

 Nutritional Status: Food and Fluid Intake

 Nutritional Status: Nutrient Intake

 Weight Control

Client Outcomes

 Progressively gains weight toward desired goal

 Weight is within normal range for height and

age
  Recognizes factors contributing to underweight

 Identifies nutritional requirements

 Consumes adequate nourishment

 Free of signs of malnutrition

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

 Nutrition Management

 Eating Disorders Management

 Electrolyte Management: Hypophosphatemia

 Enteral Tube Feeding

 Feeding

 Nutrition Therapy

 Nutritional Counseling

 Nutritional Monitoring

 Swallowing Therapy

 Weight Gain Assistance

 Weight Management

Nursing Interventions and Rationales

 Determine healthy body weight for age and

height. Refer to dietitian for complete nutrition
assessment if 10% under healthy body weight or if
rapidly losing weight. Legal intervention may be
necessary. Early diagnosis and a holistic team
treatment of eating disorders are desirable. Of
women who ran 15 to 30 miles per week, 20% to
25% had increased risk of eating disorders (Estok,
 Rudy, 1996). In the developed world, protein-
calorie malnutrition (PCM) most often
accompanies a disease process. Surveys of
hospitalized children in this country revealed that
20% to 40% had PCM (Baker, 1997). Over the
short term, patients involuntarily committed for
treatment of eating disorders progressed as well
as those seeking treatment voluntarily (Watson,
Bowers, Andersen, 2000).

 Compare usual food intake to USDA Food

Pyramid, noting slighted or omitted food groups.
Milk consumption has decreased among children
while intake of fruit juices and carbonated
beverages has increased. A higher incidence of
bone fractures in teenage girls has been
associated with a greater consumption of
carbonated beverages (Wyshak, 2000). Possibly
also related is the substitution of soda for milk.
Omission of entire food groups increases risk of
deficiencies.

 If client is a vegetarian, evaluate if obtaining

sufficient amounts of vitamin B12 and iron. Strict
vegetarians may be at particular risk for vitamin
B12 and iron deficiencies. Special care should be
taken when implementing vegetarian diets for
pregnant women, infants, children, and the
elderly. A dietitian can usually furnish a balanced
vegetarian diet (with adequate substitutes for
omitted foods) for inpatients and can provide
instruction for outpatients.

 Assess client's ability to obtain and use

essential nutrients. Cases of vitamin D deficiency
rickets have been reported among dark-skinned
infants and toddlers who were exclusively breast
fed and were not given supplemental vitamin D.
The children resided in northern (Fitzpatrick et al,
2000), mid-south (Kreiter et al, 2000), and
southern (Shah et al, 2000) states, indicating that
the presence of natural sunlight does not
eliminate the risk of disease.
 Observe client's ability to eat (time involved,
motor skills, visual acuity, ability to swallow
various textures). Poor vision was associated with
lower protein and energy (calorie) intakes in home
care clients independent of other medical
conditions (Payette et al, 1995).

NOTE: If client is unable to feed self, refer to

Nursing Interventions and Rationales for
Feeding Self-care deficit. If client has difficulty
swallowing, refer to Nursing Interventions
and Rationales for Impaired Swallowing.

 If client lacks endurance, schedule rest periods

before meals and open packages and cut up food
for client. Nursing assistance with activities of
daily living (ADLs) will conserve the client's energy
for activities the client values. Clients who take
longer than 1 hour to complete a meal may
require assistance (Evans, 1992).

 Evaluate client's laboratory studies (serum

albumin, serum total protein, serum ferritin,
transferrin, hemoglobin, hematocrit, vitamins, and
minerals). An abnormal value in a single
diagnostic study may have many possible causes,
but serum albumin less than 3.2 g/dl was shown
to be highly predictive of mortality in hospitals,
and serum cholesterol of less than 156 mg/dl was
the best predictor of mortality in nursing homes
(Morley, 1997).

 Maintain a high index of suspicion of

malnutrition as a contributing factor in infections.
Impaired immunity is a critical adjunct factor in
malnutrition-associated infections in all age
groups in all populations of the world (Chandra,
1997).

 Be alert for food-nutrient-drug interactions.

Individuals at greatest risk are those who are
malnourished, consume alcohol, receiving many
drugs long term for chronic diseases, or take
medications with meals or through a feeding tube
(Lutz, Przytulski, 2001). Case reports still appear
 in medical journals describing scurvy in persons
with alcoholism (Garg, Draganescu, Albornoz,
1998).

 Assess for recent changes in physiological

status that may interfere with nutrition. The
consequences of malnutrition can lead to a further
decline in the patient's condition that then
becomes self-perpetuating if not recognized and
treated. Extreme cases of malnutrition can lead to
septicemia, organ failure, and death (Arrowsmith,
1997). Diarrhea in patients receiving warfarin has
been suggested as possibly causing lower intake
and/or malabsorption of vitamin K (Black, 1994;
Smith, Aljazairi, Fuller, 1999).

 If the client is pregnant, ensure that she is

receiving adequate amounts of folic acid by eating
a balanced diet and taking prenatal vitamins as
ordered. All women of childbearing potential are
urged to consume 400 (g of synthetic folic acid
from fortified foods or supplements in addition to
food folate from a varied diet (National Academy
of Sciences, 1998).

 Observe client's relationship to food. Attempt to

separate physical from psychological causes for
eating difficulty. It may be difficult to tell if the
problem is physical or psychological. Refusing to
eat may be the only way the client can express
some control, and it may also be a symptom of
depression (Evans, 1992).

 Provide companionship at mealtime to

encourage nutritional intake. Mealtime usually is a
time for social interaction; often clients will eat
more food if other people are present at
mealtimes.

 Consider six small nutrient-dense meals vs.

three larger meals daily to reduce the feeling of
fullness. Eating small, frequent meals reduces the
sensation of fullness and decreases the stimulus
to vomit (Love, Seaton, 1991).
 Weigh client weekly under same conditions.

 Monitor food intake; specify proportion of

served food that is eaten (25%, 50%); consult
with dietitian for actual calorie count.

 Monitor state of oral cavity (gums, tongue,

mucosa, teeth).

 Provide good oral hygiene before and after

meals. Good oral hygiene enhances appetite; the
condition of the oral mucosa is critical to the
ability to eat. The oral mucosa must be moist,
with adequate saliva production to facilitate and
aid in the digestion of food (Evans, 1992).

 If a client has anorexia and dry mouth from

medication side effects, offer sips of fluids
throughout the day. Although artificial salivas are
available, more often than not clients preferred
water to the more expensive products (Ganley,
1995).

 Determine relationship of eating and other

events to onset of nausea, vomiting, diarrhea, or
abdominal pain.

 Determine time of day when the client's

appetite is the greatest. Offer highest calorie meal
at that time. Clients with liver disease often have
their largest appetite at breakfast time.

 Offer small volumes of light liquids as an

appetizer before meals. Small volumes of liquids
(up to 240 mL) stimulate the gastrointestinal
tract, which enhances peristalsis and motility
(Rogers-Seidel, 1991).

 Administer antiemetics as ordered before

meals. Antiemetics are more effective when given
before nausea occurs.

 Prepare the client for meals. Clear unsightly

supplies and excretions. Avoid invasive procedures
 before meals. A pleasant environment helps
promote intake.

 If food odors trigger nausea, remove food

covers away from client's bedside. Trapped odors
diffuse into air away from client.

 If vomiting is a problem, discourage

consumption of favorite foods. If favorite foods
are consumed and then vomited, the client may
later reject them.

 Work with client to develop a plan for increased

activity. Immobility leads to negative nitrogen
balance that fosters anorexia.

 If client is anemic, offer foods rich in iron and

vitamins B12, C, and folic acid. Heme iron in
meat, fish, and poultry is absorbed more readily
than nonheme iron in plants. Vitamin C increases
the solubility of iron. Vitamin B12 and folic acid
are necessary for erythropoiesis.

 If the client is lactose intolerant (genetically or

following diarrhea), suggest cheeses (natural or
processed) with less lactose than fluid milk.
Encourage client to identify the extent of the
intolerance. When lactose intake is limited to the
equivalent of 240 ml of milk or less a day,
symptoms are likely to be negligible and the use
of lactose-digestive aids unnecessary (Suarez.
Savaiano, Levitt, 1995).

 For the agitated client, offer finger foods

(sandwiches, fresh fruit) and fluids that can be
ingested while pacing. If a client cannot be still,
food can be consumed while he or she is in
motion.
Geriatric
 Assess for protein-energy malnutrition. Protein-
energy malnutrition in older persons is rarely
recognized and even more rarely treated
appropriately (Morley, 1997). Clients in
 institutions are susceptible to protein-calorie
malnutrition (PCM) or protein-energy malnutrition
when they are unable to feed themselves. When
followed for 6 months in a long-care hospital, 84%
of patients had an intake below estimated energy
expenditure and 30% were below estimated basal
metabolic rate (BMR) (Elmstahl et al, 1997).
Patients admitted to a geriatric rehabilitation unit
had an average of four nutritional problems. The
primary nutrition problem was protein-energy
malnutrition, which was associated with an
increased length of stay (Keller, 1997). Nutritional
risk independently increased the likelihood of
death in cognitively impaired older adults (Keller,
Ostbye, 2000).

 Interpret laboratory findings cautiously.

Compromised kidney function makes reliance on
urine samples for nutrient analyses less reliable in
the elderly than in younger persons.

 Offer high protein supplements based on

individual needs and capabilities. Give client a
choice of supplements to increase personal
control. If client is unwilling to drink a glass of
liquid supplement, offer 30 ml per hour in a
medication cup and serve it like medicine. Patients
with decreased kidney function may not be able to
excrete the waste products from protein
metabolism. Often the elderly will take
medications when they will not take food. The
supplement is then served as a medicine.

 Offer liquid energy supplements. Energy

supplementation has been shown to produce
weight gain and reduce falls in frail elderly living
in the community. It also has been shown to
decrease mortality in hospitalized older persons
and to decrease morbidity and mortality in hip
fracture patients. When given liquid preloads 60
minutes before the next meal, older persons
consistently ate a greater total energy load
(Morley, 1997). Inadequate kilocaloric intake has
 been correlated with increased mortality in the
elderly (Elmstahl et al, 1997; Incalzi et al, 1996).

 Unless medically contraindicated, permit self-

selected seasonings and foods. Older persons rate
flavor as the most important determinant of their
food choice. Ability to taste declines in most but
not all aging clients. Usually salt receptors are
most affected and sweet receptors least affected.
Blindfolded older subjects have about one half the
ability of younger subjects to recognize blended
foods, which predominantly results from a decline
in olfactory sense (Morley, 1997). In hospitalized
patients permitted their preferred food, ice cream,
ad libitum, protein-energy malnutrition was
reversed (Winograd, Brown, 1990).

 Play relaxing dinner music during mealtime. On

a nursing home ward for demented patients, the
patients ate more calmly and spent more time
with dinner when music was played (Ragneskog et
al, 1996). Selections with a slow tempo, at or
below the human heart rate, have usually been
used to dampen environmental noises that might
otherwise startle clients. Fewer incidents of
agitated behaviors occurred during the weeks that
music was played compared with weeks without
music (Denney, 1997).

 Assess components of bone health: calcium

intake, vitamin D status, and regular exercise. The
Adequate Intake (AI) for calcium for adults aged
19 to 50 years is 1000 mg. For those >50 years of
age the amount is 1200 mg (National Academy of
Sciences, 1998). Milk and milk products are the
best animal sources of calcium, followed by
sardines, clams, oysters, and salmon. In milk,
calcium is combined with lactose, which increases
absorption (although only 28% of the available
calcium in milk is absorbed). Besides lactose,
another advantageous component in milk is the
protein the osteoblasts need to rebuild the bone
matrix. In sum, milk is such an important source
of calcium that it is virtually impossible to obtain
 adequate dietary calcium without milk or dairy
products (Lutz, Przytulski, 2001). In the absence
of adequate exposure to sunlight, the AI for
vitamin D is set at 5 mg/day for persons 31 to 50
years of age, 10 mg for those 51 to 70 years of
age, and 15 mg for persons (71 years of age
(National Academy of Sciences, 1998). An 80-
year-old person requires almost twice as much
time in the sun to produce the same amount of
vitamin D as a 20-year-old person does (Ryan,
Eleazer, Egbert, 1995). Even among
institutionalized elderly, prevalence of vitamin D
deficiency showed significant seasonal variation
(Liu et al, 1997). The USDA Modified Food Guide
Pyramid for People Over 70 Years of Age specifies
calcium, vitamin D, and vitamin B12
supplementation (Russell, Rasmussen,
Lichtenstein, 1999). Exercise not only increases
bone density but also increases muscle mass and
improves balance (Nelson et al, 1994).

 Instruct in wise use of supplements. Milk-alkali

syndrome has occurred in women ingesting 4 to
12 g of calcium carbonate daily (Beall, Scofield,
1995).

 Consider social factors that may interfere with

nutrition (e.g., lack of transportation, inadequate
income, lack of social support). Nutritional
deficiencies are seen in at least one third of the
elderly in industrialized countries (Chandra,
1997). In most surveys, poverty was found to be
the major social cause of food insecurity and
weight loss, but friendship networks play an
important role in maintaining adequate food
intake (Morley, 1997).

 Assess for psychological factors that impact

nutrition. Watch for signs of depression. In
persons with depression, 90% of the elderly lose
weight, compared with 60% of younger persons
(Morley, 1997).

 Consider the effects of medications on food

intake. Appetite-stimulating drugs may have a role
 in some cases. The side effects of drugs are a
major cause of weight loss in older persons
(Morley, 1997). Compared with a placebo,
megestrol acetate improved appetite and
promoted weight gain in geriatric patients (Yeh et
al, 2000).

 Provide appropriate food textures for chewing

ease. Insert dentures (if needed) before meals.
Assess fit of dentures. Refer for dental
consultation if needed. The bony structure of jaws
changes over time, requiring adjustment of
dentures. The most common feeding difficulties
among geriatric rehabilitation clients involved
dentures (lack of or ill fitting) and oral infections
(Keller, 1997).

NOTE: If client unable to feed self, refer to

Nursing Interventions and Rationales for
Feeding Self-care deficit.
Multicultural
 Assess for dietary intake of essential nutrients.
Studies have shown that black women have
calcium intakes of (75% of the RDA (Zablah et al,
1999). Hispanics with type II diabetes also often
have inadequate protein nutritional status
(Castenada, Bermudez, Tucker, 2000). Mexican-
American women have a higher prevalence of iron
deficiency anemia than non-Hispanic white
females (Frith-Terhune et al, 2000). Rural black
men had low caloric intakes coupled with high fat
intakes but nutrient deficiencies (Vitolins et al,
2000).

 Assess for the influence of cultural beliefs,

norms, and values on the client's nutritional
knowledge. What the client considers normal
dietary practices may be based on cultural
perceptions (Leininger, 1996).

 Discuss with the client those aspects of their

diet that will remain unchanged. Aspects of the
client's life that are meaningful and valuable to
 them should be understood and preserved without
change (Leininger, 1996).

 Negotiate with the client regarding the aspects

of his or her diet that will need to be modified.
Give and take with the client will lead to culturally
congruent care (Leininger, 1996).

 Validate the client's feelings regarding the

impact of current lifestyle, finances, and
transportation on ability to obtain nutritious food.
Validation lets the client know that the nurse has
heard and understands what was said, and it
promotes the nurse-client relationship (Stuart,
Laraia, 2001; Giger, Davidhizer, 1995)

Client/Family Teaching

 Help client/family identify area to change that

will make the greatest contribution to improved
nutrition. Change is difficult. Multiple changes may
be overwhelming.

 Build on the strengths in the client's/family's

food habits. Adapt changes to their current
practices. Accepting the client's/family's
preferences shows respect for their culture.

 Select appropriate teaching aids for the

client's/family's background.

 Implement instructional follow-up to answer

client's/family's questions.

 Suggest community resources as suitable (food

sources, counseling, Meals on Wheels, Senior
Centers).

 Teach client and family how to manage tube

feedings or parenteral therapy at home.
Nursing Diagnosis: Impaired Oral mucous
membrane
Betty J. Ackley
NANDA Definition: Disruptions of the lips and soft tissues of
the oral cavity

Defining Characteristics: Purulent drainage or exudates;

gingival recession, pockets deeper than 4 mm; enlarged
tonsils beyond what is developmentally appropriate; smooth
atrophic, sensitive tongue; geographic tongue; mucosal
denudation; presence of pathogens; difficult speech; self-
report of bad taste; gingival or mucosal pallor; oral
pain/discomfort; xerostomia (dry mouth); vesicles, nodules,
or papules; white patches/plaques, spongy patches, or white
curd-like exudate; oral lesions or ulcers; halitosis; edema;
hyperemia; desquamation; coated tongue; stomatitis; self-
report of difficult eating or swallowing; self-report of
diminished or absent taste; bleeding; macroplasia; gingival
hyperplasia; fissures, cheilitis; red or bluish masses (e.g.,
hemangiomas)

Related Factors: Chemotherapy; chemical (e.g., alcohol,

tobacco, acidic foods, regular use of inhalers); depression;
immunosuppression; aging-related loss of connective,
adipose, or bone tissue; barriers to professional care; cleft lip
or palate; medication side effects; lack of or decreased
salivation; chemical trauma (e.g., acidic foods, drugs,
noxious agents, alcohol); pathological conditions—oral cavity
(radiation to head or neck); NPO for more than 24 hours;
mouth breathing; malnutrition or vitamin deficiency;
dehydration; infection; ineffective oral hygiene; mechanical
(e.g., ill-fitting dentures, braces, tubes
[endotracheal/nasogastric], surgery in oral cavity); decreased
platelets; immunocompromised; impaired salivation;
radiation therapy; barriers to oral self-care; diminished
hormone levels (women); stress; loss of supportive
structures

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

 Oral Health
  Tissue Integrity: Skin and Mucous Membranes

Client Outcomes

 Maintains intact, moist oral mucous membranes

that are free of ulceration and debris

 Describes or demonstrates measures to regain

or maintain intact oral mucous membranes

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

 Oral Health Restoration

Nursing Interventions and Rationales

 Inspect oral cavity at least once daily and note

any discoloration, lesions, edema, bleeding,
exudate, or dryness. Refer to a physician or
specialist as appropriate. Oral inspection can
reveal signs of oral disease, symptoms of systemic
disease, drug side effects, or trauma of the oral
cavity (White, 2000).

 Assess for mechanical agents such as ill-fitting

dentures or chemical agents such as frequent
exposure to tobacco that could cause or increase
trauma to oral mucous membranes. Irritative and
causative agents for stomatitis should be
eliminated (Rhodes, McDaniel, Johnson, 1995).

 Monitor client's nutritional and fluid status to

determine if adequate. Refer to the care plan for
Deficient Fluid volume or Imbalanced
Nutrition: less than body requirements if
applicable. Dehydration and malnutrition
predispose clients to impaired oral mucous
membranes.

 Encourage fluid intake up to 3000 ml per day if

not contraindicated by client's medical condition
(Rhodes, McDaniel, Johnson, 1995). Fluids help
 increase moisture in the mouth, which protects
the mucous membranes from damage and helps
the healing process.

 Determine client's mental status. If client is

unable to care for self, oral hygiene must be
provided by nursing personnel. The nursing
diagnosis Bathing/Hygiene Self-care deficit is
then also applicable.

 Determine client's usual method of oral care

and address any concerns regarding oral hygiene.
Whenever possible, build on client's existing
knowledge base and current practices to develop
an individualized plan of care.

 If client does not have a bleeding disorder and

is able to swallow, encourage to brush teeth with a
soft pediatric-sized toothbrush using a fluoride-
containing toothpaste after every meal and to
floss teeth daily. The toothbrush is the most
important tool for oral care. Brushing the teeth is
the most effective method for reducing plaque and
controlling periodontal disease (Buglass, 1995;
Stiefel et al, 2000; Roberts, 2000).

 Use tap water or normal saline to provide oral

care; do not use commercial mouthwashes
containing alcohol or hydrogen peroxide. Also, do
not use lemon-glycerin swabs. Alcohol dries the
oral mucous membranes Hydrogen peroxide can
damage oral mucosa and is extremely foul tasting
to clients (Tombes, Gallucci, 1993; Winslow,
1994). Lemon-glycerin swabs can result in
decreased salivary amylase and oral moisture, as
well as erosion of tooth enamel (Crosby 1989,
Stiefel et al, 2000; Roberts, 2000).

 Use foam sticks to moisten the oral mucous

membranes, clean out debris, and swab out the
mouth of the edentulous client. Do not use to
clean the teeth or else the platelet count is very
low, and the client is prone to bleeding gums.
Studies have shown that foam sticks are probably
 not effective for removing plaque from teeth
(Roberts, 2000). However, they are useful for
cleaning the mouth of the edentulous client
(Curzio, McCowan, 2000).

 If client's oral cavity is dry, the keep inside of

the mouth moist with frequent sips of water and
salt water rinses (1/2 tsp salt in 8 oz of warm
water) or artificial saliva. Moisture promotes the
cleansing effect of saliva and helps avert mucosal
drying, which can result in erosions, fissures, or
lesions (Rhodes, McDaniel, Johnson, 1995).
Sodium chloride rinses have been shown to be
effective for the prevention and treatment of
stomatitis (Feber, 1994).

 Keep lips well lubricated using petroleum jelly

or a similar product (Yeager et al, 2000).

 For clients with stomatitis, increase frequency

of oral care up to every hour while awake if
necessary. Increasing the frequency of oral care
has been shown to be effectively decrease
stomatitis (Armstrong, 1994).

 Provide scrupulous oral care to critically ill

clients. Cultures of the teeth of critically ill clients
have yielded significant bacterial colonization,
which can cause nosocomial pneumonia
(Scannapieco, Stewart, Mylotte, 1992).

 If mouth is severely inflamed and it is painful to

swallow, contact the physician for a topical
anesthetic agent or analgesic order. Modification
of oral intake (e.g., soft or liquid diet) may also be
necessary to prevent friction trauma. The nursing
diagnosis Imbalanced Nutrition: less than
body requirements may apply.

 If whitish plaques are present in the mouth or

on the tongue and can be rubbed off readily with
gauze, leaving a red base that bleeds, suspect a
fungal infection and contact the physician for
follow-up. Oral candidiasis (moniliasis) is
 extremely common secondary to antibiotic
therapy, steroid therapy, HIV infection, diabetes,
or immunosuppressive drugs and should be
treated with oral or systemic antifungal agents
(Fauci et al, 1998; Epstein, Chow, 1999).

 If client is unable to swallow, keep suction

nearby when providing oral care.

 Refer to Impaired Dentition if the client has

problems with the teeth.
Geriatric

 Carefully observe oral cavity and lips for

abnormal lesions such as white or red patches,
masses, ulcerations with an indurated margin, or a
raised granular lesion. Malignant lesions are more
common in elderly persons than in younger
persons (especially if there is a history of smoking
or alcohol use), and many elderly persons rarely
visit a dentist (Aubertin, 1997).

 Ensure that dentures are removed and

scrubbed at least once daily, removed and rinsed
thoroughly after every meal, and removed and
kept in an appropriate solution at night. This is an
evidence-based protocol for denture care (Curzio,
McCowan, 2000). Denture plaque-containing
candidiasis can cause denture-induced stomatitis,
which is more common with unhealthy lifestyles
and poor oral hygiene than otherwise (Sakki et al,
1997; Nikawa, Hamada, Yamamoto, 1998).

Home Care Interventions

 Instruct client to avoid alcohol- or hydrogen

peroxide-based commercial products for mouth
care and to avoid other irritants to the oral cavity
(e.g., tobacco, spicy foods). Oral irritants can
further damage the oral mucosa and increase the
client's discomfort.
  Instruct client in ways to soothe the oral cavity
(e.g., cool beverages, Popsicles, viscous lidocaine)
(Jaffe, Skidmore-Roth, 1993).

 If client often breathes by mouth, add humidity

to room unless contraindicated.

 If necessary, refer for home health aide

services to support family in oral care and
observation of the oral cavity.

Client/Family Teaching

 Teach client how to inspect the oral cavity and

monitor for signs and symptoms of infection,
complications, and healing.

 Teach how to implement a personal plan of oral

hygiene including a schedule of care.
Encouragement and reinforcement of oral care are
important to oral outcomes (Armstrong, 1994).