Patients who have experienced oral mucositis report it as the most bothersome side effect of cancer therapy. It can result in pain, infection, and nutritional defi cits, and can interfere with appropriate cancer treatment. Many patients with mucositis are opiate-naive, presenting clinical challenges.
A survey at Memorial Sloan- Kettering Cancer Center (MSKCC) uncovered discrepancies in mucositis assessment and management; the need for a practice change at MSKCC was identified. This was accomplished through comprehensive assessment of the medical literature and of current evidence-based guidelines on mucositis, focusing on prevention and management recommendations relevant to nursing.
A database was used to collect information from each citation detailing the size of the population assessed; the scientific rigor of the study; the assessment tool used; and specific recommendations regarding oral care, rinses, cryotherapy, and any other strategies for prevention or treatment. The multidisciplinary team from MSKCC that worked to develop the evidence-based nursing intervention for mucositis outlined in this article included nurses from both the inpatient and ambulatory areas, a nutritionist, a dentist, a pharmacist, and physicians (who reviewed the fi nal protocol).
OUTCOME GOALS
• Consistent oral mucositis assessment and patient education
• Patient understanding of oral cavity care
• Minimized discomfort and weight loss from mucositis
PATIENT ASSESSMENT
Initial Assessment
• Assess the patient's risk for mucositis. Treatment-related factors that increase risk of mucositis include bone marrow or hematopoietic stem cell transplant, radiation to the head and neck (with risk increased further when radiation is concurrent with fl uorouracil), and chemotherapy/biologic agents that interfere with DNA synthesis. Patient-related factors include prolonged neutropenia, previous history of severe herpes simplex infection, poor nutritional status, poor oral hygiene, periodontal disease, dental caries, ill-fitting dentures, and continued use of alcohol(Drug information on alcohol) or tobacco.
• Assess current oral hygiene and dental care measures (eg, use of mouthwash, dental floss, oral irrigation).
• Inspect all surfaces of the oral cavity using direct lighting and a tongue blade to ensure all areas are visualized.
• Use the Common Terminology Criteria for Adverse Events (CTCAE) v.3.0 scale (mucositis— clinical exam): 0 = None; 1 = Erythema of mucosa; 2 = Patchy ulcerations or pseudomembranes; 3 = Confluent ulcerations or pseudomembranes, bleeding with minor trauma; 4 = Tissue necrosis, significant spontaneous bleeding, life-threatening consequences.
• Observe for unhealed surgical incisions, evidence of poor oral hygiene, ill-fitting dental appliance, and signs or symptoms of infection.
• Assess ability to swallow solids, soft foods, and liquids. Use the CTCAE v.3.0 scale (mucositis—functional/symptomatic): 0 = No symptoms; 1 = Minimal symptoms, normal diet; 2 = Symptomatic but can eat and swallow modified diet; 3 = Symptomatic and unable to adequately aliment or hydrate orally; 4 = Symptoms associated with life-threatening consequences.
• Assess for presence and severity of mouth or throat pain using a numerical scale (0–10) or a categorical scale (none, mild, moderate, severe).
• Assess nutritional status (ie, oral intake, current weight, and amount of weight loss during previous 3 months).
