Symptom: Pain, Mouth

Initial Grading Reminder

Grade 1: Mild pain
Grade 2: Moderate pain; limiting instrumental ADLs
Grade 3: Severe pain; limiting self-care ADLs

Assessment and Grading

Assess any pre-existing comorbidities that may predispose to mouth pain. Assess whether the patient is on steroids, which is a risk factor for thrush.

Characterize the symptom (onset, pace)

Ask the patient:

Is this a new or worsening symptom? When did it start or get worse? Any new medications (e.g., steroids)? Has it developed gradually or suddenly? Have you had any issues with pain in your mouth in the past?

Grade the symptom

Ask the patient:

How  much pain are you experiencing in your mouth? Are there actual sores in your mouth or on your tongue? Are your tongue/gums swollen? Is the pain leading you to alter your eating/drinking habits? How much fluid are you drinking per day? Are you able to eat enough? Are you able to swallow?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you feeling weak, dizzy, or confused? Are you in intense pain?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with newly emergent moderate or worse mouth pain should be evaluated.

    Patients with any of the red-flag symptoms should be evaluated immediately.

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    Nursing Assessment of Potential Causes

    Mucositis & Xerostomia - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Difficulty talking?
    • Licking lips to moisten often?
    • Weight loss?
    • Does the patient appear dehydrated?
    • Does the patient have thrush?
    • Does the patient report?
      • Mouth pain (tongue, gums, buccal mucosa)
      • Mouth sores
      • Difficulty eating
      • Waking during the sleep to sip water
      • Recent dental-related issues
      • Need for dental work (e.g., root canal, tooth extraction)
    • Have symptoms worsened?
    • A history of mouth sores
    • Does patient smoke?
    • Concomitant medications associated with causing dry mouth?
    • Reports of dry mouth often accompany mucositis
    • Other reports of dry membranes (e.g., eyes, nasal passages, vagina)

    Differential Diagnosis

    What do you suspect is the cause of the mouth pain?