Symptom: Sores in Mouth

Initial Grading Reminder

CTCAE grading of mouth sores:

Grade 2 (Moderate): Moderate pain; not interfering with oral intake; modified diet indicated
Grade 3 (Severe): Severe pain; interfering with oral intake
Grade 4 (Life-threatening): Urgent intervention required

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have any history of cold sores?  Are you taking steroids? Is this a new or worsening symptom? Where are the sores (e.g., on your tongue, the inside or outside of your gums, your lips)? When did it start or get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

How much pain are you experiencing in your mouth? Is it leading you to alter your eating/drinking habits? Are you able to eat enough? How much fluid are you drinking per day? 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 moderate or worse symptoms should be seen.

    Patients with any of the red-flag symptoms should be seen 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)

    Skin Toxicities - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is there an obvious rash?
    • Is the patient scratching during the visit?
    • Is skin integrity intact?
    • Are there skin changes?
      • Xerosis
      • Changes in skin pigment or color
    • Is there oral involvement of the rash?
    • Does the patient have pruritus with or without rash? Is there a rash with or without pruritus?
    • Are symptoms interfering with ADLs?
    • With sleep?
    • Have symptoms worsened?
    • Is there a history of dermatitis, pre-existing skin issues (psoriasis, wounds, etc.)?
    • Laboratory abnormalities consistent with other etiologies (e.g., eosinophils on complete blood count, liver function abnormalities)

    Differential Diagnosis

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