What is the recommended treatment and nursing mouth‑care orders for oral candidiasis in an elderly nursing‑home resident with a prior cerebrovascular accident, limited mobility, and dysphagia?

Treatment of Oral Candidiasis in a Post-Stroke Nursing Home Resident

For mild to moderate oral candidiasis in this patient, prescribe oral fluconazole 100-200 mg daily for 7-14 days, and immediately implement a structured oral hygiene protocol performed by nursing staff every 4-6 hours to address the underlying risk factors that led to this infection. 1

Antifungal Treatment Selection

Fluconazole is the first-line systemic agent for oral candidiasis in this clinical context. 1, 2

• Start with fluconazole 100-200 mg orally once daily for 7-14 days for moderate disease severity 1
• If the patient has difficulty swallowing pills due to dysphagia, fluconazole can be crushed or use the liquid suspension formulation 2
• For severe disease or if the patient cannot tolerate oral medications, use intravenous fluconazole 200-400 mg daily 1

Alternative Topical Options for Mild Disease

• Clotrimazole troches 10 mg dissolved in mouth 5 times daily for 7-14 days are effective for mild disease 1
• Nystatin suspension 4-6 mL (400,000-600,000 units) swished and swallowed 4 times daily for 7-14 days is another topical option 1
• However, given this patient's history of CVA with likely dysphagia, systemic fluconazole is more practical than troches that require prolonged oral dissolution 1, 3

Critical Nursing Orders for Oral Hygiene

The oral candidiasis in this patient reflects inadequate mouth care, which is the primary modifiable risk factor in nursing home residents with dysphagia and limited mobility. 4, 5

Structured Oral Care Protocol (Write These Specific Orders)

Order: Oral hygiene care every 4-6 hours while awake, performed by nursing staff:

1. Gently brush all tooth surfaces (or gums if edentulous) with a soft-bristled toothbrush and fluoride toothpaste 4
2. Use moistened oral swabs to clean tongue, palate, and buccal mucosa, removing all visible debris and coating 4, 5
3. Apply water-based lip balm to prevent cracking 6
4. If patient has dentures: Remove, clean thoroughly with denture brush and cleanser, soak in denture solution overnight, and ensure proper fit 1
5. Provide small sips of water after oral care (if swallow evaluation permits) or use oral moisturizing gel if NPO 6, 5

Documentation Requirements

Order: Document completion of oral care at each shift with notation of:

• Presence of white plaques, erythema, or bleeding 5
• Patient tolerance of procedure 4
• Any difficulty with swallowing observed during care 3, 5

Addressing Underlying Risk Factors

This patient's oral candidiasis developed due to a convergence of risk factors common in post-stroke nursing home residents. 3, 5, 7

Key Contributing Factors in This Patient

• Dysphagia from CVA leads to pooling of oral secretions and reduced mechanical cleansing 3, 7
• Limited mobility prevents self-care and increases dependence on staff for oral hygiene 5, 7
• Nursing home residents with stroke have 85% prevalence of impaired swallow safety and efficacy 5
• Poor oral hygiene is nearly universal (98.7% of hospitalized elderly with dysphagia have nutritional risk and oral health problems) 5

Swallowing Evaluation

Order a bedside swallow evaluation by speech therapy if not recently completed (within past 3 months) 3, 5

• Document current diet texture and liquid consistency recommendations 5
• Ensure staff are aware of aspiration precautions: upright positioning during and 30 minutes after meals, small bites, supervised feeding 3, 4
• 67.4% of elderly patients with dysphagia have periodontitis, which worsens aspiration pneumonia risk 5

Monitoring and Follow-Up

Schedule clinical reassessment in 7 days to evaluate treatment response. 1

• If symptoms persist after 7-14 days of fluconazole, consider fluconazole-refractory disease and switch to itraconazole solution 200 mg daily or posaconazole suspension 400 mg twice daily 1
• Chronic suppressive therapy with fluconazole 100 mg three times weekly may be needed if candidiasis recurs 1

Common Pitfalls to Avoid

Do not rely solely on antifungal treatment without addressing oral hygiene—the infection will recur. 4, 5

• Missed oral care is one of the most neglected nursing interventions despite being essential for preventing aspiration pneumonia, dysphagia complications, and oral infections in this population 4
• Do not use nystatin as monotherapy in moderate-to-severe disease—it has lower efficacy than systemic azoles 1
• Avoid prescribing troches or pastilles that require prolonged oral dissolution in patients with severe dysphagia—they pose aspiration risk 1, 3
• Do not overlook denture hygiene if present—denture-related candidiasis requires disinfection of the denture in addition to antifungal therapy 1

Quality of Life Considerations

Oral candidiasis causes significant discomfort (pain, altered taste, difficulty eating) that directly impacts this patient's already compromised quality of life. 5

• Effective treatment and prevention through oral care improves ability to eat, reduces aspiration pneumonia risk (a leading cause of death in nursing home residents with dysphagia), and enhances comfort 3, 4, 7
• Mortality in nursing home residents with dysphagia and pneumonia ranges from 20-65%, making prevention of oral infections critical 3, 7