Visualized Empowerment Nursing Pathway for Nutritional Outcomes in Lymphoma with Chemotherapy-Induced Oral Mucositis: A Retrospective Cohort Study

Samenvatting

The visualized empowerment nursing pathway was associated with better nutritional status, oral mucositis recovery, self-management ability, and quality of life than routine nursing care in lymphoma patients with chemotherapy-induced oral mucositis.

Samenvatting

This study examined the effect of an empowerment nursing model on the nutritional status of patients with lymphoma who developed oral mucositis during chemotherapy and further developed a visualized implementation pathway. A total of 133 patients with lymphoma who received chemotherapy and developed oral mucositis between March 2024 and October 2025 were included. Based on previous nursing records, 62 patients who had received an empowerment nursing model centered on "assessment-identification-goal setting-training-implementation-feedback-continuing management" were assigned to the study group, while 71 patients who had received routine nursing were assigned to the control group. After baseline adjustment, the study group showed more favorable Patient-Generated Subjective Global Assessment (PG-SGA) and Nutritional Risk Screening (NRS) 2002 scores, body weight, body mass index (BMI), serum nutritional markers, dietary intake, self-management, symptom burden, and quality-of-life outcomes than the control group, while the change in oral mucositis grade and the visual analog scale (VAS) pain score also favored the study group. After false-discovery-rate correction, ulcer duration, mucosal healing time, and length of hospital stay remained shorter in the study group, whereas the differences in malnutrition rate, oral nutritional supplement use, and medication-use duration were no longer significant. These findings suggest that the visualized empowerment nursing pathway was associated with better nutritional status and oral intake, faster recovery from oral mucositis, and stronger self-management ability.

Inleiding

Lymphoma comprises a heterogeneous group of malignancies originating from the lymphohematopoietic system, with varied clinical manifestations and treatment responses¹. In recent years, survival outcomes for patients with lymphoma have improved due to continued advances in immunochemotherapy, targeted therapy, and supportive care. Even so, nutritional deterioration, increased infection risk, and impaired quality of life during chemotherapy remain prominent clinical concerns². Epidemiological data show that in 2022, approximately 550,000 new cases of non-Hodgkin lymphoma and about 260,000 related deaths occurred worldwide, indicating that this disease still imposes a substantial burden³. Most patients with lymphoma require multiple cycles of combined chemotherapy. During treatment, bone marrow suppression, gastrointestinal reactions, and oral mucosal injury may overlap, leading to reduced food intake, insufficient nutritional intake, and increased physiological consumption, which may then affect tolerance to subsequent therapy⁴. Among these complications, oral mucositis is relatively common in patients with lymphoma receiving chemotherapy. Its occurrence is associated with direct injury to oral epithelial cells caused by chemotherapeutic drugs, the release of inflammatory factors, decreased immune function, and changes in the oral microecology⁵. Studies have shown that the incidence of oral mucositis is about 40% among patients with hematological tumors receiving high-dose chemotherapy. In adult patients with malignant tumors undergoing chemotherapy, the incidence of oral mucositis can vary considerably depending on treatment regimen, tumor type, baseline oral condition, and assessment criteria^6,7. This complication is not limited to local oral injury. As mucosal congestion, erosion, ulceration, and pain worsen, patients may develop dysphagia, taste changes, fear of eating, and sleep disturbance. Severe cases may require analgesic treatment, anti-infective therapy, or nutritional support, and may even lead to chemotherapy delay or dose adjustment⁸.

Meanwhile, malnutrition is also an important issue during the treatment of hematological tumors. Studies have reported that the incidence of malnutrition in patients with hematological tumors can exceed 30%, and malnutrition is closely associated with infection, prolonged hospitalization, reduced treatment tolerance, and decreased quality of life^9,10. Oral mucositis and impaired nutritional status are therefore closely linked. Together, they may compromise treatment continuity and the quality of recovery in patients with lymphoma.

At present, clinical nursing for chemotherapy-related oral mucositis mainly focuses on oral cleaning, mouth-rinse guidance, pain assessment, dietary education, and symptom management¹¹. Although these measures have clinical value, several shortcomings remain in practice. For example, nursing content is often delivered as separate measures, and oral care, nutritional intervention, and symptom monitoring are not always connected in a continuous way. Between chemotherapy cycles, patients may also be unable to recognize early symptoms, adjust their diet, record their nutritional intake, or report abnormalities, so some problems go undetected and unmanaged until they worsen. With increasing clinical demand, the empowerment nursing model has been used more widely. This model starts with patients' needs and practical problems and improves their understanding of the disease and treatment-related complications through health education, skills training, shared decision-making, dynamic feedback, and family collaboration, thereby encouraging active participation in self-management^12,13. For patients with lymphoma undergoing chemotherapy and complicated by oral mucositis, empowerment nursing may help transform traditional one-way nursing education into a continuous, interactive, and feedback-based management process. It may also support more stable behavioral patterns in oral care, dietary choices, symptom observation, and cooperation with nutritional support.

Therefore, to promote the clinical application of empowerment nursing, this study constructed a visualized implementation pathway for the empowerment nursing model, integrating oral care, nutritional support, symptom monitoring, behavioral feedback, and continuing management into an interconnected nursing process. At the same time, nutritional status, intake compliance, and recovery from oral mucositis were observed from multiple perspectives, allowing the intervention content, key nodes, and possible mechanisms to be presented more clearly. Accordingly, the primary objective was to determine whether the visualized empowerment pathway was associated with better nutritional status and oral mucositis recovery than routine nursing; we hypothesized that integrating oral care, nutritional management, symptom monitoring, and feedback within a single staged pathway would improve both outcomes, while the simultaneous evaluation of pathway fidelity and patient outcomes represented the main novelty of the study.

Protocol

Ethics statement
The study protocol was reviewed and approved by the Shanxi Provincial People's Hospital ethics committee (No. 1357/02/2022). All study data were anonymized before extraction and analysis, and the requirement for written informed consent was waived.

Study design
We conducted a single-center retrospective cohort study. Both nursing approaches were used during the same study period, and group assignment was based on the nursing model documented for each eligible hospitalization rather than on treatment before or after a calendar-based implementation date. The study population comprised patients with lymphoma who received chemotherapy and developed oral mucositis at the Department of Hematologic Oncology of Shanxi Provincial People's Hospital between March 2024 and October 2025. The study therefore evaluated nursing management and recovery after oral mucositis had developed, rather than the prevention of mucositis occurrence. All data were obtained from existing medical and nursing records in the hospital. Patients were grouped according to the nursing model implemented during hospitalization, as documented in the nursing records. Patients were classified in the study group when the nursing plan explicitly documented implementation of the visualized empowerment pathway; completion of every pathway component was not required for classification. Of the 62 patients in this group, 51 (82.26%) had complete closed-loop documentation, and 11 had partial implementation, which was retained for the implementation-fidelity analysis. Patients whose records documented routine nursing without the empowerment pathway were classified as controls, whereas records in which the nursing model could not be determined were excluded. Patient identifiers were checked before analysis to ensure that everyone was included only once.

Screening criteria for study participants
Inclusion criteria: ① patients pathologically, immunohistochemically, or cytologically diagnosed with lymphoma, including Hodgkin lymphoma and non-Hodgkin lymphoma; ② age ≥18 years; ③ patients who received chemotherapy, immunochemotherapy, or combined treatment containing cytotoxic drugs in the Department of Hematologic Oncology of our hospital between March 2024 and October 2025; ④ patients who developed oral mucositis during or after chemotherapy, with clear documentation in nursing records, progress notes, or adverse event records; ⑤ patients with relatively complete main outcome data, including at least oral mucositis grade, nutritional score, body weight or body mass index (BMI), and serum albumin.

Exclusion criteria: ① patients who already had severe oral ulcers, oral infection, oral leukoplakia, recurrent aphthous ulcers, or other oral diseases that could interfere with the assessment of oral mucositis before chemotherapy; ② patients who had previously received or were concurrently receiving head and neck radiotherapy, and in whom it was not possible to determine whether oral mucosal injury was mainly caused by chemotherapy; ③ patients with severe liver failure, renal failure, cardiac insufficiency, or other end-stage diseases that could affect nutritional metabolism; ④ patients with other malignant tumors or severe wasting diseases; ⑤ patients without an evaluable post-care assessment of oral mucositis and nutritional status; ⑥ patients whose nursing model records were unclear, making it impossible to determine whether they had received routine nursing or empowerment nursing pathway management; ⑦ patients with severe missing data in major observation indicators, making them unsuitable for statistical analysis.

Nursing content
Routine nursing in the control group
After admission, the responsible nurses provided routine education in accordance with departmental procedures, including disease-related information, chemotherapy precautions, oral hygiene methods, and dietary precautions. After patients developed oral mucositis, nurses observed the oral condition and recorded pain in response to changes in the disease, and implemented mouth-rinse care, mucosal protection, analgesia, anti-infective treatment, and nutritional support according to medical orders. Regarding oral care, patients were routinely instructed to clean their mouths with a soft-bristled toothbrush and to avoid spicy, rough, overheated, or irritating foods. For patients with obvious oral pain, reduced intake, or dysphagia, nurses recorded symptom changes and reported them to physicians in a timely manner. Nutritional care was generally based on dietary guidance, with patients advised choosing high-calorie, high-protein, and easily digestible foods. When patients developed obvious insufficient intake, weight loss, or increased nutritional risk, oral nutritional supplementation, enteral nutrition, or parenteral nutrition was provided according to medical orders. Overall, nursing in the control group primarily involved observing symptoms, providing routine education, and implementing medical orders. No fixed empowerment pathway or staged goal-feedback mechanism was found in the nursing records.

Empowerment nursing model and visualized implementation pathway in the study group
Based on the severity of oral mucositis, nutritional risk, and self-management ability, a continuous nursing process was constructed around assessment, identification, goal setting, training, implementation, feedback, and continuing management. The nursing content included special assessment of oral mucositis, individualized nutritional guidance, oral care skills training, dynamic symptom feedback, family collaboration, and continuing management after discharge. The specific implementation pathway is shown in Table 1.

Data collection
Data extraction was independently completed by two researchers who had received unified training. Baseline was defined as the first eligible assessment recorded after oral mucositis was identified and before initiation of the nursing model for that episode, whereas post-care values were taken from the final eligible assessment before discharge. Because the interval between these assessments depended on the clinical course and hospitalization, the observation period was not strictly standardized across patients and was therefore taken into account when interpreting the findings. Using a predesigned data extraction form, the researchers collected general information, disease-related data, chemotherapy-related data, nursing model information, oral mucositis-related indicators, nutritional status indicators, dietary intake indicators, self-management indicators, quality-of-life indicators, inflammatory and immune indicators, and clinical outcome indicators. Use of oral nutritional supplements, enteral or parenteral nutritional support, analgesic treatment, anti-infective treatment, chemotherapy delay, and chemotherapy dose adjustment were also extracted. Detailed chemotherapy regimens, corticosteroid exposure, and granulocyte colony-stimulating factor use were not consistently available in the retrospective records and, therefore, could not be included as covariates.

Observation indicators
(1) Nutritional status indicators. These included Nutritional Risk Screening (NRS) 2002 score, Patient-Generated Subjective Global Assessment (PG-SGA) score, BMI, body weight change, serum albumin, prealbumin, hemoglobin, upper arm circumference, grip strength, and incidence of malnutrition^14,15. An NRS 2002 score ≥3 was defined as nutritional risk. A PG-SGA score ≥4 indicated the need for nutritional intervention, and a score ≥9 indicated the need for active nutritional intervention. (2) Dietary intake and nutritional support indicators. These included daily energy intake compliance rate (actual intake reaching at least 80% of the target amount prescribed by physicians, recommended by dietitians, or recorded in the medical record), protein intake compliance rate, oral intake (ordinary diet, soft diet, semi-liquid diet, liquid diet, and almost unable to eat orally), changes in dietary texture, use of oral nutritional supplements, enteral nutrition support rate, and parenteral nutrition support rate. (3) Oral mucositis was graded according to the World Health Organization (WHO) oral mucositis scale documented in the nursing records; the same 0–4 grading system was used for all included assessments, and grades 3–4 were defined as severe oral mucositis¹⁶. The extracted outcomes also included oral pain visual analog scale (VAS) score, ulcer duration, mucosal healing time, and the proportion of patients with mucositis-related eating restriction¹⁷. (4) Self-management ability and nursing compliance indicators. These included oral care implementation rate, compliance rate of mouth-rinsing or toothbrushing frequency, nutrition record completion rate, health knowledge mastery score, self-efficacy score, and family collaborative participation. (5) Symptom burden, quality of life, and nursing experience. These included fatigue, nausea and vomiting, dysphagia, dry mouth, sleep disturbance, and pain-related effects. (6) Inflammatory, immune system, and hematological indicators. C-reactive protein, neutrophil count, lymphocyte count, and neutrophil-to-lymphocyte (NLR) ratio were collected. (7) Clinical outcomes and safety indicators. These included chemotherapy delay (failure to proceed with the next cycle of chemotherapy as originally scheduled because of oral mucositis, infection, nutritional deterioration, bone marrow suppression, or other treatment-related adverse reactions), chemotherapy dose adjustment, infection, anti-infective medication use, analgesic medication use, length of hospital stay, unplanned readmission (readmission within 30 days after discharge due to oral mucositis, infection, feeding difficulty, nutritional deterioration, or chemotherapy-related adverse reactions), and discharge outcome.

Statistical methods
Continuous variables were assessed for normality and are presented as mean ± standard deviation or median (interquartile range), as appropriate, while categorical variables are presented as counts and percentages. For continuous outcomes measured both before and after care, the primary between-group analysis was performed using analysis of covariance (ANCOVA), with the post-care value as the dependent variable, nursing group as the fixed factor, and the corresponding baseline value as a covariate; adjusted mean differences with 95% confidence intervals were reported. Because oral mucositis grade is ordinal, change from baseline was compared using the Mann-Whitney U test, with rank-biserial correlation reported as the effect-size measure. Categorical outcomes were compared using the χ² test or Fisher's exact test, with risk ratios and 95% confidence intervals reported where appropriate. Medication-use duration was analyzed only among patients who received the corresponding medication and was expressed as median and interquartile range. To account for multiple testing, all reported between-group outcome comparisons and the satisfaction analysis were included in a single Benjamini-Hochberg false-discovery-rate correction; q < 0.05 was considered statistically significant. Because this retrospective study included all eligible patients identified during the predefined study period, no a priori sample-size calculation was performed. All tests were two-sided.

Resultaten

Case screening and comparison of baseline data
During the study period, 198 potentially eligible patients were screened. 65 patients were excluded: 9 because of pre-existing oral conditions that could interfere with mucositis assessment, 6 because of previous or concurrent head and neck radiotherapy, 7 because of severe end-stage organ disease, 5 because of another malignancy or severe wasting disease, 12 because no evaluable post-care assessment was available, 11 because the nursing model could not be reliably classified, and 15 because of major missing outcome data. A total of 133 unique patients were therefore included, comprising 62 in the study group and 71 in the control group. There were no statistically significant differences between the two groups in age, sex, lymphoma type, Ann Arbor stage, Eastern Cooperative Oncology Group (ECOG) performance status, or chemotherapy cycle (P > 0.05, Table 2).

Implementation of the visualized pathway for the empowerment nursing model
Within the study group, implementation records were available for most components of the empowerment pathway, and complete closed-loop documentation was present in 51 of 62 patients (82.26%), while the remaining 11 patients had partial implementation. Because routine nursing records were not structured around the same pathway components, Table 3 was used to describe implementation fidelity within the study group rather than to compare documentation quality between groups.

Comparison of core nutritional status outcomes
Baseline nutritional indicators were comparable between groups. After adjustment for the corresponding baseline values, the study group had lower PG-SGA and NRS 2002 scores and more favorable body weight, BMI, albumin, prealbumin, hemoglobin, upper arm circumference, and grip strength than the control group, and all of these differences remained significant after false-discovery-rate correction (q < 0.05). Body weight decreased from 60.87–59.63 kg in the control group but changed only from 60.43–60.21 kg in the study group, corresponding to an adjusted between-group difference of 1.00 kg (95% CI 0.44–1.57, q = 0.001). The post-care malnutrition rate was numerically lower in the study group (38.71% vs. 56.34%), but this comparison did not remain significant after correction (P = 0.042, q = 0.068; Table 4).

Comparison of dietary intake and nutritional support
Before care, the two groups showed no differences in energy intake, protein intake, oral intake, or dietary texture score (P > 0.05). After baseline adjustment, energy intake compliance, protein intake compliance, oral intake, and dietary texture score were more favorable in the study group, and all four differences remained significant after false-discovery-rate correction (q < 0.001). Oral nutritional supplement use was numerically higher in the study group (62.90% vs. 45.07%), but the difference did not remain significant after correction (P = 0.040, q = 0.066); enteral and parenteral nutritional support also did not differ between groups (Table 5).

Comparison of oral mucositis severity and recovery
The distribution of change in WHO oral mucositis grade favored the study group (q = 0.008), and the baseline-adjusted VAS pain score was also lower (adjusted mean difference -0.75, 95% CI -0.91 to -0.59, q < 0.001). Ulcer duration and mucosal healing time were shorter by 1.69 days and 1.71 days, respectively, and both differences remained significant after false-discovery-rate correction. Severe oral mucositis, eating restriction, and analgesic intervention did not differ significantly between groups (Table 6).

Comparison of self-management ability and nursing compliance
Before care, oral care implementation rate, compliance rate of mouth-rinsing or toothbrushing frequency, nutrition record completion rate, health knowledge mastery score, self-efficacy score, and family collaborative participation were comparable between the two groups (P > 0.05). After baseline adjustment, all continuous self-management outcomes favored the study group, while family collaborative participation was also higher; all differences remained significant after false-discovery-rate correction (q < 0.001, Table 7).

Comparison of symptom burden, quality of life, and nursing experience
After adjustment for the corresponding baseline values, fatigue, nausea and vomiting, dysphagia, dry mouth, and sleep quality scores were lower in the study group, whereas the quality-of-life score was higher; all six comparisons remained significant after false-discovery-rate correction (q < 0.001, Figure 1). The overall satisfaction rate (90.32% vs. 82.28%) did not differ significantly between groups (χ² = 2.612, P = 0.106, q = 0.141).

Comparison of inflammatory, immune, and hematological indicators
After baseline adjustment, C-reactive protein was lower in the study group than in the control group (adjusted mean difference -4.45, 95% CI -5.56 to -3.35, q < 0.001), whereas neutrophil count, lymphocyte count, and NLR did not differ significantly between groups (Figure 2).

Comparison of clinical outcomes and safety indicators
Length of hospital stay was shorter in the study group than in the control group (14.18 ± 4.06 vs. 16.06 ± 4.58 days; mean difference -1.88 days, 95% CI -3.37 to -0.38, q = 0.024). Among patients who received anti-infective or analgesic medication, treatment duration did not differ significantly between groups after reanalysis, and no significant between-group differences were observed in chemotherapy delay, dose adjustment, infection, febrile neutropenia, medication use, 30-day readmission, chemotherapy completion, or mucositis healing status at discharge (Table 8).

Overall, the study group showed more favorable baseline-adjusted nutritional, dietary intake, oral mucositis recovery, self-management, symptom, quality-of-life, C-reactive protein, and length-of-stay outcomes than the control group, whereas several categorical clinical outcomes and medication-use measures did not differ significantly after false-discovery-rate correction.

DATA AVAILABILITY:
The raw data of this study have been uploaded as Supplementary File 1.

Figure 1: Changes in symptom burden and quality of life before and after care in the control and study groups. (A) Fatigue score, (B) nausea and vomiting score, (C) dysphagia score, (D) dry mouth score, (E) sleep quality score, and (F) quality-of-life total score. ^* and ^# indicates a significant baseline-adjusted between-group and within-group differences after false-discovery-rate correction, q < 0.05. Please click here to view a larger version of this figure.

Figure 2: Changes in inflammatory, immune, and hematological indicators before and after care in the control and study groups. (A) C-reactive protein (mg/L), (B) neutrophil count (×10⁹/L), (C) lymphocyte count (×10⁹/L), and (D) neutrophil-to-lymphocyte ratio (NLR). ^* and ^# indicates a significant baseline-adjusted between-group and within-group differences after false-discovery-rate correction, q < 0.05. Please click here to view a larger version of this figure.

Implementation step	Main assessment or nursing content	Empowerment focus	Implementation approach	Recording and evaluation indicators
Initial assessment	Assessment of oral mucosal condition, pain severity, food intake, dietary texture, nutritional risk, self-management ability, and family support	To identify the patient's current major problems and nursing needs	Bedside assessment, nursing assessment form, nutritional risk screening	Oral mucositis grade, VAS score, NRS 2002, PG-SGA, oral intake
Problem identification	Identification of oral pain, worsening ulceration, eating restriction, insufficient nutritional intake, and inadequate oral care implementation	To help patients understand the relationship between symptoms and nutritional status	Nurses summarized problems based on assessment results and communicated them with patients	Nursing problem records, risk stratification results
Goal setting	Development of goals for daily oral care frequency, mouth-rinse performance, pain control, energy and protein intake, and nutrition recording	To shift patients from passive receipt of care to active participation in management	Nurses worked with patients and family members to set staged goals	Pathway sheet, bedside education sheet, goal completion records
Skills training	Guidance on soft-bristled toothbrush use, mouth-rinsing methods, oral mucosal self-checking, eating strategies during pain, and dietary texture selection	To improve practical skills and self-care ability	Bedside demonstration, visual education, process-based guidance	Oral care implementation rate, compliance rate of mouth-rinsing or toothbrushing frequency
Nutritional management	Stratified guidance based on BMI, nutritional score, serum protein, pain severity, and food intake	To promote oral intake and reduce further nutritional deterioration	Small frequent meals, soft high-protein diet, oral nutritional supplementation, and nutritional support when necessary	Energy intake compliance rate, protein intake compliance rate, dietary texture score, ONS use
Dynamic feedback	Continuous observation of mucositis grade, pain score, food intake, dietary texture, body weight, and laboratory indicators	To identify unmet goals in time and adjust nursing priorities	Daily review of records, feedback to patients, and reporting to physicians or dietitians when necessary	Dynamic symptom feedback records, nursing goal adjustment records
Family collaboration	Guidance for family members to participate in meal preparation, oral care supervision, symptom observation, and reporting of abnormalities	To extend nursing support and improve continuity of home-based implementation	Family members received education and participated in the nursing plan	Family collaborative participation records, discharge guidance records
Continuing management	Reinforcement of oral care, dietary adjustment, nutritional supplementation, symptom warning signs, and follow-up requirements before discharge	To maintain nursing measures during chemotherapy intervals	Discharge guidance, follow-up records, abnormal symptom feedback	Continuing-care guidance records, readmission status, oral mucosal recovery

Table 1: Visualized implementation pathway of the empowerment nursing model in the study group. The table summarizes the seven linked stages of the pathway-assessment, identification, goal setting, training, implementation, feedback, and continuing management, and the corresponding oral-care, nutritional-support, symptom-monitoring, family-collaboration, and follow-up activities applied after oral mucositis was identified.

	Study group (n = 62)	Control group (n = 71)	Statistic (t/χ2)	P value
Age (years)	55.84 ± 10.73	56.41 ± 11.26	-0.298	0.766
Male	35 (56.45)	40 (56.34)	<0.001	0.989
Female	27 (43.55)	31 (43.66)	—	—
Hodgkin lymphoma	7 (11.29)	8 (11.27)	<0.001	0.997
Non-Hodgkin lymphoma	55 (88.71)	63 (88.73)	—	—
Ann Arbor stage I-II	20 (32.26)	24 (33.80)	0.036	0.850
Ann Arbor stage III-IV	42 (67.74)	47 (66.20)	—	—
ECOG score	1.42 ± 0.64	1.45 ± 0.67	-0.274	0.784
Chemotherapy cycles	3.18 ± 1.21	3.24 ± 1.27	-0.287	0.774

Table 2: Baseline demographic and clinical characteristics of the study group (visualized empowerment nursing pathway, n = 62) and control group (routine nursing, n = 71). The table presents between-group comparisons before pathway-based care, including age, sex, lymphoma type, Ann Arbor stage, Eastern Cooperative Oncology Group (ECOG) performance status, and chemotherapy cycle. Data are presented as mean ± SD for continuous variables and n (%) for categorical variables.

Indicator	Study group (n = 62)
Completed specialized oral mucositis assessment	60 (96.77)
Completed dynamic nutritional risk assessment	58 (93.55)
Had explicit staged nursing goal records	55 (88.71)
Completed oral care skills guidance	59 (95.16)
Completed individualized dietary guidance	57 (91.94)
Had daily intake or nutrition records	53 (85.48)
Had dynamic symptom feedback records	56 (90.32)
Had family collaborative management records	49 (79.03)
Had discharge continuing-care guidance records	54 (87.10)
Complete closed-loop management records	51 (82.26)

Table 3: Implementation fidelity of the visualized empowerment nursing pathway in the study group (n = 62). The table reports documentation of individual pathway components and overall closed-loop implementation; 51 patients had complete closed-loop documentation, and 11 had partial implementation. Percentages use the 62 study-group patients as the denominator. This table is descriptive and does not represent a comparison with the control group. Data are presented as n (%).

Outcome	Time point	Study group (n = 62)	Control group (n = 71)	Effect estimate (95% CI)	P value	q value
PG-SGA score	Before care	8.63  ±  2.21	8.79  ±  2.34	—	0.688	—
	After care	6.13  ±  1.86	7.34 ± 2.12	aMD −1.07 (−1.24 to −0.90)	<0.001	<0.001
NRS 2002 score	Before care	3.48  ±  0.92	3.52  ±  0.94	—	0.818	—
	After care	2.74  ±  0.77	3.18  ±  0.85	aMD −0.41 (−0.56 to −0.27)	<0.001	<0.001
Body weight (kg)	Before care	60.43  ±  8.92	60.87  ±  9.17	—	0.778	—
	After care	60.21  ±  8.72	59.63  ±  8.90	aMD 1.00 (0.44 to 1.57)	<0.001	0.001
BMI (kg/m²)	Before care	21.76  ±  2.38	21.69  ±  2.45	—	0.865	—
	After care	21.70  ±  2.31	21.25  ±  2.37	aMD 0.38 (0.25 to 0.51)	<0.001	<0.001
Albumin (g/L)	Before care	34.82  ±  4.16	34.57  ±  4.29	—	0.736	—
	After care	37.06  ±  3.92	35.48  ±  4.11	aMD 1.35 (1.15 to 1.54)	<0.001	<0.001
Prealbumin (mg/L)	Before care	164.72  ±  36.52	162.41  ±  38.07	—	0.722	—
	After care	194.28 ± 33.48	176.35 ± 36.19	aMD 15.79 (14.16 to 17.41)	<0.001	<0.001
Hemoglobin (g/L)	Before care	105.86 ± 14.30	104.92 ± 15.08	—	0.714	—
	After care	108.15 ± 13.92	105.47 ± 14.73	aMD 1.83 (1.24 to 2.42)	<0.001	<0.001
Upper arm circumference (cm)	Before care	24.18 ± 2.41	24.09 ± 2.36	—	0.824	—
	After care	24.25 ± 2.34	23.91 ± 2.31	aMD 0.25 (0.08 to 0.42)	0.004	0.007
Grip strength (kg)	Before care	22.43 ± 5.72	22.19 ± 5.64	—	0.805	—
	After care	23.11 ± 5.36	21.83 ± 5.47	aMD 1.05 (0.73 to 1.37)	<0.001	<0.001
Malnutrition, n (%)	Before care	39 (62.90)	46 (64.79)	—	0.821	—
	After care	24 (38.71)	40 (56.34)	RR 0.687 (0.473 to 0.999)	0.042	0.068

Table 4: Baseline and post-care core nutritional outcomes in the study group (visualized empowerment nursing pathway, n = 62) and control group (routine nursing, n = 71). Continuous data are presented as mean ± SD and categorical data as n (%). For continuous outcomes, post-care between-group differences were estimated using analysis of covariance (ANCOVA), with the corresponding baseline value included as a covariate, and are reported as adjusted mean differences with 95% confidence intervals (CIs); categorical outcomes were compared using the χ² test or Fisher's exact test, as appropriate. P values are unadjusted, whereas q values were obtained using the Benjamini-Hochberg false-discovery-rate (FDR) procedure, with q < 0.05 considered statistically significant. Abbreviations: PG-SGA, Patient-Generated Subjective Global Assessment; NRS 2002, Nutritional Risk Screening 2002; BMI, body mass index.

Outcome	Time point	Study group (n = 62)	Control group (n = 71)	Effect estimate (95% CI)	P value	q value
Energy intake compliance rate (%)	Before care	61.34 ± 14.82	60.76 ± 15.13	—	0.824	—
	After care	80.51 ± 12.34	72.42 ± 13.82	aMD 7.59 (6.75 to 8.43)	<0.001	<0.001
Protein intake compliance rate (%)	Before care	58.72 ± 15.35	57.96 ± 15.81	—	0.779	—
	After care	77.86 ± 12.90	69.36 ± 14.24	aMD 7.84 (6.96 to 8.72)	<0.001	<0.001
Oral intake as proportion of usual intake (%)	Before care	54.63 ± 16.28	53.91 ± 16.76	—	0.802	—
	After care	76.34 ± 13.40	66.82 ± 15.15	aMD 8.90 (8.15 to 9.66)	<0.001	<0.001
Dietary texture score	Before care	2.37 ± 0.81	2.34 ± 0.84	—	0.82	—
	After care	3.45 ± 0.74	3.00 ± 0.79	aMD 0.42 (0.30 to 0.55)	<0.001	<0.001
Use of oral nutritional supplements, n (%)	Before care	18 (29.03)	19 (26.76)	—	0.771	—
	After care	39 (62.90)	32 (45.07)	RR 1.40 (1.01 to 1.92)	0.04	0.066
Enteral nutrition support, n (%)	Before care	4 (6.45)	5 (7.04)	—	0.892	—
	After care	8 (12.90)	12 (16.90)	RR 0.76 (0.33 to 1.75)	0.52	0.53
Parenteral nutrition support, n (%)	Before care	3 (4.84)	4 (5.63)	—	0.838	—
	After care	5 (8.06)	12 (16.90)	RR 0.48 (0.18 to 1.28)	0.128	0.165

Table 5: Baseline and post-care dietary intake, dietary texture, and nutritional-support outcomes in the study group (visualized empowerment nursing pathway, n = 62) and control group (routine nursing, n = 71). Continuous data are presented as mean ± SD and categorical data as n (%). Continuous post-care outcomes were compared using ANCOVA with adjustment for the corresponding baseline value, whereas categorical nutritional-support outcomes were compared using the χ² test or Fisher's exact test, as appropriate. P values are unadjusted, and q values are Benjamini-Hochberg FDR-adjusted, with q < 0.05 considered statistically significant.

Outcome	Time point	Study group (n=62)	Control group (n=71)	Effect estimate (95% CI)	P value
Oral mucositis grade	Before care	2 (1–2)	2 (1–2)	—	0.777
	After care	1 (1–1)	1 (1–1)	—	—
Change in oral mucositis grade	After vs. before care	−1(−1 to −1)	−1 (−1 to 0)	r_rb = -0.252	0.005
Grade III–IV oral mucositis, n (%)	Before care	11 (17.74)	14 (19.72)	—	0.771
	After care	3 (4.84)	8 (11.27)	RR 0.43 (0.12 to 1.55)	0.179
VAS pain score	Before care	4.32 ± 1.18	4.41 ± 1.25	—	0.686
	After care	2.05 ± 0.93	2.86 ± 1.07	aMD -0.75 (-0.91 to -0.59)	<0.001
Eating restriction due to oral mucositis, n (%)	Before care	45 (72.58)	53 (74.65)	—	0.787
	After care	17 (27.42)	29 (40.85)	RR 0.67 (0.41 to 1.10)	0.104
Need for analgesic medication intervention, n (%)	Before care	26 (41.94)	31 (43.66)	—	0.841
	After care	15 (24.19)	25 (35.21)	RR 0.69 (0.40 to 1.18)	0.167
Ulcer duration (d)	Observation period	6.48 ± 2.37	8.17 ± 2.91	MD -1.69 (-2.60 to -0.77)	<0.001
Mucosal healing time (d)	Observation period	8.42 ± 2.85	10.13 ± 3.36	MD -1.71 (-2.79 to -0.63)	0.002

Table 6: Oral mucositis severity, pain, and recovery outcomes in the study group (visualized empowerment nursing pathway, n = 62) and control group (routine nursing, n = 71). Oral mucositis grade and change in grade are presented as median (interquartile range), continuous data as mean ± SD, and categorical data as n (%). Between-group differences in changes in oral mucositis grade are reported using the rank-biserial correlation coefficient (r_rb). Post-care between-group differences in VAS pain score were estimated using analysis of covariance (ANCOVA), with the corresponding baseline value included as a covariate, and are reported as adjusted mean differences (aMDs) with 95% confidence intervals (CIs). Categorical outcomes are reported as risk ratios (RRs) with 95% CIs, and ulcer duration and mucosal healing time as mean differences (MDs) with 95% CIs. P values are unadjusted, whereas q values were obtained using the Benjamini-Hochberg false-discovery-rate (FDR) procedure, with q < 0.05 considered statistically significant. VAS, visual analog scale.

Indicator	Time point	Study group (n = 62)	Control group (n = 71)	Effect estimate (95% CI)	P value	q value
Oral care implementation rate (%)	Before care	58.34 ± 14.62	57.81 ± 15.04	—	0.838	—
	After care	86.33 ± 10.40	72.42 ± 13.84	aMD 13.49 (12.35 to 14.63)	<0.001	<0.001
Compliance rate of mouth-rinsing or toothbrushing frequency (%)	Before care	55.71 ± 15.35	54.96 ± 15.82	—	0.781	—
	After care	84.72 ± 10.82	70.18 ± 14.52	aMD 13.93 (12.79 to 15.06)	<0.001	<0.001
Nutrition record completion rate (%)	Before care	32.65 ± 17.44	31.93 ± 18.12	—	0.817	—
	After care	75.28 ± 14.05	48.57 ± 17.61	aMD 26.09 (24.45 to 27.73)	<0.001	<0.001
Health knowledge mastery score	Before care	61.29 ± 10.47	60.73 ± 10.92	—	0.765	—
	After care	84.37 ± 8.42	72.85 ± 9.96	aMD 11.05 (10.50 to 11.60)	<0.001	<0.001
Self-efficacy score	Before care	58.37 ± 9.82	57.94 ± 10.11	—	0.806	—
	After care	78.42 ± 8.76	66.73 ± 9.64	aMD 11.30 (10.63 to 11.97)	<0.001	<0.001
Family collaborative participation, n (%)	Before care	18 (29.03)	19 (26.76)	—	0.771	—
	After care	45 (72.58)	25 (35.21)	RR 2.06 (1.45 to 2.93)	<0.001	<0.001

Table 7: Baseline and post-care self-management ability and nursing-compliance outcomes in the study group (visualized empowerment nursing pathway, n = 62) and control group (routine nursing, n = 71). Continuous data are presented as mean ± SD and categorical data as n (%). For continuous outcomes, post-care between-group differences were estimated using analysis of covariance (ANCOVA), with the corresponding baseline value included as a covariate, and are reported as adjusted mean differences (aMDs) with 95% confidence intervals (CIs). Categorical outcomes are reported as risk ratios (RRs) with 95% CIs. P values are unadjusted, whereas q values were obtained using the Benjamini-Hochberg false-discovery-rate (FDR) procedure, with q < 0.05 considered statistically significant.

Indicator	Study group (n = 62)	Control group (n = 71)	Effect estimate (95% CI)	P value	q value
Chemotherapy delay, n (%)	10 (16.13)	19 (26.76)	RR 0.60 (0.30 to 1.20)	0.139	0.171
Chemotherapy dose adjustment, n (%)	7 (11.29)	13 (18.31)	RR 0.62 (0.26 to 1.45)	0.259	0.274
Infection, n (%)	10 (16.13)	20 (28.17)	RR 0.57 (0.29 to 1.13)	0.097	0.14
Febrile neutropenia, n (%)	5 (8.06)	10 (14.08)	RR 0.57 (0.21 to 1.58)	0.274	0.284
Use of anti-infective medication, n (%)	14 (22.58)	24 (33.80)	RR 0.67 (0.38 to 1.17)	0.153	0.181
Duration of anti-infective medication use (d)*	4.50 (3.25–6.00), n = 14	6.00 (4.75–8.00), n = 24	r_rb = -0.315	0.107	0.141
Use of analgesic medication, n (%)	15 (24.19)	25 (35.21)	RR 0.69 (0.40 to 1.18)	0.167	0.188
Duration of analgesic medication use (d)*	4.00 (3.00–4.50), n = 15	4.00 (4.00–6.00), n = 25	r_rb = -0.360	0.056	0.086
Length of hospital stay (d)	14.18 ± 4.06	16.06 ± 4.58	MD -1.88 (-3.37 to -0.38)	0.014	0.024
30-day unplanned readmission after discharge, n (%)	6 (9.68)	12 (16.90)	RR 0.57 (0.23 to 1.44)	0.224	0.243
Chemotherapy completed as scheduled, n (%)	52 (83.87)	52 (73.24)	RR 1.15 (0.96 to 1.37)	0.139	0.171
Oral mucositis not healed at discharge, n (%)	18 (29.03)	32 (45.07)	RR 0.64 (0.40 to 1.03)	0.057	0.086

Table 8: Clinical outcomes and safety indicators in the study group (visualized empowerment nursing pathway, n = 62) and control group (routine nursing, n = 71). Data are presented as n (%), mean ± SD, or median (interquartile range), as appropriate. Effect estimates are reported as risk ratios (RRs), mean differences (MDs), or rank-biserial correlations (r_rb), with 95% confidence intervals (CIs) where applicable. P values are unadjusted; q values are Benjamini-Hochberg FDR-adjusted, with q < 0.05 considered statistically significant.

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Discussie

Based on previous medical and nursing records, this study analyzed the application effect of the empowerment nursing model and its visualized implementation pathway in patients with lymphoma undergoing chemotherapy and complicated by oral mucositis. Compared with routine nursing, the study group showed more favorable post-care trends in nutritional risk, oral intake, oral mucositis recovery, self-management ability, symptom burden, and some clinical outcomes. These findings suggest that empowerment nursing does not simply increase the frequency of health education. More importantly, it brings together oral care and nutritional support, which are often implemented separately, into a continuous management process through assessment, goal setting, skills guidance, behavioral feedback, and continuing management. Compared with routine nursing, which was largely symptom-triggered and focused on general education and implementation of medical orders, the visualized pathway added predefined assessment, shared goal setting, skills training, family participation, and structured feedback; unlike oral-care programs focused primarily on mucositis symptoms, it also linked mucositis management directly with nutritional monitoring and self-management.

Improvement in nutritional status was one of the main findings of this study. During chemotherapy, patients with cancer often develop nutrition-impact symptoms such as oral ulcers, dysphagia, loss of appetite, nausea, and vomiting, which may lead to insufficient oral intake¹⁸. The empowerment nursing pathway emphasizes early assessment and dynamic feedback, allowing nurses, patients, and family members to identify reduced intake and increasing nutritional risk at an earlier stage. With daily intake goals, intake records, and timely adjustments to dietary plans, patients become more involved in nutritional management, and nutritional interventions are more likely to translate into daily behavior. Previous studies have suggested that the effect of nutritional intervention in patients with cancer is closely related to timing, individualization, and continuous follow-up, which is consistent with our findings¹⁹. Baseline-adjusted analyses also showed modest but significant differences in body weight, BMI, upper arm circumference, and grip strength. In particular, body weight decreased by approximately 1.24 kg in the control group but by only 0.22 kg in the study group, yielding an adjusted between-group difference of 1.00 kg; this pattern is more consistent with short-term preservation of nutritional status than with substantial weight gain. PG-SGA and NRS 2002 scores showed larger relative changes in the present study; however, these tools capture different dimensions of nutritional status, with NRS 2002 incorporating nutritional status, disease severity, and age, whereas PG-SGA additionally captures weight change, food intake, nutrition-impact symptoms, functional status, metabolic requirements, and physical findings²⁰.

The improvement in dietary intake further helps explain the changes in nutritional outcomes. After the intervention, the study group had better energy intake compliance, protein intake compliance, oral intake, and dietary texture score, suggesting that empowerment nursing mainly worked by maintaining and improving oral intake rather than relying solely on enteral or parenteral nutrition support. Reduced intake in patients with oral mucositis is not determined only by ulcer area or the degree of mucosal injury. Anticipated pain, previous unpleasant eating experiences, inappropriate food choices, and concern about symptom aggravation may also affect intake^21,22. Through bedside demonstration, visual education, and staged feedback, empowerment nursing helped patients choose cool, soft, high-protein foods according to pain severity and adopt strategies such as small, frequent meals, pain management before eating, and oral nutritional supplementation²³. Although oral nutritional supplement use was numerically higher in the study group, this difference did not remain significant after false-discovery-rate correction, while enteral and parenteral nutritional support were also similar between groups; the more consistent finding was therefore the improvement in actual energy, protein, and oral intake rather than greater reliance on artificial nutritional support.

The oral mucositis-related findings also support the value of this nursing pathway. The change in oral mucositis grade favored the study group, as did pain score, shorter ulcer duration, and mucosal healing time. Several components of the intervention may have contributed to this effect. First, special assessment may have facilitated earlier recognition of mucosal changes, allowing nursing measures to begin while the injury was still mild or moderate. Second, standardized oral hygiene, mouth-rinse guidance, and mucosal protection may have reduced local irritation and secondary oral complications. Third, pain management and dietary texture adjustment may have reduced discomfort during eating and pain-related food avoidance; these measures are consistent with guideline-based oral care during cancer therapy¹¹.

Previous studies on chemotherapy-related oral mucositis have shown that structured education and oral-care guidance can reduce mucositis severity and support symptom management during treatment, which is consistent with the present findings^24,25. Still, severe oral mucositis, eating restriction, and analgesic medication did not differ significantly between groups after care. This may be related to the limited number of severe cases, insufficient sample size, and the relatively limited detail of symptom-change records in this retrospective study. Further validation is therefore needed.

The improvement in self-management ability in the study group indicates a shift from passive receipt of nursing care to active participation in disease management. The value of empowerment nursing lies not in repeatedly telling patients, "what they should do", but in helping them understand their own problems, master specific methods, and recognize the effects of behavioral change through feedback. Oral complications related to cytotoxic therapy may vary in timing and duration and can require supportive care during and after chemotherapy²⁶. Nurse supervision during hospitalization alone may be insufficient to support continued self-management after discharge or between chemotherapy cycles. In this context, greater family collaboration in the study group may have strengthened continuity in home-based dietary preparation, symptom monitoring, and oral care supervision.

Symptom relief and quality-of-life improvement may have resulted from several linked changes. As oral pain decreased, patients became more confident in eating, and improved oral intake may have helped relieve fatigue and treatment-related discomfort. The visualized pathway and staged goals also gave patients a clearer understanding of the care process and recovery trajectory, reducing uncertainty stemming from symptom fluctuations. Evidence for nurse-led self-management interventions on quality of life and self-efficacy remains mixed, although peer-support interventions have shown benefits for both outcomes in patients with cancer^27,28. These findings provide context for, but do not establish the mechanism underlying, the quality-of-life difference observed in the study group. The overall satisfaction rate did not differ significantly, which may partly reflect the ceiling effects commonly observed in satisfaction measures. Because dichotomization can reduce variation in satisfaction data, continuous satisfaction scores may be more sensitive to between-group differences in nursing experience²⁹.

The findings regarding inflammatory, immune, and hematological indicators should be interpreted with caution. Although C-reactive protein was lower after care in the study group, this finding should not be attributed to a single mechanism; chemotherapy-induced oral mucositis involves inflammatory signaling, and poorer nutritional status in hematological malignancies has also been associated with systemic inflammation^5,9. Length of hospital stay remained shorter in the study group after false-discovery-rate correction, whereas medication-use duration, chemotherapy delay, infection, and unplanned readmission did not differ significantly between groups. These findings suggest a possible reduction in the hospitalization burden, but they do not support a broader conclusion that the pathway reduced major treatment-related complications; larger prospective studies are needed for confirmation.

This study has several limitations. First, it was a single-center retrospective study in which the nursing model was determined by routine clinical practice rather than random allocation; consequently, unmeasured factors such as patient motivation, clinical complexity, nurse experience, staffing or shift patterns, education level, baseline family support, and treatment characteristics may have influenced both receipt of the empowerment pathway and the observed outcomes, and comparability of the measured baseline variables cannot exclude residual selection or indication bias. Second, clinical and nursing documentation was not standardized prospectively, and the empowerment pathway itself encouraged more structured recording; differential documentation between groups may therefore have introduced information or detection bias. The interval between baseline and post-care assessment was also not strictly standardized, while exclusion of patients without an evaluable post-care assessment may have introduced additional selection bias if early discharge was related to disease severity. Detailed chemotherapy regimens, corticosteroid exposure, and granulocyte colony-stimulating factor use were not consistently available and could not be adjusted for. In addition, because eligibility requires documented oral mucositis, this study cannot determine whether the pathway prevents mucositis or reduces its incidence among the broader population receiving chemotherapy. Finally, the retrospective sample size was determined by the number of eligible records rather than by an a priori sample size calculation. Multicenter prospective studies with standardized assessment intervals, more comprehensive treatment data, and longer follow-up are needed to confirm these associations.

In conclusion, the empowerment nursing model and its visualized implementation pathway were associated with reduced nutritional risk, improved oral intake, faster recovery from oral mucositis, and enhanced self-management ability in patients with lymphoma undergoing chemotherapy and complicated by oral mucositis. By integrating oral care and nutritional support into a clearer nursing process through continuous assessment, goal setting, skills training, dynamic feedback, and continuing management, this model showed good clinical feasibility.

Materialen

Lijst van materialen gebruikt in dit artikel

Naam	Bedrijf	Catalogusnummer	Opmerkingen
Analgesic medications	Chartwell RX, LLC	Lidocaine Hydrochloride Oral Topical Solution USP 2% (Viscous), 100 mL; NDC 62135-712-42	Representative topical oral analgesic/local-anesthetic candidate. The manuscript only states analgesia according to medical orders; verify the actual formulary drug(s) used.
Anti-infective medications	Genus Lifesciences Inc.	Nystatin Oral Suspension USP 100,000 units/mL, 60 mL; NDC 64950-372-06	Representative oral antifungal candidate. The manuscript only states anti-infective treatment according to medical orders; verify the actual agent(s), including any systemic anti-infectives.
CTCAE v5.0 oral mucositis grading	National Cancer Institute (NCI), U.S. NIH	CTCAE Version 5.0 (2017; MedDRA 20.1)	CTCAE v5.0 'Mucositis oral' grading criterion; added because the manuscript lists CTCAE 5.0 as an alternative grading system used in records.
Disposable gloves	Ansell	MICRO-TOUCH® Nitrile, size M code 6034302	Representative powder-free nitrile examination glove candidate for infection prevention during oral care; glove size/product used clinically may vary.
Electronic medical record system	Winning Health Technology Group / Shanxi Winning Software (publicly linked candidate)	Winning Health EMR/HIS platform; exact deployed module/version to verify	Public sources link Shanxi Provincial People's Hospital with Shanxi Winning/Winning Health information-system projects. This is the best-supported vendor candidate; confirm the exact 2024–2025 EMR/HIS product/version with hospital IT.
NRS 2002 screening form	ESPEN / Kondrup et al.	NRS 2002; DOI 10.1016/S0261-5614(02)00214-5; PMID 12765673	Nutritional Risk Screening 2002 method used for nutritional-risk screening.
Nutritional intake record sheet	Department of Hematology, Shanxi Provincial People's Hospital	Study-specific departmental intake record sheet; no commercial catalog	Used for recording daily intake/goal attainment in the empowerment pathway; verify any internal form code if applicable.
Oral care education materials	Department of Hematology, Shanxi Provincial People's Hospital	Study-specific departmental visual education material; no commercial catalog	Visual oral-care/empowerment-pathway education material described in the manuscript; verify any internal document/form code if the department assigns one.
Oral mucosal protective agent	Alliance Pharmaceuticals Limited	Gelclair® Concentrated Oral Gel; MPC ELZ012; EAN 5024403001506	Representative bioadherent oral mucosal protective gel for oral mucositis; 21 × 15 mL sachets. Candidate to be checked against the medication/nursing record.
Oral nutritional supplements	Abbott Nutrition (Abbott Laboratories)	Ensure® Plus Therapeutic Nutrition, Vanilla 237 mL; List No. 64905	Representative institutional oral nutritional supplement candidate for high-energy nutritional support; verify the actual ONS brand/formulation used.
Penlight/medical examination light	Rudolf Riester GmbH	e-xam® LED 2.5 V, black, with tongue blade holder; 5131-01	Representative diagnostic penlight candidate for throat/oral-cavity examination; verify the actual ward device.
PG-SGA assessment form	Pt-Global / Faith D. Ottery, MD, PhD	PG-SGA© (copyrighted instrument; research/publication permission required)	Patient-Generated Subjective Global Assessment for nutritional-status evaluation. Verify the exact language/version used in the hospital record.
Soft-bristled toothbrush	Sunstar Americas, Inc.	GUM Technique Deep Clean Soft, Compact 525; SKU 00070942006293	Representative web-verified soft-bristled toothbrush candidate for oral hygiene care; verify the actual ward brand/model against nursing records.
SPSS Statistics 27.0	IBM	Version 27.0.x; IBM PID 5725-A54	Statistical-analysis software; version 27.0 is explicitly stated in the manuscript.
Sterile saline mouth rinse	B. Braun Medical Inc.	0.9% Sodium Chloride Irrigation, USP; Product Code R5200-01 (1000 mL)	Representative sterile 0.9% saline candidate for bland oral rinsing/cleansing; verify the actual hospital-pharmacy product.
Thermometer	Welch Allyn (Baxter)	SureTemp® Plus 692; Model SURETEMP692	Representative hospital oral/axillary/rectal thermometer candidate for fever/infection monitoring; verify the actual ward model.
Tongue depressor	Puritan Medical Products	25-705	Representative 6-inch sterile senior wood tongue depressor for oral-cavity examination.
Visual Analog Scale (VAS) form	Huskisson EC / The Lancet	DOI 10.1016/S0140-6736(74)90884-8; PMID 4139420	Pain-intensity assessment method reference used to identify the non-commercial VAS form.
WHO oral mucositis grading criteria	World Health Organization	WHO Offset Publication No. 48; ISBN 9241700483 (1979)	WHO Handbook for Reporting Results of Cancer Treatment; added because the manuscript states WHO oral-mucositis grading was used in medical/nursing records.