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NANDA Impaired Oral Mucous Membrane

NANDA Definition: Disruptions of the lips and soft tissues of the oral cavity

Defining Characteristics:

  • Purulent drainage or exudates; 
  • gingival recession, pockets deeper than 4 mm; 
  • enlarged tonsils beyond what is developmentally appropriate; 
  • smooth atrophic, sensitive tongue; 
  • geographic tongue; 
  • mucosal denudation; 
  • presence of pathogens; 
  • difficult speech; 
  • self-report of bad taste; 
  • gingival or mucosal pallor; 
  • oral pain/discomfort; 
  • xerostomia (dry mouth); 
  • vesicles, nodules, or papules; 
  • white patches/plaques, spongy patches, or white curd-like exudate; 
  • oral lesions or ulcers; 
  • halitosis; 
  • edema; 
  • hyperemia; 
  • desquamation; 
  • coated tongue; 
  • stomatitis; 
  • self-report of difficult eating or swallowing; 
  • self-report of diminished or absent taste; 
  • bleeding; macroplasia; gingival hyperplasia; 
  • fissures, cheilitis; 
  • red or bluish masses (e.g., hemangiomas)

Related Factors:
  • Chemotherapy; 
  • chemical (e.g., alcohol, tobacco, acidic foods, regular use of inhalers); 
  • depression; 
  • immunosuppression; 
  • aging-related loss of connective, adipose, or bone tissue; 
  • barriers to professional care; 
  • cleft lip or palate; 
  • medication side effects; 
  • lack of or decreased salivation; 
  • chemical trauma (e.g., acidic foods, drugs, noxious agents, alcohol);
  • pathological conditions—oral cavity (radiation to head or neck); 
  • NPO for more than 24 hours; 
  • mouth breathing; 
  • malnutrition or vitamin deficiency; 
  • dehydration; 
  • infection; 
  • ineffective oral hygiene; 
  • mechanical (e.g., ill-fitting dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity); 
  • decreased platelets; 
  • immunocompromised; 
  • impaired salivation; 
  • radiation therapy; 
  • barriers to oral self-care; 
  • diminished hormone levels (women); 
  • stress; 
  • loss of supportive structures

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Oral Health
  • Tissue Integrity: Skin and Mucous Membranes
Client Outcomes
  • Maintains intact, moist oral mucous membranes that are free of ulceration and debris
  • Describes or demonstrates measures to regain or maintain intact oral mucous membranes
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Oral Health Restoration

Read More :

http://nanda-nic-noc.blogspot.com/2013/03/impaired-oral-mucous-membrane-nursing.html
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