Nursing Diagnosis for Impaired Oral Mucous Membrane

Nursing Diagnosis for 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

Nursing Diagnosis for Impaired Oral Mucous Membrane

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