00045 Deterioration Of The Integrity Of The Oral Mucous Membrane

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: <00045
Nanda label: deterioration of the integrity of the oral mucous membrane
Diagnostic focus: Mucous membrane integrity
Approved 1982 • Revised 1998, 2013, 2017 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « deterioration of the integrity of the oral mucous membrane is defined as: lip injury, soft tissues of the oral cavity and/or oropharynx. P>

Definite characteristics

  • Boca’s bad taste
  • bleeding
  • Queilitis
  • Saburral language
  • Decrease in the perception of taste
  • Descamination
  • Difficulty eating
  • Difficulty in swallowing
  • Dysphonia
  • AGREGDALAS ENGREEMENT
  • Geographic language
  • Gingival hyperplasia
  • Gingival paleness
  • Periodontal bag with depth greater than 4 mm
  • Gingival recession
  • Halitosis
  • Hyperemia
  • Macroplasia
  • Mucosa’s peel
  • Oral discomfort
  • Oral edema
  • Oral fissure
  • Oral injury
  • paleness of the oral mucosa
  • Oral nodules
  • Oral pain
  • Oral papules
  • Oral ulcers
  • Oral vesicles
  • Pathogen exposure
  • Mass presence
  • Purulent oronasal drainage
  • Exudate Purulent Oronasal
  • Lisa Atrophic Language
  • Spongy plates in the mouth
  • Stomatitis
  • White spots on the mouth
  • White plates in the mouth
  • White exudate, like curd
  • xerostomy

Related factors

  • Alcohol consumption
  • Cognitive dysfunction
  • Decrease in salivation
  • Dehydration
  • Depressive symptoms
  • Difficulty to perform the personal care of the mouth
  • Inappropriate access to dental care
  • Inappropriate knowledge about oral hygiene
  • Inadequate oral hygiene habits
  • Inappropriate use of chemical agent
  • Malnutrition
  • Oral breathing
  • smoking
  • Stressors

Risk population

  • People at economic disadvantage

Associated problems

  • allergies
  • Autosomic disease
  • Behavioral disorder
  • Chemotherapy
  • Decrease in female hormonal levels
  • Decrease in platelets
  • Depression
  • Immune system diseases
  • Immunosuppression
  • Infections
  • Loss of oral support structures
  • Mechanical factor
  • Oral anomalies
  • Absolute diet> 24 hours
  • Oral trauma
  • Radiation therapy
  • Sjögren syndrome
  • Surgical procedures
  • Trauma
  • Therapeutic regime

Suggested alternative diagnostics

  • Self -care, deficit of: hygiene
  • Dentition, deterioration of the
  • Tissue integrity, deterioration of the

NOC Results

  • Oral hygiene: mouth, teeth, gums and tongue
  • Tissue integrity: skin and mucous membranes: structural integrity and normal physiological functioning of the skin and mucous membranes

Evaluation objectives and criteria

  • Demonstrates oral hygiene, as manifested by the following indicators (specify from 1 to 5: seriously, substantially, moderately, slightly or not compromised):
    • Boca cleaning, teeth, gums, tongue, teeth or dental devices
    • moisture of the oral mucosa and the tongue
    • Color of mucous membranes (pink)
    • Oral mucosa integrity, tongue, gums and (teeth)
  • Demonstrates tissue integrity: skin and mucous membranes, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Mucous membrane lesions
    • Erythema
    • necrosis
  • Other examples

    • Eat food and fluids increasingly comfort
    • Does not present halitosis
    • Performs essential oral hygiene as prescribed and indicates

    NIC Interventions

    • Help in self -care: to help another to carry out the activities of daily life (AVD)
    • Teaching: Individual: Planning, implementation and evaluation of a teaching program designed to deal with the particular needs of a patient
    • Maintenance of oral health: maintenance and promotion of oral and dental hygiene of a patient at risk of developing oral or dental lesions
    • Restoration of oral health: Promotion of healing in a patient who has dental lesion or oral mucosa

    Nursing Activities

    Valuations

    • Identify irritating substances, such as tobacco, alcohol, food, medicines, food at extreme temperatures, condiments
    • Assess the patient’s knowledge and his ability to perform oral care
    • (NIC) RESTORATION OF OLAL HEALTH:
      • Determine the patient’s perception of changes in taste, swallowing, voice quality and comfort
      • Watch in each turn if the patient has dryness of the oral mucosa
      • Monitor the signs and symptoms of glossitis and stomatitis
      • Monitor the therapeutic effects of topical anesthetics, oral protective creams and topical or systemic analgesics, as required

    Patient and family education

    • (NIC) Health restoration Bucai.
      • Strengthen the oral hygiene regime as part of the teaching before medical discharge
      • Indicate the patient to avoid commercial mouth rinses
      • Instruct the patient to immediately report any infection signal to the doctor

    Collaboration activities

    • Consult a doctor about the recipe of an antifungicide oral rinse or an anesthetic oral topic in case of fungal infection
    • (NIC) Health restoration Bucai.
      • Consult a doctor if the signs and symptoms of glossitis and stomatitis persist or worsen
      • Apply topical anesthesia, oral protection creams and topical or systemic analgesics, as necessary

    Others

    • Provide oral care before meals and when necessary
    • Avoid the use of candies and chewing rubber with sugar
    • Clean the dentures after each meal
    • Remove the teeth in case of severe stomatitis
    • (NIC) Health restoration Bucai.
      • Plan reduced and frequent meals, select soft foods and serve cold foods or at room temperature
      • Help the patient select soft, soft and non -acidic foods
      • Increase the frequency of oral care once every two hours and twice at night if stomatitis is not controlled
      • Use a soft toothbrush to remove waste between the teeth
      • Recommend frequent rinses of the mouth with any of the following products: Sodium bicarbonate solution, lukewarily serum or hydrogen peroxide solution
      • Avoid the use of rinses with lemon and glycerin
      • A advise the consumption of tobacco and alcohol

    At home

    • above interventions can adapt to their use at home; The main difference is that the nursing professional is more likely to perform interventions to a hospitalized patient, while at home it is more likely to teach the patient or the caregiver to carry out the interventions
    • Suggest the use of cold drinks and ice palettes to reduce discomfort
    • Suggest the use of a humidifier of the environment if the home air is dry

    Babies and Children

    • Teach parents that it is normal for children’s gums to be reddened and inflamed during the dentition
    • Replace the child’s toothbrush every three months
    • Indicate parents to give the child something safe to chew during the dentition

    Older people

    • Evaluate whether the patient is able to perform his own oral hygiene
    • Observe if there are lesions on the lips and oral cavity (for example, packages, ulcers, red or white plates, granular lesions)
    • Keep in mind that many older people visit the dentist on rare occasions. Encourage them to go on a regular basis; Help them get transport and financial aid, if necessary