00045 Impaired oral mucous membrane integrity

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00045 Impaired oral mucous membrane integrity

Definition of the NANDA label

State in which the individual presents alterations in the integrity of the lips and soft tissues of the oral cavity.

Injury to the lips, soft tissue, buccal cavity, and/or oropharynx.

Defining characteristics

• Purulent drainage or exudate.
• Gingival recession, pockets larger than 4 mm.
• Enlargement of the tonsils greater than adequate.
• Soft, atrophic, sensitive tongue.
• Geographic language.
• Coated tongue.
• Denuded mucosa.
• Presence of pathogens.
• Difficulty speaking.
• Reports of bad taste.
• Pale gums or mucosa.
• Oral pain or discomfort.
• Xerostomia (dry mouth).
• Vesicle, nodules or papules.
• White patches or patches, fluffy patches, or thick white exudate.
• Oral lesions or ulcers.
• Halitosis.
• Edema.
• Hypervolemia.
• Flaking.
• Stomatitis.
• Reports of difficulty eating or swallowing.
• Reports of decreased or absent taste.
• Bleeding.
• Macroplasia.
• Gingival hyperplasia.
• Fissures, cheilitis.
• Red or bluish masses (eg, hemangiomas).

Related factors

• Chemotherapy.
• Chemical factors (eg, alcohol, tobacco, acidic foods, drugs, habitual inhaler use, or other causative agents).
• Age-related loss of bone, cartilage or connective tissue.
• Barriers to professional care.
• Depression.
• Cleft lip or palate.
• Immunosuppression.
• Side effects of medication.
• Lack or reduction of salivation.
• Trauma.
• Pathological states of the oral cavity (radiation from the head or neck).
• Absolute diet for more than 24 hours.
• Mouth breathing.
• Malnutrition or vitamin deficiency.
• Dehydration.
• Infection.
• Ineffective oral hygiene.
• Mechanical factors (eg, ill-fitting dentures, bridges, tubes [endotracheal / nasogátric], oral cavity surgery).
• Decrease in platelets.
• Immune compromise.
• Radiation therapy.
• Barriers to oral self-care.
• Decreased hormonal level (in women).
• Stress.
• Lack of support structures.

At risk population

• Economically disadvantaged

Associated condition

• Allergy
• Alteration in cognitive functioning
• Autoimmune disease
• Autosomal disorder
• Behavioral disorder
• Chemotherapy
• Cleft lip
• Cleft palate
• Decrease in hormone level in women
• Decrease in platelets
• Immunodeficiency
• Immunosuppression
• Infection
• Loss of oral support structure
• Mechanical factor
• Nil per os (NPO) > 24 hours
• Oral trauma
• Radiation therapy
• Sjögren’s Syndrome
• Surgical procedure
• Trauma
• Treatment regimen

NOC

• Oral health.
• Tissue integrity: skin and mucous membranes.

NIC

• Maintenance of oral health.
• Promote oral health.
• Pain management.
• Restoration of oral health.
• Nutrition management.

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