NANDA Nursing Diagnosis: Deterioration of the Integrity of the Oral Mucous Membrane
Introduction
The oral mucous membrane is a vital part of the body’s defense system, providing a barrier against infection and injury. When this barrier is compromised, it can lead to a variety of problems, including infection, pain, and difficulty eating or speaking. One common nursing diagnosis for this type of problem is “Deterioration of the Integrity of the Oral Mucous Membrane.”
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of this diagnosis is: “A disruption in the normal structure and function of the oral mucous membrane, characterized by inflammation, ulceration, and possible infection.”
Defining Characteristics
Subjective
- Patient reports pain or discomfort in the mouth
- Patient reports difficulty eating or speaking
- Patient reports a change in the appearance of the oral mucous membrane (e.g. redness, swelling, ulceration)
Objective
- Inflammation or ulceration of the oral mucous membrane is observed
- Patient has difficulty eating or speaking
- Patient has a change in the appearance of the oral mucous membrane (e.g. redness, swelling, ulceration)
Related Factors
- Inadequate oral hygiene
- Tobacco use
- Alcohol consumption
- Certain medical conditions (e.g. diabetes, HIV/AIDS)
- Certain medications (e.g. chemotherapy, radiation therapy)
Risk Population
- Older adults
- Individuals with chronic medical conditions
- Individuals who use tobacco or alcohol
- Individuals who are receiving certain types of medical treatment (e.g. chemotherapy, radiation therapy)
Associated Problems
- Infection
- Pain
- Difficulty eating or speaking
- Malnutrition
- Dehydration
Suggestions for Use
- Assess the patient’s oral hygiene and provide instruction as needed
- Assess the patient’s diet and provide nutrition education as needed
- Encourage the patient to quit smoking and limit alcohol consumption
- Assist the patient in managing any underlying medical conditions (e.g. diabetes, HIV/AIDS)
- Monitor the patient for signs of infection and implement appropriate interventions
Suggested Alternative NANDA Diagnoses
- Impaired oral mucous membrane
- Impaired oral comfort
- Ineffective oral hygiene
- Risk for infection related to compromised oral mucous membrane
Usage Tips
- Consider the patient’s overall health status and any underlying medical conditions when making a diagnosis
- Be specific when documenting the appearance of the oral mucous membrane (e.g. redness, swelling, ulceration)
- Consider using additional diagnoses to address associated problems (e.g. risk for infection, impaired oral comfort)
NOC Results and Explanation
- Oral Mucous Membrane Integrity: The patient’s oral mucous membrane is intact and functioning properly
- Oral Comfort: The patient is comfortable and able to eat and speak without difficulty
- Infection Control: The patient is free from infection and appropriate interventions are in place to prevent infection
NIC Interventions and Explanation
- Oral Care: Provide appropriate oral hygiene care to maintain integrity of oral mucous membrane
- Pain Management: Administer pain medication as needed and implement other pain management techniques
- Infection Control: Implement appropriate infection control measures to prevent and manage infection
- Nutrition Support: Provide appropriate nutrition support to maintain oral comfort and prevent malnutrition
Conclusion
Deterioration of the integrity of the oral mucous membrane is a serious condition that can lead to a variety of problems, including infection, pain, and difficulty eating or speaking. It is important for nurses to be aware of the risk factors, associated problems, and interventions for this diagnosis in order to provide effective care for patients.