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)

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