Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00045
Nanda label: Impaired oral mucous membrane integrity
Diagnostic focus: Mucous membrane integrity
Oral mucous membrane integrity refers to the health of the mucous membranes that line the mouth. When patients suffer from conditions such as stomatitis, angular cheilitis, and burning mouth syndrome, they may be diagnosed with impaired oral mucous membrane integrity. Nurses are well-positioned to provide diagnosis, patient education, and treatments aimed at restoring the health of the oral mucous membrane.
NANDA Nursing Diagnosis Definition
The National Alliance of Nursing Diagnosis and Development (NANDA) defines the nursing diagnosis of impaired oral mucous membrane integrity as, “A disruption in the protective mucosal lining of the mouth resulting in easy susceptibility to infection, discomfort, and alteration in taste sensation.”
Subjective defining characteristics include patient report of pain, burning, or numbness around the mouth. Patients may also report altered taste sensation, dryness, itching, or the presence of cutaneous lesions. Objective defining characteristics may include visual inspection of unilateral or bilateral redness and swelling of the mucous membranes; the presence of candidiasis, herpetic lesions, or a significant amount of plaque; dry or flaking lips, fissures and/or erosions; and alterations in taste sensation.
- Local Trauma: Any trauma sustained to the mouth resulting from dental, medical or surgical procedures, or contact with objects can lead to impaired oral mucous membrane integrity.
- Vitamin Deficiencies: The lack of vital vitamins and minerals can lead to an increase in sensitivity and inflammation.
- Cancer Treatment: Cancer therapies, both pharmaceutical and non-pharmaceutical, can compromise the mucous membranes resulting in soreness, burning sensation, and xerostomia (dry mouth).
- Chemotherapy: Chemotherapy drugs can lead to severe mucositis if not properly managed.
- HIV and AIDS: Certain oral changes that occur with HIV infection often contribute to the presence of impaired oral mucous membrane integrity.
At Risk Population
Individuals who are most at risk for developing impairments of the oral mucous membrane are those with conditions such as diabetes mellitus, HIV, cancer, dry mouth, smoking, pregnancy, and immune deficiency disorders. Individuals taking medications that are known to cause dryness of the mouth such as antihistamines and diuretics may also be at an increased risk.
Impaired oral mucous membrane integrity is associated with a variety of different conditions such as stomatitis, angular cheilitis, burning mouth syndrome, candidiasis, periodontal disease, and gingivitis. Some patients may experience varying levels of pain depending on the severity of oral changes.
Suggestions for Use
When working with patients who are experiencing impaired oral mucous membrane integrity, nurses should suggest preventive measures that can reduce the likelihood of further inflammation. These measures may include good oral hygiene, avoiding foods and beverages that are high in sugar, avoiding spicy or acidic foods, and using a soft-bristled toothbrush. Frequently rinsing the mouth with a saline solution may also be recommended.
Suggested Alternative NANDA Nursing Diagnoses
- Risk for Impaired Mucous Membrane Integrity: This diagnosis may be appropriate for individuals who are at an increased risk for developing impaired oral mucous membrane integrity due to disease process, underlying condition, or environmental factors associated with the condition.
- Pain, Oral: This diagnosis indicates that the patient is experiencing pain due to an impaired mucous membrane condition or the treatment thereof.
- Ineffective Swallowing: This diagnosis would be appropriate for patients who have difficulty swallowing food, drinks, or medications due to an impaired mucous membrane condition.
When diagnosing and treating impaired mucous membrane integrity, nurses should strive to provide patient-centered care. They should take the time to educate patients and their families about the potential risks and interventions for the condition. Additionally, nurses should routinely monitor patient progress, offering advice and lifestyle modifications that can help overcome the condition.
- Mucous Membrane Integrity: This outcome measures the level of tissue integrity of the oral mucous membrane.
- Comfort Level: This outcome evaluates a patient’s level of comfort based on various subjective and objective factors.
- Oral Hygiene: This outcome assesses a patient’s ability to maintain good oral hygiene.
- Nutritional Status: This outcome assesses the patient’s overall nutritional status, taking into account the subjective factors that may affect it.
- Tissue Perfusion: This outcome measures the ability of mucosal tissues to receive adequate blood flow.
Evaluation Objectives and Criteria
Evaluation objectives and criteria for a patient who is being observed for impaired oral mucous membrane integrity may include monitoring for signs of tissue damage, assessment of comfort level, evaluation of patterns of oral hygiene, evaluation of nutritional intake and absorption, and monitoring of tissue perfusion.
- Oral Care: This intervention involves providing frequent cleaning and protection of the oral tissues.
- Nutrient Management: This intervention addresses any problems related to nutrition and provides support for meeting nutrient needs.
- Pain Management: This intervention focuses on the administration of medications and lifestyle modifications that can reduce discomfort.
- Oral Hygiene Instruction: This intervention focuses on teaching the patient strategies for promoting healthy oral hygiene practices.
- Mucositis Prevention: This intervention focuses on preventative measures that can be taken to reduce the risk of mucositis.
When providing patient care, the nurse is responsible for assessing the condition of the patient’s oral mucous membrane, providing patient education, administering prescribed medications, and monitoring for signs of complications. The nurse is also responsible for providing reassurance and emotional support to the patient throughout the course of treatment.
In conclusion, impaired oral mucous membrane integrity is a condition that should be taken seriously by healthcare professionals. Nurses play an important role in diagnosis, patient education, and treatment. It is vital to educate patients about preventive measures that can reduce the risk of further inflammation and to provide medication and lifestyle modifications that can help restore mucous membrane health.
- What is Impaired Oral Mucous Membrane Integrity? Impairment of the oral mucous membrane is a condition that results in inflammatory changes to the tissues of the mouth. It can be caused by local trauma, vitamin deficiencies, cancer treatments, chemotherapy, and HIV/AIDS.
- What Are the Symptoms of Impaired Oral Mucous Membrane Integrity? Symptoms can include pain, burning sensation, changes in taste sensation, redness and swelling, dry lips, fissures and/or erosions, and the presence of lesions.
- Who Is at Risk for Impaired Oral Mucous Membrane Integrity? Individuals at risk for impaired oral mucous membrane integrity include those with diabetes mellitus, HIV, cancer, dry mouth, smoking, pregnancy, immune deficiency disorders, and those taking certain medications.
- How Do Nurses Assess and Treat Impaired Oral Mucous Membrane Integrity? Nurses may use a variety of assessments and treatments when working with patients suffering from impaired oral mucous membrane integrity. These include patient education, assessments of tissue integrity, comfort level, pain management, oral hygiene instruction, and mucositis prevention.
- What Are the Evaluation Objectives and Criteria for Impaired Oral Mucous Membrane Integrity? Evaluation objectives and criteria for impaired oral mucous membrane integrity may include monitoring for signs of tissue damage, assessment of comfort level, evaluation of patterns of oral hygiene, evaluation of nutritional intake and absorption, and monitoring of tissue perfusion.