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
- 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
