NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00045 Impaired oral mucous membrane integrity

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.


Area 11 Safety/Defense
Category 2 Bodily injury Bodily harm or injury

00045 Impaired oral mucous membrane integrity

Nursing Diagnosis: Impaired oral mucous membrane integrity
Definition: Conditions with damage to the lips, soft tissues, oral vestibule, oropharynx

1. Indications for Nursing Diagnosis “Oral Mucosal Disorder”

・Damage to the oral mucosa:
・ Burns, detachment of mucous membranes due to burns
・ Stomatitis
・Bleeding
・ Bleeding tendency, immunosuppressants, anticancer drugs, radiotherapy
・Oral edema
・ Cracks in the oral cavity
・ Papules in the oral cavity
・ Oral ulcers
・ Blisters in the oral cavity
・Drainage from the nasal cavity
・Oropharynx soft tissue:
・Tongue (tongue coating, tongue atrophy, autoimmune disease, giant tongue due to Down’s syndrome)
・Oral vestibule (the space between the surface of the teeth and gums and between the lips and buccal mucosa):
・Gingiva (pale gingiva due to poor blood flow, gingival disease with a depth of 4 mm or more, gingival recession
・cheilitis,
Sjogren’s syndrome (dry mouth, swelling of the parotid and submandibular glands)
・Conditions leading to dry mouth:
・Artificial respiration
・Dehydration
· Insufficient saliva secretion due to autoimmune disease
Habits that interfere with oral self-cleaning:
・smoking
・Drinking
・Tube feeding
・No eating or drinking・
・Insufficient oral self-care
・Attention Deficit Disorder

2. aim setting

Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

· Oral hygiene (1100)
(Definition: condition of oral cavity, teeth, gums, and tongue)
・Pain level (2102)
(definition: observed or reported severity of pain)
・Self-care: oral hygiene (0308)
(Definition: Autonomous oral and dental care, regardless of the use of assistive devices)
   Personal behavior by force)
· Immunity status (0702)
(Definition: Congenital/acquired resistance to internal and external antigens)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”
・Acquire correct tooth brushing habits and maintain oral hygiene.
・If you feel pain in your mouth, bleeding, or other abnormalities, you can consult a m
edical professional.
・ During the period when oral mucosal damage is likely to occur due to anticancer drugs, oral care can be performed particularly gently.
・For poor salivary secretion due to autoimmune disease, swallowing exercises and ice massage can be performed before meals to promote salivary secretion.

3. Nursing plan 

1 >> Observation plan <OP>

・Presence/absence of teeth grinding and wearing a mouthpiece
・Dentures, partial dentures
・Inserts such as implants
・Gingivitis
·stomatitis
・Swollen gums
·bleeding
・Color tone of oral mucosa, erosion
・tartar
·bad breath
・Cleanliness of the tongue, tongue coating
・Tooth decay
・Tooth pain
・Pain in mouth
・Saliva secretion
・Presence or absence of underlying disease (autoimmune disease)
・Brushing habits (whether self-care is lacking)
・Tooth brushing technique (whether you are brushing correctly) (how to use a toothbrush) (strength)
・ Appetite (cannot eat due to toothache, etc.)
・Diminished saliva secretion due to poor chewing
・(Infants) The habit of polishing
・Smoking habits
·Drinking
・Respirator (dry mouth)
・Dehydration (dry mouth)

2 》 Action plan 《TP》

・Inform your doctor if you have persistent inflammation, pain, or bleeding.
・Mouth care should be performed after each meal.
 Use a moisturizer if your skin is very dry.
・Recommend brushing teeth after each meal. (setting, assistance)
・Use of a tongue brush is recommended. (setting, assistance)
・Use of mouthwash is recommended. (setting, assistance)
・Use of dental floss is recommended. (setting, assistance)
・Remove dirt from dentures and partial dentures with a brush.
・ Soak your dentures in a denture cleanser before going to bed.
・Keep the mouthpiece clean.
・Apply fluoride to teeth.
・If a child refuses treatment due to fear, explain in an easy-to-understand manner what kind of treatment will be given.
・If the child refuses treatment due to fear, care should be taken to provide a sense of security, such as accompanying the child.

3 >> Education plan 《EP》

・Encourage regular dental check-ups.
・Explain how to brush your teeth correctly.
・Explain the effects of periodontal disease such as gingivitis on teeth (tooth loss due to chronic inflammation).
・Explain what happens when teeth fall out (hard foods cannot be eaten and nutritional balance is disrupted).
・Explain not to put up with tooth pain.
・Explain to let the patient know as soon as the filling or covering comes off.
・Explain that food should be chewed well to promote saliva secretion.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

Thank you for coming this far. If you have any comments, impressions or questions, we are waiting for you from the comment section below (゚▽゚)

投稿者

florence.no.tomoshibi@gmail.com

コメントを残す

メールアドレスが公開されることはありません。 が付いている欄は必須項目です