After 5 days of nursing interventions, the patient's oral mucosal condition will improve. Goals: moist and intact tounge and lips, absence of pain and lesions. Fluids help increase moisture in the mouth, which protects the mucous membranes from damage.
After 5 days of nursing interventions, the patient's oral mucosal condition will improve. Goals: moist and intact tounge and lips, absence of pain and lesions. Fluids help increase moisture in the mouth, which protects the mucous membranes from damage.
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After 5 days of nursing interventions, the patient's oral mucosal condition will improve. Goals: moist and intact tounge and lips, absence of pain and lesions. Fluids help increase moisture in the mouth, which protects the mucous membranes from damage.
Copyright:
Attribution Non-Commercial (BY-NC)
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Download as DOC, PDF, TXT or read online from Scribd
Px: John Ritchie Tagana 37y/o Rm: 334B Dx: SVI t/c DFS
Cues Nursing Analysis Goals and Nursing Rationale Evaluation
Diagnosis Objectives Interventions Independent: Subjective Cues: Impaired Oral Tissue Goal • Inspect the oral • Oral inspection • “Nung Mucous inflammation in • After 5 days cavity at least can reveal signs • The client’s naadmit ako Membrane the oral of nursing once daily and of oral disease, oral mucosal nung Monday related to mucosa or interventions, note any symptoms of condition meron na Infection as gums the patient’s discoloration, systemic improved. akong singaw evidenced by oral mucosal lesions, edema, disease, drug eh” as stated mouth sores condition will bleeding, side effects, or by the client improve as exudate, or trauma of the • “Kumikirot sya Redness, evidenced by dryness. Refer to oral cavity. tapos ulceration, and moist and a physician or (Gonsalves WC, mahapdi” as fissures in the intact tounge dental specialist Chi, AC, Neville stated by the mouth and lips, and as appropriate. BW: Common client absence of oral lesions: part • “Nahihirapan pain and I. Superficial nga akong lesions. mucosal lesions, kumain dahil Mouth Ulcers Am Fam dito eh” as Physician • The client stated by the Objectives: • Encourage fluid 75(4):501506, was able to client. • After 5 intake of up to 2007.) identify 4 out • “Hindi talaga minutes of 3000 mL/day if of 5 sya makakain discussion, not • Fluids help importances dahil sa the client will contraindicated increase of oral singaw nya, be able to by the client's moisture in the hygiene humahapdi. identify 4 out medical mouth, which within 3 Yan ngang of 5 condition protects the minutes. lugaw di nya importances mucous maubos eh of oral membranes • The client hygiene from damage was able to dahil masakit within 3 and helps the identify 4 out daw” as stated minutes. healing process. of 5 foods by the client’s (Roberts J: and agents wife. • After 5 Developing an that can • “Nagsisipilyo minutes of oral assessment exacerbate naman ako 3 discussion the and intervention the oral beses sa isang patient will be • Give the client tool for older condition araw” as able to frequent sips of people: 2, Br J within 2 stated by the identify 4 out water, and ask Nurs 9(18):2033, minutes. client of 5 different client to rinse 2000.) • “Oo foods and the mouth with naninigarilyo agents that water regularly. • The use of water ako” as stated can to moisten the • The client by the client. exacerbate mouth has been was able to the condition shown to be as demonstrate within 2 effective as proper oral minutes. many other hygiene Objective Cues: agents. (Joanna within 2 • Small, round, • After 3 Briggs Institute: minutes. crater shaped minutes of Prevention and sores in the oral demonstratio • Monitor the treatment of oral cavity n, the client client's mucositis in • Open sores in will be able to nutritional and cancer patients: the mouth demonstrate fluid status to best practice • The client • Pain in the proper oral determine if it is information was able to mouth hygiene adequate. sheet) perform • Pale to within 2 appropriate yellowish minutes. • Dehydration and mouth care appearance of malnutrition using soft- the sores • At home, the predispose bristle • Swollen mouth client will be clients to toothbrush sores able to impaired oral and non- perform • Determine the mucous abrasive appropriate client's usual membranes. toothpaste mouth care method of oral (Evolve, Ackley: at least 2x a using soft- care and address Nursing day. bristle any concerns Diagnosis toothbrush regarding oral Handbook, 8th • The client and non- hygiene. Edition) was able to abrasive stop alcohol toothpaste at • Whenever and smoking least 2x a possible, build usage. day. on the client's existing • At home, the • If the client does knowledge base client will be not have a and current able to stop bleeding practices to alcohol and disorder and is develop an smoking able to swallow, individualized usage. encourage the plan of care. client to brush (Evolve, Ackley: the teeth with a Nursing soft toothbrush Diagnosis using fluoride- Handbook, 8th containing Edition) toothpaste at least twice per • The toothbrush day. is the most important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling periodontal disease. (American Dental • Instruct the Association client to avoid (ADA): Cleaning alcohol-based or your teeth and hydrogen gums, March peroxidebased 2007; Pearson commercial LS, Hutton JL: A products for controlled trial to mouth care and compare the to avoid other ability of foam irritants to the swabs and oral cavity (e.g., toothbrushes to tobacco, spicy remove dental foods). plaque, J Adv Nurs 39:5, • Discourage 2002.) alcohol or cigarette use • Oral irritants can further damage the oral mucosa and increase the client's discomfort. (Evolve, Ackley: Nursing Diagnosis Dependent: Handbook, 8th • Administer Edition) medications as prescribed by the physician • Alcohol and cigarette usage can cause infection and can aggravate the oral sores. It can also alter the healing process. . (Evolve, Ackley: Nursing Diagnosis Handbook, 8th Edition)
• To relieve pain an d to promote faster healing process (Evolve, Ackley: Nursing Diagnosis Handbook, 8th Edition)