PRELIMINARY REPORT

NURSING CARE IN TONGUE CANCER PATIENT

IN DAHLIA 1 RSUP DR. SARDJITO

Submitted for Application of Nursing Theory & Standardiezed Nursing Language

Approach in Medical Surgical Nursing Course

Disusun oleh :
Adhin Al Kasanah
Arni Budi Meisa Ndari
Bardah Wasalamah

MAGISTER SCHOOL OF NURSING

FACULTY OF MEDICINE
UNIVERSITAS GADJAH MADA
YOGYAKARTA
2016
 THEORETICAL BASIS OF TONGUE CANCER

A. Definition
Tongue cancer is a type of oral cancer that forms in the front two-thirds of
the tongue. Cancer that forms in the back one third of the tongue is
considered a type of head and neck cancer. Tongue cancer usually develops in
the squamous cells, the thin, flat cells that cover the surface of the tongue
(Albuquerque et al., 2011). Tongue cancer also known as squamous cell
carcinoma of the tongue is malignancy of the tongue that Tongue cancer is
divided into that on the anterior tongue and that at the base of the tongue. The
anterior tongue is the front two-thirds while the base is the back third of the
tongue. The anterior tongue is the site of two-thirds of all tongue cancers.
Three-quarters of these tumors are small and can be effectively treated by
surgery or radiation (Yadav, 2006).
Squamous cell carcinoma is defined as a malignant epithelial neoplasm
exhibiting squamous differentiation as characterized by the formation of
keratin pearls and/ or presence of intercellular bridges. It is the most common
neoplasm of the oral cavity. The main cause of oral cancer has been attributed
to the use of tobacco in its various forms, especially when associated with the
use of alcohol (Tyagi & Tyagi, 2013).
Based on several definitions above can be inferred that tounge cancer or
Squamous cell carcinoma is malignancy of the tongue and part of the oral
cancer that occurs in the squamous cells, the thin, flat cells that cover the
surface of the tongue, devided into the anterior tongue and that at the base of
the tongue, the anterior tongue is the front two-thirds while the base is the
back third of the tongue.
B. Risk factor
As stated by Yadav (2006), there are several factors causing Tongue cancer as
follow:
1) Tobacco
Tobacco is the single most important risk factor for cancers of the oral
cavity including tongue cancers. The use of both smoked as well as
smokeless tobacco predisposes a person to cancer. Tobacco specific
nitrosamines (TSNA) present in smokeless tobacco are the most harmful
carcinogens which are also responsible for various precancerous lesions.
2) Alcohol
Alcohol is a known group 1 carcinogen for oral cavity cancers. Alcohol,
acting both independently as well as synergistically with smoking, has
been implicated in oral carcinogenesis. More importantly, alcohol may act
as a solvent and enhance the penetration of carcinogens into target tissues.
Acetaldehyde, which is the alcohol metabolite, has been identified
recently as a tumor promoter. Studies have reported several fold increased
risk of cancer in the presence of excessive use of both the agents. The use
of alcohol is an important risk factor for carcinoma of oral tongue and
floor of mouth.
3) Betal quit and Areca Nut
Betel chewing is reported to be the most important etiological factor in
oral submucous fibrosis. The use of betel quid, containing both areca nut
and tobacco, is associated with a much higher relative risk of oral cancer,
between 8-15 times as compared to that of 1-4 times, associated with
using the quid, without tobacco. BQ chewing produces ROS that is
detrimental to oral mucosa and can be directly involved in tumor
initiation process, by inducing mutation, or by making the mucosa
susceptible to BQ ingredients and environmental toxicants. Betel quid
(BQ) chewing produces reactive oxygen species (ROS), that have
multiple detrimental effects upon the oral mucosa. The production and
 release of ROS occurs under alkaline conditions during the autooxidation
of areca nut (AN) polyphenols, in the BQ chewer’s saliva. The ROS can
be directly involved in the tumour initiation process, by inducing
genotoxicity and gene mutation, or by attacking the salivary proteins and
oral mucosa, leading to structural change in the oral mucosa, that may
facilitate the penetration by other BQ ingredients and environmental
toxicants.
4) Viruses
Another risk factor is human papillomavirus (HPV), which is also closely
associated with benign and malignant oral lesions. This virus is detected
in condylomas, focal epithelial hyperplasia, squamous cell papilloma and
malignant oral lesions. HPV positivity is higher in tumors from the oral
cavity (59%), pharynx (43%) and larynx (33%). Among those, only a
small fraction of HPV-infected lesions rarely proceed to malignant
transformation, specially those with HPV subtypes 16,18.Hence, these
studies indicate that tumorigenic conversion requires the presence of other
risk factors.
5) Malnutrition or a diet lacking in chemo-protective vitamins namely A, C
& E has been shown to be a predisposing factor. Fruits and vegetables
(high in vitamins A and C) are described as protective in oral neoplasia,
whereas meat and red chilli powder are thought to be risk factors.
Although the individual micronutrients responsible have not been
formally identified, vegetables and fruits that protect against oral cancer
and precancer, are rich in b-carotene, vitamin C and vitamin E, with anti-
oxidant properties
6) Poor dental hygiene and sharp teeth are also implicated in the etiology of
tongue cancers.
C. Epidemiology
Tongue cancer also known as oral Squamous cell carcinoma (SCC) more
frequently affects men than women (M:F = 1.5:1) most probably because
more men than women indulge in high-risk habits. The probability of
developing tongue increases with the period of exposure to risk factors, and
increasing age adds the further dimension of age-related mutagenic and
epigenetic changes. In the USA the median age of diagnosis of it is 62 years.
However, the incidence of tongue cancer in persons under the age of 45 is
increasing. In Western countries tongu cancer affects the tongue in 20% -
40% of cases and the floor of the mouth in 15% - 20% of the cases, and
together these sites account for about 50% of all cases of oral SCC. The
gingivae, palate, retromolar area and the buccal and labial mucosa are oral
sites less frequently affected (Feller & Lemmer, 2012).
The ventral surface of the tongue and the floor of the mouth are the sites
most commonly affected by touge cancer or SCC because they are lined by
thin non-keratinised epithelium. Not only do carcinogens readily penetrate
this thin epithelium to reach the progenitor cell compartment, butcarcinogens,
particularly tobacco products and alcohol in solution, constantly accumulate
in the floor of the mouth and bathe the tissues of the floor of the mouth and
the ventrum of tongue. The mean 5-year survival rate of persons with toung
cancr is about 50% with no gender difference; but black persons have a lower
five year survival rate than persons of other races. Other socio-demographic
factors such as age, potentially carcinogenic habits (using alcohol, tobacco,
betel quid) or socio-economic status are not consistently related to survival
rates.

D. Pathophysiology
In oral squamous cell carcinoma (OSCC), modern DNA technology,
especially allelic imbalance (loss of heterozygosity) studies, have identified
chromosomal changes suggestive of the involvement of tumor suppressor
genes (TSGs), particularly in chromosomes 3, 9, 11, and 17. Functional TSGs
seem to assist growth control, while their mutation can unbridle these control
mechanisms. The regions most commonly identified thus far have included
some on the short arm of chromosome 3, a TSG termed P16 on chromosome
9, and the TSG termed TP53on chromosome 17, but multiple other genes are
being discovered. As well as damage to TSGs, cancer may also involve
damage to other genes involved in growth control, mainly those involved in
cell signaling (oncogenes), especially some on chromosome 11 (PRAD1in
particular) and chromosome 17 (Harvey ras [H-ras]). Changes in these and
other oncogenes can disrupt cell growth control, ultimately leading to the
uncontrolled growth of cancer. H-ras was one of the oncogenes that first
caught the attention of molecular biologists interested in cell signaling, cell
growth control, and cancer. It and the gene for epidermal growth factor
receptor (EGFR) are involved in cell signaling.
The genetic aberrations involve, in order of decreasing frequency,
chromosomes 9, 3, 17, 13, and 11 in particular, and probably other
chromosomes, and involve inactivated TSGs, especially P16, and TP53 and
overexpressed oncogenes, especially PRAD1. Carcinogen-metabolizing
enzymes are implicated in some patients. Alcohol dehydrogenase oxidizes
ethanol to acetaldehyde, which is cytotoxic and results in the production of
free radicals and DNA hydroxylated bases; alcohol dehydrogenase type 3
genotypes appear predisposed to OSCC. Cytochrome P450 can activate many
environmental procarcinogens. Ethanol is also metabolized to some extent by
cytochrome P450 IIEI (CYP2E1) to acetaldehyde. Mutations in some TSGs
may be related to cytochrome P450 genotypes and predispose to OSCC.
Glutathione S transferase (GST) genotypes may have impaired activity; for
example, the null genotype of GSTM1 has a decreased capacity to detoxify
tobacco carcinogens. Some GSTM1 and GSTP1 polymorphic genotypes and
GSTM1 and GSTT1 null genotypes have been shown to predispose to
OSCC. N -acetyltransferases NAT1 and NAT2 acetylate procarcinogens. N -
 acetyl transferase NAT1*10 genotypes may be a genetic determinant of
OSCC, at least in some populations.
Tobacco is a potent risk factor for oral cancer. An interaction occurs
between redox-active metals in saliva and the low reactive free radicals in
cigarette smoke. The result may be that saliva loses its antioxidant capacity
and instead becomes a potent pro-oxidant milieu (Feller & Lemmer, 2012).
E. Clinical Manifestation
Most patients with tongue cancer are asymptomatic or may be misdiagnosed
by their health care provider and given anti fungal treatment, steroids or
mouthwash. This often results in late diagnosis of the tongue cancers :
a) 51% occur on the lateral margin of the middle third of the tongue
b) 25% occur in the posterior third
c) 20% in the anterior third
d) 4% occur on the dorsum.
They manifest in different ways:
a) An exophytic and ulcerated lesion
b) An ulcer within a fissure,
c) An area of superficial ulceration in which muscle infiltration has
occurred
d) A leucoplakia associated lesion
e) A red or white patch on the tongue, that will not go away
f) A sore throat that does not go away
g) A sore spot (ulcer) or lump on the tongue that does not go away
h) Pain when swallowing
i) Numbness in the mouth that will not go away
j) Unexplained bleeding from the tongue (that is not caused by biting your
tongue or other injury)
k) Pain in the ear (rare)
l) An asymptomatic atrophic depapillated area
Intermediate lesions present as a persistent fixated ulcer and there may be
lymphadenopathy. Late lesions manifest as large indurated crater ulcers with
 granular floors and rolled margins. There may be pain, numbness or
parasthesia. Pain may be severe and radiate to the neck and ears. Lesions may
be bleeding and necrotic. Lymph node metastases are common in later stages.
Fifty percent of patients have palpable nodes at presentation. There is early
nodal spread in this form of cancer, so that 12% of patients who present with
a lump in the neck show no evidence of a primary cancer. Any patient with an
ulcer present for more than three weeks and cervical lymphadenopathy should
be considered at risk (Ionmhain, 2007).
F. Prevention
The overall aim of cancer prevention is to reduce the incidence of the disease;
and of cancer control is to detect the disease in its initial stages and to
promptly institute effective and efficient treatment. The prevention of tongue
cancer are :
1) Primary prevention can be achieved by advising cessation of smoking and
moderation of alcohol intake. Smoking cessation has also been shown to
be associated with regression of pre-malignant lesions such as
leucoplakia. Other suggestions include the improvement of diet and the
use of antioxidants to prevent recurrance or prevent malignant
transformation. However, this has not been proven. Among the reasons
cited for poor prognosis in oral cancer are poor knowledge and education
about the presentation of oral cancer. Screening and educational
campaigns have also been suggested, however, in the west oral cancers
are rare so that screening may not be cost effective.
2) Dental care has a major role in the prevention and detection of oral
squamous cell carcinoma. However, lower socio economic groups and
other groups such as the elderly rarely attend for dental care. Therefore, in
the interest of preventive care, regular dental check ups should be
encouraged by offering financial assistance to patients within such
groupings.
3) Poor referral rates from doctors are believed to arise from a failure to
recognise signs and symptoms. This is thought to be partly due to the lack
 of emphasis on oral examination in medical school. Therefore medical
student education is an important target in prevention (Ionmhain, 2007).

G. Treatment of Tongue cancer

The treatment of oral SCC generally requires the services of a
multidisciplinary team. The primary aim of treatment always being to
eradicate the cancer, to prevent recurrence, and insofar as is possible to
restore the form and function of the affected parts. The selection of a specific
treatment modality is dictated by the nature of the carcinoma and by the
general condition of the patient. Salient factors related to the carcinoma
include the specific site affected, the clinical size, the extent of local invasion,
histopathological features, regional lymphnode involvement and distant
metastasis. Patient factors include age, general health status, a history of
previously treated oral SCC and high-risk habits. A variety of modalities are
available for the treatment of oral SCC. These include excision/resection,
radio-therapy, systemic cytotoxic chemotherapy and blocking of epithelial
growth factor receptor (EGF-R), or a combination of these, either
concurrently or in an orderly sequence.
a) Surgery is the preferred first line treatment of small, accessible oral SCCs.
However, advanced-stage oral SCC is usually treated by a combined
treatment program of surgery, chemotherapy, and radiotherapy. In cases
of recurrent oral SCC, EGF-R inhibitor coupled with chemoradiotherapy,
is the first line of treatment.
b) Surgical resection of oral carcinoma with tumour free margins of less than
5 mm may be followed by local recurrence and possibly by distant
metastasis, and usually necessitates the administration of post-surgery
chemoradiotherapy. The importance of the presence of dysplastic
epithelium in post-resection carcinoma-free margins is of debatable
importance, but it is not usually considered to be a strong indication for
further treatment.
 c) Radiotherapy is indicated in primary treatment. It can also be used to
debulk the cancer or to prevent recurrences. It should also be considered
in older patients who are poor surgical candidates. Post operative
combination radiotherapy and chemotherapy are offered in advanced
disease.If radiotherapy is being provided, a dental evaluation must be
sought to decide if teeth in the field of irradiation need to be extracted.
This generally involves :
1) Removal of teeth with advanced caries
2) Teeth with advanced periodontal involvement
3) Teeth with periapical pathology. Chemotherapy is mainly used in
palliation.
H. Nursing Diagnose
1. Acute pain related to biological injury (oral lesions)
2. Impaired oral mocus membrane related to oral lesions
3. Deficit knowledge related to Insufficient information
4. Imbalanced Nutrition: Less Than Body Requirements related to inability
to ingest adequate nutrition due to oral conditions.
 NURSING CARE PLAN

No Nursing Diagnosis NOC / Outcome NIC / Intervention

1. Neusea Nausea & Vomiting control Nausea Management
A subjective phenomenon of an Definition Definition :
unpleasent feeling in the black of Personal action to control nausea, retching, and Prevention and allevation of nausea
the throat and stomatch, which vomiting symptoms Activities :
may or may not result in vomiting Outcome: 1. Encourage patient to monitor own
After nursing action for, client will maintain nausea experience
May evidenced by (defining Nausea & vomiting control as evidence by : 2. Encourage patient to learn strategies
characteristic) : No Indicators Initial Target for managing own nausea
Aversion toward food, nausea, 1 Recognizes of nausea 5 3. Perform complete assessment of
sour taste, gagging sensation, 2 Describe causal factors 5 nausea, including frequency, duration,
3 Recognizes precipitating 5
increas in salivations severity, and precipitating factors,
stimuli
using such as tools as self care journal,
4 Avoids causal factors 5
Related Factors when possible visual analog scales, duke descriptive
Biophysical (Treatment regimen) 5 Avoids disagreeable odors 5 scales, and Rhodes Index of Nausa and
6 Uses antimetic medication 5 Vomiting (INV) form 2
as recommended
4. Identify factors (e.g medication and
7 Report uncontrolled 5
procedures) thay may cause of
symptoms to health
contribute nausea
 professional 5. Ensure that effective antiemetic drugs
8 Reports nausea, retching, 5 are given to prevent nausea when
and vomiting controlled
possible
6. Control environment factors that may
Nausea & vomiting Severity evoke nausea (e.g aversive smells,
Definition : sound, and unpleasant visual
Severity of signs, and symptoms of nausea, stimulation)
retching, and vomiting 7. Reduce or eliminate personal factors
Outcome : that precipitate or increase the nausea
After nursing action for, client will maintain (anxiety, fear, fatigue, lack of

Nausea & vomiting severity as evidence by : knowledge)

No Indicators Initial Target 8. Identify strategies that have been

1 Frequency of nausea 5 successful in relieving nausea
2 Intencity of nausea 5 9. Teach the use of nonpharmacological
3 Distress of usea 5
techniques (e.g bio feedback,
4 Frequency of retching 5
hypnosis, relaxion, guided imaginary,
5 Intensity of retching 5
6 Distrees of retching 5
music therapy, distraction,
7 Frequency of vomiting 5 acupressure) to manage nausea
8 Intensity of vomiting 5 10. Encourage the use of
9 Distrees of vomiting 5 nonpharmacological techniques
before, during, and after
 chemotherapy, before nausea occurs or
increase, and long with other nausea
control measures
11. Promote adequate rest and sleep to
facilitate nausea relief
12. Use frequent oral hygiene to promote
comfort, unless it stimulates nausea
13. Encourage eating small amounts of
food that are appealing to the
nauseated person
14. Monitor recorded intake for nutritional
content and calories
Vomiting Management
Definition
Prevention and alleviation of vomiting
Activities :
1. Asess emesis for color, consistency, blood,
tining, and extent to which it is forceful
2. Measure or estimate emesis volume
3. Suggest carrying plastic bag for emesis
contaiment
4. Determine vomiting frequency and
duration, using such as scales Duke
Descriptive Scales, and Rhodes Index of
Nausea and Vomiting (INV) form 2
5. Obtain a complate pretreatment history
6. Obtain dietary history containing the
person’s likes, dislikes, and cultural food
preferences
7. Identify factors (e.g medication and
procedures) thay may cause of contribute
nausea
8. Ensure that effective antiemetic drugs are
given to prevent nausea when possible
9. Control environment factors that may
evoke vomiting (e.g aversive smells,
sound, and unpleasant visual stimulation)
10. Reduce or eliminate personal factors that
precipitate or increase vomiting (anxiety,
fear, fatigue, lack of knowledge)
11. Position to prevent aspiration
12. Maintain oral airway
13. Provide physical support during vomiting
such as assisting person to bend over or
support the person’s head
14. Provide comfort such as cool cloth to
forehead, sponging face, or providing
clean dry clothes during the vomiting
episode
15. Wait at least 30 minutes after vomiting
episode before offering more fluid to
patient (assuming normal gastrointestinal
tract and normal peristalsis
16. Gradually increase fluid if no vomiting
occurs over 30 minutes period
17. Monitor fluid and electrolyte balance
18. Encourage rest
19. Utilize nutritional supplemnts, if necessary
to maintain body weight
20. Teach the use of nonfarmacological
techniques (e.g biofeedback, hypnosis,
relaxation, guided imagery, music therapy,
distraction, acupressure to manage
vomiting
2. Acute Pain Pain Level Pain Management
An unpleasant sensory and Definition : Alleviation of pain or a reduction in pain to a
emotional experience associated Severity of observed or reported pain. From severe level of comfort that is acceptable to the
with actual or potential tissue to none. patient.
damage, or described in terms of Outcome: 1. Perform a comprehensive assessment of
such damage (International After nursing action for, client will maintain pain to include location, characteristics,
Association for the Study of Pain); pain level onset, duration, frequency, quality,
sudden or slow onset of any intensity or severity, and precipitating
 Verbalize relief of pain (intensity and length of
intensity from mild to severe with factors of pain.
pain episodes).
an anticipated or predictable end. 2. Consider cultural influences on pain
 Display relaxed manner.
May evidenced by (defining response (e.g., cultural beliefs about pain
 Absence of abnormal change in BP, HR, RR
characteristic) : may result in a stoic attitude).
from baseline data.
Reports of pain, self-focusing/ 3. Reduce or eliminate factors that precipitate
as evidenced by:
narrowed focus, facial expression or increase pain experience
No Indicators Initial Target
of pain, guarding behavior, 1 Report pain 5
4. Identify diversional activities appropriate
distraction behavior, protective 2 Length of pain 5 for client’s age, physical abilities, and
behavior, alteration in episodes personal preferences.
physiological parameter (vital 3 Facial expression 5 5. Teach the use of non-pharmacologic
of pain
sign, muscle tone and autonomic techniques (e.g., relaxation, guided
4 Restlessness 5
responses) 5 Respiratory rate 5
imagery, music therapy, distraction, and
massage) before, after, and if possible
Risk factors may include : 6 Apical heart rate 5 during painful activities; before pain
 Biological injury agent 7 Blood pressure 5 occurs or increases; and along with other
(neoplasm, infection) pain relief measures.
Pain Control 6. Medicate before an activity to increase
Definition : participation, but evaluate the hazard of
Personal action to control pain. From never medication. Let client know it is important
demonstrated to consistently demonstrated. to request medication before pain becomes
Outcome : severe.
 Demonstrate use of relaxation skills and 7. Evaluate and document the effectiveness
diversional activities, as indicated for of the pain control measures used through
individual situation (e.g., uses of non- ongoing assessment of pain experience.
analgesic relief measures, uses analgesics as
recommended). Analgesic Administration
 Able to report pain controlled. Use of pharmacologic agents to reduce or
 Able to report uncontrolled symptoms to eliminate pain
healthcare professional. 1. Collaborate with the physician and make
specific recommendation based on
equianalgesic principles.
2. Check the medical order for drug, dose,
and frequency of analgesic prescribed.
as evidenced by : 3. Determine analgesic selections (narcotic,
No Indicators
1 Recognize pain onset
2 Describe causal factor
3 Report changes in
pain symptom to
health professional
4 Report uncontrolled
symptom to health
professional
5 Report pain controlled
Initial Target non-narcotic, or NSAID) based on type
5 and severity of pain.
5
4. Institute safety precautions as appropriate
5
(for those receiving narcotics)
5. Evaluate the effectiveness of analgesic at
5 regular, frequent intervals after each
administration and especially after the
initial doses, also observing for any signs
5
and symptoms of untoward effects (e.g.,
respiratory depression, nausea and
vomiting, dry mouth, and constipation).
6. Document response to analgesics and any
untoward effects.
7. Implement actions to decrease untoward
effects of analgesics (e.g., constipation
and gastric irritation).
Imbalanced nutrition : less than Nutritional status : Nutrient intake Nutritional management
body requirenment Definition : Definition :
Definition : Nutrient intake to meet metabolic needs. Providing and promoting a balanced intake of
Intake of nutrients insufficient to Outcome : nutrients
meet metabolic needs. After nursing action for, client will maintain Activities :
nutrition status : nutrient intake, as evidence by 1. Determine patient’s nutritional status and
May evidenced by (defining : ability to meet nutritional needs
characteristic) : No Indicators Initial Target 2. Determine patient’s food prefrence
Below idal weight range, food 1 Caloric intake 5 3. Instruct patient about nutritional needs
aversion, food intake less than 2 Protein intake 5 4. Determine number of calories and type of
3 Fat intake 5
reqomended daily allowence nutrients needed to meet nutrition
4 Carbohydrate intake 5
(RDA), pale mucous membranes, requirenment
5 Fiber intake 5
perceived inability to ingest food, 6. Vitamin intake 5
5. Provide optimal environment for meal
sor buccal cavity, weight loss with 7. Mineral intake 5 consumption such as clean, well
adequate food intake 8. Calsium intake 5 ventilated, relaxed, free from strong odors
Related Factors : 9. Sodium intake 5 6. Assist patient with openig packages,
10. Iron intake 5
Inability to ingest food, cutting food, and eating if needed.
insufficient dietary intake 7. Instruct patient on necessary diet
Nutrition status :
medication such as clar liquid, full liquid,
Definition :
soft, and or diet as tolerated
Extent to which nutrients are ingested and absorbed
to meet metabolic needs 8. Ensure that diet includes foods high in
Outcome : fiber contnt to prevent constipation
After nursing action for, client will maintain 9. Monitor trend in weight loss and gain
nutrition status, as evidence by : Nutritional Therapy
No Indicators Initial Target Definition :
1 Nutrient intake 5 Administration of food and fluids to support
2 Food itake 5 metabolic process of a patient who is
3 Fluid intake 5
malnourished or at high risk for bcoming
4 Energy 5
malnourished
5 Weight/height ratio 5
6. Hydration 5 Activitis :
1. Complete a nutritional assessment
2. Monitoe food and fluid ingested and
calculate daily caloric intake as appropriate
3. Determine in collaboration with dietitian,
the number of calories and type of nutrints
needed to met nutrition requirenment, as
appropriate
4. Encourage patient to select soft food if lack
of saliva hinders swallowing
5. Encourage intake high calcium foods, as
 appropriate
6. Ensure that diet includes food high in fiber
content to prevent constipation
7. Provide patient to high protein, high
calorie, nutritious finger foods and drinks
that can be readily consumed
8. Assist patient to sitting position before
eating or feeding
9. Instruct patient and family about prescribd
diet
10. Refer for diet teaching and planning as
needed
4. Impaired oral mucous Oral Health Oral Health restiration
membrane Definition : condition of the mouth, teeth, gums, and Definition :
Disruptions of the lips and soft tounge Promotion of healing for patient who has an
tissues, buccal cavity, and/or Outcome : oral mucosa or dental lesion

oropharynx Maintains intact, moist oral mucous membranes Activities :

May evidenced by (defining that are free of ulceration and debris
characteristic )
 Oral lesions
 Oral pain/discomfort
 Bad taste in mouth
 Coated tongue
 Difficulty eating
1. Monitor condition of patient’s mouth (e.g
lips, tongue, mocous, teth, gums, and dental
As avidenced by
appliance and their fit) including character
No Indicators Initial Target
1 Cleanlines of 5 of abnormalities (size, color, and location of
mouth intrnal and internal lesions or inflammation,
2 Cleanliness of 5 and other signs of infection
tongue
2. Monitor change in taste, swallowing, quality
3 Moisture of oral 5
mucosa and
of voice, and comfort

 Difficulty speaking tongue 3. Obtain order from health care provider to

 Presence of mass
 White plague in mouth
Risk factors may include :
 Chemical (e.g., alcohol,
4 Oral mucosa
lssions
5 Tongue intrgrity
5 perform oral hygiene, if applicable
4. Determine necessary frquency for oral care,
5
encouraging patient or patient’s family to
adhere to schdule or assisting with oral care
as needed
 tobacco, acidic foods, 5. Instruct the patient to use soft bristed
regular use of inhalers) Tissue Intgrity : skin and mucous toothbrush or disposable mouth sponge

 Insufficient oral Definition : 6. Admistere mouth rinse to patient e.g

anesthetic, effervescent, saline, coating tc.
hygiene Structural intactness and normal physiological
7. Administer medication
 Pathological conditions- function of skin and mucous membrances
8. Apply lubricant to moisten lips and oral
oral cavity (radiation to Outcome :
mucosa as needed
head or neck); Describes or demonstrates measures to regain or
9. Discourage smoking and tobacco chewing
 Chemotherapy maintain intact oral mucous membranes. 10. Discourage alcohol consumption
 Autoimmune disease As evidenced by : 11. Instruct patient or patient’s family on
No Indicators Initial Target
frequency and quality of proper oral health
1 Abnormal 5
care (e.g flossing, brushing, rinsing,
pigmentation
2 Skin lesions 5
adequat nutrition, suplement, etc.
3 Mucous mmbrane 5 12. Instruct patint to avoid products containing
lesions glycerin, alcohol, or other drying agents
4 Scar tissue 5
13. Instruct patient to keep toothbrushes and
5 Skin cancers 5
othr cleaning equipment clean.
6 Skin flaking 5
7 Skin scaling 5
4. Deficient Knowledge Knowledge: Disease Process Teaching: Disease Process
Absence of deficiency of Extent of understanding conveyed about a specific Assisting the patient to understand information
cognitive information related to a disease process and potential complications. related to a specific disease process.
specific topic.  Verbalize understanding of condition, sign 1. Review patient’s knowledge about
and symptoms, and prognosis. condition.
May evidenced by (defining  Able to report the important of strategy to 2. Describe the disease process, as appropriate
characteristic) : minimize disease process (therapy and follow 3. Provide information to the patient about
Inappropriate behavior, up) condition, as appropriate
insufficient knowledge.  Show understanding in available support 4. Identify changes in physical condition for
equipment and support group. patient.
Risk factors may include : 5. Discuss importance of clinical and therapy
 Insufficient information. Knowledge: Treatment Procedure follow-up appointments.
 Misinformation presented Extent of understanding conveyed about a procedure 6. Identify signs and symptoms requiring
by others. required as part of a treatment regimen. medical evaluation (e.g., severe pain, fever
 Show understanding in purpose and steps in or chills, or foul odors; changes in

procedure. sensation, swelling, burning, numbness,

 Able to use the correct equipment and giving tingling, skin discoloration, paralysis, or

proper care of the equipment. white/cool toes or fingertips, and warm

 Understand the side effect and complications spots, soft areas, or cracks in the cast.)
Teaching: Procedure/Treatment
Preparing a patient to understand and mentally
prepare for a prescribed procedure or
treatment.
1. Inform the patient or significant other about
when and where the procedure/treatment
will take place, for how long, and who will
be performing the procedure/treatment.
2. Explain the procedure/treatment.
3. Explain the need for and function certain
equipment (e.g., the cast, traction,
monitors.)
4. Correct unrealistic expectations of the
procedure/treatment, as appropriate.
5. Discuss alternative treatment, as
appropriate.
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