SSSs

NURSING CARE PLAN for PATIENT C (PROBLEM 2)

CUES NURSING RATIONALE GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS TO NURSING OBJECTIVES INTERVENTIONS TO NURSING
DIAGNOSIS INTERVENTIO
N
SUBJECTIVES: At the end of the shift, INDEPENDENT: At the end of the shift,
“Maluya ha lawas Impaired oral Environmental, Patient C will be able Patient C is able to:
ngan mucous Physiological, Health to: ~ Plan and implement a ~Mouth care prevents
maturutrangkaso membrane factors meticulous mouth acre formation of oral  Demonstrated
tulo ngda upat ka related to  Demonstrate regimen after each meal plaques and bacteria. normal/healthy
adllaw na. Low fluid intake normal/health regularly and every 4 Patients with oral oral mucous
dehydration as
nagsisinuka ngan y oral mucous hours while awake. catheters and oxygen membrane
evidenced by
gihap ako mintras membrane may require additional
cracked lips, Inadequate nutrients care.  Achieved soft
nasakit tak ulo,
matubig gihap tak furrowed flow in the  Have soft lips lips and
baya,” as tongue, and dry bloodstream that and healthy ~increase the frequency ~This will reduce healthy tongue
verbalized. mucosal supply to the whole tongue of oral hygiene by rinsing further damage and
membrane. body with one of the may promote comfort.  Demonstrated
OBJECTIVES:  Demonstrate suggested solutions adequate
Physical exam: adequate between brushings and nutrients and
H: 160 cm (5’3”) Alteration of the lips or nutrients and once during the night. fluid intake
soft tissues of te oral fluid intake
W: 66.2 kg
cavity by drying. ~If patient does not have ~The toothbrush is the  Demonstrated
(146lb.)
 Demonstrate a bleeding disorder and is most important tool for proper oral
T: 38.6 °C Source: proper oral capable to swallow, oral acre. Brushing the hygiene
(101.5°F) www.nurselabs.com hygiene encourage to brush teeth teeth is the best and
P: 96 beats/min with a soft pediatric-sized effective method for  Achieved
BP: 102/84  Have toothbrush using a reducing plaque and individualized
mmHg individualized fluoride-containing controlling periodontal oral hygiene
oral hygiene toothpaste after every disease. plan of care
Scant urine plan of care meal and to floss teeth
output, daily.
Dry oral mucosa,
Furrowed ~Use tap water or normal
tongue, saline to provide oral ~Alcohol dries the oral
care; do not use mucous membranes
Cracked lips.
commercial Hydrogen peroxide can
mouthwashes containing injure oral mucosa and
Diagnostic data: alcohol or hydrogen is remarkably foul-
Urine Specific peroxide. Also, do not tasting to patients.
gravity: 1.035 use lemon-glycerin Lemon Glycerin swabs
swabs. can result in decreased
Serum Sodium: salivary amylase and
145 mEq/L oral moisture, as well as
erosion of tooth
Serum Potassium: enamel.
3.5 mEq/L ~Maintain the use of
lubricating ointment on ~Lubrication prevents
Chest X-ray : the lips. drying and cracking.
Negative
~Encourage a diet high in
protein and vitamins, ~Dietary modifications
serve foods and fluids may be needed to
lukewarm or cold, serve facilitate healing and
frequent small meals or tissue integrity.
snacks spaced
throughout the day, void
citrus juices, encourage
soft foods (e.g., mashed
potatoes, pudding
creamy cereals)

~Maintain the inside of

the mouth moist with ~Moisture promotes
frequent sips of water the cleansing effect of
and salt water rinses. saliva and helps avert
mucosal drying, which
can result in erosions,
fissures, or lesions.
~Educate patient on how
to inspect the oral cavity ~Build on patient’s
and monitor for signs and existing knowledge to
symptoms of infection, develop individualized
complications, and plan of care.
healing.

~Educate patient on how

to implement a personal ~Encouragement and
plan of oral hygiene reinforcement of oral
including schedule of care significant o oral
care. outcomes

DEPENDENT

~ Administer Gelclair per

Doctor’s order. ~This is a bio adherent
oral gel that covers the
oral cavity and forms a
protective coat to avoid
further abrasion or
dryness.