TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines
Name: Jeremiah Earl T. Magcalas
Section/Group: BSN 3A – A4
NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Impaired oral Short term INDEPENDENT: Short term goals:
mucous membrane goals:
“Nahihirapan related to infection 1. Assess oral cavity at 1. Oral > After 30 minutes of
napo akong as evidenced by > After 30 least once a day for inspection can rendering proper
kumain dahil sa presence of mouth minutes of any lesions, edema, reveal signs nursing interventions
laso ko sa bibig ulcers. rendering discoloration, of oral the patient recognizes
tatlong araw napo proper exudate, bleeding, or disease, three or five separate
parang lalagnatin nursing dryness. If required, symptoms of foods and agents that
ako” as stated by interventions consult a physician or systemic can aggravate or
the patient. the patient a consultant. disease, drug worsen the condition.
will be side effects,
expected to or trauma of > After 15-20 minutes
Objective data: recognise 2. Assess for the oral cavity of rendering proper
- Open three or five mechanical or 2. Dentures and nursing interventions,
mouth separate chemical agents that tobacco use the patient
sores foods and could induce or can aggravate demonstrated proper
agents that enhance damage to impairment of oral hygiene.
- Small, can the oral mucous the oral
round, aggravate or membranes, such as mucous Long term goal:
crater worsen the ill-fitting dentures or membranes.
shaped condition. frequent tobacco use.
sores in
 the oral 3. Give the patient 3. Water has > The patient's oral
cavity > After frequent sips of been found to mucosa status
15-20 water, and ask him to be as improved after 2-3
- Pale to minutes of rinse his mouth with effective as days of receiving
reddish rendering water or alcohol free many other adequate nursing
appearance proper mouthwash. agents in interventions, as shown
of the nursing moistening by moist and intact
sores interventions the mouth. tongue and lips, as well
- Mouth , the patient 4. If not 4. Fluids tend to as the lack of pain and
redness, will be able contraindicated, keep the lesions as, evidenced
ulceration, to encourage him to mouth moist, by;
and demonstrate drink up to 3000 mL which “ medyo nakakakain na
fissures proper oral of fluid each day. supports the ako at nawawala na
hygiene. mucous ang kirot saaking
- Swollen membranes bibig”
mouth Long term and speeds up
ulcers/sore goal: the healing “Nag mumumog ako
s process. ng warm water minsan
- Vital signs > The 5. Building a nilalagyan ko ng asin”
5. Determine his regular
taken as patient's oral rapport to the as stated by the patient.
oral hygiene routine
follows: mucosa patient will
and discuss any oral
PR: 120 status will enable you to
hygiene concerns.
bpm, RR: improve after take his oral
25cpm, T: 2-3 days of patterns and
37.9 receiving practices.
adequate 6. Moisture
nursing 6. Keep the inside of the encourages
interventions mouth moist with saliva
, as shown repeated sips of water cleansing and
by moist and and salt water rinses prevents oral
intact tongue (1/2 teaspoon salt in 8 mucosa
and lips, as ounces warm water) drying, which
well as the if dry. may lead to
lack of pain ulcerations,
and lesions. fissures, or
lesions.
Sodium
chloride
rinses have
been shown
to be effective
for the
prevention
and soothing
7. Use petroleum jelly mouth sores.
or a related substance
to keep his lips
lubricated. 7. It can help
lips to be
moist and
prevent
damage to it.
8. Advise him to brush
his teeth rugarly with
a soft bristled
8. The
pediatric brush and if
toothbrush is
there's fluoride
the most
containing toothpaste
essential
use it and floss daily.
piece of oral
hygiene
equipment.
Brushing the
teeth is the
most effective
way to reduce
bacteria build
 DEPENDENT: up and
control
1. Administer pain periodontal
medications such as disease.
acetaminophen 500
mg P.O every 4 to 6
hours p.r.n. As
ordered. 1. To relieve
mild pain and
fever.

Shown to me: Jeremiah Earl T. Magcalas Clinical Instructor: