Nursing Diagnosis

Impaired Oral Mucous Membrane

Risk for Infection
Fatigue

NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Impaired Oral Within 3 days of nursing - Assess mucous membranes and - Edema, open lesions, and After 3 days of nursing
“Sige ko ka Mucous Membrane interventions, the patient’s oral document all oral lesions. Note crusting on oral mucous interventions, the patient’s
sorethroat, murag related to mucosal will be able to: reports of pain, swelling, membranes and throat may oral mucosal condition is free
two weeks na ni dili Immunologic deficit - Display intact mucous difficulty with chewing and cause pain and difficulty with of inflammation & able to
mawala-wala, unya and presence of membranes, which are swallowing. chewing and swallowing. demonstrate techniques to
sige ko lesion as evidenced pink, moist, and free of maintain integrity of oral
gikalibanga... ma by mouth ulcers, inflammation/ulcerations. - Provide oral care daily and after - Alleviates discomfort, prevents mucosa.
resolve sya tapos vesicles  Demonstrate techniques food intake, using soft acid formation associated with
mubalik na sab... to restore/maintain toothbrush, nonabrasive retained food particles, and Goal met.
wa nako kasabot integrity of oral mucosa. toothpaste, non-alcohol promotes feeling of well-being.
na unsa ko. Unya mouthwash, floss, and lip
mura kog maglisod moisturizer.
ug ginhawa
gamay... murag di - Rinse oral mucosal lesions with - Reduces spread of lesions and
sya normal na pag saline and dilute hydrogen encrustations from candidiasis,
ginhawa nako.” As peroxide or baking soda and promotes comfort.
verbalized by the solutions.
patient
- Suggest use of sugarless gum - Stimulates flow of saliva to
Objective: and candy. neutralize acids and protect
-Fatigue mucous membranes.
-Sore throat
-Mouth ulcers - Plan diet to avoid salty, spicy, - Abrasive foods may open healing
-Swollen lymph abrasive, and acidic foods or lesions. Open lesions are painful
nodes beverages. Check for and aggravated by salt, spice,
Vital signs: temperature tolerance of foods. acidic foods or beverages.
T: 37.7 C Offer cool or cold smooth foods. Extreme cold or heat can cause
PR: 38 bpm pain to sensitive mucous
RR: 20 cpm membranes.
BP: 120/80 mmHg
- Encourage oral intake of at least - Maintains hydration and
2500 mL/day prevents drying of oral cavity.

- Obtain culture specimens of - Reveals causative agents and

lesions. identifies appropriate therapies.

- Administer medications, as - To reduce discomfort

prescribed.