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BSN 211

Px: John Ritchie Tagana 37y/o Rm: 334B Dx: SVI t/c DFS

Cues Nursing Analysis Goals and Nursing Rationale Evaluation

Diagnosis Objectives Interventions
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
• 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
• 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
(Evolve, Ackley:
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:
Handbook, 8th

• To relieve pain
an d to promote
faster healing
process (Evolve,
Ackley: Nursing
Handbook, 8th