Ncp. Oral Mucosa

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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Impaired oral INDEPENDENT: Short term:


SUBJECTIVE: Mucous Inflammatory process Short term: If there is changes of the GOAL MET
Membrane Assessed for the changes mucous membrane include
“ Nagkaroon po may be After 30 minutes of in the lips and oral cavity. dry fissured lips. After 30 minutes of nursing
ako ng singaw related to Swelling of tissues nursing intervention the patient was
simula nong na inflammatory
hospital ako “ process and intervention the able to demonstrate
- as dehydration Disruption of skin patient will be able Evaluated client’s ability to To promote wellness techniques to maintained
verbalize as evidenced surfaces to demonstrate provide self-care and integrity of oral mucosa.
d by the by dry / techniques to availability of necessary
patient fissures of maintain integrity equipment/assistance.
lips. Impaired Mucous
of oral mucosa. Educated the
Membrane To promote awareness Long term:
Inflammatory process parents/guardians to and prevention of severe
watch out for signs of dehydration. GOAL MET
dehydration After 8 hours of nursing
Long term:
OBJECTIVE; Swelling of tissues intervention the client was
COLLABORATIVE; free from dryness.
After 8 hours of Advised parents to avoid
- Irritability To maintain nutritional
nursing irritating foods/fluids,
- Dry Disruption of skin status of the client and to
intervention the temperature extremes and
cracked surfaces prevent irritation of oral
client will be free provided soft or pureed
lips mucosa.
from dryness of diet as required
- Pain
oral mucosa.
scale of Impaired Mucous
2/10 Membrane DEPENDENT:
Applied soothing
ointments to the lips as
ordered.

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