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The nursing care plan involves a patient with impaired skin integrity around the mouth due to aphthous ulcers. The plan includes assessing the wounds, providing wound care and oral hygiene instruction, administering antibiotics as needed, and monitoring for complications like infection. Goals are for the wounds to heal without issues within a month. Nursing interventions focus on keeping the area clean and dry, giving health teachings to the mother, and referring to other specialists as needed. Evaluations show the wounds healing with no further complications after one month.
The nursing care plan involves a patient with impaired skin integrity around the mouth due to aphthous ulcers. The plan includes assessing the wounds, providing wound care and oral hygiene instruction, administering antibiotics as needed, and monitoring for complications like infection. Goals are for the wounds to heal without issues within a month. Nursing interventions focus on keeping the area clean and dry, giving health teachings to the mother, and referring to other specialists as needed. Evaluations show the wounds healing with no further complications after one month.
The nursing care plan involves a patient with impaired skin integrity around the mouth due to aphthous ulcers. The plan includes assessing the wounds, providing wound care and oral hygiene instruction, administering antibiotics as needed, and monitoring for complications like infection. Goals are for the wounds to heal without issues within a month. Nursing interventions focus on keeping the area clean and dry, giving health teachings to the mother, and referring to other specialists as needed. Evaluations show the wounds healing with no further complications after one month.
Subjective: Ang dami ng sugat niya sa bibig as verbalized by the mother Objective: *Erythmatous wounds around the mouth *isru!tion o" s#in sur"ace on mouth *estruction o" s#in layer bother e!idermis and dermis $m!aired s#in integrity r%t erythmatous wounds on mouth secondary to A!hthous &lcer e"inition: Altered e!idermis and%or dermis' (ac#ground )heory: According to *lorence +ightingale the environmental sanitation and !ro!er hygiene !lays a vital role in a !atient,s healing !rocess- with this- nursing care must "ocus on mani!ulating the environmental sanitation and im!roving or enhancing !atient,s hygiene' S).: At the end one /01 hour nursing interventions- !atient will be able to: *(e "ree "rom "urther com!lications' *(e "ree "rom develo!ing more ulcers' 2).: At the end o" one /01 month nursing interventions- !atient will be able to: *emonstrate timely healing o" erythamous wounds without com!lication' $nde!endent: 01 Establish ra!!ort' 3: )o gain coo!eration and trust 41 Ascertain attitudes o" mother about condition- note "or misconce!tions' 3: $denti"ies areas to be addressed in teaching !lan- and !otential re"erral' 51 6ee! area clean- dry- care"ully dress wounds' 3: )o avoid com!lications' 71 8rovided health teachings to mother: 9+utrition: :$nstructed to avoid eating s!icy and hot "oods' 3: )his may lead to aggreviating the ulcer "urther' :$nstructed to eat "oods that are so"t- but rich in vitamins and minerals' 3: So"t "oods will be easy to eat thus not touching the wounds and will not !rovide more aggreviation to the ulcer' 9*luids: :$nstructed to avoid inta#e o" hot "luids' 3: ;ot "luids will cause more !ain to the ulcer' e!endent: <1 Administered antibiotics as !rescribed' 3: )o !rovide !ro!hyla=is and to control in"ection' >1 ?onitor and regulate $@*' 3: )o maintain adeAuate hydration' Bollaborative: C1 3e"er to nutritionist and dietician on a!!ro!riate "oods and what to avoid' 3: )o have !ro!er "ood and "luid inta#e' S).: A"ter one /01 hour o" nursing interventions- goal was !artially met as evidenced by: */D1 to com!lications' *A"ebrile 2).: A"ter one /01 month o" nursing interventions- goal was success"ully met as evidenced by: *Erythmatous wounds are healed *+o "urther ulcers were develo!ed' NURSING CARE PLAN FOR RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION Subjective: ;indi na siya #uma#ain masyado ng solid "oods- at di na niya nauubos isang bote ng gatas simula ng dumami sugat niya sa bibig as verbalized by the mother Objective: *Erythmatous wounds around the mouth *Slightly !aled conjunctiva *Bonsumed only 5 oz' o" E oz' served mil# *loss o" a!!etite 3is# "or imbalanced nutrition: less than body reAuirements r%t di""iculty o" inta#ing "ood and "luids r%t A!thous ulcer e"inition: At ris# o" inta#e o" nutrients is insu""icient to meet metabolic needs' (ac#ground )heory: According to @irginia ;enderson,s theory o" 07 human needs- it is stated that a !erson,s nutrition must be adeAuate to achieve o!timum level o" homeostasis' S).: At the end one /01 hour nursing interventions- !atient will be able to: *(e able to consume Eoz' o" mil# during shi"t' 2).: At the end o" one /01 month nursing interventions- !atient will be able to: *emonstrate !rogressive inta#e o" "ood' $nde!endent: 01 Establish ra!!ort' 3: )o gain coo!eration and trust 41 Assist in !roviding oral care' 3: )o im!rove !atient,s taste' 51 Blean the area and avoid malodorous stimulus' 3:)o avoid !atient,s loss o" a!!etite 71 8rovided health teachings to mother: 9+utrition: :$nstructed to avoid eating s!icy and hot "oods' 3: )his may lead to aggreviating the ulcer "urther' :$nstructed to eat "oods that are so"t- but rich in vitamins and minerals' 3: So"t "oods will be easy to eat thus not touching the wounds and will not !rovide more aggreviation to the ulcer' 9*luids: :$nstructed to avoid inta#e o" hot "luids' 3: ;ot "luids will cause more !ain to the ulcer' e!endent: <1 Administered antibiotics as !rescribed' 3: )o !rovide !ro!hyla=is and to control in"ection' >1 ?onitor and regulate $@*' 3: )o maintain adeAuate hydration' Bollaborative: C1 3e"er to nutritionist and dietician on a!!ro!riate "oods and what to avoid' 3: )o have !ro!er "ood and "luid inta#e' S).: A"ter one /01 hour o" nursing interventions- goal was !artially met as evidenced by: Subjective: +aintindihan #o- lagi #o na gagawin ang mga yan' Objective: *Oral care was done to !atient by mother as seen in ward' *8atient consumes a total o" > oz' during shi"r' 2).: A"ter one /01 month o" nursing interventions- goal was success"ully met as evidenced by: *8atient eats regularly and consumes "ood "ully' NURSING CARE PLAN FOR READINESS FOR ENHANCED KNOWLEDGE: PREVENTION OF REOCCURRENCE OF ULCERS ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION Subjective: ?aam- ano !o yung mga #ailangan #o gawin !ara hindi na ito lumala !a o mag#aroon ulitFDas verbalized by mother Objective: *Burious *Activily as# Aueries about the disease 3eadiness "or enhanced #nowledge: 8revention o" reoccurence o" ulcers r%t erythamous lesions secondary to A!thous ulcers' e"inition: )he !resence or acAuisition o" cognitive in"ormation related to a s!eci"ic to!ic is su""icient "or meeting healthDrelated goals and can be strengthened' (ac#ground )heory: According to +ola G 8ender- ;ealth !romotion is directed at increasing a client,s level o" well being' )he health !romotion model describes the multi dimensional nature o" !ersons as they interact within their environment to !ursue health' )here"ore nursing actions must "ocus on health !romotion S).: At the end one /01 hour nursing interventions- !atient,s mother will be able to: *@erbalize understanding o" health teachings 2).: At the end o" one /01 month nursing interventions- !atient will be able to: *emonstrate li"estyle changes that !revents reoccurrence o" a!thous ulcer to child' $nde!endent: 01 Establish ra!!ort' 3: )o gain coo!eration and trust' 41 8rovided health teachings to mother: 9+utrition: :$nstructed to avoid eating s!icy and hot "oods' 3: )his may lead to aggreviating the ulcer "urther' :$nstructed to eat "oods that are so"t- but rich in vitamins and minerals' 3: So"t "oods will be easy to eat thus not touching the wounds and will not !rovide more aggreviation to the ulcer' 9*luids: :$nstructed to avoid inta#e o" hot "luids' 3: ;ot "luids will cause more !ain to the ulcer' 9Environment: :Assisted in cleaning the room and !rovided adeAuate ventillation' 9;ygienic Bare: :emonstrated !ro!er handwashing techniAue' :$nstructed to do daily bath :Assisted to do oral care to !atient' 518rovided health teachings to mother on how to acAuire a!thous ulcer' 3: )o avoid triggers' S).: A"ter one /01 hour o" nursing interventions- goal was !artially met as evidenced by: Subjective: Salamat- naiitindihan #o- alam #o na ngayon #ung ano mga da!at iwasan' Objective: *Oral care done as seen in ward' *8ro!er handwashing techniAue done as seen in the ward' NURSING CARE PLAN FOR ACUTE INTERMITTENT PAIN ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION Subjective: Sa#it mama /while !ointing to mouth1 *8ain Scale: >%0H *Iuality:)hrobbin g **reAuency: $nterD mittent Das !er mother,s descri!tion Objective: *Jith erythmatous wounds aroung mouth *Brying **rowning *8ointing to ulcers Acute intermittent moderate !ain r%t !resence o" ulcers around mouth e"inition: &n!leasant sensory K emotional e=!erience rising "rom actual or !otential tissue damage' (ac#ground )heory: According to @irginia ;enderson- $t is one o" the 07 needs o" the client is to be "ree "rom !ain and be sa"e at all times' S).: At the end o" eight /E1 hours nursing intervention- client will be able to: *?ani"est a decrease in !ain *emonstrate use o" rela=ation techniAues K other diversional activities' $nde!endent: *8rovide bedside care' 3: (edside care hel!s in ma#ing the environment clean and !leasing to the eyes K "eeling o" the !atient- thereby decreasing !ain and !romoting com"ort' * 8rovide diversional activities such as !laying and listening to music' 3: iversional activities and rela=ation techniAues !rovides a re"reshing "eeling and e""ective way o" diverting client,s attention to !ain inde!endently' *$nstruct client to avoid moving as much as !ossible i" unnecessary' 3: ?oving "reAuently that is unnecessary will cause !ain to the !atient' e!endent: *Administer !ain reliver as !rescribed' 3: 8rescribed !ain relivers aids in alleviating the !ain o" the !atient' S).: A"ter one /01 hour o" nursing interventions- goal was !artially met as evidenced by: *8atient sle!t' NURSING CARE PLAN FOR RISK FOR INFECTION ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION Subjective: Ang dami ng sugat niya sa bibig as verbalized by the mother Objective: *Erythmatous wounds around the mouth *isru!tion o" s#in sur"ace on mouth *estruction o" s#in layer bother e!idermis and dermis 3is# "or in"ection r%t damage o" !rimary line o" de"ense: s#in e"inition: At increased ris# "or being invaded by !athogenic microorganisms' (ac#ground )heory: According to *lorence +ightingale the environmental sanitation and !ro!er hygiene !lays a vital role in a !atient,s healing !rocess- with this- nursing care must "ocus on mani!ulating the environmental sanitation and im!roving or enhancing !atient,s hygiene' S).: At the end o" one /01 hour nursing intervention- client will be able to: *@erbalize understanding o" individual causative%ris# "actors to in"ection' *$denti"y interventions to !revent ris# o" in"ection *?aintain normal vital signs' $nde!endent: 01 Establish ra!!ort' 3: )o gain coo!eration and trust 41 6ee! area clean- dry- care"ully dress wounds' 3: 8athogenic ?icroogranisms thrive in moist environment' 51 8rovide bedside care' 3: (edside care hel!s in ma#ing the environment clean and conducive to healing !rocess thereby !reventing acAuisition o" !athogenic microorganisms that causes in"ection' 71 8rovide wound dressing 3: Jound dressing will #ee! the ulcer "ree "rom in"ection' <18rovided health teachings to mother: 9+utrition: :$nstructed to avoid eating s!icy and hot "oods' 3: )his may lead to aggreviating the ulcer "urther' :$nstructed to eat "oods that are so"t- but rich in vitamins and minerals' 3: So"t "oods will be easy to eat thus not touching the wounds and will not !rovide more aggreviation to the ulcer' 9*luids: :$nstructed to avoid inta#e o" hot "luids' 3: ;ot "luids will cause more !ain to the ulcer' e!endent: >1 Administer antibiotics as !rescribed' 3: Antibiotics !revents develo!ment o" in"ection S).: A"ter one /01 hour o" nursing interventions- goal was !artially met as evidenced by: */D1 to com!lications' *A"ebrile 2).: A"ter one /01 month o" nursing interventions- goal was success"ully met as evidenced by: *Erythmatous wounds are healed *+o "urther ulcers were develo!ed' C1 ?onitor and regulate $@*' 3: )o maintain adeAuate hydration' Bollaborative: C1 3e"er to nutritionist and dietician on a!!ro!riate "oods and what to avoid' 3: )o have !ro!er "ood and "luid inta#e'
E. The Qualities and Responsibilities of A Good Health Care Provider To The Client, Society and Its Profession Basic Qualities of A Health Care Practitioner