ASSESMENT NURSING GOALS AND INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOMES
Subjective: Impaired STG: DX: Goals are partially meet. The
“Nasakit piman nu oral mucous After 4 hours Note presence of systemic or local Oral mucositis is a major patient has still dry and cracked
magmagna jay lips membrane of nursing conditions such as oral infections; complication lips. But can eat and drink without
na” as verbalized related to intervention dehydration, malnutrition, facial of chemotherapy and/or difficulty.
by the moher. mouth patient will fractures, head or neck cancers or radiation therapy.
breathing. have treatment including chemotherapy
Objective: improvement or, radiation that can affect health
-Without IVF, with towards dry of buccal tissues.
noted hep lock, lips. White ulcerated spots
-without diaphoresis Observe for abnormal lesions of may be canker sores,
-noted cough with LDG mouth, tongue, and cheeks especially in children; white
dry lips and drinking After 8 of (e.g., white or red patches, ulcers). curd patches (thrush) are
with a straw. nursing common in infants. Reddened,
-Initial vital signs as intervention swollen bleeding gums may
follows-patient the patient indicate infection, poor
T- 37, PR- 152BMR, will have be nutrition, or poor oral hygiene.
RR-44CPM SPO02- able to eat A red tongue may be related
96% and drink to vitamin deficiencies.
without Malignant lesions are more
difficulty. common in elderly than
younger persons (especially if
there is a history of smoking or
alcohol use), or in persons who
rarely visit a dentist.

Investigate reports of oral pain to To identify needed

determine possible source interventions and reduce risk of
(e.g., oral lesion, gum disease, tooth complications such as systemic
abscess, ill-fitting dentures) infection.

Obtain history of client’s medications To identify those medications

that can impact health of
buccal tissues or cause
immunosuppression which can
impact oral health.
TX:
Provide dietary modifications (e.g.,
food of comfortable texture,
temperature, density)
Maintain bed rest.
Provide information about health
oral health as required to correct
deficiencies.
ED:
Educated mother about hydration to
reduce risk associated with impaired
tissues.
To reduce discomfort and
improve
intake, and adequate nutrients
and vitamins to promote
healing.
Educating significant other
about hydration can help
reduce dryness of lips and
prevent dehydration that can
lead to further complications.