NURSING CARE PLAN: Impaired Mucous Membrane

CUES
Subjective: Medyo sumasakit pa at di ako masyadong makapagsalit a dahil kakaopera lang sa akin. The client verbalized. -Rated pain as 4 out 10 (1 the lowest and 10 as the highest) Objective: -redness of the operative site -difficulty in speech/ swallowing

NURSING DIAGNOSIS
Impaired Mucous membrane r/t surgery in the oral cavity as manifested by pain, redness at the site

ANALYSIS
Pain with swallowing is the hallmark and is often referred to the ears. High fever, malaise, headache, and GI upset are common, as are halitosis and a muffled voice. A scarlatiniform or nonspecific rash may also be present. The tonsils are swollen and red and often have purulent exudates. Tender cervical lymphadenopathy may be present. Fever, adenopathy, palatal petechiae, and exudates are somewhat more common. (http://www.merck manuals.com)

GOALS/OBJECTIVES
GOAL: After 2 days of nursing interventions, the client will be able to restore integrity of the oral mucosa. OBJECTIVES:

NURSING INTERVENTIONS

RATIONALE

EVALUATION
Was the client able to restore integrity of the oral mucosa? Yes _________ No _________ Why/How? ____________

Independent: -After the nursing interventions, the client will be able assisted in managing impaired mucous membrane, especially preventing damage to oral mucosa. -Assist the client -Mouth care helps with proper oral reduce the risk of by hygiene techniques infection maintaining circulation (e.g.mouthwash) to the mucous membrane and by decreasing bacteria in the mouth. (Medicalsurgical care planning by Holloway, p. 749)

-Encourage client - Fluids are very with adequate important the first 48 hours after surgery. fluids Fluids should be encouraged, as surgery and the healing process can contribute to dehydration, even

though the patient does experience pain when swallowing. Fact Sheet: Tonsillectomy. American Academy of Otolaryngology.

-Encourage -Adequate nutrition is adequate nutrition, helpful in preventing when the tolerated infection (Brunnar

and Suddarth s textbook of Canadian medical-surgical nursing by Day et.al, p. 1081)

Dependent:

- Administer antibiotics as prescribed.

-Antibiotics may be prescribed prophylactically. (Brunnar and Suddarth s textbook of Canadian medicalsurgical nursing by Day et.al, p. 1081)

Collaborative: -Advise regular follow up checkups with primary

- To determine the effectiveness of current therapeutic regimen and to promote general

care provider.

well-being. (Nurse's Pocket Guide Doenges p.79)