NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Impaired oral mucous Short-term goals: INDEPENDENT: After all of the

Subjective: membrane related to 1. Assess mouth daily for oral ulcers, pain, ability to ingest foods; provide meticulous nursing
After 6 hours of
oral hygiene, to prevent oral breakdown and to promote healing: usage of a softsponge
“ May singaw siya administration of good nursing toothbruch, administer frequent mouth rinses, at least 4 hrs. and after meals., normal interventions
sa bibig, tapos ang chemotherapy as interventions, the saline with or without bicarbonate solution. done, the
kirot ng pakiramdam manifested by dryness of patient will be R: To effectively treat oral ulcers nad to promote healing; to prevent bacterial patient was
kasi lagi niyang oral mucosa and presence able to attain and Candida infections; to prevent trauma to oral mucosa. able to achieve
iniinda…” as of mouth sores. normal condition and maintain
2. Apply lip balm daily.
verbalized by the of the oral R: To prevent cracking and fissuring of lips; to maintain lip integrity. desired
patient’s mother. mucosa. mucous
 After 8 hours 3. Advise to avoid using lemon glycerin swabs. membrane
Objective: of nursing care, R: To prevent irritation of mouth ulcers and decay of teeth. status as
 Oral ulcers are the patient will be evidenced by:
4. Advise to avoid juices containing ascorbic acid, hot, cold or spicy foods.
present comfortable with R: To avoid discomfort to oral ulcers.  verbalization
Oral ulcers are regards to status of the parents
red and eroded quo 5. Encouraged to avoid use of hydrogen peroxide as a mouth rinse. and child with
R: It will delay healing of oral ulcers by breaking down protein. the
Mucous
membrane is dry Long-term goal: development
6. Provide education to parents and child: 1) chemotherapy and radiation may cause
After the entire oral ulcers; 2) effective oral hygiene strategies to prevent and treat oral ulcers; 3) child The child
nursing exposure, may require hospitalization (for hydration, parenteral nutrition, psin control of oral declared
the oral mucous ulcers) if stomatitis interferes with food or fluid intake. decrease in
membrane of the R: Promotes understanding of oral stomatitis, significance of daily oral hygiene, pain and can
and pain control for oral ulcers.
patient will be readily
intact without DEPENDENT: communicate
lesions. 1. Administer acyclovir (topically) for oral herpes lesions as ordered by physician. better than
R: To prevent or treat herpetic infections. before.
 No new
COLLABORATIVE:
1. Consult or refer with a nutritionist as needed to develop a bland and soft diet with lesions were
consideration to child’s selection of foods. noted
R: To minimize oral discomfort and irritation, enhances sense of control,
independence, decrease sense of helplessness; may increase child’s level of
nutrition.
 NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Pain membrane related to Short-term goals: INDEPENDENT: After all of the

Subjective: administration of After 6 hours of 1. Assess the following three areas: 1) self-report responses of the nursing
“ Ansakit po ng chemotherapy as good nursing child’s pain (use words and pain assessment tools that help the child to interventions
katawan tuwing manifested by cognitive of interventions, the describe pain. 2) behavioral manifestations (i.e., crying, facial done, the
pagkatapos ng self-report, physiologic patient will be expressions, muscle tension, screaming, pain verbalization, physical patient was
chemotherapy…” as responses and behavioral able to attain resistance, favors affected body parts, more common to observe during able to achieve
verbalized by the manifestations. relief with the painprocedure-related pain or acute episodes); and 3) physiologic reponses a desired pain
patient. he feels. (evaluation of sweating palms, increased heart and respiratory rates, perception
 After 8 hours increased blood pressure, use along with self-report and behavioral status as
Objective: of nursing care, assessments). evidenced by:
Behavioral the patient will beR: Provides information about pain that varies with age,  verbalization
response such comfortable with developmental level of child and is unique to a particular child’s of the parents
as being short- regards to status learned emotional responses; degree of pain and fatigue influence and child with
tempered quo ability of child to perceive and identify discomfort. the
Patient is development
touching the Long-term goal: 2. Assess need for pain management. The child
wound brought After the entire R: Ensures consistency of pain management strategies. declared
about by the side nursing exposure, decrease in
effect of the patient will 3. Evaluate effectiveness of pain relief from all pain medication used. pain.
chemotherapy rank pain as less R: Ensures effective pain control and management.
than the stated
rank by the 4. Promote rest and avoid disturbing child unnecessarily.
patient. R: Decreases stimuli that increase pain, and promotes rest to
conserve energy.

5. Maintain body alignment and support, and immobilize limbs with

pillows and sand bags.
R: Promotes comfort and prevents prevents contractures.

6. Apply heat (moist or dry) to painful areas.

R: Relieves pain by promoting circulation to the area.

7. Provide toys and activities for quiet play appropriate for age; use
music, relaxation techniques; remain with child when pain is most acute.
R: Provides diversion and distraction from pain.
8. Inform child of cause of pain and interventions to relieve it, of how
medications are administered and actions to expect, to report pain
before it becomes severe..
R: Promotes understanding of pain response and methods to
reduce it.

9. Educate child and parents on various distraction techniques (i.e.,

counting, music, imagery, deep breathing, self-talk, positioning,
reassurance, prayer, massage, therapeutic touch, relaxation).
R:Enhances trust between the nurse, child and the family; also,
may minimize the child’s pain perceptions and foster a sense of
control during intrusive procedures.

DEPENDENT:
1. Administer analgesics as prescribed, on a preventive pain schedule,
and monitor side effects of analgesics.
R: Ensures effective pain management; promotes comfort and rest;
fosters a trusting and caring relationship between the child, family,
and health care team.

COLLABORATIVE:
1. Consult or refer with a nutritionist as needed to develop a diet with
regards to child’s selection of foods.
R: To facilitate comfort, enhances sense of control, independence,
decrease sense of helplessness; may increase child’s level of
nutrition.