West Visayas State University
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West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City NURSING CARE PLAN Name: K.L.C. Age: 13 y.o_____ CLUSTERED CUES
8/28/08 @ 830AM S – “ Ginakagat nya na iya nga bibig kung mag waras, kapin pa guro kung may gusto nga ihambal galing kay hindi man ka mitlang.” As verbalized by the mother “Gadako na gawa, sadto daw lag-ob lang kag pilas sa bibig tapos daw naglapad.” “Mu na guro kaisa nga ginakipot niya bibig nya magtulog kay siguro mahapdi.” O – canker sore on lower lip of about 2cm in diameter
Ward/ Bed Number: PSW B NURSING DIAGNOSIS
Impaired oral mucous membrane r/t mechanical trauma secondary to status epilepticus
RATIONALE
OUTCOME CRITERIA
Disruption of the lips and soft tissue of the oral cavity with the related factor of mechanical trauma.
1. The patient will be able to elicit decreased involuntary movements as to clenching of teeth as evidenced by sedation or of by REM (sleeping) provided by efficacy of drug administration after 2 hours (1030AM) on 8/28/08.
Status epilepticus patient have alterations in behavior such as sensoryhallucinatory phenomena, motor effects (eye movements, muscular contractions) Source: Maternal and Child Health Nursing, pp. 1102; Nurse’s Pocket Guide
2. The patient will be able to show signs of healing on the lower lip as evidenced by reduced redness and/or swelling after 5 hours (130PM) on 8/28/08.
Attending Physician: Dr. G________ Impression/Diagnosis: Status Epilepticus____
NURSING INTERVENTIONS
RATIONALE
EVALUATION
1. Check for vital signs.
Give an overview of current state of distress as to temperature reading that could indicate infection.
2. Implement meticulous mouth care regimen after every NGT feeding to have a systematic and grouped procedures to be done without overstimulating the patient.
a. After the feeding via NGT, the patient will have decrease saliva production which could be prone to infection.
8/28/08 @ 1030AM 1. Goal met: The patient was sedated but awake after administering of medication; no clenching of teeth was noted.
b. Decreased stimulation of patient experiencing tonic-clonic seizure therefore prevent further eliciting of exaggerated involuntary movements that could further put the patient at risk
8/28/08 @ 130AM 2. Goal partially met: The patient canker sore showed signs of healing but of lesser degree; fluid-filled lesion still present, partially pinkish and moist lip.
Redness around the canker sore on lower lip Pain upon direct palpation of the surrounding unaffected area of lower lip as evidenced by grimacing Dry buccal mucosa Fluid filled sore with 5 mm elevation Clenching of teeth seen during generalized tense movements for 40 seconds
3. The patient will be able to demonstrate decreased in pain sensation upon direct palpation of the surrounding unaffected area as evidenced by less guarding behavior as to moving away to stimuli after 5 hours (130PM) on 8/28/08.
for trauma especially to the oral mucosa.
2. Apply lubricating gel to the affected area especially on the entire lips with the use of cotton applicator.
Reduce friction and will help in moistening of the lips to prevent further damage to the tissue.
3. Apply topical analgesics (if prescribed).
Reduce pain, or provide a “numbing” sensation.
4. Administer antiepileptic drug and sedatives (Phenobarbital) as prescribed.
Sedate and put patient to sleep and will temporarily prevent any involuntary movements that could lead to further damage of tissues.
5. Rinse the mouth with water as necessary with aspiration precaution. While doing so position client to sidelying position (if tolerated or sedated).
Cleansing the mouth with water to prevent dryness of the buccal mucosa and of the lips. Aspiration precaution is considered.
Dry buccal mucosa
8/28/08 @ 1030AM 3. Goal partially met: The patient cannot be thoroughly assessed for pain felt; no further justification of subjective cues from the patient herself however upon direct palpation of the surrounding unaffected area on the lower lip, the patient showed decreased guarding behavior.
6. Application of cold compress or providing cold beverages (not greater than 10 ml for aspiration precaution).
Promote vasoconstriction of the inflammed area, relieving pain, swelling and redness.
8/28/08 @ 830AM S – “ Ginakagat nya na iya nga bibig kung mag waras, kapin pa guro kung may gusto nga ihambal galing kay hindi man ka mitlang.” As verbalized by the mother “Gadako na gawa, sadto daw lag-ob lang kag pilas sa bibig tapos daw naglapad.” “Mu na guro kaisa nga ginakipot niya bibig nya magtulog kay siguro mahapdi.” O – canker sore on lower lip of about 2cm in diameter
Ward/ Bed Number: PSW B NURSING DIAGNOSIS
Impaired oral mucous membrane r/t mechanical trauma secondary to status epilepticus
RATIONALE
OUTCOME CRITERIA
Disruption of the lips and soft tissue of the oral cavity with the related factor of mechanical trauma.
1. The patient will be able to elicit decreased involuntary movements as to clenching of teeth as evidenced by sedation or of by REM (sleeping) provided by efficacy of drug administration after 2 hours (1030AM) on 8/28/08.
Status epilepticus patient have alterations in behavior such as sensoryhallucinatory phenomena, motor effects (eye movements, muscular contractions) Source: Maternal and Child Health Nursing, pp. 1102; Nurse’s Pocket Guide
2. The patient will be able to show signs of healing on the lower lip as evidenced by reduced redness and/or swelling after 5 hours (130PM) on 8/28/08.
Attending Physician: Dr. G________ Impression/Diagnosis: Status Epilepticus____
NURSING INTERVENTIONS
RATIONALE
EVALUATION
1. Check for vital signs.
Give an overview of current state of distress as to temperature reading that could indicate infection.
2. Implement meticulous mouth care regimen after every NGT feeding to have a systematic and grouped procedures to be done without overstimulating the patient.
a. After the feeding via NGT, the patient will have decrease saliva production which could be prone to infection.
8/28/08 @ 1030AM 1. Goal met: The patient was sedated but awake after administering of medication; no clenching of teeth was noted.
b. Decreased stimulation of patient experiencing tonic-clonic seizure therefore prevent further eliciting of exaggerated involuntary movements that could further put the patient at risk
8/28/08 @ 130AM 2. Goal partially met: The patient canker sore showed signs of healing but of lesser degree; fluid-filled lesion still present, partially pinkish and moist lip.
Redness around the canker sore on lower lip Pain upon direct palpation of the surrounding unaffected area of lower lip as evidenced by grimacing Dry buccal mucosa Fluid filled sore with 5 mm elevation Clenching of teeth seen during generalized tense movements for 40 seconds
3. The patient will be able to demonstrate decreased in pain sensation upon direct palpation of the surrounding unaffected area as evidenced by less guarding behavior as to moving away to stimuli after 5 hours (130PM) on 8/28/08.
for trauma especially to the oral mucosa.
2. Apply lubricating gel to the affected area especially on the entire lips with the use of cotton applicator.
Reduce friction and will help in moistening of the lips to prevent further damage to the tissue.
3. Apply topical analgesics (if prescribed).
Reduce pain, or provide a “numbing” sensation.
4. Administer antiepileptic drug and sedatives (Phenobarbital) as prescribed.
Sedate and put patient to sleep and will temporarily prevent any involuntary movements that could lead to further damage of tissues.
5. Rinse the mouth with water as necessary with aspiration precaution. While doing so position client to sidelying position (if tolerated or sedated).
Cleansing the mouth with water to prevent dryness of the buccal mucosa and of the lips. Aspiration precaution is considered.
Dry buccal mucosa
8/28/08 @ 1030AM 3. Goal partially met: The patient cannot be thoroughly assessed for pain felt; no further justification of subjective cues from the patient herself however upon direct palpation of the surrounding unaffected area on the lower lip, the patient showed decreased guarding behavior.
6. Application of cold compress or providing cold beverages (not greater than 10 ml for aspiration precaution).
Promote vasoconstriction of the inflammed area, relieving pain, swelling and redness.
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