Nursing Care Plan

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

EXPLANATION
SUBJECTIVE DATA: Impaired Inadequate SHORT TERM INDEPENDENT: INDEPENDENT SHORT TERM
 “hindi siya Dentition brushing and GOAL:  Inspect oral  To determine the GOAL:
laging nag related to flossing can lead to After 2 hours of cavity and need for After 2 hours of
babrush ng inadequate plaque buildup, nursing evaluate the instruction or nursing
ngipin, mahilig oral hygiene tooth decay, and intervention, client status of coaching, assistive interventions, the
din siya sa habits as gum disease, all of will be able to: dental hygiene devices, and/or goal was met as the
matatamis na manifested by which can affect  Verbalize and oral referral to dental patient was able to:
pagkain kaya presence of dentition. and health care providers.  Verbalize and
sira-sira yang dental caries
ngipin niya” ↓ demonstrate
effective
 Document the
presence of
 To
possible
determine demonstrate
effective
verbalized by Diets high in sugar dental conditions interventions dental
the client’s and acidic foods can hygiene that affect the and/or treatment hygiene skills
significant erode tooth enamel, skills. health of the needs. such as
other. contributing to  Maintain a teeth.  To provide brushing and
cavities and other balanced  Ascertain continuity of care using mouth
dental problems. diet client’s usual and build on the rinse after
OBJECTIVE DATA:
 (+) Dental
↓  Follow
through on
method of oral
care
client’s
knowledge
existing
base
meals.
 Maintain a
Caries at right Genetic conditions referrals for and current balanced diet
lower 1st molar (like amelogenesis appropriate practices in as evidenced
and left lower imperfecta) or dental care. developing a plan by increased
1st and 2nd developmental of care. intake
molar disturbances during  To avoid tooth calcium,
 Tooth enamel tooth formation  Remind client decay and improve magnesium,
has yellowish (e.g., malnutrition, to brush teeth overall health. and
discoloration illnesses in as indicated  Toothbrushing phosphate
childhood) can lead  Demonstrate techniques are vital rich foods
 during his
meals.
to defects in the LONG TERM proper for maintaining
 Follow
enamel or shape of GOAL: toothbrushing oral health and
through on
teeth. Within 4 days of techniques preventing dental
referrals for
↓ nursing
interventions, the
such
spending
as problems such as
cavities, gum
appropriate
Trauma to the patient will: dental care
several disease, and
mouth from as evidenced
 Display minutes impaired dentition.
accidents or sports by
healthy brushing, Teaching and
can cause teeth to compliance
gums, reaching all practicing these
break, shift, or upon referral
mucous tooth surfaces, techniques with
become misaligned. to dental
membranes, brushing after children from an
service.
and teeth in meals, and early age is
LONG TERM GOAL:
good repair. daily flossing. essential for
Within 4 days of
Brush the building lifelong
nursing
child’s teeth healthy habits.
interventions, the
until he can
goal was partially
perform alone.  These electrolytes
met as the patient
 Advise client can help protect
was able to:
to maintain a your teeth and
 Display
balanced diet overall oral health
healthy
that includes
mucous
calcium,
membranes,
magnesium
and gums
and phosphate  Staying hydrated
however,
 Advise client supports saliva
there were
to increase production, which
still cavities
fluid intake is vital for
left and the
neutralizing acids
teeth is not
and remineralizing
yet in good
teeth.
repair as
evidenced by
 DEPENDENT:
 To treat dental and
DEPENDENT: gum infection to
 Administer reduce risk of
antibiotics infective
therapy, also endocarditis or
prior to dental migration of
procedure bacteria to other
prescribed by body organs.
the physician  To treat dental pain
as needed
 Administer
analgesics
prescribed by
the physician
as needed COLLABORATIVE:
 To reduce the
COLLABORATIVE: buildup of plaque
 Provide an and the risk of
appropriate cavities caused by
diet for acids associated
optimal with the
nutrition, breakdown of
considering sugar and starch.
the client’s
special needs,
such as age
and
developmental
 concerns, and
offer low
sugar, low
starch foods  Utilizing dental
and snacks. resources is critical
 Refer to for maintaining
Dentist for optimal dental
tooth hygiene and overall
extraction and oral health
resources to
maintain
dental hygiene

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

EXPLANATION
 SHORT TERM
GOAL:
SUBJECTIVE DATA: Impaired Oral Damage or SHORT TERM GOAL: INDEPENDENT: INDEPENDENT
After 3 hours of
 “namamaga po Mucous disruption to the After 3 hours of  Perform oral  Standardized tools
nursing interventions,
yung loob ng pisngi membrane protective lining of nursing intervention, screening or are beneficial in
the goal was met as
niya ilang araw na” integrity the mouth, known clients will be able to: comprehensiv evaluating the
the:
verbalized by the related to as the oral mucosa,  SO will e assessment health of the
 Patient
significant other. inadequate occur due to verbalize upon entire mouth as
oral hygiene trauma, infections, understanding admission to well as the verbalized
systemic diseases, of causative facility. condition of understanding
and other factors risk factors natural teeth and of causative
OBJECTIVE DATA: risk factors as
 (+) inflamed right ↓  Identify
specific  Note presence
status of oral
hygiene. evidenced by
submandibular The oral mucosa, interventions of systemic or  This can affect the encouraging
area which consists of to promote local health of oral child to
 Laboratory: epithelial tissue and healthy oral conditions and tissues perform oral
PCT 0.430 % underlying mucosa disease or care regularly
WBC 12.71 10^9/L connective tissue, trauma that to improve oral
NEU 10.46 10^9/L serves as a crucial can affect hygiene and
barrier that buccal tissues.
protects the mouth avoid damage
from physical to oral mucosa.
 To determine
damage, pathogens,  Investigate possible source  Patient
irritants, and reports on oral and to identify identified
harmful substances pain needed specific
interventions
↓ interventions and
reduce the risk of to promote
When this barrier is complications healthy oral
compromised, it can such as systemic mucosa as
lead to a cascade of infection. evidenced by
problems such as encouraging
pain, infections, and  To reduce child to brush
complications that  Provide discomfort and teeth regularly
and
 independently
then use mouth
affect overall oral dietary improve intake
rinse
and systemic health. modifications and adequate
afterwards.
such as food of nutrients and

comfortable vitamins to
LONG TERM GOAL:
texture, promote healing.
Within 4 days of
temperature,
nursing interventions,
LONG TERM GOAL: and density
the goal was met as
Within 4 days of  Review  To correct
the:
nursing interventions, current oral deficiencies and
 Patient
the patient will: hygiene encourage proper
continue
 Demonstrate patterns and care
demonstrating
techniques to provide
techniques to
restore the information
restore the
integrity of about oral
integrity of oral
oral mucosa hygiene
mucosa as
 Improvement techniques
evidenced by
of the oral DEPENDENT: DEPENDENT:
performing oral
mucous  Administer  To treat oral
care (brushing
membrane medications as infections or
the teeth) to
integrity prescribed reduce potential
the patient and
such as for bacterial
encouraging
antibiotics, overgrowth
child to
anti-fungal
practice oral
agents,
care
including
independently
antimicrobial
and regularly.
mouth rinse
 Patient show
signs of oral
mucous
COLLABORATIVE:
membrane
 Recommend COLLABORATIVE:
integrity as
 evidenced by
no signs of
regular dental  To maintain oral
disruption and
checkups and health and reduce
inflammation
care risks associated
on the lining of
with impaired
oral mucous
tissues.
membrane.

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

EXPLANATION
SUBJECTIVE DATA: Acute Pain Dental caries, or SHORT TERM GOAL: INDEPENDENT: INDEPENDENT SHORT TERM GOAL:
 “Sumasakit po related to cavities, develop After 1 hour of nursing  Determine and  Acute pain is that After 1 hour of nursing
yung ngipin niya, infection due to prolonged intervention, client will document which follows an intervention, the goal
ilang araw na” secondary to exposure of teeth be able to: presence of injury, trauma, or was met as the client
verbalized by the Dental to plaque.  Report pain is possible Patho procedure such as was:
significant other Caries Plaque is a sticky controlled physio-logical surgery, or occurs  Able to report
 Patient film of bacteria  Follow and suddenly with the lessened pain as
verbalized a pain that forms on prescribed psychological onset of a painful evidenced by
level of 6 out of teeth from food pharmacological causes of pain condition. verbalizing a
10 at right particles, regimen (ex. pain scale from
submandibular especially sugars  Verbalize sense inflammation; 6 out of 10 to 3
area. and starches. of control of trauma, out of 10.
↓ response
acute situation
to fractures;
surgery;
 Show signs of
relief as
Bacteria in and positive infections; heart evidenced by
OBJECTIVE DATA: plaque produce outlook for the attack or lesser facial
 Guarding acids that slowly future. angina; grimace and
behavior on break down the abdominal guarding
painful area enamel (the hard, conditions (e.g., behavior.
 Facial Grimace protective outer appendicitis,  Show
 VS: PR-88 compliance to
 Laboratory: pharmacological
layer of teeth). If cholecystitis)
PCT 0.430 % regimen as
untreated, this  Assess for
WBC 12.71 evidenced by
decay progresses potential types
10^9/L adhering to the
through the of pain that may  To aid in
NEU 10.46 doctor’s order
enamel into be affecting understanding the
10^9/L on medication.
deeper layers of client (i.e., reason for severity of
 Verbalize
the tooth. nociceptive pain pain associated with
knowledge on
↓ LONG TERM GOAL:
After 4 days of nursing
or neuropathic
pain)
client's condition and
point toward needed
pain
As the decay management
interventions, patient  Note client's age interventions for
advances, it measures for
will be able to: and pain management.
reaches the the future.
 Report pain is developmental  Appropriate pain
dentin (the relieved level and management in
softer, inner layer  Show no signs current childhood is
of the tooth) and of discomfort condition (e.g., imperative because
eventually the  Verbalize infant/child children's early pain
pulp. The pulp LONG TERM GOAL:
knowledge critically ill, experiences can
contains nerves After 4 days of nursing
regarding health ventilated, shape their response
and blood interventions, patient
teaching on oral sedated, or to pain as adults.
vessels. was able to:
hygiene cognitively
 Show signs of
↓ techniques impaired onset
affecting ability
relief of pain as
Once bacteria evidenced by a
to report pain
penetrate the pain scale of o
parameters or
pulp, the immune out of 10 using
response to pain
system responds the Wong-
and pain
by sending white baker’s face
management  Client's perception of
blood cells to pain rating
interventions and expression of
fight the scale.
 Assess client's pain are influenced
infection, leading  Show signs of
perceptions of by age,
to inflammation. relief as
pain, along with developmental stage,
evidenced by
 absence of facial
grimace and
This can result in behaviors and underlying problems
guarding
a dental cultural causing pain,
behavior.
abscess, which is expectations cognitive, and
 Perform oral
a pocket of pus regarding pain behavioral and
care as
caused by sociocultural factors.
evidenced by
bacterial  To determine
brushing teeth
infection. positive and negative
regularly and
↓  Assist with and
review results of
findings with the
client.
using mouth
The infection and wash after
laboratory tests
inflammation in meals 3 times
and diagnostic
the pulp and per day as a part
studies  To demonstrate
surrounding of his daily
depending on improvement in
tissues cause routine.
results of status or to identify
acute pain. Pain history and worsening of
occurs because physical underlying
the infection examination. condition/developing
increases  Evaluate pain complications.
pressure inside characteristics  Failure to meet the
the tooth and the and intensity. standard of assessing
surrounding for pain can be
area. legally interpreted as
 Review client's nursing negligence.
previous
experiences
with pain and
methods found
either helpful or
unhelpful for
pain control in
the past. Be
 aware of the
client’s "Right to
Treatment" with
regards to 10
pain
management,
which includes
prevention of or  Promotes active,
adequate relief rather than passive,
from pain. role and enhances
 Provide for sense of control.
individualized
physical therapy
or exercise
program that
can be
continued by
the client after DEPENDENT:
discharge.  Pain medications
may include
DEPENDENT: pills/liquids or
 Establish a suckers, skin patch,
collaborative or suppository
approach for forms; injections, IV
pain dosing; or patient-
management- controlled analgesia
based (PCA) or regional
stimulator. on analgesia (e.g.,
client’s epidural and spinal
understanding blocking) based on
about and client's
 acceptance of symptomatology and
available mechanism of pain as
treatment well as tolerance for
options pain and various
analgesics.
 Increasing or
decreasing dosage,
 Evaluate and stepping program
document (switching from
clients’ injection to oral
response to route, increased time
analgesia and span as pain lessens)
assist in helps in self-
transitioning or management of pain.
altering drug
regimen, based
on individual  Provides opportunity
needs and to modify pain
protocols management
 Identify specific regimen and allows
signs/symptoms for timely
and changes in intervention for
pain developing
characteristics complications.
requiring
medical follow-
up
 EVALUATION
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE
EXPLANATION
SUBJECTIVE DATA: Impaired skin Bacterial, viral, or SHORT TERM GOAL: INDEPENDENT: INDEPENDENT SHORT TERM GOAL:
 “Ilang araw nang integrity fungal infections can After 2 hours of nursing After 2 hours of
namamaga at related to further damage the intervention, nursing intervention,
nagkasugat na din inflammation skin’s layers  SO will goal was met as:
yung sa bandang on right
pisngi niya” as submandibular ↓ demonstrate
understanding
 SO
demonstrated
verbalized by the area secondary and skill in understanding
SO. to dental caries impairing wound wound care. and skill in
healing and  Patient will have wound care as
weakening the reduced risk of evidenced by
skin’s natural further DEPENDENT: DEPENDENT:
OBJECTIVE DATA: defense impairment of   .
 (+) inflamed right mechanisms. skin integrity
submandibular
area
↓ LONG TERM GOAL:
 Presence of fistula LONG TERM GOAL: 
 Laboratory: Infections cause After 2 days of nursing
PCT 0.430 % inflammation, which intervention, patient
WBC 12.71 10^9/L can delay the repair will:
NEU 10.46 10^9/L process and worsen  Experience
the extent of skin healing of
damage. wound and
regain skin
integrity.
 Perform
techniques in
maintaining
good skin
integrity
 ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
EXPLANATION
SUBJECTIVE DATA: Deficient lack of knowledge SHORT TERM GOAL: INDEPENDENT: INDEPENDENT: SHORT TERM GOAL:
 “hindi po siya Knowledge about hygiene After 1 hour of  Determine the  Assessing the After 1 hour of nursing
nagsisipilyo araw- related to rooted in various nursing intervention: patient and patient’s current intervention, the goal
araw kaya sira po inadequate factors, including  The patient SO’S current level of was met as:
mga ngipin niya” information understanding will verbalize understanding understanding  The patient
as verbalized by and microbial understanding of oral care helps identify verbalized
the S.O. understanding transmission, and practices, specific knowledge understanding
of proper oral socioeconomic importance of proper hygiene gaps, of effective oral
hygiene status, cultural effective oral and any misconceptions, care practices
OBJECTIVE DATA: practices, beliefs, and access care practices misconceptions and areas that
 (+) Dental Caries secondary to to education. that need to be need targeted  The patient
at right lower 1st dental caries
molar and left ↓  The patient
will verbalize
addressed. education.
ensures that the
This verbalized the
importance of
lower 1st and 2nd the teaching is tailored regular dental
molar lead to poor importance of to the patient’s checkups and
 Teeth enamel has hygiene practices regular dental needs and starts oral hygiene.
yellowish
discoloration ↓ checkups and
oral hygiene.  Teach the
from
appropriate level.
an
 The patient
 Long dirty nails patient correct  Providing demonstrated
increased risk of  The patient tooth brushing education on appropriate
infections will techniques correct brushing oral hygiene
adversely affecting demonstrate (e.g., brushing and flossing techniques
health outcomes appropriate at least twice a techniques ensures within our shift
oral hygiene day, using a that the patient such as tooth
 brushing and
using mouth
techniques soft-bristled knows how to
wash after
brush at a 45- maintain oral
meals.
degree angle). hygiene effectively.
Brushing at least
 SO performed
twice a day and
proper
using the correct
grooming and
technique prevents
care to the
plaque buildup
patient as
and reduces the
evidenced by
risk of dental
the patient was
caries. Daily
bathed and had
flossing helps
newly trimmed
remove food
and clean nails
particles and
in hands and
plaque from areas
feet
that a toothbrush
LONG TERM GOAL:
cannot reach,
After 2 days of nursing
LONG TERM GOAL: further reducing
intervention, patient
After 2 days of the risk of tooth
will:
nursing intervention,  Educate the decay and gum
 Practice
patient will: patient on the disease.
effective oral
 Practice importance of  Sugary foods and
care practices
effective oral limiting sugary beverages promote
regularly as
care practices foods and the growth of
evidenced by
regularly drinks to bacteria that
tooth brushing
 Patient will reduce the risk produce acids,
and using
have of tooth decay. leading to tooth
mouth wash
improved oral decay. Educating
after meals.
hygiene the patient about
 Patient will
limiting sugar
have improved
intake and
overall hygiene
 as evidenced by
patient is
maintaining a
regularly
balanced diet helps
bathed, regular
reduce the risk of
handwashing
 Explain dental caries and
and trimmed
importance of supports overall
nails
proper hygiene oral health.
such as  Proper overall
trimming nails, hygiene is
bathing every essential for
day, preventing
handwashing, diseases,
and brushing maintaining
teeth regularly. physical health,
and promoting
mental well-being.
Regular hygiene
practices, such as
handwashing and
dental care, help
control infections
and reduce the risk
of chronic
diseases.
Additionally, good
hygiene boosts
self-esteem and
COLLABORATIVE: improves social
 Refer to dentist interactions,
for regular contributing to
dental better mental
checkups health.
(every 6 COLLABORATIVE:
months) for  Regular dental
professional checkups are
cleaning and essential for
early detection maintaining oral
of oral health health and
issues preventing dental
issues. They enable
early detection of
problems like
cavities, gum
disease, and oral
cancer, allowing
for more effective
treatment.
Professional
cleanings remove
plaque and tartar
that regular
brushing may
miss, while
dentists provide
personalized
advice on oral
hygiene and
preventive
treatments such as
fluoride and
sealants.
: