Criptograf´ıa RSA

Report or demonstrate a decrease in symptoms.

Identify specific interventions to promote healthy oral mucosa. Demonstrate techniques to restore and maintain mucosal integrity.

NOC

N U R S I N G D I A G N O S I S :

impaired Oral Mucous Membrane

ACTIONS/INTERVENTIONS

RATIONALE

Oral Health Restoration Independent

Inspect oral cavity and note changes in: Saliva

Tongue

Lips

NIC

Damage to salivary glands may decrease production of saliva, resulting in dry mouth. Pooling and drooling of saliva may occur because of compromised swallowing capability or pain in throat and mouth.

Surgery may have included partial resection of tongue, soft palate, and pharynx. This client has decreased sensation and movement of tongue, with difficulty swallowing and increased risk of aspiration of secretions, as well as poten- tial for hemorrhage.

Surgical removal of part of lip may result in uncontrollable drooling.

ACTIONS/INTERVENTIONS

RATIONALE

Teeth and gums

Mucous membranes

Suction oral cavity gently and frequently. Have client perform self-suctioning when possible or use gauze wick to drain secretions.

Show client how to brush inside of mouth, palate, tongue, and teeth.

Apply lubrication to lips; provide oral irrigations as indicated. Avoid alcohol-based mouthwashes. Use normal saline or mix-

ture of salt water and baking soda for rinsing. Suggest use of artificial saliva preparations, such as pilocarpine hydrochloride (Salagen), if mucous membranes are dry.

Teeth may not be intact (surgical) or may be in poor condition because of malnutrition, chemical therapies, and neglect. Gums may also be surgically altered or inflamed because of poor hygiene, long history of smoking or chewing tobacco, or chemical therapies.

May be excessively dry, ulcerated, erythematous, and edematous.

Saliva contains digestive enzymes that may be erosive to exposed tissues. Because drooling may be constant, client can promote own comfort and enhance oral hygiene by performing self-suctioning.

Frequent oral care reduces bacteria and risk of infection and promotes tissue healing and comfort.

Counteracts drying effects of therapeutic measures and negates erosive nature of secretions.

Alcohol can be drying and irritating. Salt and soda rinses return mouth to neutral rather than acidic environment. Although drooling is often present and abundant immedi- ately postoperatively, surgical or radiation damage to the parotid glands can drastically reduce saliva production on a permanent basis. Cholinergic effect of medication can increase saliva production.

May be related to Surgical incisions Tissue swelling

Presence of nasogastric or orogastric feeding tube Possibly evidenced by

Discomfort in surgical areas Pain with swallowing Facial mask of pain

Distraction behaviors, restlessness; guarding behavior

Desired Outcomes/Evaluation Criteria—Client Will

Report pain is relieved or controlled.

Demonstrate relief of pain and discomfort by reduced tension and relaxed manner and sleeping or resting appropriately.

NOC

N U R S I N G D I A G N O S I S :

acute Pain

ACTIONS/INTERVENTIONS

RATIONALE

Pain Management Independent

Support head and neck with pillows. Show client how to support neck during activity.

Provide comfort measures, such as back rub and position change, and diversional activities, such as television, visiting, and reading.

Encourage client to expectorate saliva or to suction mouth gently if unable to swallow.

Evaluate pain level frequently.

Investigate changes in characteristics of pain. Check mouth and throat suture lines for fresh trauma.

Note nonverbal indicators and autonomic responses to pain. Evaluate effects of analgesics.

NIC

Muscle weakness results from muscle and nerve resection in the structures of the neck and shoulders. Lack of support aggravates discomfort and may result in injury to suture areas.

Promotes relaxation and helps client refocus attention on something beside self and discomfort. May reduce analgesic dosage frequency.

Swallowing causes muscle activity that may be painful because of edema or strain on suture lines.

Pain is a major concern for clients undergoing laryngectomy and it is believed as many as 32% still suffer severe distress, with the administered dosing less than needed to obtain optimal pain relief (Orgill et al, 2002).

May reflect developing complications requiring further evalua- tion or intervention. Tissues are inflamed and congested and may be easily traumatized by suction catheter or feeding tube.

Aids in determining presence of pain, effectiveness of medication, or the need for pain relief.

CHAPTER 5

RESPIRA

T

OR

Y—RADICAL NECK SURGER

Y

ACTIONS/INTERVENTIONS

RATIONALE

Medicate before activity and treatments, as indicated. Schedule care activities to balance with adequate periods of

sleep or rest.

Recommend use of stress management behaviors, such as relaxation techniques and guided imagery.

Collaborative

Provide oral irrigations, anesthetic sprays, and gargles. Instruct client in self-irrigations.

Administer analgesics such as on a scheduled basis and prn (as necessary) or via patient-controlled analgesia; adjust dosages according to pain level per protocols.

Avoid medications containing aspirin.

May enhance cooperation and participation in therapeutic regimen.

Prevents fatigue or exhaustion and may enhance coping with stress or discomfort.

Promotes sense of well-being and may reduce analgesic needs and enhance healing.

Improves comfort, promotes healing, and reduces halitosis. Note: Commercial mouthwashes containing alcohol or phenol are to be avoided because of their drying effect. Degree of pain is related to extent and psychological impact of

surgery as well as general body condition. Allowing client to control medication or giving medications on schedule rather than just prn and using report of pain level to adjust dosage minimizes chance that pain escalates “out of control.” Products containing aspirin are contraindicated because they

potentiate bleeding.

May be related to

Temporary or permanent alteration in mode of food intake

Altered feedback mechanisms of desire to eat, taste, and smell because of surgical or structural changes, radiation, or chemotherapy

Possibly evidenced by

Inadequate food intake, perceived inability to ingest food

Aversion to eating, lack of interest in food, reported altered taste sensation Weight loss

Weakness of muscles required for swallowing or mastication

Desired Outcomes/Evaluation Criteria—Client Will