| 📝 Nursing Diagnosis |
Impaired oral mucous membrane related to malignant ulceration and radiation therapy as evidenced by mouth pain, ulcers, and difficulty eating.
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| 📋 Subjective Data |
“My mouth burns and I can’t eat anything.”
“My tongue feels sore and it’s hard to speak.”
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| 🧾 Objective Data |
Ulceration on tongue and cheek, red and swollen oral tissues, drooling, weight loss, foul odor, hoarseness, difficulty swallowing.
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| 🎯 Goals/Expected Outcomes |
- 🟢 Patient will maintain intact oral mucosa within 7 days.
- 🟢 Patient will report decreased pain within 48 hours.
- 🟢 Patient will demonstrate adequate nutritional intake by discharge.
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| 👩⚕️ Nursing Interventions & Rationales |
- 👁️🗨️ Assess oral cavity daily for lesion progression, swelling, or bleeding — to monitor healing or worsening.
- 🧼 Encourage oral hygiene with soft sponge applicator — minimizes trauma and prevents infection.
- 💧 Instruct patient to rinse mouth with saline or prescribed mouthwash every 2–4 hours — promotes comfort and hygiene.
- 💊 Apply topical anesthetics before meals — relieves pain and encourages intake.
- 🥣 Offer high-protein, soft, bland, cool meals — supports tissue repair and reduces irritation.
- 📉 Monitor weight, I&O, and hydration status — evaluates nutritional adequacy.
- 📚 Educate patient to avoid tobacco and alcohol — to promote healing and reduce recurrence risk.
- 🤝 Refer to speech therapist if needed — supports communication in post-op oral cancer patients.
- 🧑⚕️ Collaborate with dietitian — to plan nutrient-rich meals suited to patient’s condition.
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| ✅ Evaluation |
- ✔️ Oral lesions reduced, mucosa healing observed.
- ✔️ Patient reports pain level reduced to 2/10.
- ✔️ Patient consumes 75–100% of prescribed diet.
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