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Unit 3
Applying concepts from the nursing process
Nursing interventions
g. Avoid tight clothing in the area. Use
cotton clothing.
h. Apply vitamins A&D ointment to the
area.
2. If wet desquamation occurs:
a. Do not disrupt any blisters that have
formed.
b. Avoid frequent washing of the area.
c. Report any blistering.
d. Use prescribed creams or
ointments.
e. If area weeps, apply a thin layer of a
non-adherent dressing.
f. If the area is without drainage, use
moisture and vapour-permeable
dressings such as hydrocolloids and
hydrogels on non-infected areas.
g. Consult with wound care nurse and
physician if eschar forms.
Rationale
g. Allows air circulation to affected
area.
h. Aids healing.
2. Open weeping areas are susceptible
to bacterial infection. Care must
be taken to prevent introduction of
pathogens.
a. Disruption of skin blisters disrupts
skin integrity and may lead to
increased risk of infection.
b. Frequent washing may lead
to increased irritation and skin
damage, with increased risk for
infection.
c. Blistering of skin represents
progression of skin damage.
d. Decreases irritation and
inflammation of the area.
e. Enhances new cell growth.
f. Promotes healing.
g. Eschar must be removed to
promote healing and prevent
infection. Wound care nurses have
expertise in the care of wounds.
Expected outcomes
• Exhibits absence of infection of
blistered and opened areas.
• Wound is free from the development
of eschar.
Plan of Nurs ing Care
Care of patient with cancer
(
continued
)
CHART
11-4
Nursing interventions
1. Assess oral cavity daily.
2. Instruct patient to report oral burning,
pain, areas of redness, open lesions
on the lips, pain associated with
swallowing, or decreased tolerance to
temperature extremes of food.
3. Encourage and assist in oral hygiene.
Preventive
a. Avoid commercial mouthwashes.
b. Brush with soft toothbrush; use
non-abrasive toothpaste after meals
and bedtime; floss every 24 hours
unless painful or platelet count falls
below 40 × 10
9
/L.
Mild stomatitis
(generalised
erythema, limited ulcerations, small
white patches: Candida)
Rationale
1. Provides baseline for later evaluation.
2. Identification of initial stages of
stomatitis will facilitate prompt
interventions, including modification of
treatment as prescribed by physician.
3. Patients who are having discomfort
or pain, or other symptoms related to
the disease and treatment may require
encouragement and assistance in
performing oral hygiene.
a. Alcohol content of mouthwashes
will dry oral tissues and potentiate
breakdown.
b. Limits trauma and removes debris.
Expected outcomes
• States rationale for frequent oral
assessment and hygiene.
• Identifies signs and symptoms of
stomatitis to report to nurse or doctor.
• Participates in recommended oral
hygiene regime.
• Avoids mouthwashes with alcohol.
• Brushes teeth and mouth with soft
toothbrush.
• The lips are soft and non-irritated.
• Avoids hard-to-chew, spicy and hot
foods.
• Exhibits clean, intact oral mucosa.
• Exhibits no ulcerations or infections of
oral cavity.
• Exhibits no evidence of bleeding.
• Reports absent or decreased oral pain.
• Reports no difficulty swallowing.
Nursing problem:
Impaired oral mucous membranes: stomatitis
Goal:
Maintenance of intact oral mucous membranes
