Textbook of Medical-Surgical Nursing 3e

244

Unit 3   Applying concepts from the nursing process

Plan of Nurs ing Care Care of patient with cancer ( continued )

CHART 11-4

Expected outcomes • Exhibits absence of infection of blistered and opened areas. • Wound is free from the development of eschar.

Nursing interventions

Rationale

g. Avoid tight clothing in the area. Use cotton clothing. h. Apply vitamins A&D ointment to the area. 2. If wet desquamation occurs:

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.

a. Do not disrupt any blisters that have formed.

b. Avoid frequent washing of the area.

c. Blistering of skin represents progression of skin damage. d. Decreases irritation and inflammation of the area. e. Enhances new cell growth.

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.

f. Promotes healing.

g. Eschar must be removed to promote healing and prevent

infection. Wound care nurses have expertise in the care of wounds.

Nursing problem: Impaired oral mucous membranes: stomatitis Goal: Maintenance of intact oral mucous membranes

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.

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.

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)