Nursing Analysis Goal/Objectives Nursing Interventions Rationale Evaluation

Problem/Cues
Impaired Oral Dehydration, Goal: After 8 hours of After 8 hours of
Mucous Membrane excessive loss of nursing interventions, nursing
r/t Dehydration water from body the client’s mother will intervention, the
tissues, be able to demonstrate client’s mother was
Cues: accompanied by a techniques to restore/ able to demonstrate
Subjective: disturbance in the maintain integrity of techniques to
> Xerostomia balance of essential oral mucosa. restore/ maintain
electrolytes, integrity of oral
Objective: particularly sodium, Objectives: mucosa.
> gingival potassium, and
and mucosal pallor chloride. Signs of 1. To identify Determine nutrition / fluid intake Dehydration and malnutrition
> halitosis dehydration include causative / and report changes predispose clients to impaired
> dry skin poor skin turgor, contributing oral mucous membranes.
> sunken eyeballs flushed dry skin, factors affecting
coated tongue, dry oral health Assess medication use and Some medications may affect
mucous possibility of side effects health or integrity of oral
membranes, mucous membranes
oliguria, irritability,
and confusion. Inspect the oral cavity at least Oral inspection can reveal
once daily and note any signs of oral disease,
discoloration, lesions, edema, symptoms of systemic
bleeding, exudates, or dryness. disease, drug side effects, or
trauma of the oral cavity

2. To correct Encourage adequate fluids Prevents dry mouth and

identified
problem
Provide dietary modifications and
adequate nutrients and vitamins
Keep lips well lubricated using
petroleum jelly or a similar
product
dehydration
Reduces discomfort and
improves intake which can
promote healing.
Lubricating the lips prevents it
from breaking due to dryness.
 If client's oral cavity is dry, the
keep inside of the mouth moist
with frequent sips of water and
salt water rinses
Review current oral hygiene
3. To promote patterns and provide information
wellness about oral health as required
Instruct parents tin oral hygiene
techniques and proper dental
care for children
Provide nutritional information to
correct deficiencies
Moisture promotes the
cleansing effect of saliva and
helps avert mucosal drying,
which can result in erosions,
fissures, or lesions. Sodium
chloride rinses have been
shown to be effective for the
prevention and treatment of
stomatitis.
Corrects deficiencies and
encourages proper care
Encourages early initiation of
good oral health practices and
timely intervention for
treatable problems
To reduce irritation or gum
diseases and to prevent oral
problems
Reference:
Doenges, et. Al. Nurse’s
Pocket Guide (NANDA 11th
edition