PRIORITIZED NURSING DIAGNOSIS NURSING DIAGNOSIS

Acute pain related to periodontal abscess w/ periorbital cellulitis as evidenced by pain scale of 6/10

RANK 1

JUSTIFICATION
This is the first prioritized problem. Since pain is considered as the 5th vital sign. And according to Maslows hierarchy of needs, pain is under physiological needs. Human needs to be in a state of homeostasis in able to survive. Therefore, we should give attention to pain so that the patient can be comfortable and can cooperate well in treatment regimen and be able to survive. This is the second prioritized problem. According to Maslows hierarchy of needs, this is also under physiologic needs. The patient should gain all needed metabolic requirement in able to survive. Therefore, we should give attention to this so that the patient can have timely wound healing and limit the metabolic demands needed to survive. This is the third prioritized problem. According to Maslows hierarchy of needs, this is under selfesteem. Esteem presents the normal human desire to be accepted and valued by others. Human needs to engage themselves to gain recognition and have activities that give the

Impaired oral mucous membrane related to periodontal abscess as evidenced by maxillary swelling

Disturbed Body Image related to periodontal abscess as evidenced by clients verbalization I cant go to my work due to my current condition

Risk for Injury related to periodontal abscess

Readiness for enhanced therapeutic regimen management

person a sense of contribution. Imbalances at this level can result in low self-esteem. And depression can also result to that. Therefore, the patients condition should be given attention for her to have high Self-esteem. This is the fourth prioritized problem since it is a risk diagnosis. Risk diagnosis should not be ignored since it can cause complications that can risk the patients life. Therefore, we need to implement precaution/prevention so that the patient would be safe. This is the last prioritized problem since it is a readiness diagnosis. Regulating and integrating program for treatment of illness into daily living is sufficient for meeting health related goals.

NURSING DIAGNOSIS Subjective Data: Acute pain r/t Medyo masakit periodontal pa din siya abscess w/ specially if Im periorbital continuously cellulitis aeb pain talking as scale of 6/10 verbalized by the client Objective Data: P = it is painful when she uses her facial muscles while continuously talking, or eating/chewing Q = It is like a burning crushing pain R = The pain is radiates around her face and sometimes on her head S = pain scale of 6/10 T = it lasts just a few minutes

ASSESSMENT

Discharge Outcome: Gums pull away After 8 hours of teeth nursing intervention, the client will be Creates deep pockets able to relieve pain of space between with pain scale of teeth & gums 0/10 Short Term Outcome: After 4 hours of Bacterial pathogens nursing intervention, in the injured tissue the client will be able to: Inflammatory -control pain with response pain scale of 3/10 -verbalize at least 2 Vasoconstriction non pharmacological Vasodilation methods that provide relief Increased blood flow -follow prescribed on affected area pharmacological (calor & rubor) regimen Bacteria grows on deep pockets Increase permeability of blood vessels (tumor & dolor)

SCIENTIFIC EXPLANATION Periodontal disease

PLANNING

NURSING INTERVENTION Independent: 1. Obtain clients assessment of pain to include location, onset, frequency, quality, intensity and aggravating factors. Note changes from previous reports 2. Provide comfort measures like repositioning every 2 hrs., warm compress on affected area 3. Provide quiet environment and calm activities 4. Encourage use of relaxation techniques like breathing exercise

RATIONALE

EVALUATION FULLY ACHIEVED

-To rule out worsening of underlying condition

Discharge Outcome: PARTIALLY ACHIEVED The client was able to relieve pain with pain scale of 0/10 Short Term Outcome: FULLY ACHIEVED The client was able to: -control pain with pain scale of 3/10 -verbalize at least 2 non pharmacological methods that provide relief -follow prescribed pharmacological regimen

-To promote nonpharmacologi cal pain management

-To promote nonpharmacologi cal pain management -To distract attention and reduce tension

5. Encourage diversional activities like watching TV, listening to radio socialization with others Dependent: 1. Administer analgesic as prescribed (Mefenamic Acid Dolfenal 1 tab PRN for pain)

-To maintain acceptable level of pain

NURSING SCIENTIFIC DIAGNOSIS EXPLANATION Subjective Data: Impaired mucous Periodontal disease membrane r/t Gums pull away periodontal teeth Objective Data: abscess aeb -right sided maxillary Creates deep pockets polysinusitis swelling of space between -periodontal teeth & gums abscess -maxillary Bacteria grows on swelling deep pockets

ASSESSMENT

PLANNING Discharge Outcome: After 1 week of nursing intervention, the client will be able to display progressive improvement in wound healing

Short Term Outcome: Bacterial pathogens After 4 hours of in the injured tissue nursing intervention, the client will be Inflammatory able to: response -identify at least 3 interventions Vasoconstriction appropriate for her condition Vasodilation -demonstrate lifestyle changes to Increased blood flow promote healing and on affected area prevent (calor & rubor) complications Increase permeability of blood vessels (tumor & dolor)

NURSING INTERVENTION Independent: 1. Assess skin/tissues. Note presence, location and degree of edema. 2. Inspect wounds daily or as appropriate for changes like signs of infection/compli cation 3. Promote optimum nutrition with high quality protein and sufficient calories, vitamins and mineral supplements 4. Encourage adequate periods of rest and sleep

RATIONALE

EVALUATION

-To assess degree of impairment and for comparative baseline -To promote timely healing intervention

Discharge Outcome: PARTIALLY ACHIEVED The client was able to display progressive improvement in wound healing Short Term Outcome: FULLY ACHIEVED The client was able to: -identify at least 3 interventions appropriate for her condition -demonstrate lifestyle changes to promote healing and prevent complications

-To promote healing

5. Provide

-To limit metabolic demands, maximize energy available for healing -To promote

comfort measure like warm compress over maxillary area 6. Provide/assist with oral care by teaching oral/dental hygiene like using gargle (bactidol) Dependent: 1. Review medical regimen (bactidol gargle TID) (Oxymetazoline 2 sprays each nostrils TID)

comfort

-To prevent further damage to mucous membrane