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Case CA Rt Buccal Bed 20 - Coggle Diagram

- - - - Mucositis are Inflammation or ulceration of the mouth and throat, most commonly in head and neck cancer patients receiving radiation and chemotherapy. which is the main cause of suffering in these patients and may result in a lack of treatment interruption.
      - Nursing Intervention
        
        Provide fluid throughout 24 hrs period within prescribed limit.
        
        Offer frequent mouth care.
        
        Inspect oral cavity: moistness, Character of saliva ,present of inflammation,ulcerations,
        leukoplakia..
        
        Encourage good dental hygiene.
        
        Administer antibiotic medicine follow the medical order.
        
        Dressing wound
        
        Assess sign and symptoms of infection such as fever, vomitting and redness
- - - - Nursing Intervention
        
        monitor the patient intake and output every shift.
        
        Assess skin, face, dependent areas for edema. Evaluate degree of edema
        
        Promote nutrition.LTD.Sodium.
        
        Reensure the laboratory of creatinine and eGFR.
        
        Admister 20% Mannitol 10 gm IV in 15 min for Increase the amount of urine excreted by inhibiting water reabsorption.
        
        Assess sign and symptoms of renal dysfunction.
- - - - Nursing Intervention
        
        Assess and note for signs and symptoms related to pain such as redness, swollen or burning.
        
        Evaluate the patient’s approach towards pharmacological and nonpharmacological
        
        Assess and document pain characteristics
        
        Administer MST for relieve pain.
        
        Assess pain score.
- - - - Review laboratory values that indicate well-being or deterioration
      - Assess the physical signs of poor nutritional intake
      - Provide good oral hygiene and dentition
      - Observe for signs associated with swallowing problems (e.g., coughing, choking, spitting of food, drooling, difficulty handling oral secretions, double swallowing or major delay in swallowing, watering eyes, nasal discharge, wet or gurgly voice, decreased ability to move tongue and lips, decreased mastication of food, decreased ability to move food to the back of the pharynx, slow or scanning speech)
      - Promote the food that easy to swallow and complete nutrition.
      - Admister Ondansetron 8 mg + NSS 50 mL IV in 15 min for prevent neusea and vomitting,
      - Admister Dexamethasone 20 mg +NSS to 20 mL IV push slowly for relieve pain.
- - - - Determine patterns of sleep in the past in a normal environment: amount, bedtime routines, depth, length, positions, aids, and other interfering factors
      - Note physical or psychological circumstances that hinder sleep
      - Evaluate the patient’s knowledge on the cause of sleep problems and potential relief measures to facilitate treatment
      - Introduce relaxing activities such as warm bath, calm music, reading a book, and relaxation exercises before bedtime
      - Admister Lorazepam 1 x hr pro for decrease anxiety.
      - Promote the environment appropriate to sleep.
      - Promote mental health of patient for decrease stress and anxiety.