Serquina, Johniza Hope G.

February 25, 2021

BSN -3A NCM 116
Activity 1
Client’s Profile
Name: Mendoza, D.
Age: 51 y/o
Address: San Nicolas, Pangasinan

Health History
 History of Present Illness
M.D is a 51 year-old, female, with present dental caries and tooth misalignment. According
to her, fixing her teeth is not a priority ever since. But it affected her self-confidence every
time she faces many people. Whenever she feels toothache, she neglects it because for her,
going to the dentist to have a check-up is costly. Sometimes, to ease the pain, she gargles
warm water with salt. Client states that she has a hard time chewing her food especially the
hard ones. When drinking cold drinks, she experiences pangingilo. M.D also feels
constipated. According to her, she has an inability to pass stools every day. Her normal
passing of stools is five times a week and usually it is a soft brown stool. Hemorrhoids is
present she stated. Usual fluid intake is 4-6 glasses of water a day and has a low fiber diet.
 Past Medical and Dental History:
The client is complete in vaccines and has no known allergies. (+) Hypertension since
2015. Last dental check-up was last January 2020 during the free dental check-up initiated
by our municipality. Wisdom tooth was taken away when she was 15 years old.
 Family History:
The client has reported that on her maternal side there is a history of hypertension while
on her paternal side, there is a history of heart failure. There were no reported history of
other diseases such as diabetes mellitus, tuberculosis or asthma.
 Social History:
The client is our house keeper and living with her husband, 2 children and 1 grandchildren.
Denies vices. But she is exposed to cigarette smoke because of his husband. No travel
history for the past 5 years.
  Oral Hygiene Habit
Client brushes her teeth twice a day. After breakfast and before going to bed. Not using
dental floss nor mouth wash. Usually uses toothpick or small stick to remove small food
particles in her tooth.
Physical Assessment
 General Survey: Client is alert, oriented and cooperative. Speech is loud and clear, but
with slur or stutter. Expresses ideas and feelings clearly. Makes eye contact and
maintains conversation appropriately while sitting on the chair. Clothes is clean and
appropriate for season.
 Skin, Hair, Nails: Skin is brown in color. Warm and dry to touch. 2cm brown-black
mole noted in the neck. Turgor is intact with immediate recoil of skin and over the
clavicle. Hair is black with scattered gray streaks, short and curly. No scalp lesions or
flaking noted. Fingernails are well trimmed; immediate capillary refill of two (2) seconds.
No clubbing or beau's lines.
 Head and Neck: Head symmetrically round, hard and smooth, without lesions or bumps.
Face is round, smooth and symmetric. Bilateral temporomandibular joints with full ROM.
No lymph nodes noted.
 Eyes: Eyes are symmetrical. Conjunctiva and sclera moist and smooth. Eyebrows sparse
with equal distribution. Denies wearing any kind of glasses. Denies itching, excessive
tearing, discharge, and redness. PERRLA.
 Ears: Bilateral auricles without deformity, lumps or lesions. Bilateral auditory canals
contain scant amount of yellow cerumen. Denies pain, discharge or trauma to ears.
 Nose: External structure without deformity, asymmetry, or inflammation. Nares patent.
Frontal and maxillary sinuses nontender.
 Mouth, Throat, Nose and Sinuses: Lips dark brown in color, smooth and moist. No
lesions or ulcerations. Bucal mucosa and gums pink and moist without inflammation,
bleeding or discoloration. Teeth are not complete. Presence of dental caries are present in
her 4 molars. There is a tooth enamel discoloration observed. Wears crown and some
 teeth are with pasta. Last dental examination was a year ago. Total no. of teeth: 26.
Tongue midline when protruded. Tonsils present, without exudate, edema, ulcers or
enlargement. Nose external structure without deformity, asymmetry, or inflammation.
Nares patent. Frontal and maxillary sinuses nontender.
 Thorax and Lungs: Thorax expands symmetrical without retraction. Clear to
auscultation anterior and posterior bilaterally. Respirations are even, unlabored and
regular. Respiratory rate: 18, no reports of dyspnea.
 Abdomen: Abdomen round and symmetric, without masses, lesions, or peristaltic waves.
Presence of hyperactive bowel sounds, Abdomen free of hair. Stretch marks are
observed.
 Upper Extremities: Equal in size and symmetric. Skin brown in color; warm and dry to
touch, without edema, bruising or lesions. Radial and brachial pulses 2+ and equal
bilaterally.
 Lower Extremities: Symmetric in size and shape. Skin intact, brown in color, warm and
dry to touch without edema.

Nursing Care Plan 1

Assessment

Subjective: “Nangigilo ngipin ko pag umiinom ako ng malamig” as stated by the client.
“Minsan pag napapakain ng matamis, medyo sumasakit ngipin at pag kumakain ng matitigas”
she added.

Objective:
 A total of 26 teeth
 Dental caries on the 2 right upper molars
 Dental caries on the 2 left lower molars
 Tooth enamel discoloration observed

Nursing diagnosis: Impaired Dentition related to Ineffective Oral Hygiene

Goals and outcomes:

After the intervention, the client will be able to:

  Show ability to care for own teeth and mouth freely and individually as evidenced by
daily routine of brushing and flossing, and using mouthwash properly.
 Do daily denture cleaning and care.
 Exhibit a clean teeth, healthy gums, and mouth with a pleasant odor upon examination.
 Get regular dental checkups if possible or feasible.

Intervention:

Intervention
Offer a mouth care routine including tooth
brushing at regular intervals with a soft-bristle
toothbrush and fluoride toothpaste.
Teach gentle flossing teeth with unwaxed
dental floss.
Instruct the patient to rinse the mouth with
warm saline or an antiplaque mouth rinse.
Encourage to avoid high-sugar foods.
Give the client a health teaching about the
advantages and disadvantages of having a
good oral hygiene. The client should know
the complications that may occur if you have
ineffective oral hygiene.
Rationale
Cleaning of teeth with a toothbrush and
fluoride-containing toothpaste prevents the
build-up of plaque.
Flossing promotes gum health and prevents
the build-up of plaque.
These measures help promote oral hygiene.
High sugar foods may cause tooth decay and
promotes good oral health and healing.
Good oral health allows for healthy eating
habits and may decrease the client’s chance
of having dental caries.

Encourage and instruct patient to obtain Regular dental check-ups identify dental
regular dental check-ups and follow-ups. problems early.
Educate the patient regarding the importance Check-ups help identify dental problems
of dental check-ups and follow-ups. early.

Evaluation:

After the intervention, goal was fully met because the client was able to:

 Show ability to care for own teeth and mouth freely and individually
 Do daily denture cleaning and care.
 Exhibit a clean teeth, healthy gums, and mouth with a pleasant odor upon examination.
 Get regular dental checkups if possible or feasible.

Nursing Care Plan 2

Assessment
Subjective: “Hirap ako mag bawas ngayon at minsan masakit pwet ko pag tumatae” stated by
the client. “May almoranas na nga ako eh” she added.

Objective:

 Inability/ infrequent passage of stools

 Passage of black hard dry stool
 There is a change in bowel pattern
 Pain with defecation
 Decrease fluid intake
 Low fiber diet

Nursing diagnosis: Constipation related to low fiber diet and decrease fluid intake as evidenced
by infrequent, hard stools and painful defecation

Goals and outcomes:

After the nursing intervention, the client will be able to:

 Maintain passage of soft, formed stool at a frequency perceived as “normal” by the client.
 State relief from discomfort of constipation and elimination pattern will return to normal.
 Consume high-fiber diet, unless contraindicated
 Maintain oral fluid intake of 2,500 mL daily.

Intervention:

Intervention Rationale
Monitor and record frequency and Careful monitoring forms the basis of an
characteristics of stool. effective treatment plan.
Record intake and output accurately To ensure correct fluid replacement therapy.
Unless contraindicated, encourage fluid intake To ensure correct fluid replacement therapy.
of 2, 500 mL daily
Teach client to gently massage along the To stimulate bowel’s spastic reflex and aid
transverse and descending colon stool passage
Instruct client in relationship of diet, exercise These measures promote muscle tone and
and fluid intake to constipation. circulation.
Evaluation:

After the intervention, goal was fully met because the client was able to:

 Maintain passage of soft, formed stool at a frequency perceived as “normal” by the client.
 State relief from discomfort of constipation and elimination pattern.
 Consume a high-fiber diet.
 Maintain oral fluid intake of more than 2,500 mL daily.