IMPAIRED DENTITION Nursing Care Plan

Jolito is a very lazy boy. He sleeps late at night playing mobile games and wakes up in the afternoon to find food. After he takes his lunch he will go outside and play basketball without taking a bath first and without brushing his teeth. He will return at the dinner time to eat and sleep and forget or intentionally don't want to take care of his cleanliness. One day, he woke up with a painful tooth and all his family members were laughing at him and told him that it was because of not brushing his teeth. Below is a sample of nursing care plan of impaired dentition of Jolito, a 15 years old boy. 


ASSESSMENT 
Subjective: 
"My tooth is aching, "as verbalized by the patient.

Objectives: 
I smell foul odor from the patient's mouth as he/she is talking to me. This foul smell of his/her breath is called halitosis. I also noticed that he/she has a tooth enamel discoloration and erosion. There is excessive plaque all over her/his teeth as well as dental carries. By observing him/her, I assume that he/she had a toothache because the patient is guarding his/her left, lower quadrant of his/her face. I used pain scale to the patient and graded it 7/10. 


Vital signs was taken and noted as follows: Body temperature is 35.5 degrees Celsius, blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, and pulse rate is 120 beats per minute. Body temperature, respiratory rate, and pulse rate are normal while his/her blood pressure is above normal and categorize as pre-hypertension. 


DIAGNOSIS 
Impaired dentition related to toothache as evidenced by tooth enamel discoloration and excessive plaque. (Toothache if a pain or soreness perceive by the person located within or around his/her tooth. Enamel is a hard substance that creates a thin layer which covers the tooth). 


PLANNING 
After 4 hours of nursing intervention the patient's toothache will be diminished. (You can also add to your planning, "also his/her tooth enamel discoloration and excessive plaque will be treated." 


INTERVENTION 
- The first you need to do is to evaluate Jolito's current status of dental hygiene and oral health to determine his possible intervention and treatment needs. Note his absence of teeth and dentures and ascertain its significance in terms of nutritional needs and aesthetics. Document presence of factors affecting Jolito's dentition such as chronic user of tobacco, coffee or tea because these drinks are tooth-strainer causes enamel damage. Bulimia and vomiting causes stomach acid goes to the mouth which destroys the tooth enamel. 

- Document or get a photo of Jolito before treatment to provide a pictorial baseline for his future comparison or evaluation. Encourage Jolito to use soft toothbrush and use tap water, saline or diluted alcohol-free mouth washers. If needed, administer him antibiotics to treat oral or gum infection and analgesics of topical analgesics for his dental pain. In addition, encourage Jolito to limit sugary foods and midnight snacks because as food left on his teeth at night is more likely to cause cavities. Note: If Jolito is young, regarding age-appropriate concerns, refrain from letting him fall asleep with milk or juice in left in his mouth instead let him drink water or advise him brush his teeth before he sleep. Avoid sharing his eating utensils among family members and don't forget to teach him to brush teeth while still young. 


- For further management of the teeth, refer Jolito to appropriate care providers such as dental hygienists, dentists, periodontists or oral surgeon. 


EVALUATION 
After 4 hours of nursing intervention, the patient's toothache has been diminished. (If you add the tooth enamel discoloration and excessive plaque in your planning, just add to your evaluation, "and his/her tooth enamel discoloration and excessive plaque were treated).


For more samples of nursing care plan you are free to check it out in our NCP LIST page.