Care Plan for Dental Problem

Category / Primary Body System

• Oral Health

Problem

• Patient is at risk for complications related to dental problems.

Goal

• Patient will not have difficulty chewing and will not show signs of infection for the next 90 days.

Plan/Approach

1. Oral Hygiene and Care

   • Provide thorough oral care every shift and as needed to maintain oral hygiene and prevent infections.

2. Monitoring and Assessment

   • Monitor the mouth daily for lesions, swelling, bleeding, sores, and loose or broken teeth.
   • Monitor PO (oral) intake to ensure adequate nutrition and identify any issues with chewing or swallowing.
   • Monitor for any difficulty chewing or swallowing to promptly address any problems.

3. Weight Monitoring

   • Measure the patient's weight weekly to track nutritional status and detect any significant changes.

4. Dental Consult

   • Arrange for dental consults per MD/RNP orders to address any identified dental issues.

Rationale

1. Oral Hygiene and Care

   • Regular oral care helps prevent infections, maintain oral health, and improve overall well-being.

2. Monitoring and Assessment

   • Daily monitoring of the mouth allows for early detection of dental issues, preventing complications such as infections.
   • Monitoring oral intake and chewing/swallowing abilities ensures the patient maintains adequate nutrition and identifies any functional problems early.

3. Weight Monitoring

   • Regular weight monitoring helps assess the patient's nutritional status and identify any issues related to oral health that may affect eating.

4. Dental Consult

   • Professional dental consultations ensure timely and appropriate treatment of dental problems, preventing complications and maintaining oral health.

Actions

1. Oral Hygiene and Care

   • Perform thorough oral care every shift, including brushing teeth, cleaning dentures if applicable, and using mouthwash as appropriate.
   • Document oral care provided and any observations regarding the patient's oral health.

2. Monitoring and Assessment

   • Inspect the patient's mouth daily for any signs of lesions, swelling, bleeding, sores, or loose/broken teeth, documenting findings.
   • Monitor oral intake during meals, noting any difficulties in chewing or swallowing.
   • Record and report any issues with chewing or swallowing to the healthcare provider immediately.

3. Weight Monitoring

   • Weigh the patient weekly, documenting weight and noting any significant changes.
   • Report significant weight changes to the healthcare provider to assess for underlying causes.

4. Dental Consult

   • Schedule and coordinate dental consults as ordered by the MD/RNP.
   • Follow up on recommendations from dental consults, ensuring any prescribed treatments are implemented.