GI System Lecture 2


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GI System Lecture 2

  1. 1. Learning Objectives:At the end of this lecture, you will be able to:1. Use the nursing process as a framework for care ofpatients with conditions of the oral cavity.2. Describe the relationship of dental hygiene and dentalproblems to nutrition.JOFRED M. MARTINEZ, RN
  2. 2. 3. Describe the nursing management of patients withabnormalities of the lips, gums, teeth, mouth, andsalivary glands.4. Use the nursing process as a framework for care ofpatients with cancer of the oral cavity.5. Identify the physical and psychosocial long-termneeds of patients with oral cancer.6. Use the nursing process as a framework for care ofpatients undergoing neck dissection.7. Use the nursing process as a framework for care ofpatients with conditions of the esophagus.Learning Objectives (Cont’d.):
  3. 3. 8. Describe the various conditions of the esophagus andtheir clinical manifestations and management.Learning Objectives (Cont’d.):
  4. 4. DENTAL PLAQUE AND CARIESTooth decay is an erosive process that begins with theaction of bacteria on fermentable carbohydrates in themouth, which produces acids that dissolve tooth enamel.The extent of damage to the teeth depends on thefollowing:• The presence of dental plaque• The strength of the acids and the ability of the saliva toneutralize them• Length of time the acids are in contact with the teeth• The susceptibility of the teeth to decayDisorders of the Teeth
  5. 5. • Dental decay begins with a small hole, usually in afissure or in an area that is hard to clean.• Left unchecked, the affected area penetrates theenamel into the dentin.• When the blood, lymph vessels, and nerves areexposed, they become infected and an abscess mayform, either within the tooth or at the tip of the root.• Soreness and pain usually occur with an abscess.• As the infection continues, the patient’s face may swell,and there may be pulsating pain.Disorders of the Teeth
  6. 6. PREVENTIONMeasures used to prevent and control dental cariesinclude:• practicing effective mouth care• reducing the intake of starches and sugars (refinedcarbohydrates)• applying fluoride to the teeth or drinking fluoridatedwater• refraining from smoking• controlling diabetes• and using pit and fissure sealantsDisorders of the Teeth
  7. 7. Disorders of the TeethPATIENT EDUCATION• Brush teeth using a soft toothbrush at least two timesdaily.• Floss at least once daily.• Use an antiplaque mouth rinse.• Visit a dentist at least every 6 months, or when youhave a chipped tooth, a lost filling, an oral sore thatpersists longer than 2 weeks, or a toothache.• Avoid alcohol and tobacco products, includingsmokeless tobacco.• Maintain adequate nutrition and avoid sweets.• Replace toothbrush at first signs of wear, usually every2 months.
  8. 8. Disorders of the TeethDENTOALVEOLAR ABSCESS / PERIAPICAL ABSCESS• Periapical abscess, more commonly referred to as anabscessed tooth, involves the collection of pus in theapical dental periosteum and the tissue surrounding theapex of the tooth.• The abscess has two forms: Acute periapical abscess is usually secondary to asuppurative pulpitis that arises from an infectionextending from dental caries. Chronic dentoalveolar abscess, a slowly progressiveinfectious process. This eventually leads to a “blinddental abscess,” which is really a periapical granuloma.
  9. 9. Disorders of the TeethCLINICAL MANIFESTATIONS• The abscess produces a dull, gnawing, continuouspain, often with a surrounding cellulitis and edema ofthe adjacent facial structures, and mobility of theinvolved tooth.• The gum opposite the apex of the tooth is usuallyswollen on the cheek side.• In well-developed abscesses, there may be a systemicreaction, fever, and malaise.
  10. 10. Disorders of the TeethMANAGEMENT• A dentist or dental surgeon may perform a needleaspiration or drill an opening into the pulp chamber torelieve tension and pain and to provide drainage.• After the inflammatory reaction has subsided, the toothmay be extracted or root canal therapy performed.• Antibiotics may be prescribed.
  11. 11. Disorders of the TeethNURSING MANAGEMENT• The nurse assesses the patient for bleeding aftertreatment and instructs the patient to use a warm salineor warm water mouth rinse to keep the area clean.• The patient is also instructed to take antibiotics andanalgesics as prescribed.• Advance from a liquid diet to a soft diet as tolerated.• Instruct to keep follow-up appointments.
  12. 12. Disorders of the TeethMALOCCLUSION• Malocclusion is a misalignment of the teeth of the upperand lower dental arcs when the jaws are closed.Malocclusion can be inherited or acquired.• Malocclusion makes the teeth difficult to clean and canlead to decay, gum disease, and excess wear onsupporting bone and gum tissues.
  13. 13. Disorders of the TeethMANAGEMENT• Correction of malocclusion requires an orthodontist withspecial training, a patient who is motivated andcooperative, and adequate time.• Most treatments begin when the patient has shed thelast primary tooth and the last permanent successor haserupted, usually at about 12 or 13 years of age, buttreatment may occur in adulthood.• Preventive orthodontics may be started at age 5 years ifmalocclusion is diagnosed early.
  14. 14. Disorders of the TeethMANAGEMENT• To realign the teeth, the orthodontist gradually forcesthe teeth into a new location by using wires or plasticbands (braces).• In the final phase of treatment, a retaining device isworn for several hours each day to support the tissuesas they adjust to the new alignment of the teeth.
  15. 15. Disorders of the TeethNURSING MANAGEMENT• The patient must practice meticulous oral hygiene, andthe nurse encourages the patient to persist in thisimportant part of the treatment.• An adolescent undergoing orthodontic correction who isadmitted to the hospital for some other problem mayhave to be reminded to continue wearing the retainer.
  16. 16. Disorders of the JawTEMPOROMANDIBULAR DISORDERSTemporomandibular disorders are categorized as follows:(National Oral Health Information Clearinghouse, 2000)• Myofascial pain—a discomfort in the musclescontrolling jaw function and in neck and shouldermuscles• Internal derangement of the joint—a dislocated jaw, adisplaced disc, or an injured condyle• Degenerative joint disease—rheumatoid arthritis orosteoarthritis in the jaw joint
  17. 17. Disorders of the JawCLINICAL MANIFESTATIONS• Patients have pain ranging from a dull ache tothrobbing, debilitating pain that can radiate to the ears,teeth, neck muscles, and facial sinuses.• They often have restricted jaw motion and locking of thejaw.• They may hear clicking and grating noises, andchewing and swallowing may be difficult.• Depression may occur in response to these symptoms.
  18. 18. Disorders of the JawASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnosis is based on the patient’s subjectivesymptoms of pain, limitations in range of motion,dysphagia, difficulty chewing, difficulty with speech, orhearing difficulties.• Magnetic resonance imaging, x-ray studies, and anarthrogram may be performed.
  19. 19. Disorders of the JawMANAGEMENT• Patient education in stress management may be helpful(to reduce grinding and clenching of teeth).• Occasionally, a bite plate or splint may be worn toprotect teeth from grinding; however, this is a short-termtherapy.• Patients may also benefit from range-of-motionexercises. Pain management measures may includenonsteroidal anti-inflammatory drugs (NSAIDs), with thepossible addition of opioids, muscle relaxants, or mildantidepressants.
  20. 20. Disorders of the JawSURGICAL MANAGEMENT• Correction of mandibular structural abnormalities mayrequire surgery involving repositioning or reconstructionof the jaw.• Rigid plate fixation (insertion of metal plates and screwsinto the bone to approximate and stabilize the bone) isthe current treatment of choice in many cases ofmandibular fracture and in some mandibularreconstructive surgery procedures.• Bone grafting may be performed to replace structuraldefects using bones from the patient’s own ilium, ribs,or cranial sites. Rib tissue may also be harvested fromcadaver donors.
  21. 21. Disorders of the JawNURSING MANAGEMENT• The patient who has had rigid fixation should beinstructed not to chew food in the first 1 to 4 weeks aftersurgery.• A liquid diet is recommended, and dietary counselingshould be obtained to ensure optimal caloric andprotein intake.
  22. 22. Disorders of the Salivary GlandsPAROTITIS• Parotitis is the most common inflammatory condition ofthe salivary glands.• Mumps (epidemic parotitis), a communicable diseasecaused by viral infection and most commonly affectingchildren, is an inflammation of a salivary gland, usuallythe parotid.• Elderly, acutely ill, or debilitated people with decreasedsalivary flow from general dehydration or medicationsare at high risk for parotitis.• The organism is usually Staphylococcus aureus (exceptin mumps).
  23. 23. Disorders of the Salivary GlandsCLINICAL MANIFESTATIONS• The onset of this complication is sudden, with anexacerbation of both the fever and the symptoms of theprimary condition.• The gland swells and becomes tense and tender.• The patient feels pain in the ear, and swollen glandsinterfere with swallowing.• The swelling increases rapidly, and the overlying skinsoon becomes red and shiny.
  24. 24. Disorders of the Salivary GlandsPREVENTIVE MEASURES• Advising the patient to have necessary dental workperformed before surgery.• Maintaining adequate nutritional and fluid intake, goodoral hygiene, and discontinuing medications (eg,tranquilizers, diuretics) that can diminish salivation mayhelp prevent the condition.
  25. 25. Disorders of the Salivary GlandsMANAGEMENT• If parotitis occurs, antibiotic therapy is necessary.Analgesics may also be prescribed to control pain.• If antibiotic therapy is not effective, the gland may needto be drained by a surgical procedure known asparotidectomy.
  26. 26. Disorders of the Salivary GlandsSIALADENITIS• Sialadenitis may be caused by dehydration, radiationtherapy, stress, malnutrition, salivary gland calculi(stones), or improper oral hygiene.• The inflammation is associated with infection by S.aureus, Streptococcus viridans, or pneumococcus.• In hospitalized or institutionalized patients the infectingorganism may be methicillin-resistant S. aureus(MRSA).
  27. 27. Disorders of the Salivary GlandsCLINICAL MANIFESTATIONS• Symptoms include pain, swelling, and purulentdischarge.MANAGEMENT• Antibiotics are used to treat infections.• Massage, hydration, and corticosteroids frequently curethe problem.• Chronic sialadenitis with uncontrolled pain is treated bysurgical drainage of the gland or excision of the glandand its duct.
  28. 28. Disorders of the Salivary GlandsSALIVARY CALCULUS (SIALOLITHIASIS)• Sialolithiasis, or salivary calculi (stones), usually occursin the submandibular gland.• Salivary calculi are formed mainly from calciumphosphate.• Salivary gland ultrasonography or sialography (x-raystudies filmed after the injection of a radiopaquesubstance into the duct) may be required todemonstrate obstruction of the duct by stenosis.
  29. 29. Disorders of the Salivary GlandsCLINICAL MANIFESTATIONS• Calculi within the salivary gland itself cause nosymptoms unless infection arises; however, a calculusthat obstructs the gland’s duct causes sudden, local,and often colicky pain, which is abruptly relieved by agush of saliva.• On physical assessment, the gland is swollen and quitetender, the stone itself can be palpable, and its shadowmay be seen on x-ray films.
  30. 30. Disorders of the Salivary GlandsMANAGEMENT• The calculus can be extracted fairly easily from the ductin the mouth.• Occasionally lithotripsy, a procedure that uses shockwaves to disintegrate the stone, may be used instead ofsurgical extraction for parotid stones and smallersubmandibular stones. Lithotripsy requires noanesthesia, sedation, or analgesia. Side effects caninclude local hemorrhage and swelling.• Surgery may be necessary to remove the gland ifsymptoms and calculi recur repeatedly.
  31. 31. Disorders of the Salivary GlandsNEOPLASMS• Tumors occur more often in the parotid gland.• The incidence of salivary gland tumors is similar in menand women.• Risk factors include prior exposure to radiation to thehead and neck.• Diagnosis is based on the health history and physicalexamination and the results of fine needle aspirationbiopsy.
  32. 32. Disorders of the Salivary GlandsMANAGEMENT• The common procedure involves partial excision of thegland, along with all of the tumor and a wide margin ofsurrounding tissue.• If the tumor is malignant, radiation therapy may followsurgery.• Radiation therapy alone may be a treatment choice fortumors that are thought to be contained or if there is riskof facial nerve damage from surgical intervention.• Chemotherapy is usually used for palliative purposes.Local recurrences are common, and the recurrentgrowth usually is more aggressive than the original.
  33. 33. Cancer of the Oral Cavity• Cancers of the oral cavity, which can occur in any partof the mouth or throat, are curable if discovered early.• These cancers are associated with the use of alcoholand tobacco.• About 95% of cases of oral cancer occur in people olderthan 40 years of age, but the incidence is increasing inmen younger than age 30 because of the use ofsmokeless tobacco, especially snuff.• Chronic irritation by a warm pipe stem or prolongedexposure to the sun and wind may predispose a personto lip cancer. Predisposing factors for other oral cancersare dietary deficiency, and ingestion of smoked meats.
  34. 34. Cancer of the Oral CavityPATHOPHYSIOLOGY• Malignancies of the oral cavity are usually squamouscell cancers.• Any area of the oropharynx can be a site for malignantgrowths, but the lips, the lateral aspects of the tongue,and the floor of the mouth are most commonly affected.
  35. 35. Cancer of the Oral CavityCLINICAL MANIFESTATIONS• Many oral cancers produce few or no symptoms in theearly stages.• Later, the most frequent symptom is a painless sore ormass that will not heal. A typical lesion in oral cancer isa painless indurated ulcer with raised edges. Tissuefrom any ulcer of the oral cavity that does not heal in 2weeks should be examined through biopsy.• As the cancer progresses, the patient may complain oftenderness; difficulty in chewing, swallowing, orspeaking; coughing of blood-tinged sputum; or enlargedcervical lymph nodes.
  36. 36. Cancer of the Oral Cavity
  37. 37. Cancer of the Oral CavityASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnostic evaluation consists of an oral examination aswell as an assessment of the cervical lymph nodes todetect possible metastases.• Biopsies are performed on suspicious lesions (those thathave not healed in 2 weeks).• High-risk areas include the buccal mucosa and gingiva forpeople who use snuff or smoke cigars or pipes.• For those who smoke cigarettes and drink alcohol, high-risk areas include the floor of the mouth, the ventrolateraltongue, and the soft palate complex (soft palate, anteriorand posterior tonsillar area, uvula, and the area behind themolar and tongue junction).
  38. 38. Cancer of the Oral CavityMEDICAL MANAGEMENT• Management varies with the nature of the lesion, thepreference of the physician, and patient choice.• Surgical resection, radiation therapy, chemotherapy, ora combination of these therapies may be effective.• In cancer of the lip, small lesions are usually excisedliberally; larger lesions involving more than one third ofthe lip may be more appropriately treated by radiationtherapy because of superior cosmetic results.• Tumors larger than 4 cm often recur.
  39. 39. Cancer of the Oral Cavity• Cancer of the tongue may be treated with radiationtherapy and chemotherapy to preserve organ functionand maintain quality of life.• A combination of radioactive interstitial implants andexternal beam radiation may be used.• If the cancer has spread to the lymph nodes, thesurgeon may perform a neck dissection.• Surgical treatments leave a less functional tongue;surgical procedures include hemiglossectomy and totalglossectomy.
  40. 40. Cancer of the Oral Cavity• Often cancer of the oral cavity has metastasizedthrough the extensive lymphatic channel in the neckregion, requiring a neck dissection and reconstructivesurgery of the oral cavity.• A common reconstructive technique involves use of aradial forearm free flap.
  41. 41. Cancer of the Oral CavityNURSING MANAGEMENT (PRE-OP)• The nurse assesses the patient’s nutritional statuspreoperatively, and a dietary consultation may benecessary.• The patient may require enteral (through the intestine)or parenteral (intravenous) feedings before and aftersurgery to maintain adequate nutrition.• If a radial graft is to be performed, an Allen test on thedonor arm must be performed to ensure that the ulnarartery is patent and can provide blood flow to the handafter removal of the radial artery.
  42. 42. Cancer of the Oral CavityNURSING MANAGEMENT (POST-OP)• Postoperatively, the nurse assesses for a patent airway.The patient may be unable to manage oral secretions,making suctioning necessary.• If grafting was included in the surgery, suctioning mustbe performed with care to prevent damage to the graft.• The graft is assessed postoperatively for viability.Although color should be assessed (white may indicatearterial occlusion, and blue mottling may indicatevenous congestion), it can be difficult to assess the graftby looking into the mouth.
  43. 43. Cancer of the Oral CavityNURSING MANAGEMENT (POST-OP)• A Doppler ultrasound device may be used to locate theradial pulse at the graft site and to assess graftperfusion.
  44. 44. The Patient with Conditions in the Oral CavityASSESSMENT• The history includes questions about the patient’snormal brushing and flossing routine; frequency ofdental visits; awareness of any lesions or irritated areasin the mouth, tongue, or throat; recent history of sorethroat or bloody sputum; discomfort caused by certainfoods; daily food intake; use of alcohol and tobacco,including smokeless chewing tobacco; and the need towear dentures or a partial plate.NURSING PROCESS:
  45. 45. The Patient with Conditions in the Oral CavityASSESSMENT• A careful physical assessment follows the health history.Both the internal and the external structures of themouth and throat are inspected and palpated.• Dentures and partial plates are removed to ensure athorough inspection of the mouth.• The examination can be accomplished by using a brightlight source and a tongue depressor.• Gloves are worn to palpate the tongue and anyabnormalities.
  46. 46. The Patient with Conditions in the Oral CavityLIPS• The examination begins with inspection of the lips formoisture, hydration, color, texture, symmetry, and thepresence of ulcerations or fissures.• The lips should be moist, pink, smooth, and symmetric.• The patient is instructed to open the mouth wide; atongue blade is then inserted to expose the buccalmucosa for an assessment of color and lesions.
  47. 47. The Patient with Conditions in the Oral Cavity
  48. 48. The Patient with Conditions in the Oral CavityGUMS• The gums are inspected for inflammation, bleeding,retraction, and discoloration.• The odor of the breath is also noted.• The hard palate is examined for color and shape.TONGUE• The dorsum of the tongue is inspected for texture, color,and lesions.• A thin white coat and large, vallate papillae in a “V”formation on the distal portion of the dorsum of thetongue are normal findings.
  49. 49. The Patient with Conditions in the Oral Cavity
  50. 50. The Patient with Conditions in the Oral CavityTONGUE• The patient is instructed to protrude the tongue andmove it laterally.• Any lesions of the mucosa or any abnormalitiesinvolving the frenulum or superficial veins on theundersurface of the tongue are assessed for location,size, color, and pain.• The patient is told to tip the head back, open the mouthwide, take a deep breath, and say “ah.” This brieflyallows a full view of the tonsils, uvula, and posteriorpharynx
  51. 51. The Patient with Conditions in the Oral Cavity
  52. 52. The Patient with Conditions in the Oral CavityTONGUE• These structures are inspected for color, symmetry, andevidence of exudate, ulceration, or enlargement.• The neck is examined for enlarged lymph nodes(adenopathy).
  53. 53. The Patient with Conditions in the Oral CavityNURSING DIAGNOSES• Impaired oral mucous membrane related to a pathologiccondition, infection, or chemical or mechanical trauma(eg,medications, ill-fitting dentures)• Imbalanced nutrition, less than body requirements,related to inability to ingest adequate nutrientssecondary to oral or dental conditions• Disturbed body image related to a physical change inappearance resulting from a disease condition or itstreatment• Pain related to oral lesion or treatment
  54. 54. The Patient with Conditions in the Oral CavityNURSING DIAGNOSES• Impaired verbal communication related to treatment• Risk for infection related to disease or treatment• Deficient knowledge about disease process andtreatment plan
  55. 55. The Patient with Conditions in the Oral CavityPLANNING AND GOALS• The major goals for the patient may include improvedcondition of the oral mucous membrane, improvednutritional intake, attainment of a positive self-image,relief of pain, identification of alternative communicationmethods, prevention of infection, and understanding ofthe disease and its treatment.
  56. 56. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSPROMOTING MOUTH CARE• The nurse reinforces the need to perform oral care andprovides such care to patients who are unable toprovide it for themselves.• If a bacterial or fungal infection is present, the nurseadministers the appropriate medications and instructsthe patient in how to administer the medications athome.• The nurse monitors the patient’s physical andpsychological response to treatment.
  57. 57. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSPROMOTING MOUTH CAREXEROSTOMIA• The patient is advised to avoid dry, bulky, and irritatingfoods and fluids, as well as alcohol and tobacco.• The patient is also encouraged to increase intake offluids and to use a humidifier during sleep.• The use of synthetic saliva, a moisturizing antibacterialgel may be helpful.
  58. 58. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSPROMOTING MOUTH CARESTOMATITIS OR MUCOSITIS• Prophylactic mouth care is started when the patientbegins receiving treatment.• If a patient receiving radiation therapy has poordentition, extraction of the teeth before radiationtreatment in the oral cavity is often initiated to preventinfection.• Many radiation therapy centers recommend the use offluoride treatments for patients receiving radiation to thehead and neck.
  59. 59. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSENSURING ADEQUATE FOOD AND FLUID INTAKE• The patient’s weight, age, and level of activity arerecorded to determine whether nutritional intake isadequate.• The nurse recommends changes in the consistency offoods and the frequency of eating, based on thedisorder and the patient’s preferences.• The goal is to help the patient attain and maintaindesirable body weight and level of energy, as well as topromote the healing of tissue.
  60. 60. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSSUPPORTING A POSITIVE SELF-IMAGE• The patient is encouraged to verbalize the perceivedchange in body appearance and to realistically discussactual changes or losses.• The nurse offers support while the patient verbalizesfears and negative feelings (withdrawal, depression,anger).• Referral to support groups, a social worker, or a spiritualadvisor may be useful in helping the patient to cope withanxieties and fears.
  61. 61. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSSUPPORTING A POSITIVE SELF-IMAGE• Emphasizing that the patient’s worth is not diminishedby a physical change in a body part can be a helpfulapproach.• The nurse should be alert to signs of grieving andshould record emotional changes.• By providing acceptance and support, the nurseencourages the patient to verbalize feelings.
  62. 62. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSMINIMIZING PAIN AND DISCOMFORT• Avoiding foods that are spicy, hot, or hard.• The patient is instructed about mouth care.• It may be necessary to provide the patient with ananalgesic such as viscous lidocaine or opioids, asprescribed.• The nurse can reduce the patient’s fear of pain byproviding information about pain control methods.
  63. 63. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSPROMOTING EFFECTIVE COMMUNICATION• Pen and paper are provided postoperatively to patientswho can use them to communicate.• A communication board with commonly used words orpictures is obtained preoperatively and given aftersurgery to patients who cannot write so that they maypoint to needed items.• A speech therapist is also consulted postoperatively.
  64. 64. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSPREVENTING INFECTION• Laboratory results should be evaluated frequently andthe patient’s temperature checked every 4 to 8 hours foran elevation that may indicate infection.• Visitors who might transmit microorganisms areprohibited because the patient’s immunologic system isdepressed.• Sensitive skin tissues are protected from trauma tomaintain skin integrity and prevent infection.
  65. 65. The Patient with Conditions in the Oral CavityNURSING INTERVENTIONSPREVENTING INFECTION• Aseptic technique is necessary when changingdressings. adequate nutrition is helpful in preventinginfection.• Signs of wound infection are reported to the physician.Antibiotics may be prescribed prophylactically.
  66. 66. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES1. Shows evidence of intact oral mucous membranesa. Is free of pain and discomfort in the oral cavityb. Has no visible alteration in membrane integrityc. Identifies and avoids foods that are irritating.2. Describes measures that are necessary for preventivemouth carea. Complies with medication regimenb. Limits or avoids use of alcohol and tobacco3. Attains and maintains desirable body weight
  67. 67. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES4. Has a positive self-imagea. Verbalizes anxietiesb. Is able to accept change in appearance and modifyself concept accordingly5. Attains an acceptable level of comforta. Verbalizes that pain is absent or under controlb. Avoids foods and liquids that cause discomfortc. Adheres to medication regimen
  68. 68. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES6. Has decreased fears related to pain, isolation, and theinability to copea. Accepts that pain will be managed if not eliminatedb. Freely expresses fears and concerns7. Is free of infectiona. Exhibits normal laboratory valuesb. Is afebrilec. Performs oral hygiene after every meal and atbedtime8. Acquires information about disease process andcourse of treatment
  69. 69. Neck Dissection• Malignancies of the head and neck include those of theoral cavity, oropharynx, hypopharynx, nasopharynx,nasal cavity, paranasal sinus, and larynx.• Depending on the location and stage, treatment mayconsist of radiation therapy, chemotherapy, surgery, or acombination of these modalities.• A radical neck dissection involves removal of all cervicallymph nodes from the mandible to the clavicle andremoval of the sternocleidomastoid muscle, internaljugular vein, and spinal accessory muscle on one sideof the neck.
  70. 70. Neck Dissection
  71. 71. Neck Dissection• Modified radical neck dissection, which preserves oneor more of the nonlymphatic structures, is used moreoften.• A selective neck dissection preserves one or more ofthe lymph node groups, the internal jugular vein, thesternocleidomastoid muscle, and the spinal accessorynerve.• Reconstructive techniques may be performed with avariety of grafts.
  72. 72. Neck Dissection(A) A classic radical neck dissection in which the sternocleidomastoid andsmaller muscles are removed. The selective neck dissection (B) is similar butpreserves the sternocleidomastoid muscle, internal jugular vein, and spinalaccessory nerve. The wound is closed (C), and portable suction drainagetubes are in place.
  73. 73. The Patient Undergoing Neck DissectionASSESSMENT• Preoperatively, the patient’s physical and psychologicalpreparation for major surgery is assessed, along withhis or her knowledge of the preoperative andpostoperative procedures.• Postoperatively, the patient is assessed forcomplications such as altered respiratory status, woundinfection, and hemorrhage.• As healing occurs, neck range of motion is assessed todetermine whether there has been a decrease in rangeof motion due to nerve or muscle damage.NURSING PROCESS:
  74. 74. The Patient Undergoing Neck DissectionNURSING DIAGNOSIS• Deficient knowledge about preoperative andpostoperative procedures• Ineffective airway clearance related to obstruction bymucus, hemorrhage, or edema• Acute pain related to surgical incision• Risk for infection related to surgical interventionsecondary to decreased nutritional status, orimmunosuppression from chemotherapy or radiationtherapy
  75. 75. The Patient Undergoing Neck DissectionNURSING DIAGNOSIS• Impaired tissue integrity secondary to surgery andgrafting• Imbalanced nutrition, less than body requirements,related to disease process or treatment• Situational low self-esteem related to diagnosis orprognosis• Impaired verbal communication secondary to surgicalresection• Impaired physical mobility secondary to nerve injury
  76. 76. The Patient Undergoing Neck DissectionPLANNING AND GOALS• The major goals for the patient include participation inthe treatment plan, maintenance of respiratory status,absence of infection, viability of the graft, maintenanceof adequate intake of food and fluids, effective copingstrategies, attainment of comfort, effectivecommunication, and absence of complications.
  78. 78. The Patient Undergoing Neck DissectionMONITORING AND MANAGING POTENTIAL COMPLICATIONSHEMORRHAGE• Vital signs are assessed.• The patient is instructed to avoid the Valsalva maneuver• Signs of impending rupture, such as high epigastricpain or discomfort, are reported.• Dressings and wound drainage are observed forexcessive bleeding.
  79. 79. The Patient Undergoing Neck DissectionMONITORING AND MANAGING POTENTIAL COMPLICATIONSHEMORRHAGE• Hemorrhage requires the continuous application ofpressure to the bleeding site or major associatedvessel.• A controlled, calm manner will allay the patient’sanxiety.• The surgeon is notified immediately, because a vascularor ligature tear requires surgical intervention.
  80. 80. The Patient Undergoing Neck DissectionMONITORING AND MANAGING POTENTIAL COMPLICATIONSCHYLE FISTULA• A chyle fistula may develop as a result of damage to thethoracic duct during surgery.• The diagnosis is made if there is excess drainage whichhas a 3% fat content and a specific gravity of 1.012 orgreater.• Treatment of a small leak (500 mL or less) includesapplication of a pressure dressing and a diet of mediumchain fatty acids or parenteral nutrition.• Surgical intervention to repair the damaged duct isnecessary for larger leaks.
  81. 81. The Patient Undergoing Neck DissectionMONITORING AND MANAGING POTENTIAL COMPLICATIONSNERVE INJURY• Nerve injury can occur if the cervical plexus or spinalaccessory nerves are severed during surgery.• If the superior laryngeal nerve is damaged, the patientmay have difficulty swallowing liquids and food becauseof the partial lack of sensation of the glottis.• Speech therapy may be indicated to assist with theproblems related to nerve injury.
  82. 82. Disorders of the EsophagusDYSPHAGIA• Dysphagia is the most common symptom of esophagealdisease.• This symptom may vary from an uncomfortable feelingthat a bolus of food is caught in the upper esophagus toodynophagia.• There are many pathologic conditions of theesophagus, including motility disorders (achalasia,diffuse spasm), gastroesophageal reflux, hiatal hernias,diverticula, perforation, foreign bodies, chemical burns,benign tumors, and carcinoma.
  83. 83. Disorders of the Esophagus
  84. 84. Disorders of the EsophagusACHALASIA• Achalasia is absent or ineffective peristalsis of the distalesophagus, accompanied by failure of the esophagealsphincter to relax in response to swallowing.• Achalasia may progress slowly and occurs most often inpeople 40 years of age or older.
  85. 85. Disorders of the EsophagusCLINICAL MANIFESTATIONS• The primary symptom of achalasia is difficulty inswallowing both liquids and solids.• As the condition progresses, food is commonlyregurgitated, either spontaneously or intentionally bythe patient to relieve the discomfort produced byprolonged distention of the esophagus by food that willnot pass into the stomach.• The patient may also complain of chest pain andheartburn. Pain may or may not be associated witheating.
  86. 86. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• X-ray studies show esophageal dilation above thenarrowing at the gastroesophageal junction.• Barium swallow, computed tomography (CT) of theesophagus, and endoscopy may be used for diagnosis;• however, the diagnosis is confirmed by manometry, aprocess in which the esophageal pressure is measuredby a radiologist or gastroenterologist.
  87. 87. Disorders of the EsophagusMANAGEMENT• The patient should be instructed to eat slowly and todrink fluids with meals.• As a temporary measure, calcium channel blockers andnitrates have been used to decrease esophagealpressure and improve swallowing.• Injection of botulinum toxin (Botox) to quadrants of theesophagus via endoscopy has been helpful because itinhibits the contraction of smooth muscle.• If these methods are unsuccessful, pneumatic (forceful)dilation or surgical separation of the muscle fibers maybe recommended.
  88. 88. Disorders of the Esophagus
  89. 89. Disorders of the EsophagusMANAGEMENT• Achalasia may be treated surgically byesophagomyotomy.• Although patients with a history of achalasia have aslightly higher incidence of esophageal cancer, long-term follow-up with esophagoscopy for early detectionhas not proved beneficial.
  90. 90. Disorders of the Esophagus
  91. 91. Disorders of the EsophagusDIFFUSE SPASM• Diffuse spasm is a motor disorder of the esophagus.The cause is unknown, but stressful situations canproduce contractions of the esophagus. It is morecommon in women and usually manifests in middle age.CLINICAL MANIFESTATIONS• Diffuse spasm is characterized by difficulty or pain onswallowing and by chest pain similar to that of coronaryartery spasm.
  92. 92. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• Esophageal manometry, which measures the motility ofthe esophagus and the pressure within the esophagus,indicates that simultaneous contractions of theesophagus occur irregularly.• Diagnostic x-ray studies after ingestion of barium showseparate areas of spasm.
  93. 93. Disorders of the EsophagusHIATAL HERNIA• In hiatus hernia, the opening in the diaphragm throughwhich the esophagus passes becomes enlarged, andpart of the upper stomach tends to move up into thelower portion of the thorax.• Hiatal hernia occurs more often in women than men.• There are two types of hiatal hernias: sliding andparaesophageal.• Sliding, or Type I, hiatal hernia occurs when the upperstomach and the gastroesophageal junction (GEJ) aredisplaced upward and slide in and out of the thorax.
  94. 94. Disorders of the EsophagusHIATAL HERNIA• About 90% of patients with esophageal hiatal herniahave a sliding hernia.• A paraesophageal hernia occurs when all or part of thestomach pushes through the diaphragm beside theesophagus.• Paraesophageal hernias may be further classified astypes II, III, or IV, depending on the extent of herniation,with type IV having the greatest herniation.
  95. 95. Disorders of the Esophagus
  96. 96. Disorders of the Esophagus
  97. 97. Disorders of the Esophagus
  98. 98. Disorders of the EsophagusCOMPLICATIONS• Malformation• Muscle weakness of the esophageal hiatus• Esophageal shortening• Obesity• Strangulation
  99. 99. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnosis is confirmed by x-ray studies, bariumswallow, and fluoroscopy.MANAGEMENT• Management for an axial hernia includes frequent,small feedings that can pass easily through theesophagus.• The patient is advised not to recline for 1 hour aftereating, to prevent reflux or movement of the hernia, andto elevate the head of the bed on 4- to 8-inch (10- to 20-cm) blocks to prevent the hernia from sliding upward.
  100. 100. Disorders of the EsophagusMANAGEMENT• Surgical repair may be needed if symptoms persist afterinstituting dietary and medical management:• Surgery is more common for large paraesophagealhernias.• The most common technique is the laparoscopic Nissenfundoplication (LNF).
  101. 101. Disorders of the Esophagus
  102. 102. Disorders of the EsophagusDIVERTICULUM• A diverticulum is an outpouching of mucosa andsubmucosa that protrudes through a weak portion of themusculature.• Diverticula may occur in one of the three areas of theesophagus—the pharyngoesophageal or upper area ofthe esophagus, the midesophageal area, or theepiphrenic or lower area of the esophagus— or theymay occur along the border of the esophagusintramurally.
  103. 103. Disorders of the Esophagus
  104. 104. Disorders of the Esophagus• The most common type of diverticulum, which is foundthree times more frequently in men than in women, isZenker’s diverticulum. It occurs posteriorly throughthe cricopharyngeal muscle in the midline of the neck. Itis usually seen in people older than 60 years of age.• Other types of diverticula include midesophageal,epiphrenic, and intramural diverticula.• Midesophageal diverticula are uncommon. Symptomsare less acute, and usually the condition does notrequire surgery.
  105. 105. Disorders of the Esophagus• Epiphrenic diverticula are usually larger diverticula inthe lower esophagus just above the diaphragm. Theyare thought to be related to the improper functioning ofthe lower esophageal sphincter or to motor disorders ofthe esophagus.• Intramural diverticulosis is the occurrence ofnumerous small diverticula associated with a stricture inthe upper esophagus.
  106. 106. Disorders of the EsophagusCLINICAL MANIFESTATIONS• Symptoms experienced by the patient with apharyngoesophageal pulsion diverticulum includedifficulty swallowing, fullness in the neck, belching,regurgitation of undigested food, and gurgling noisesafter eating.• When the patient assumes a recumbent position,undigested food is regurgitated, and coughing may becaused by irritation of the trachea.• Halitosis and a sour taste in the mouth are alsocommon because of the decomposition of food retainedin the diverticulum.
  107. 107. Disorders of the EsophagusCLINICAL MANIFESTATIONS• Symptoms produced by midesophageal diverticula areless acute.• One third of patients with epiphrenic diverticula areasymptomatic, and the remaining two thirds complain ofdysphagia and chest pain.• Dysphagia is the most common complaint of patientswith intramural diverticulosis.
  108. 108. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• A barium swallow may be performed to determine theexact nature and location of a diverticulum.• Manometric studies are often performed for patientswith epiphrenic diverticula to rule out a motor disorder.• Esophagoscopy usually is contraindicated because ofthe danger of perforation of the diverticulum, withresulting mediastinitis.• Blind insertion of a nasogastric tube should be avoided.
  109. 109. Disorders of the EsophagusMANAGEMENT• Because pharyngoesophageal pulsion diverticulum isprogressive, the only means of cure is surgical removalof the diverticulum.• The sac is dissected free and amputated flush with theesophageal wall.• In addition to a diverticulectomy, a myotomy of thecricopharyngeal muscle is often performed to relievespasticity of the musculature, which otherwise seems tocontribute to a continuation of the previous symptoms.• Postoperatively, the patient may have a nasogastrictube inserted at the time of surgery.
  110. 110. Disorders of the EsophagusMANAGEMENT• The surgical incision must be observed for evidence ofleakage from the esophagus and a developing fistula.• Food and fluids are withheld until x-ray studies show noleakage at the surgical site.• The diet begins with liquids and progresses as tolerated.• Surgery is indicated for epiphrenic and midesophagealdiverticula only if the symptoms are troublesome andbecoming worse.• Treatment consists of a diverticulectomy and longmyotomy. Intramural diverticula usually regress after theesophageal stricture is dilated.
  111. 111. Disorders of the EsophagusPERFORATION• Perforation may result from stab or bullet wounds of theneck or chest, trauma from motor vehicle crash, causticinjury from a chemical burn, or inadvertent puncture bya surgical instrument during examination or dilation.CLINICAL MANIFESTATIONS• The patient has persistent pain followed by dysphagia.• Infection, fever, leukocytosis, and severe hypotensionmay be noted.• In some instances, signs of pneumothorax areobserved.
  112. 112. Disorders of the Esophagus
  113. 113. Disorders of the Esophagus
  114. 114. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnostic x-ray studies and fluoroscopy are used toidentify the site of the injury.MANAGEMENT• Because of the high risk of infection, broad-spectrumantibiotic therapy is initiated.• A nasogastric tube is inserted to provide suction and toreduce the amount of gastric juice that can reflux intothe esophagus and mediastinum.• Nothing is given by mouth; nutritional needs are met byparenteral nutrition.
  115. 115. Disorders of the Esophagus• Surgery may be necessary to close the wound, andpostoperative nutritional support then becomes aprimary concern.• Depending on the incision site and the nature ofsurgery, the postoperative nursing management issimilar to that for patients who have had thoracic orabdominal surgery.
  116. 116. Disorders of the EsophagusFOREIGN BODIES• Swallowed foreign bodies may injure the esophagus orobstruct its lumen and must be removed.• Pain and dysphagia may be present, and dyspnea mayoccur as a result of pressure on the trachea.• The foreign body may be identified by x-ray film.Glucagon, because of its relaxing effect on theesophageal muscle, may be injected intramuscularly.• An endoscope may be used to remove the impactingfood or object from the esophagus.
  117. 117. Disorders of the EsophagusFOREIGN BODIES• A mixture consisting of sodium bicarbonate and tartaricacid may be used to increase intraluminal pressure bythe formation of a gas.• Caution must be used with this treatment because thereis risk of perforation.
  118. 118. Disorders of the Esophagus
  119. 119. Disorders of the Esophagus
  120. 120. Disorders of the EsophagusCHEMICAL BURNS• Chemical burns of the esophagus may be caused byundissolved medications in the esophagus.• This occurs more frequently in the elderly than it doesamong the general adult population.• Chemical burns of the esophagus occur most oftenwhen a patient, either intentionally or unintentionally,swallows a strong acid or base.• An acute chemical burn of the esophagus may beaccompanied by severe burns of the lips, mouth, andpharynx, with pain on swallowing.
  121. 121. Disorders of the EsophagusCHEMICAL BURNS• There may be difficulty in breathing due to either edemaof the throat or a collection of mucus in the pharynx.• The patient, who may be profoundly toxic, febrile, and inshock, is treated immediately for shock, pain, andrespiratory distress.• Esophagoscopy and barium swallow are performed assoon as possible to determine the extent and severity ofdamage.
  122. 122. Disorders of the Esophagus
  123. 123. Disorders of the EsophagusMANAGEMENT• The patient is given nothing by mouth, and intravenousfluids are administered.• A nasogastric tube may be inserted by the physician.• Vomiting and gastric lavage are avoided to preventfurther exposure of the esophagus to the caustic agent.• The use of corticosteroids to reduce inflammation andminimize subsequent scarring and stricture formation isof questionable value.• The value of the prophylactic use of antibiotics for thesepatients has also been questioned.
  124. 124. Disorders of the EsophagusMANAGEMENT• After the acute phase has subsided, the patient mayneed nutritional support via enteral or parenteralfeedings.• The patient may require further treatment to prevent ormanage strictures of the esophagus.• Dilation by balloon may be sufficient, but dilationtreatment may need to be repeated periodically.
  125. 125. Disorders of the EsophagusGASTROESOPHAGEAL REFLUX DISEASE• refers to a group of conditions that cause reflux ofgastric and duodenal contents back to the esophagusCAUSES:• idiopathic incompetent lower esophageal sphincter• pregnancy• obesity• surgical removal lower esophagus due to cancer• ascites• hiatal hernia
  126. 126. Disorders of the Esophagus
  127. 127. Disorders of the EsophagusCAUSES• Insufficient closure of lower esophageal sphincter• Gastric distention• Hiatal hernia• LifestyleSmoking, Dietary factors (including high-fat diet; increased intakeof caffeine, chocolate, alcohol, and spicy foods; and excessivelylarge meals)• MedicationsNSAIDs and some drugs to treat cardiovascular conditions(nitrates, calcium-channel blockers) place a person at risk fordeveloping GERD
  128. 128. Disorders of the Esophagus
  129. 129. Disorders of the EsophagusCLINICAL MANIFESTATIONS• dysphagia• odynophagia• pyrosis• dyspepsia• regurgitation• dysphagia or odynophagia• hypersalivation, and esophagitis• hoarseness, throat clearing or sore throat
  130. 130. Disorders of the Esophagus
  131. 131. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• Ambulatory pH monitoring to measure the frequencyand duration of reflux episodes• Barium swallow to show structural abnormalities andreflux of barium from stomach into esophagus.• Endoscopy to directly visualize tissue erythema, fragility,or erosion and detect esophageal cancer or Barrett’sesophagus.• Esophageal manometry to measure pressure ofesophageal wave motility and identify LES pressuresufficiency.• Bilirubin monitoring (Bilitec) is used to measure bilereflux patterns.
  132. 132. Disorders of the EsophagusMANAGEMENTTreatment of GERD aims to reduce reflux of gastric juicesand abdominal pressure.Dietary management includes:• Losing weight if obese• Eating a low-fat, high-protein diet• Limiting or avoiding chocolate, fatty foods, and mints• Eating small frequent meals (4 to 6 a day)• Avoiding carbonated beverages• Avoiding meals within 3 hours of going to bed
  133. 133. Disorders of the EsophagusMANAGEMENT• Avoiding spicy and high-acid foods• Avoiding alcohol, especially late at night beforebedtime.• Increasing fluid intake.Other changes include:• Discontinuing of NSAIDs, as ordered by physician.• Elevating head of the bed 6 to 12 inches or more.• Stopping smoking to improve.• Avoiding constrictive clothing.
  134. 134. Disorders of the EsophagusMANAGEMENTDrug therapy includes:• Proton-pump inhibitors - such as omeprazole(Prilosec), lansoprazole (Prevacid), esomeprazole(Nexium), and pantoprazole (Protonix)• H2-receptor blockers - such as nizatidine (Axid),ranitidine (Zantac), and famotidine (Pepcid)• Antacids - such as aluminum magnesiumcombinations (Mylanta, Maalox)• Mucosal barrier fortifiers - such as sucralfate(Carafate) to protect the mucosal barrier.
  135. 135. Disorders of the EsophagusMANAGEMENTInvasive treatments include:• Endoscopic intervention to tighten the LES and preventreflux.• Laparoscopic Nissen fundoplication (LNF) is the mostcommon procedure.
  136. 136. Disorders of the Esophagus
  137. 137. Disorders of the Esophagus
  138. 138. Disorders of the Esophagus
  139. 139. Disorders of the EsophagusCOMPLICATIONSLong-term untreated GERD causes acidic burning oftissue, leading to:• Esophagitis (erosion and ulceration of epithelium ofesophagus).• Stricture (narrowing of esophagus caused by scartissue) can lead to swallowing difficulties.• Barrett’s esophagus (a precancerous change in thetissue of the esophagus) can lead to esophagealcancer.
  140. 140. Disorders of the EsophagusCOMPLICATIONSLong-term untreated GERD causes acidic burning oftissue, leading to:• Esophagitis (erosion and ulceration of epithelium ofesophagus).• Stricture (narrowing of esophagus caused by scartissue) can lead to swallowing difficulties.• Barrett’s esophagus (a precancerous change in thetissue of the esophagus) can lead to esophagealcancer.
  141. 141. Disorders of the EsophagusBARRETT’S ESOPHAGUS• It is believed that long-standing untreated GERD mayresult in a condition known as Barrett’s esophagus.• This has been identified identified as a precancerouscondition that, if left untreated, can result inadenocarcinoma of the esophagus, which has a poorprognosis.• It is more common among middle-aged white men;however, the incidence is increasing among womenand among African Americans.
  142. 142. Disorders of the Esophagus
  143. 143. Disorders of the Esophagus
  144. 144. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• An esophagogastroduodenoscopy (EGD) is performed.• This usually reveals an esophageal lining that is redrather than pink.• Biopsies are taken, and the cells resemble those of theintestine.
  145. 145. Disorders of the EsophagusMANAGEMENT• Monitoring varies depending on the amount of cellchanges.• Some physicians may recommend a repeat EGD in 6to 12 months if there are minor cell changes.• Medical and surgical management is similar to that forGERD.
  146. 146. Disorders of the EsophagusBENIGN TUMORS OF THE ESOPHAGUS• Benign tumors can arise anywhere along theesophagus. The most common lesion is a leiomyoma,which can occlude the lumen of the esophagus.• Most benign tumors are asymptomatic and aredistinguished from cancerous lesions by a biopsy.• Small lesions are excised during esophagoscopy;lesions that occur within the wall of the esophagus mayrequire treatment via a thoracotomy.
  147. 147. Disorders of the EsophagusCANCER OF THE ESOPHAGUS• Chronic irritation is a risk factor for esophageal cancer.There seems to be an association between GERD andadenocarcinoma of the esophagus.• People with Barrett’s esophagus (which is caused bychronic irritation of mucous membranes due to reflux ofgastric and duodenal contents) have a higher incidenceof esophageal cancer.
  148. 148. Disorders of the Esophagus
  149. 149. Disorders of the Esophagus
  150. 150. Disorders of the EsophagusPATHOPHYSIOLOGY• Esophageal cancer is usually of the squamous cellepidermoid type.• Tumor cells may spread beneath the esophagealmucosa or directly into, through, and beyond themuscle layers into the lymphatics.• In the latter stages, obstruction of the esophagus isnoted, with possible perforation into the mediastinumand erosion into the great vessels.
  151. 151. Disorders of the EsophagusCLINICAL MANIFESTATIONSMany patients have an advanced ulcerated lesion of theesophagus before symptoms are manifested.Symptoms include:• dysphagia, initially with solid foods and eventually withliquids• sensation of a mass in the throat• painful swallowing• substernal pain or fullness• regurgitation of undigested food with foul breath andhiccups
  152. 152. Disorders of the EsophagusCLINICAL MANIFESTATIONS• As the tumor progresses and the obstruction becomesmore complete, even liquids cannot pass into thestomach.• Regurgitation of food and saliva occurs, hemorrhagemay take place, and progressive loss of weight andstrength occurs from starvation.• Later symptoms include substernal pain, persistenthiccup, respiratory difficulty, and foul breath.
  153. 153. Disorders of the EsophagusASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnosis is confirmed most often by EGD with biopsyand brushings.• Bronchoscopy usually is performed, especially intumors of the middle and the upper third of theesophagus, to determine whether the trachea has beenaffected and to help determine whether the lesion canbe removed.• Endoscopic ultrasound or mediastinoscopy is usedto determine whether the cancer has spread to thenodes and other mediastinal structures.
  154. 154. Disorders of the EsophagusMEDICAL MANAGEMENT• Treatment may include surgery, radiation,chemotherapy, or a combination of these modalities,depending on the extent of the disease.• Standard surgical management includes a totalresection of the esophagus (esophagectomy) withremoval of the tumor plus a wide tumor-free margin ofthe esophagus and the lymph nodes in the area.• When tumors occur in the cervical or upper thoracicarea, esophageal continuity may be maintained by freejejunal graft transfer.
  155. 155. Disorders of the Esophagus
  156. 156. Disorders of the EsophagusMEDICAL MANAGEMENT• Postoperatively, the patient will have a nasogastric tubein place that should not be manipulated.• The patient is given nothing by mouth until x-raystudies confirm that the anastomosis is secure and notleaking.• Palliative treatment may be necessary to keep theesophagus open, to assist with nutrition, and to controlsaliva.• Palliation may be accomplished with dilation of theesophagus, laser therapy, placement of anendoprosthesis (stent), radiation, or chemotherapy.
  157. 157. Disorders of the EsophagusMEDICAL MANAGEMENT• Postoperatively, the patient will have a nasogastric tubein place that should not be manipulated.• The patient is given nothing by mouth until x-raystudies confirm that the anastomosis is secure and notleaking.• Palliative treatment may be necessary to keep theesophagus open, to assist with nutrition, and to controlsaliva.• Palliation may be accomplished with dilation of theesophagus, laser therapy, placement of anendoprosthesis (stent), radiation, or chemotherapy.
  158. 158. The Patient with Conditions in the EsophagusASSESSMENT• The nurse asks about the patient’s appetite.• Has it remained the same, increased, or decreased?• Is there any discomfort with swallowing?• If so, does it occur only with certain foods?• Is it associated with pain?• Does a change in position affect the discomfort?• Does anything aggravate it?NURSING PROCESS:
  159. 159. The Patient with Conditions in the EsophagusASSESSMENT• Are there any other symptoms that occur regularly, suchas regurgitation, nocturnal regurgitation, eructation,heartburn, substernal pressure, a sensation that food issticking in the throat, a feeling of becoming full aftereating a small amount of food, nausea, vomiting, orweight loss?• Are the symptoms aggravated by emotional upset?NURSING PROCESS:
  160. 160. The Patient with Conditions in the EsophagusASSESSMENT• This history also includes questions about past orpresent causative factors, such as infections andchemical, mechanical, or physical irritants.• The nurse determines whether the patient appearsemaciated and auscultates the patient’s chest todetermine whether pulmonary complications exist.NURSING PROCESS:
  161. 161. The Patient with Conditions in the Oral CavityNURSING DIAGNOSES• Imbalanced nutrition, less than body requirements,related to difficulty swallowing• Risk for aspiration related to difficulty swallowing or totube feeding• Acute pain related to difficulty swallowing, ingestion ofan abrasive agent, tumor, or frequent episodes ofgastric reflux• Deficient knowledge about the esophageal disorder,diagnostic studies, medical management, surgicalintervention, and rehabilitation
  162. 162. The Patient with Conditions in the Oral CavityPLANNING AND GOALS• The major goals for the patient may include attainmentof adequate nutritional intake, avoidance of respiratorycompromise from aspiration, relief of pain, andincreased knowledge level.
  164. 164. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES1. Achieves an adequate nutritional intakea. Eats small, frequent mealsb. Drinks water with small servings of foodc. Avoids irritantsd. Maintains desired weight2. Does not aspirate or develop pneumoniaa. Maintains upright position during feedingb. Uses oral suction equipment effectively
  165. 165. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES3. Is free of pain or able to control pain within a tolerablelevela.Avoids large meals and irritating foodsb.Takes medications as prescribed and with adequatefluids, and remains upright for at least 10 minutesafter taking medicationsc. Maintains an upright position after meals for 1 to 4hoursd.Reports that there is less eructation and chest pain
  166. 166. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES4. Increases knowledge level of esophageal condition,treatment, and prognosisa. States cause of conditionb. Discusses rationale for medical or surgicalmanagement and diet or medication regimenc. Describes treatment programd. Practices preventive measures so injuries areavoided
  167. 167. The Patient with Conditions in the Oral CavityEVALUATIONEXPECTED PATIENT OUTCOMES4. Has a positive self-imagea. Verbalizes anxietiesb. Is able to accept change in appearance and modifyself concept accordingly5. Attains an acceptable level of comforta. Verbalizes that pain is absent or under controlb. Avoids foods and liquids that cause discomfortc. Adheres to medication regimen