Chapter 35 Management of Patients With Oral and Esophageal Disorders

1. Chapter 35Management of Patients With Oral and Esophageal Disorders

2. Question What is xerostomia? • Protrusion of an organ in the mouth • Difficulty swallowing • Heartburn • Dry mouth

3. Answer D Hernia is a protrusion of an organ or a part of an organ through the wall of the cavity that normally contains it. Dysphagia is difficulty swallowing. Pyrosis is heartburn. Xerostomia is dry mouth.

4. Disorders of the Jaw and Salivary Glands • Temporomandibular disorders: • Myofascial pain • Internal derangement of joint • Degenerative joint disease • Fractures (of bone) • Parotitis • Sialadenitis • Sialolithiasis • Neoplasms

5. Temporomandibular disorders Myofascial pain: pain of the muscles of the jaw/neck/shoulder Internal derangement of joint: dislocated jaw Degenerative joint disease: rheumatoid arthritis or osteoarthritis

6. Symptoms • Dull ache and pain • Headaches • Earaches • Dizziness • Healing problems • Clicking popping grating of jaw

7. Treatment • ROM • Stress management or bite guards if grinding and clenching is a problem • NSAIDS, muscles relaxants, opioids • Orthotics • Surgery warrants a second opinion

8. Disorders of the Teeth • Dental plaque • Dental caries • Periapical abscess • Malocclusion

9. Promotion of Oral Health • Effective mouth care including regular brushing and flossing • Reduce intake of starches and sugars, and maintain good nutrition • Fluoride application or fluorinated water • Refrain from smoking and alcohol • Control diabetes • Regular dental care

10. Disorders of the Lips, Mouth, and Gums • Lips • Herpes simplex 1-“cold sore” • Chancre • Mouth • Leukoplakia, hairy leukoplakia, • Candidiasis • Stomatitis • Gums: gingivitis, periodontitis

11. Disorders Lips Herpes simplex 1-“cold sore”: cluster painful vesicles that rupture delayed up to 20 days • Acyclovir ointment Chancre –Reddened circumscribed lesion that ulcerates and becomes crusted (primary lesion of syphilis contagious) • Cold soaks to lips

12. Disorders Mouth Leukoplakia/hairy leukoplakia-White patches usually in the buccal mucosa common in smokers(only 2%malignant) Candidiasis-Cheesy while plaque that wipes off, erythematous base/bleeding • Antifungal (mycostatin) swish and spit

13. Disorders Mouth Stomatitis-Mild red painful swollen ulcerations (bleeding and secondary infections common)caused from chemotherapy. • Prophylaxis oral care • Soft bristled brush or oral swab • Avoid alcohol based mouth rinses • Apply topical anti-infammatory agents

14. Oral Cancer • Risk factors • Tobacco use including smokeless tobacco • Alcohol • Increased incidence in men, persons over age 40, and in African Americans • Usually a squamous cell cancer • May occur in any area, but lips, lateral tongue, and floor of the mouth are most frequently affected

15. Manifestations of Oral Cancer • Painless mass or sore that does not heal. • Any lesion present more than 2 weeks or that does not heal should be examined and biopsied. • Later manifestations include complaints of tenderness, difficulty in chewing, swallowing, or speaking; coughing up blood-tinged sputum, and enlarged cervical lymph nodes.

16. Medical Management of Oral Cancer • Surgical resection • Radiation therapy • Chemotherapy

17. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity

18. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity— Assessment • Health history • Symptoms related to oral problems • Oral hygiene preventative dental care • Use of tobacco products & alcohol • Eating/nutrition patterns • Inspect and palpate the structures of the mouth and neck.

19. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity—Diagnoses • Impaired oral mucous membranes • Imbalanced nutrition • Disturbed body image • Fear of pain and social isolation • Pain • Impaired verbal communication • Risk for infection • Deficient knowledge

20. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity—Planning • Improved condition of the oral mucosa • Improved nutritional intake • attainment of self-image • Relief of pain • Identification of alternative methods of communication • Prevention of infections • Understanding of disease process and preventative measures

21. Impaired Oral Mucous Membranes • Preventive oral care • Dental care prior to surgery or radiation therapy • Frequent gentle brushing and flossing, or if patient cannot tolerate brushing, use of mouthwashes and other methods of cleaning and rinsing • Patient education related to oral hygiene • Encourage fluid intake to reduce dry mouth • Use of synthetic saliva such as Oral Balance or a saliva production stimulant such as Salagen

22. Imbalanced Nutrition • Assess nutritional requirements and dietary patterns. • Assess patient preferences and take into account social and cultural factors when encouraging and recommending dietary intake. • A calorie count may be needed to assess if intake is meeting needs. • Dietary consult.

23. Other Interventions • Support a positive self-image • Encourage patient to verbalize • Listen and offer acceptance and support • Referral to support group, psychiatric liaison, or spiritual advisor • Pain • Avoid hot, spicy, or hard foods • Oral care • Viscous xylocaine or other pain medications

24. Other Interventions • Prevent infection • Assess for signs and symptoms of infections • Appropriate wound and skin care • Teach patients prevention and early signs of infection

25. Malignancies of the head and neck Oral cavity, oropharynx, hypopharynx, nasopharynx nasal cavity, paranasal sinus and larnyx

26. <5% of all cancers • Depending on location, treatment • Radiation therapy • Chemotherapy • Surgery • Or combination Death is attributed to local/regional metastasis to the cervical lymph nodes

27. Radical Neck Dissection and Selective Radical Neck Dissection

28. Nursing Process: The Care of the Patient with a Radical Neck Dissection— Assessment • Postoperatively, the patient will need careful monitoring and assessment. • Airway and breathing (stridor /wheezing) • Pain • Potential bleeding and wound drainage system

29. Nursing Process: The Care of the Patient with a Radical Neck Dissection—Diagnoses Ineffective airway r/t mucous obstruction, hemorrhage or edema • Acute pain r/t inflammation and tissue trauma • Impaired tissue integrity r/t trauma and nutritional increase • Impaired physical mobility secondary to nerve injury • Risk for infection r/t compromised defense

30. Collaborative Problems/Potential Complications • Hemorrhage • Chyle fistula • Nerve injury • Pneumonia *Chyle-leakage of lymphatic fluid from the lymphatic vessels, typically accumulating in the thoracic or abdominal cavities

31. Maintaining the Airway • Frequent assessment • Place in Fowler’s position • Encourage coughing and deep breathing • If patient has a tracheostomy provide tracheostomy care as required. • Humidification to keep secretions thin

32. Patient Education • Patient and family will require postoperative teaching related to self-care and home management. • Sign and symptoms to report (bleeding and respiratory distress) • Wound care, dressings and drains if present • Diet and medications • Exercises and activity • Enteral or parental feeding if unable to take food by mouth

33. Referrals • Speech therapy • Facial nerve (speech) • Superior Laryngeal nerve (swallowing) • Alternative communication if larynx involved • OT/Physical Therapy • Ability to communicate/ eat physical appearance

34. Impaired Tissue Integrity • Suctioning should be done with great care to protect suture lines. • Support the head and neck when moving the patient. • Assess wound drain system and empty as required. • Assess dressings, wound, and graft condition

35. Imbalanced Nutrition • Assess nutritional state preoperatively and intervene early to prevent nutritional problems. • Encourage high-density, high-quality intake. • Diet may need to be modified to liquid diet, or to soft, pureed, and liquid foods. • Consider patient preferences and cultural considerations in food selection. • Provide oral care before and after eating. • Nasogastric or gastrostomy feedings may be required.

36. Question Is the following statement True or False? After a radial neck dissection, when the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in the supine position to facilitate breathing and promote comfort.

37. Answer False the patient may be placed in the Fowler’s position, not supine position, to facilitate breathing and promote comfort.

38. Disorders of the esophagus

39. Disorders of the Esophagus • Dysphagia • Achalasia • Diffuse spasm • Hiatal hernia • Perforation • Foreign bodies • Chemical burns • GERD: gastroesophageal reflux disease • Esophageal cancer

40. Achalasia • Ineffective peristalsis • Narrowing of esophagus just above the stomach • Failure of the esophageal sphincter to relax

41. Clinical Manifestations Achalasia • Difficulty swallowing liquids and solids • Sensation of food sticking on the lower esophagus • Regurgitation • Chest pain and heart burn • Pulmonary complications from aspiration gastric contents

42. Treatment • Ca channel blockers and nitrates decrease pressure • Botox injection via endoscopy inhibits smooth muscle contraction • Pneumatic dilation

43. Treatment of Achalasia —Pneumatic Dilation

44. Sliding Esophageal and Paraesophageal Hernia

45. Clinical Manifestations Hernias • Heartburn • Regurgitation dysphagia (not with paraesophageal hernia because sphincter is intact) • Many are asymptomatic • Hemorrhage, obstruction and strangulation can occur

46. Management • Diagnosis with barium swallow • Eat small frequent meals • Stay upright after eating for 1hr • Elevate HOB for sleeping • Surgical intervention in 15%

47. Gastroesophageal reflux disease (GERD)

48. GERD • Backflow of gastric or duodenal contents into the esophagus • Normal if not excessive • Increases with aging

49. Causes of GERD • Incompetent lower esophageal sphincter • Pyloric stenosis • Motility disorder

50. Clinical ManifestationsGERD • Pyrosis (burning sensation) • Dyspepsia • Regurgitation • Dysphagia • Painful swallowing • Hypersalivation • Mimic heart attack