Transcript 06 Interventions for clients with oral cavity problems. Interventions

Interventions for
clients with oral cavity
problems.
Interventions for
clients with
esophageal disorders.
Mouth
 Consists of lips and oral cavity-disorders can
impact speech, nutritional intake and overall
health.
 Provides entrance and initial processing for
nutrients and sensory data: taste, texture and
temperature.
 Salivary glands produce secretions containing
ptyalin for starch digestion and mucus for
lubrication
 Pharynx aids in swallowing from mouth to
esophagus.
Stomatitis
Painful inflammation & ulceration of the mouth
as a result of
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Infection
Vitamin deficiency
Systemic disease
Medications
Trauma
Food allergy
Clinical findings vary by cause
 Dry mouth
 Ulcerations/lesions
 Fissures
 Bacterial or fungal growth
 Pain
 Odor
Stomatitis
 Dry, painful mouth, open ulcerations,
predisposing the client to infection
 Commonly found on the buccal mucosa,
soft palate, oropharyngeal mucosa, and
lateral and ventral areas of the tongue
 If candidiasis, white plaquelike lesions on
the tongue; when wiped away, red sore
tissue appears
Stomatitis
Nursing Care
 Frequent gentle mouth care
 soft brush or toothette; brush if tolerated
 Avoid commercial mouthwashes; rinse with saline,
bicarbonate, or peroxide solutions
 Medications if infectious cause: antifungals or
antivirals
 Pain management
 Topical anesthethetics
 Appropriate food selection
Stomatitis
 Antibiotics such as tetracycline syrup and
minocycline (swish and swallow)
 Antifungals such as nystatin oral
suspension (swish and swallow)
 Intravenous acyclovir for
immunocompromised clients with herpes
simplex stomatitis
 Anti-inflammatory agents and immune
modulators
 Symptomatic topical agents such as gargle
or mouthwash
Oral Tumors
Pre Malignant Lesions
 Leukoplakia
 Erythroplakia
Oral lesions that do not
heal, especially in
clients who smoke
tobacco, use “snuff”,
alcohol use, sun
exposure
 Slowly developing changes
in the oral mucous
membranes characterized
by thickened, white, firmly
attached patches that are
slightly raised and sharply
circumscribed.
 Related to factors that
cause oral mucous
membrane irritation (i.e.
poorly fitting dentures,
smoking)
 Cannot be removed when
scraped unlike candidal
infection
 Most common oral lesion
among adults
Erythroplakia
 Red, velvety mucosal lesions on the
surface of the oral mucosa
 Higher degree of malignant transformation
in erythroplakia than in leukoplakia
 Commonly found on the floor of the mouth,
tongue, palate, and mandibular mucosa
 Erythroplakia is a general term for red, flat,
or eroded velvety lesions that develop in
the mouth. In this image, a squamous cell
carcinoma is surrounded by a margin of
erythroplakia.
Squamous Cell Carcinoma
 Most common oral malignancy: can
be found on the lips, tongue, buccal
mucosa, and oropharynx
 Highly associated with aging, tobacco
use, and alcohol ingestion
 Tumor, node, metastasis classification
system for tumors of the lips and oral
cavity
Basal Cell Carcinoma
 Occurs primarily on the lips
 Lesion is asymptomatic and
resembles a raised scab; evolves into
ulcer with a raised pearly border
 Aggressively involves the skin of the
face, but does not metastasize
 Major etiologic factor is exposure to
sunlight
Kaposi’s Sarcoma
 Malignant lesion arising in blood
vessels
 Usually painless
 Raised purple nodule or plaque
 Found on the hard palate, gums,
tongue, or tonsils
 Most often associated with AIDS
Tumors of the Oral Cavity
Nursing Assessment
 History for risk factors, esp. alcohol, tobacco
 Inspection of mouth for lesions
 Palpation of submandibular nodes
 Pain assessment
Diagnosis
 CT of head and neck
 Biopsy of lesions
Treatment of Oral Cancer
 Radiation therapy
 Skin care
 Mouth care
 Nutrition
Surgical Excision
 Procedure depends on size & location of tumor, and
presence of metastasis: simple excision of lesion to
removal of tongue and part of mandible
Surgical Management
 Preoperative care
 Operative procedure
 Postoperative care
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Maintaining airway patency
Protecting the operative area
Relieving pain
Promoting nutrition
Nonsurgical Management
 Airway management
 Cough management
 Aspiration precautions
Acute Sialadenitis
 Inflammation of a salivary gland, caused by
infectious agents, irradiation, or
immunologic disorders
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Hydration
Application of warm compresses
Massage of the gland
Use of saliva substitute
Use of sialagogues
Salivary Gland Tumors
 Relatively rare among oral tumors
 Often associated with radiation of the head
and neck areas
 Assessment: ability to wrinkle brow, raise
eyebrows, squeeze eyes shut, wrinkle nose,
pucker lips, puff out cheeks, and grimace or
smile
 Treatment of choice: surgical excision of
the parotid gland
Esophageal Disorders
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Gastroesophageal reflux disease
Hiatal hernia
Esophageal cancer
Esophageal diverticula
Esophageal strictures
Achalasia
Esophageal varices
Gastroesophageal Reflux
Disease
 Occurs as a result of the backward flow
(reflux) of gastrointestinal contents into the
esophagus
 Reflux esophagitis characterized by acute
symptoms of inflammation
 Esophageal reflux occurs when gastric
volume or intra-abdominal pressure is
elevated, the sphincter tone of the lower
esophageal sphincter is decreased, or it is
inappropriately relaxed.
Clinical Manifestations
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Dyspepsia
Regurgitation
Hypersalivation or water brash
Dysphagia and odynophagia
Others manifestations: chronic cough,
asthma, atypical chest pain, eructation
(belching), flatulence, bloating, after
eating, nausea and vomiting
Diagnostic Assessment
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24-hr ambulatory pH monitoring
Endoscopy
Esophageal manometry
Esophagoscopy Indications and Contraindications.
Indications include:
 Dysphagia
 Reflux
 Hematemesis
 Atypical chest pain
 Many other conditions
 Contraindications:
 To assess reflux symptoms that respond to medical
management
 A uncomplicated sliding hiatal hernia
Nonsurgical Management
 Diet therapy
 Client education
 Lifestyle changes: elevate head of bed 6 in.
for sleep, sleep in left lateral decubitus
position; stop smoking and alcohol
consumption; reduce weight; wear
nonbinding clothing; refrain from lifting
heavy objects, straining, or working in a
bent-over posture
Drug Therapy
 Antacids elevate the level of the gastric
contents.
 Histamine receptor antagonists decrease
acid production.
 Proton pump inhibitors provide effective,
long-acting inhibition of gastric acid
secretion.
 Prokinetic drugs increase gastric emptying
and improve lower esophageal sphincter
pressure and esophageal peristalsis.
Hiatal Hernia
 Most common abnormality found of x-ray
of upper GI
 More common in older adults and in
women
Hiatal Hernia
 Protrusion of the stomach through the
esophageal hiatus of the diaphragm into the
thorax
 Sliding hernia most common, occurring
when esophagogastric junction and a
portion of the fundus of the stomach slide
upward through the esophageal hiatus into
the thorax
 Rolling hernia: fundus rolls into the thorax
beside the esophagus
Assessment
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Heartburn
Regurgitation
Pain
Dysphagia
Belching
Worsening symptoms after eating or
when in recumbent position
Nonsurgical Management
 Drug therapy: antacids, histamine receptor
antagonists
 Diet therapy: avoid eating in the late
evening and avoid foods associated with
reflux
 Weight reduction
 Elevate head of bed 6 in. for sleep, remain
upright for several hours after eating, avoid
straining and vigorous exercise, avoid
nonbinding clothing.
Surgical Management
 Operative procedures
 Preoperative care
 Postoperative care
 Respiratory care
 Nasogastric tube management
 Nutritional care for complications of
surgery including gas bloat syndrome
and aerophagia (air swallowing)
Achalasia
 Rare, chronic disorder
 Affects 1 in 100,000 Americans
 Affects all ages and both genders
Achalasia
Etiology and Pathophysiology
 Esophageal motility disorder believed
to result from esophageal denervation
characterized by chronic and
progressive dysphagia
 Primary symptoms: dysphagia and
regurgitation of solids, liquids, or both
Achalasia
Clinical Manifestations
 Symptoms
 Dysphagia
 Most common symptom
 Globus sensation
 Substernal chest pain
 During/after a meal
 Halitosis
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Inability to belch
GERD
Regurgitation
Weight loss
Achalasia
Diagnostic Studies
 Radiologic studies
 Manometric studies of lower esophagus
 Endoscopy
Drug and Diet Therapy
 Calcium channel blockers
 Nitrates
 Direct injection of botulinum toxin into
the lower esophageal muscle
 Semisoft foods
 Arching the back while swallowing
 Avoidance of restrictive clothing
Esophageal Dilation
 Metal stents used to keep the esophagus
open for longer durations
 Complications: bleeding, signs of
perforation, chest and shoulder pain,
elevated temperature, subcutaneous
emphysema, hemoptysis
 Passage of progressively larger sizes of
esophageal bougies using polyurethane
balloons on a catheter
Esophagomyotomy
 Surgical procedure for achalasia is done to
facilitate the passage of food.
 Laparoscopic approach is most common.
 For long-term refractory achalasia, the
surgeon may attempt excising the affected
portion of the esophagus with or without
replacement of a segment of colon or
jejunum.
Esophageal Tumors
 Esophageal tumors can be benign or
malignant.
 Barrett’s esophagus is ultimately malignant.
 Clinical manifestations include dysphagia,
odynophagia, regurgitation, vomiting, foul
breath, chronic hiccups, pulmonary
complications, chronic cough, and
hoarseness.
Surgical Management
 Esophagectomy: the removal of all or
part of the esophagus
 Esophagogastrostomy: the removal of
part of the esophagus and proximal
stomach
 Minimally invasive esophagectomy
 Extensive preoperative care
 Operative procedures
Postoperative Care
 Highest postoperative priority:
respiratory care
 Cardiovascular care
 Wound management
 Nasogastric tube management
 Nutritional care
 Discharge planning
Diverticula
 Sacs resulting from the herniation of
esophageal mucosa and submucosa
into surrounding tissue
 Zenker’s diverticulum most common
 Diet therapy for size and frequency of
meals
 Surgical management
Diverticula
Esophageal Trauma
 Trauma to the esophagus can result from
blunt injuries, chemical burns, surgery or
endoscopy, or stress of protracted
vomiting.
 Nothing is administered by mouth; broadspectrum antibiotics are given.
 Surgical management requires resection of
part of the esophagus with a gastric pullthrough and repositioning or replacement
by a bowel segment.