Transcript 08. Interventions for clients with oral cavity problems, esophageal

Interventions for
clients with oral cavity
problems, esophageal,
stomack and intestinal
disorders
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
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
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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
Acute Sialadenitis
 Inflammation of a salivary gland, caused by infectious agents,
irradiation, or immunologic disorders
 Interventions
 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 intraabdominal 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
Hiatal Hernia
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
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
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
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
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
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.
Interventions for
clients with stomack
and intestinal
disorders
Stomach Disturbances
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Gastritis
Peptic Ulcer Disease
Gastric Surgery
Zollinger-Ellison Syndrome
Dumping Syndrome
Gastritis
 Gastritis is defined as inflammation of
the gastric mucosa; two types:
 Acute gastritis
 Chronic gastritis
 Type A gastritis
 Type B gastritis
 Atrophic gastritis
 Helicobacter pylori, Escherichia coli
can cause gastritis.
Peptic Ulcer Disease
 PUD is a mucosal lesion of the stomach or duodenum as a
result of gastric mucosal defenses impaired and no longer
able to protect the epithelium from the effects of acid and
pepsin.
 Acid, pepsin, and Helicobacter pylori infection play an
important role in the development of gastric ulcers.
Duodenal Ulcers
 Most duodenal ulcers occur in the first portion of
the duodenum.
 Duodenal ulcers present as deep, sharply
demarcated lesions that penetrate through the
mucosa and submucosa into the muscularis
propria.
Differentiating Gastric and
Duodenal Ulcers
 Gastric Ulcer
 Increase of pain with
eating, antacids
30min
 Hematemesis
 Duodenal Ulcer
 Relief with food,
antacids 90min-3hr
 Pain awakens at
night
 Melena
Stress Ulcers
 Acute gastric mucosa lesions occurring after an
acute medical crisis or trauma
 Associated with head injury, major surgery, burns,
respiratory failure, shock, and sepsis.
 Principal manifestation: bleeding caused by gastric
erosion
Complications of Ulcers
 Hemorrhage—hematemesis
 Perforation—a surgical emergency
 Pyloric obstruction—manifested by
vomiting caused by stasis and gastric
dilation
 Intractable disease—the client no longer
responds to conservative management, or
recurrences of symptoms interfere with
ADLs
Drug Therapy
 Four primary goals for drug therapy:
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Provide pain relief
Eradicate H. pylori infection
Heal ulcerations
Prevent recurrence
Diet Therapy
 Diet therapy may be directed toward
neutralizing acid and reducing
hypermotility.
 A bland, nonirritating diet is recommended
during the acute symptomatic phase.
 Avoid bedtime snacks.
 Avoid alcohol and tobacco.
Irritable Bowel Syndrome
(IBS)
Treatment
 Education—teaching the client to avoid problem
stimulants
 Diet therapy—elimination of offending or upsetting
foods
 Drug therapy—bulk-forming laxatives, antidiarrheal
agents, anticholinergic agents, tricyclic
antidepressants, and 5-HT4 agonists.
 Stress management based on the client’s current
and ongoing stressors
 Complementary and alternative therapies used to
reduce symptoms and discomfort
Herniation
 Weakness in the abdominal muscle wall through
which a segment of bowel or other abdominal
structure protrudes
 Types of hernia include:
 Indirect inguinal
 Direct inguinal
 Femoral
 Umbilical
 Incisional or ventral
Colorectal Cancer
 Colorectal refers to the colon and the
rectum, which together make up the large
intestine.
 95% of cancers of the colon or rectum are
adenocarcinomas.
 Etiology
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Genetic considerations
Personal factors
Dietary factors
Inflammatory bowel disease
Clinical Manifestations
 Rectal bleeding, hematochezia, passage of red
blood via the rectum
 Anemia
 Change in stool texture
 Mass in abdomen
Laboratory Assessment
 Hemoglobin and hematocrit values
usually decreased
 Fecal occult blood test
 Possible elevation of
carcinoembryonic antigen
 Radiographic assessment
 Other diagnostic assessments
Intestinal Obstruction
 Mechanical obstruction
 Nonmechanical obstruction, known as paralytic
ileus
 Strangulated obstruction resulting from tumors,
hernias, fecal impactions, strictures,
intussusception, volvulus, fibrosis, vascular
disorder, and adhesions
Clinical Manifestations of
Mechanical Obstruction
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Midabdominal pain or cramping
Vomiting
Obstipation
Diarrhea
Alteration in bowel pattern and stool
Abdominal distention
Borborygmi
Abdominal tenderness
Clinical Manifestations of
Nonmechanical Obstruction
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Constant diffuse discomfort
Abdominal distention
Decreased to absent bowel sounds
Vomiting
Obstipation
Assessment
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Laboratory assessment
Radiographic assessment
Endoscopy
Barium enema
Computed tomography
Hemorrhoids
 Unnaturally swollen or distended veins in the anorectal
region
 Internal hemorrhoids
 External hemorrhoids
 Nonsurgical management
 Surgical management: hemorrhoidectomy