Chapter 35 Management of Patients With Oral and Esophageal Disorders

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

2. 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

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

4. Promotion of Oral Health (See Chart 35-2) • 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

5. Disorders of the Lips, Mouth, and Gums (See Table 35-1) • Lips • Actinic cheilitis • Herpes simplex 1 (“cold sore”) • Chancre • Mouth • Leukoplakia, hairy leukoplakia, lichen planus • Candidiasis • Stomatitis • Gums: gingivitis, periodontitis

6. Oral Cancer • Risk factors • Tobacco use, including smokeless tobacco • Alcohol • Increased incidence in men, persons over age 40, and 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

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

8. Medical Management • Surgical resection • Radiation therapy • Chemotherapy

9. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Assessment • Health history: include symptoms related to oral problems, oral hygiene and dental care, use of tobacco and alcohol, and eating and nutrition • Inspect and palpate the structures of the mouth and neck.

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

11. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Planning • Goals may include improved condition of the oral mucosa, improved nutritional intake, positive self-image, relief of pain, identification of alternative methods of communication, prevention of infections, and understanding of disease process.

12. 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

13. 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

14. 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

15. Other Interventions • Promote effective communication: • Assess patient’s writing ability preop. • Plan communication preop. • Communication board or pencil and paper • Speech therapy • Prevent infection: • Assess for signs and symptoms of infections. • Appropriate wound and skin care • Patient teachingSee Chart 35-4

16. Radical Neck Dissection and Selective Radical Neck Dissection

17. Nursing Process: The Care of the Patient with a Radical Neck Dissection: Assessment • Assess knowledge. • Assess for risks for potential complications. • Postoperatively, the patient will need careful monitoring and assessment: • Airway and breathing • Pain • Potential bleeding and wound drainage system • Other

18. Nursing Process: The Care of the Patient with a Radical Neck Dissection- Planning • Major goals include patient participation in the treatment plan, maintenance of respiratory status, attainment of comfort, absence of infection, viability of graft, maintenance of adequate nutrition and fluid intake, effective coping strategies, effective communication, maintenance of neck and shoulder motion, and absence of complications.

19. Nursing Process: The Care of the Patient with a Radical Neck Dissection: Diagnosis • Knowledge deficiency • Ineffective airway • Acute pain • Impaired tissue integrity • Imbalanced nutrition • Impaired physical mobility secondary to nerve injury

20. Collaborative Problems/Potential Complications • Hemorrhage • Chyle fistula • Nerve injury

21. 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.

22. Patient Education (See Chart 35-6) • Patient should be aware of the extent and nature of the surgery and what to expect in the postoperative period. • Patient and family will require postoperative teaching related to self-care and home management: • Sign and symptoms to report • Wound care, dressings and drains if present • Diet and medications • Exercises and activity • Speech therapy, support resources, and follow-up care

23. 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 drainage system and empty as required. • Assess dressings, wound, and graft condition.

24. 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, puréed, 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.

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

26. Treatment of Achalasia: Pneumatic Dilation

27. Sliding Esophageal and Paraesophageal Hernia

28. Esophageal Reconstruction with Free Jejunal Transfer