Ch. 46 - Oral & Esophageal Problems

Black hairy tongue
causes?
where does it get its name from?
s/s?
tx?
ask?

caused by overgrowth of bacteria filiform: poor oral hygiene, excessive coffee or tea, tobacco use especially smoking, antibiotic use, mouthwashes or oxidizing agents, dry mouth, or dehydration

it gets its name from a buildup of dead skin cells on papillae that elongate them and make them look hairy

very bad smelling breath. It makes their mouth very dry and need to offer them solutions

usually will resolve on its own with improved habits. Only need antifungal if a fungal cause is confirmed.

It is not cancer. Ask what medications they are taking - even pepto bismol can make your tongue and stool black. 

Who is at risk for candidiasis

• older adults

• decreased immunity (diabetes & malnourishment)

• those under a lot of stress

• those taking meds that cause dryness

difference in candida and leukoplakia

• candida: can be scraped off & it will be red and painful underneath it; ask about meds (antibiotics)

• leukoplakia

  • causes thickened, white, firmly attached patches

  • cannot be scaraped off

  • pre cancerous

• important to ask what meds the pt is on for both

key features of leukoplakia

• long-term oral membrane irritation

  • ex.) poorly fitting dentures, cheek chewing, and broken teeth

• oral hairy leukoplakia

  • develops in those who are immunocompromised, HIV as early s/s or epstein barre virus

key features of candida

• thrives in warm, damp environment

• can go down to esophagus - ask for antifungals and antibiotics; they would need to a swish and swallow to get down there and not spit it out.

• swish w baking soda and normal saline if cant brush or use finger

• popsicles and ice chips help

• give them probiotics

• tx: swish and swallow or swish and spit nystatin, give soft food

BOX 46.1

mainting a healthy oral cavity consists of…

• eating a well balanced diet and staying hydrated

• manage stress using healthy mechanisms

• perform weekly self exam of your mouth and report changes

• report occlusion of teeth, mouth pain, or swelling to PCP

• make sure dentures fit properly

• brush and floss teeth or dentures twice a day

• avoid mouthwash containing alcohol, can damage tissue integrity

• avoid drugs that increase inflammation in mouth or reduce saliva

• see dentist regularly at least once/twice per year and address dental probs asap

ACTION ALERT

PASS

• dysphagia can result in airway obstruction, aspiration pneumonia, and malnutrition

• use PASS for quick assessment

  • Probable that the pt will have swallowing difficulty?

  • Account for previous swallowing problems

  • Screen for s/s

  • Speech-language pathologist referral

• s/s include: coughing/choking when swallowing, sensation of food “sticking” in pharynx, or difficulty swallowing

dry mouth

• normal flora is killed and causes bad breath

• biotene toothpaste can help, doesnt contain sodium loralsulfate

• use products that do not contain alcohol

stomatitis is?
ulcer? from?

broad term referring to inflammation in the oral cavity

aphthous ulcer - from stress or a cut that causes inflammation. There is a genetic risk. From infection, vitamin and mineral deficiencies (folate, zinc, and iron), irritants like tobacco and alcohol, coffee, cheese, nuts, and gluten can trigger aphthous ulcers. 

primary stomatitis

• includes apthous (cancher) stomatitis, herpes simplex, traumatic ulcers

• painful and lasts about 10 days or less

secondary stomatitis

• results from opportunistic viruses, fungi, or bacteria in pts who are immunocompromised or chemo, radiation, or steroid use

stomatitis is more common in what gender

women

DRUG ALERT

lidocaine

• use with extreme caution

• causes topical anesthetic effect

• pt may not easily feel burns from hot liquids

• the risk for aspiration increases

how to determine if a mouth ulcer is cancer

• if had < 2wks, not cancer

• cancer

  • >2wks warrants concern

  • painless mass w firm nodule in early stages

  • becomes painful in later stages

  • report sus nonhealing lesions to ENT

tips for assessing oral cavity lesions

• always ask about hx: trauma, smoking, alcohol use, denture fit

• inspect and palpate under good lighting

• document size, shape, color, texture, length of time present

• lesions under tongue often benign, but should not be ignored, assess carfully and educate pts on risk fx & when to escalate

BOX

genetics r/t oral cancer

• TP53 gene increases risk

BOX 46.3

key features of oral cancer

• bleeding from the mouth

• poor appetite, compromised nutrition status

• difficulty chewing or swallowing

• unplanned weight loss

• thick or absent saliva

• painless oral lesion that is red, raised, or eroded

• thickening or lump in cheek

ACTION ALERT

precaution for oral cancer pt

• must be placed on aspiration precautions

• assess pt’s LOC, gag reflex, and ability to swallow

• place pt in semi-high fowlers and keep suction equipment nearby

• feed in small amnts

• inform visitors to ask before offering pt food, thickened liquids may be needing

• coordinate w speech pathologist, may recommend a swallow study

what is erythroplakia

• red raised velvety patches on tongue

• precancerous

• doesnt scrape off

BOX 46.2

care of pt w oral cavity problems

• proper oral hygiene

• remove dentures if pain, bland diet w no spices

• use soft brush or even finger

• no lemon glycerin swabs

• oral care q2h

• frequent rinsing of the mouth w baking soda

• diphenhydramine liquid: childrens benadryl numbs

• dyclonine lozenges/magnesium hydroxide/OTC meds

• topical anesthetics (KANKA

BOX 46.4

at home care of pt w oral cancer

• inspect mouth daily for changes like redness/hyperpigmentation, lesions, or infection

• continue meticulous oral hygiene at home

• use ultrasoft toothbrush or chemobrush and clean after every use

• keep all follow up appts

• use thickening agent for liquids if dysphagia

• eat soft foods if stomatitis occurs

• use saliva substitute as prescribed if needed

key features acute sialadentitis

• inflammation of salivary gland

• type: xerostomia- very dry mouth by severe reduction in the flow of saliva w/in 24 hrs

• if untreated, abcess can develop

• occurs w ionizing radiation to head or neck

• can be caused by stone, poor oral hygiene, radiation, bacterial infection

• can become chronic if persists for wks-months

• Treatment includes hydration, moist heat, massage, NSAIDs, antibiotics, warm compresses

• Use of sialagogues, fruit candy, lemon swabs, saliva substitutes to wet mouth.

differences in sialadentitis and stomatitis

• sialadentitis

  • salivary gland

• stomatitis

  • soft tissues in the mouth

what is barretts esophagus

• pre cancerous condition where normal squamous lining of esophagus is replaced w columnar epithelium known as intestinal metaplasia

• linked to long-term GERD which damages lining from constant acid exposure and raises risk for esophageal adenocarcinoma

risk fx for barretts esophagus

• chronic GERD 5+ yrs

• heavy alcohol use and smoking

• male

• 50+

• obesity, especially abdominal

phrase for barretts esophagus

the bodies SOS signal after yrs of acid damage

esophageal stricture

• caused by fibrosis and scarring from healing process of GERD

• leads to progressive difficulty swallowing

• Should have crushed or liquid medications. Nutrient dense foods with lots of protein, preferably soft or liquid. 

BOX 46.6

key features of GERD

• Dyspepsia (indigestion)

• Regurgitation (may lead to aspiration or bronchitis)

• Water brash (hypersalivation - sour taste?^)

• Dental caries (severe cases)

• Dysphagia

• Odynophagia (painful swallowing)

• Globus (feeling of something in back of throat)

• Pharyngitis

• Coughing, hoarseness, or wheezing at night

• Chest pain

• Pyrosis (heartburn)

• Epigastric pain

• Generalized abdominal pain

• Belching

• Flatulence

• Nausea

OLDER ADULT BOX

GERD

• at risk for dev severe complications

• may have age-related physiologic changes, increased morbidities due to. multiple health conditions, more prone to polypharmacy

• experiences to dysphagia, vomiting, anorexia, anemia, cough and resp concerns rather than typical s/s

• Collab w PCP when reporting these s/s, pt may benefit from a workup for GERD

NG tube causes GERD because

sphincter stays open

drug therapy for GERD

• antacids

  • tums

  • mylanta

  • rolaids

  • peptobismol

  • all short acting

• PPIs

  • esomeprazole

  • pantoprazole

  • good for 28 days, have to wean off - can cause hip fracture and rebound effect

• histamine receptor blockers

  • famotidine

  • cimetidine

• sucralfate antiulcer agent

  • for ppl w ulcers

  • coat stomach 30min-1hr before meals

older adults and PPIs box

watch for hips fractures and rebound effect, reduces calcium absorption and protein digestion, which reduces available calcium to bone tissue

differences in PPIs & h2 blockers

• both suppress gastric secretion

• PPI

  • shut down proton pumps in the stomach

• H2

  • block histamine receptors in acid producing cells in stomach

nutrition changes for GERD

• avoid chocolate, alcohol, caffeine, fried foods

• eat nutrient dense foods that are non-spicy

• drink water, limit coke and energy drinks

sliding hernia

• upper part of the GEJ slide upward through the esophageal hiatus into the chest as a result of a weakening diaphragm

• gastroesophageal part slides up into the thoracic cavity

• with increased abdominal pressure like coughing, bending over, obesity, pregnancy, etc.

• Usually fixed with a nissen fundoplication? Common. 

paraesophageal hiatus hernia

GEJ remains at or below the diaphragm but a portion of the stomach moves alongside the esophagus into the chest
Rare

s/s sliding hernia

• heartburn

• regurgitation

• chest pain

• dysphagia

• belching

ACTION ALERT

LINX

• emphasize importance of telling each hcp about this procedure

• if mri recommended only certain pts w recent linx devices can get scan

• pts w older devices which contain magnets should never undergo mri

• hcp can determine if mri is acceptable for pt given the data of the linx device insertion

ACTION ALERT

post-op hiatal hernia repair

• primary focus is prevention of resp comp

• elevate hob at least 30 degreee to lower diaphragm and promote lung expansion

• help pt out of bed and begin ambulation asap

• be sure to support the incision during coughing to reduce pain and prevent excessive strain on suture line, esp for obese pts

BOX 46.11

key features of esophageal tumors

• Persistent and progressive dysphagia (most common feature)

• Feeling of food sticking in the throat

• Odynophagia (painful swallowing)

• Halitosis

• Chronic hiccups

• Chronic cough with increasing secretions

• Hoarseness

• Severe, persistent chest or abdominal pain or discomfort

• Anorexia

• Regurgitation

• Nausea and vomiting

• Weight loss (often more than 20 lb)

• Changes in bowel habits (diarrhea, constipation, bleeding)

CRITICAL RESCUE

esophageal tumor

• when eating or drinking monitor for s/s of aspiration which can cause airway obstruction, pneumonia or both esp in older adults

• respond to teaching caregivers how to feed the pt, monitor for aspiration, and how to respond quickly if choking occurs

ACTION ALERT

esophagectomy (removal of some or all of esophagus)

• resp care is highest postop priority

• w traditional surgery: intubation w mechanical vent necessary for at least the first 16-24hours

• risk for pulm comp is increased w the pt whos received preop radiation

• once pt is extubated, support deep breathing, turning, and coughing q1-2hrs

• assess for decreases breath sounds, sob q1-2hrs

• provide incisional support and adequate analgesia to enhance effective coughing

ACTION ALERT

fluid vol overload

• monitor for s/s of fluid vol overload esp in older adults and those who have had lymph node dissection

• assess for edema, crackles in lungs, the pt is often admitted to ice

• critical care nurses assess hemodynamic parameters like co, cardiac index, and systemic vascular resistance q2hrs to monitor for myocardial ischemia

• observe for afib, which can result from irritation of vagus nerve during surgery, manage according to agency protocol

CRITICAL RESCUE

safety & priority after esophageal surgery

• recognize fever, fluid accumulation, signs of inflammation, and s/s of early shock (tachycardia & tachypnea)

• respond by reporting to surgeon and rapid response

tx for esophageal cancer

• swallowing therapy

• chemo & radiation

• increases nutrient dense foods and small frequent meals

• j or peg tube

• esophagectomies if early

• emotional support

• aspiration risks

• EGD

labs w esophageal cancer

• decreased RBC (first sign)

• increased WBC

• decreased albumin

• decreased HGB & HCT

most common type of esophageal cancer
r/f?

adenocarcinoma
smoking and obesity. Esophageal cancer is deadly if caught late

key features esophageal trauma

• crepitus

• severe, sudden neck or chest pain, subq emphysema when esophageal rupture

• fever hematemics

what to do/interventions for esophageal trauma

• xray

• large bore IV

• monitor for sepsis and shock

Subcutaneous emphysema (feel crackling/popping) - big sign of whar?

esophageal rupture 

what is crepitus

• physical sign of escaped air often from a perforated esophagus

• required immediate intervention