Chapter 21: Mouth, Esophagus and Nutrition Support AH

reduces the bacterial film on teeth, gums, tongue, and in saliva.

mouth care

(bacterial or viral infection of the salivary glands),

sialadenitis

(the most common inflammation of the salivary glands).

parotitis

statistics of oral cancer

54,000 people were diagnosed in 2021

; overall mortality about 11%

Main modifiable risk factors oral cancer

alcohol and tobacco together

tx oral cancer

radiation, chemotherapy, and radical surgery

mouth caqncer often spreads where so what must surgeons do

neck lymph nodes (cervical lymph nodes). Surgeons remove them in a radical neck dissection

Highest priority assessment after neck dissection

respiratory status and airway clearanc

2nd priority assessment after neck dissection

Pain, anxiety, tissue integrity, blood supply to the surgical site and body image

whats happening during radial neck dissection

retractors hold tissue open to show deep neck structures. Wide margins are cut around cancerous lymph chains and major neck vessels (carotid artery, internal jugular vein)

in a modified radical neck dissection the surgeon finds and keeps the

sternocleidomastoid muscle (SCM) to preserve neck movement

what happen when closing up radial neck dissesction

a Y-shaped incision is closed and closed-suction drains (Jackson-Pratt or Hemovac) are placed to stop fluid collecting (seroma) and help healing.

expected output radial neck dissection

serosanguineous (pink/watery)

bright red blood after radial neck dissection

active hemorrhage;

what does milky fluid mean after radial neck dissection = .

chyle leak from damage to the thoracic duct (a lymph vessel)

listed espohageal disorders

achalasia, hiatal hernia, esophageal diverticulum, esophageal perforation, mechanical obstruction, chemical burns, Barrett esophagus, esophageal carcinoma

a weak or leaky lower esophageal sphincter (LES) (the valve between esophagus and stomach), slow stomach emptying from pyloric stenosis, or esophagus motility (movement) problems

GERD (gastroesophageal reflux disease)

GERD (gastroesophageal reflux disease) symptoms

: pyrosis (heartburn, burning in the esophagus), dyspepsia (indigestion), regurgitation (stomach contents coming back up), dysphagia (trouble swallowing)

GERD (gastroesophageal reflux disease) tx

lifestyle changes (diet changes, raise the head of the bed), PPIs (proton-pump inhibitors), and prokinetic agents (speed up stomach emptying)

what can anatacid do for GERD

neutralize acid but don't fix the valve, so relief is not lasting.

• 8th most common cancer worldwide and 6th leading cause of cancer death.

Esophageal cancer

over 95% of Esophageal cancer are

squamous cell carcinoma (SCC) or adenocarcinoma (AC).

esophageal cancer risk factor

male, chronic alcohol, tobacco.

esophageal cancer main tx

esophagectomy

Post-esophagectomy nursing priorities:

promote nutrition, (2) prevent aspiration pneumonia, (3) careful wound care, (4) strictly maintain and protect the NG (nasogastric) tube.

why is it important to gaurd NG tube after esophagectomy

After surgery the remaining esophagus is sewn to the stomach or bowel (an anastomosis). The NG tube empties the stomach and takes tension off that new seam. If the tube is pulled out, moved, or pushed back in blindly, it can tear the seam. GI contents then leak into the chest (mediastinitis), causing sepsis and death

gives direct access to the stomach or small intestine to: remove (decompress) fluid and air, wash out toxins (gastric lavage), give oral meds, give enteral feeding, treat obstruction, or bypass damaged areas.

GI intubation

how to check initial placement of GI tube

abdominal X-ray showing the radiopaque (shows up on X-ray) tip

Before every feeding or medication what to check for GI tube

pH below 5.5, and check the external tube length at the nostril (naris).

Used when oral intake is not enough or not possible but the gut works normally. •

Goes to the stomach or the distal duodenum/proximal jejunum, continuous or cyclic

GI tube

how to reduce aspiration risk GI tube

: raise head of bed 30 to 45 degrees. Check residual volume routinely.

cuase of dumping syndrome:

fast infusion of hypertonic (concentrated) formula

most common complication GI tube

diarrhea (formula too concentrated, or low serum osmolality)

an opening made into the stomach wall for long-term feeding. It is better than keeping an irritating NG tube for a long tim

gastrostomy

is placed with a scope through the skin

PEG (percutaneous endoscopic gastrostomy

held in by mechanical pieces. An internal 'mushroom' tip sits against the inside stomach wall, and an external crossbar with a sliding circle clamp sits on the skin. They sandwich the stomach and belly wall together

Standard gastrostomy tube

held in by a fluid-filled retention balloon against the stomach lining, with a low-profile outside bolster and a plug-in adapter port

PEG with balloon

Nursing interevntion peg tube

check the skin around the stoma daily for breakdown or leakage. Gently rotate the PEG tube daily to prevent buried bumper syndrome (the inside anchor sinks into the stomach wall)

When the gut is not working or can't be used, nutrients (amino acids, lipids, dextrose) go straight into the blood, skipping the GI tract.

Parenteral nutrition

PPN concentration

Lower osmolality (less concentrated)

where does PPN go

regular peiphreal IV

whats PPN used for

short term support

TPN concentartion

Highly concentrated, hypertonic \

where does TPN go

Central vein through a CVAD (central venous access device) because the high-flow vessel dilutes it

TPN use

long term full support

Subclavian triple-lumen catheter for TPN path in

enters via the subclavian vein (below the collarbone), passes through the subclavian and brachiocephalic veins.

Subclavian triple-lumen catheter for TPN tip location

the radiopaque tip ends in the superior vena cava (SVC), just above the right atrium. Heavy blood flow there quickly dilutes the thick TPN.

main line for CVP (central venous pressure) monitoring and thick fluids like blood. (Subclavian triple-lumen catheter for TPN)

• Distal lumen (16G)

used for TPN ONLY. Never give blood or medications through it (Subclavian triple-lumen catheter for TPN)

Middle lumen (18G):

used for routine blood draws, fluids, or IV meds (Subclavian triple-lumen catheter for TPN)

Proximal lumen (18G)

what to do before first use Subclavian triple-lumen catheter for TPN

chest X-ray must confirm the tip is in the SVC.

infection prevention Subclavian triple-lumen catheter for TPN

strict sterile dressing changes to prevent CLABSI (central line-associated bloodstream infection).

skips the gut's natural defenses (the mucosal barrier), so it carries more risk of line infection, sepsis, electrolyte/sugar problems, and fluid shifts.

TPN

keeps the gut lining working, supports the gut's immune tissue (GALT), and has less risk of life-threatening infection.

PEG