Oral & Esophageal

Management of Patients With Oral and Esophageal Disorders

Key Concepts

  • Maintain Airway Patency

  • Promote Nutrition

  • Pain Management

  • Prevent Aspiration

  • Patient Education

Vocabulary

  • Achalasia: A condition characterized by absent or ineffective peristalsis of the distal esophagus and failure of the lower esophageal sphincter to relax.

  • Barrett’s Esophagus: A condition where the lining of the esophageal mucosa is altered, which can precede esophageal cancer.

  • Dysphagia: Difficulty in swallowing.

  • Gastro-esophageal Reflux Disease (GERD): A chronic digestive condition where stomach acid or bile irritates the food pipe lining.

  • Hiatal Hernia: A condition where part of the stomach pushes through the diaphragm.

  • Pyrosis: Also known as heartburn; a burning sensation in the chest.

  • Stomatitis: Inflammation of the mucous membrane of the mouth.

  • Odynophagia: Painful swallowing.

  • Halitosis: Bad breath.

  • Xerostomia: Dry mouth due to reduced or absent saliva flow.

  • Gingivitis: Inflammation of the gums.

Oral and Esophageal Disorders Overview

  • Digestion begins in the mouth: The oral cavity plays a crucial role in the initial stages of digestion, influencing both the type and amount of food ingested.

  • Impact of Oral Disorders:
      - Diseases affecting the mouth can impede communication.
      - Esophageal issues can severely affect food and fluid intake, jeopardizing overall health.

Disorders of the Oral Cavity

  • Periodontal Disease
      - Most common cause of tooth loss in adults.
      - Gingivitis: Characterized by inflammation of the gums.
      - Periodontitis: Involves the inflammation of the soft tissue supporting the teeth, leading to potential bone loss.
      - At-Risk Individuals:
        - Older adults
        - Smokers
        - Individuals with low income and less education
        - Those connected to systemic diseases like cardiovascular disease, diabetes, and rheumatoid arthritis.
      - Clinical Manifestations:
        - Gingivitis: Painful, inflamed, swollen gums.
        - Periodontitis: Symptoms such as bleeding, infection, gum recession, and loosening of teeth.
      - Nursing Considerations:
        - Educate patients on proper oral hygiene practices including brushing, flossing, and rinsing.
        - Recommend dental appointments every 3-6 months.
        - Encourage smoking cessation.

Oral Cancer

  • Incidence: Commonly occurs in the lips, lateral tongue, and floor of the mouth; the incidence is higher in men than women, being twice as frequent.

  • Curability: Oral cancer is often curable if diagnosed early.

  • Risk Factors:
      - Tobacco use, including smokeless tobacco.
      - Alcohol consumption.
      - Infection with human papillomavirus (HPV).
      - Previous history of head and neck cancer.

Manifestations of Oral Cancer

  • Early Stage Symptoms:
      - Few or no symptoms initially.
      - Painless sore or mass that does not heal; indurated ulcer with raised edges.
      - Appearance of red or white patches (leukoplakia) that may bleed easily.

  • Later Symptoms:
      - Tenderness, difficulty in chewing, swallowing, or speaking.
      - Coughing up blood-tinged sputum.
      - Enlarged cervical lymph nodes.
      - Trismus (limited range of motion of the jaw).
      - Neck mass and weight loss.

Assessment and Diagnostic Findings

  • Health History: Gather information on symptoms related to oral problems, oral hygiene, dental care, tobacco and alcohol use, and nutritional habits.

  • Oral Examination: Inspect and palpate structures in the mouth and neck, including cervical lymph nodes.

  • Biopsies: Perform on suspicious lesions.

  • Imaging: PET Scan, MRI, and endoscopy may be used.

  • HPV Testing: Vaccine recommended for children aged 11-26.

Management of Oral Cancer

  • Treatment Options: Vary based upon the extent of the lesion, systemic involvement, and preservation of aesthetics.
      - Surgery and Radiation: Standard initial treatments.
      - Chemotherapy: May be added for advanced disease.

Surgical Options

  • Radical Neck Dissection: Removes all cervical lymph nodes from the mandible to the clavicle, along with the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve on one side.

  • Modified Radical Neck Dissection/Selective Neck Dissection: Preserves some lymph nodes and surrounding structures based on tumor involvement.

Nursing Diagnoses for Oral and Esophageal Issues

  • Impaired Airway

  • Deficient Fluid Volume

  • Impaired Tissue Integrity: Involving oral mucosa and surgical site.

  • Imbalanced Nutrition

  • Pain

  • Risk for Infection

  • Knowledge Deficit

Pre-Operative Nursing Interventions

  • Assess knowledge deficient regarding the surgical procedure.

  • Evaluate Nutritional Status: May need enteral or parenteral feedings before and after surgery.

  • Discuss Post-Op Care Requirements: Including incentive spirometry, expected activity levels, and nutritional interventions.

  • Explain the need for Alternative Communication methods if necessary.

  • Involve family and significant others in discussions.

Post-Operative Nursing Care

  • Impaired Airway/Risk for Aspiration: Monitor respiratory status closely for signs of distress including dyspnea, cyanosis, and edema.

  • Positioning: Place patient in Fowler’s position to minimize aspiration risk.

  • Suctioning: Have equipment at bedside for potential need.

  • Encourage Coughing and Deep Breathing: To maintain airway patency.

  • Speech and Swallow Consultation: Assess if needed.

  • Tracheostomy Care: If a tracheostomy is performed, perform stoma assessment and care.

Nursing Care for Deficient Fluid Volume

  • Assess for signs of Hemorrhage: Monitoring vital signs, oxygen saturation, mental status changes, tachycardia, and hypotension.

  • Monitor for Dehydration: Evaluating mental status, intake/output, skin turgor, and electrolyte balance.

Nursing Care for Impaired Tissue Integrity

  • Monitor Wound and Graft Condition: Assess drainage systems and ensure normal drainage practices (80-120 mL/24 hours of serosanguinous fluid).

  • Assess graft viability for color (should be pink), temperature (should be warm), and for signs of infection.

  • Support head and neck when moving the patient.

  • Provide Frequent Mouth Care.

Nutritional Concerns

  • Assess patient’s Food Preferences: Implement a soft diet or nutritional intervention based on assessments.

  • Consult nutrition services if required and consider enteral/parenteral therapy.

Pain Management

  • Provide analgesia via PCA (patient-controlled analgesia) as ordered.

  • Monitor pain continuously, adjusting food textures as needed (e.g., enteral or soft foods).

  • Apply viscous lidocaine as needed.

Monitoring for Infection

  • Regularly assess the oral cavity, wound drainage, presence of halitosis, white blood cell count, and vital signs, particularly temperature.

Supporting Positive Self-Image

  • Encourage patients to verbalize feelings about their condition.

  • Listen and offer both acceptance and support.

  • Provide referrals to support groups, psychiatric liaison, social work, or spiritual advisers if needed.

Patient and Family Education

  • Essential for postoperative care, focusing on self-care and home management, including:
      - Signs and Symptoms to report post-op.
      - Contact information for support outside regular hours.
      - Wound care, dressings, and management of drains, if applicable.
      - Dietary considerations and medication instructions.
      - Information about exercises and activity therapy post-surgery.
      - Speech therapy, support resources, and follow-up care instructions.

Rehabilitation Exercises

  1. Head Rotation: Gently turn head to each side, tip toward shoulder, and lift chin to chest, then lift head backward.

  2. Shoulder Movement: Stand with elbows at right angles and rotate shoulders back while relaxing the rest of the body.

  3. Body Movement with Support: Using support like a low table, bend at the waist to swing arms in various directions (e.g. front to back, wide circles).

Complications

  • Hemorrhage: Monitor for excessive bleeding post-surgery.

  • Chyle Fistula: Rare but life-threatening complication resulting from drainage from the thoracic duct into the chest; identifiable by drainage containing approximately 3% fat.

  • Nerve Injury: Risk of injury to cervical plexus or spinal accessory nerves leading to complications such as facial paralysis or dysphagia.

Disorders of the Esophagus

  • Conditions include:
      - Achalasia
      - Esophageal spasm
      - Hiatal hernia
      - Diverticulum
      - Perforation
      - Foreign bodies
      - Chemical burns
      - GERD
      - Esophageal cancer

Achalasia

  • Definition: Absence or ineffective peristalsis of the distal esophagus and failure of the sphincter to relax.

  • Manifestations: Include dysphagia, sensation of food sticking in the lower esophagus, regurgitation, and pyrosis (heartburn).

  • Assessment and Diagnosis: X-ray, barium swallow, CT of the chest, and endoscopy.

  • Management: Includes eating slowly, drinking liquids with meals, and potentially pneumatic dilation to treat narrowing.

Nursing Process for Esophageal Conditions

  • Nursing Diagnosis: Imbalanced nutrition, risk for aspiration, acute pain, and deficient knowledge.

Hiatal Hernia

  • Definition: A condition where the opening in the diaphragm through which the esophagus passes becomes enlarged, allowing the upper part of the stomach to move into the thorax.

  • Types:
      - Sliding Hiatal Hernia: Accounts for 90-95% of cases.
      - Paraesophageal Hernia.

  • Diagnosis: Through patient history, barium swallow, or endoscopy.

Hiatal Hernia Clinical Manifestations

  • Symptoms include heartburn, regurgitation, and dysphagia; many cases are asymptomatic.

  • Treatment:
      - Eating small, frequent meals.
      - Keeping the head of the bed elevated for an hour post-meal.
      - Surgery is recommended only in 15% of cases.

Diverticulum

  • Definition: An out-pouching of the mucosa and submucosa through the muscular wall of the esophagus, commonly at the Zenker (pharyngoesophageal) area.

  • Symptoms: Include dysphagia, sensation of fullness in the throat, belching, regurgitation, gurgling noises after eating, and halitosis due to retained food.

  • Diagnosis: Barium swallow and manometric studies; treatment may involve endoscopy or surgery.

Perforation of the Esophagus

  • Causes: Can result from stab wounds, motor vehicle accidents, caustic injuries, or surgical instruments.

  • Boerhaave Syndrome: A common cause of esophageal perforation usually following forceful vomiting.

  • Symptoms: Include retrosternal pain and dysphagia.

  • Management: Involves NPO status, surgical repair, IV therapy, and antibiotics. Post-op nutrition is crucial, and patients may be NPO for 7 days before transitioning to enteral or parenteral feeding.

Foreign Bodies and Chemical Burns

  • Foreign Bodies: May require intubation.

  • Chemical Burns: Can be intentional or unintentional, especially in children, and may necessitate esophagectomy or gastrectomy.

Gastro-esophageal Reflux Disease (GERD)

  • Description: Occurs when gastric contents reflux back into the esophagus due to an incompetent lower esophageal sphincter (LES) or motility disorders; hiatal hernias are also a common contributor to this condition.

  • Increased Incidence: Seen in aging patients and those with conditions like irritable bowel syndrome, asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis.

  • Associated conditions: Barrett esophagus, peptic ulcer disease, and angina.

  • Risk Factors: Include tobacco use, caffeine consumption, alcohol intake, and gastric infections by Helicobacter pylori.

GERD Symptoms and Diagnosis

  • Symptoms: Pyrosis, dysphagia, sour taste, chest pain, chronic cough, bloating, and belching. Chronic GERD can erode teeth, cause ulcerations, and lead to pulmonary complications.

  • Diagnosis:
      - Lab Tests: Include 12-36 hour esophageal pH monitoring.
      - Imaging: Can comprise UGI series or endoscopy.

Interventions for GERD

  • Dietary Adjustments: Low-fat diet, avoiding caffeine, tobacco, beer, milk, and carbonated beverages; no food or drink 2 hours before bed.

  • Positioning: Elevate the head of the bed by at least 30 degrees.

  • Surgery: Nissen fundoplication may be considered for severe cases. Refer to Table 45-2 for a list of medications commonly used to manage GERD such as antacids (Tums, Maalox), histamine-2 receptor antagonists (Pepcid- famotidine), and proton pump inhibitors (omeprazole).

Barrett’s Esophagus

  • Description: Alteration of esophageal mucosal lining due to long-standing, severe GERD; may precede esophageal cancer in approximately 30% of cases.

  • Dysplasia: Cells undergo changes from squamous origin to resemble stomach/intestine cells.

  • Diagnostic Test: Upper GI endoscopy; appearance of red mucosa instead of pink indicates this condition.

  • Treatment: Frequent surveillance and endoscopic ablation are common management strategies.

Cancerous Esophageal Tumors

  • Location: Commonly found in the distal esophagus and gastroesophageal junction.

  • Types: Include adenocarcinoma and squamous cell carcinoma.

  • Risk Factors: GERD, alcohol use, tobacco use, and Barrett's esophagus are key contributors.

  • Diagnosis: Endoscopy with biopsy.

Clinical Manifestations of Esophageal Cancer

  • Symptoms of advanced lesions include painful swallowing (dysphagia) and a sensation of a mass in the throat. Late symptoms may involve substernal pain, persistent hiccups, respiratory complications, and halitosis.

  • Management: If detected early, treatments may lead to a cure; otherwise, palliative measures are implemented.
      - Approaches: Radiation, chemotherapy, and surgical resection are typical interventions.

  • Nursing Management: In the preoperative phase, focus on improving and maintaining nutritional status and educating the patient about surgery; in the postoperative phase, monitor ABCs (airway, breathing, circulation) and position the patient to prevent reflux, keeping in mind potential tracheostomy needs.