JN

Oral Cavity and Esophageal Problems Review

Care of Patients with Oral Cavity and Esophageal Problems

Core Concepts

  • Priority Concepts: Tissue integrity, Nutrition

  • Interrelated Concepts: Gas Exchange, Pain

Learning Outcomes (Goals for Collaborative Care)

  • Plan interprofessional collaborative care to promote tissue integrity and nutrition in patients with oral and esophageal problems.

  • Educate adults on reducing the risk for oral cavity and esophageal problems.

  • Instruct patients and caregivers on common drugs and management strategies for oral and esophageal problems.

  • Develop patient- and family-centered nursing interventions to minimize the psychosocial impact of living with these conditions.

  • Apply anatomical, physiological, and pathophysiological knowledge to provide evidence-based care affecting tissue integrity and nutrition.

  • Analyze assessment and diagnostic findings to generate solutions and prioritize nursing care.

  • Organize care coordination and transition management for patients.

  • Use clinical judgment for evidence-based nursing care to promote tissue integrity, nutrition, and prevent complications.

  • Incorporate factors affecting health equity into the plan of care.

A Healthy Oral Cavity: Fundamental Linkages

  • Tissue integrity, nutrition status, and gas exchange are significantly impacted by oral and esophageal problems.

  • Patients in this category often present with high-risk factors for various complications.

Stomatitis: Oral Cavity Inflammation

Pathophysiology

  • Inflammation within the oral cavity, leading to painful, inflamed ulcerations.

Etiology and Genetic Risk

  • Primary Stomatitis: Often includes aphthous stomatitis (canker sores), herpes simplex stomatitis, and traumatic ulcers.

  • Secondary Stomatitis: Results from infection by opportunistic pathogens (e.g., Candida albicans), or is a side effect of drugs (e.g., chemotherapy) or radiation therapy.

Incidence and Prevalence

  • Recurrent Aphthous Stomatitis (RAS): Affects approximately 20\% of the general population.

  • Incidence is higher in females.

Health Promotion/Disease Prevention

  • Maintain proper oral hygiene.

  • Consume a well-balanced diet and ensure adequate hydration.

  • Implement stress management techniques.

  • Perform weekly self-examinations of the mouth and report any changing conditions promptly.

  • Ensure dentures are in good repair and fit properly.

  • Brush and floss teeth twice daily.

  • Avoid alcohol-based mouthwashes.

  • Minimize or avoid drugs known to increase inflammation.

  • Schedule regular dental check-ups.

Assessment (Recognizing Cues)

  • History Taking: Inquire about recent infections, changes in nutrition, oral hygiene habits, any oral trauma, and presence of stress.

  • Physical Assessment: Observe for signs and symptoms such as lesions, inflammation, pain, and difficulty eating.

  • Psychosocial Assessment: Evaluate the psychological and social impact of the condition, including effects on eating, communication, and self-esteem.

Analysis and Prioritization (Analyze Cues & Prioritize Hypotheses)

  • Key Issues:

    • Impaired tissue integrity due to oral and/or esophageal lesions.

    • Pain due to oral and/or esophageal lesions.

Planning and Implementation (Generate Solutions & Take Action)

  • Focus on preserving tissue integrity.

  • Implement strategies for minimizing pain.

Care Coordination and Transition Management

  • Educate on the importance of taking medication as prescribed.

  • Discuss potential side effects of prescribed pain medication.

  • Provide guidance on appropriate dietary choices to minimize irritation and promote healing.

Evaluation of Outcomes

  • Patient achieves healthy oral mucosa without inflammation or infection.

  • Patient experiences minimized discomfort or absence of pain.

Oral Tumors: Premalignant Lesions

Erythroplakia

  • Considered precancerous.

  • Appears as red, velvety mucosal lesions.

  • Common locations include the floor of the mouth, tongue, palate, and mandibular mucosa.

Leukoplakia

  • Characterized by thickened, white, firmly attached patches on the oral mucosa.

  • These patches cannot be easily scraped off.

  • Appear as slightly raised and sharply rounded lesions.

  • Most lesions are benign.

  • However, lesions located on the lips or tongue have a higher potential to progress to cancer.

  • Tobacco use is a significant risk factor for developing leukoplakia.

Hairy Leukoplakia (Special Type)

  • Manifests as white plaques on the tongue.

  • Often serves as one of the first visible signs of human immunodeficiency virus (HIV) infection.

Oral Cancer

Prevention and Risk Factors

  • Regular dental visits (twice a year) are crucial for professional dental hygiene and oral cancer screening.

  • Occupational exposure to certain chemicals or substances can increase risk.

Types of Oral Cancer

  • Squamous Cell Carcinomas: Most common type, frequently found on the lips, tongue, buccal mucosa, and oropharynx. (Visual example provided in transcript depicts squamous cell carcinoma on the tongue).

  • Basal Cell Carcinoma: Primarily affects the lips.

  • Kaposi’s Sarcoma: Can manifest on the hard palate, gums, tongue, and tonsils, often associated with immunocompromised states (e.g., HIV).

Assessment (Recognize Cues)

  • Assess the patient's oral hygiene regimen thoroughly.

  • Perform a comprehensive inspection of the oral cavity for any suspicious lesions.

  • Diagnostic Procedures: Biopsy is essential for definitive diagnosis. CT (Computed Tomography) or MRI (Magnetic Resonance Imaging) may be needed for staging and assessing metastasis.

Interventions (Take Action)

  • Nonsurgical Management: May include radiation therapy, chemotherapy, or targeted therapy depending on the type and stage of cancer.

  • Surgical Management: Involves removal of the tumor, which can range from local excision to more extensive resections, potentially requiring reconstructive surgery.

Care Coordination and Transition Management

  • Nutrition Therapies: Often necessary due to difficulty eating, requiring a dietary consult (e.g., with a Registered Dietitian Nutritionist).

  • Educate the patient to report any symptoms of infection promptly.

Sialadenitis: Salivary Gland Inflammation

Definition

  • Inflammation of a salivary gland.

Complications

  • If left untreated, an abscess can develop within the gland.

Etiology

  • Often occurs after ionizing radiation to the head or neck area.

Treatment

  • Prioritize patient hydration.

  • Apply moist heat to the affected gland.

  • Perform massage of the gland to promote drainage.

  • Administer NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) for pain and inflammation.

  • Prescribe antibiotics if bacterial infection is suspected or confirmed.

Gastroesophageal Reflux Disease (GERD)

Pathophysiology

  • The most common upper GI disorder in the U.S.

  • Occurs due to the backward flow of stomach contents into the esophagus.

  • This reflux can damage the esophageal mucosa.

Etiology and Genetic Risk

  • There is no single causative agent for GERD; it's often multifactorial.

  • Presence of a nasogastric (NG) tube can compromise lower esophageal sphincter (LES) function.

  • Genetic predisposition or connection is observed in some cases.

  • Certain lifestyle factors significantly contribute (e.g., obesity, diet, smoking).

  • Barrett Esophagus (Barrett Epithelium): A complication where the normal esophageal lining is replaced by abnormal columnar epithelium, increasing the risk of esophageal cancer.

Incidence and Prevalence

  • 18-28\% of adults in North America experience reflux disease.

Health Promotion/Disease Prevention

  • Patients may initially be asymptomatic, emphasizing the importance of preventive measures.

  • Adopt healthy eating habits, limiting fried, fatty, spicy foods, and caffeine.

  • Remain in an upright position for at least one hour after eating to aid digestion and prevent reflux.

Assessment (Recognize Cues)

  • History Taking: Inquire about heartburn, morning hoarseness, and nocturnal coughing or wheezing.

  • Physical Assessment/Signs and Symptoms: Look for dyspepsia (indigestion), and auscultate lungs for crackles, which may indicate aspiration.

  • Psychosocial Assessment: Evaluate the impact on quality of life, sleep, and anxiety levels.

  • **Diagnostic Assessment:

    • Upper Endoscopy (Esophagogastroduodenoscopy - EGD): Allows direct visualization of the esophagus, stomach, and duodenum, and tissue biopsy.

    • Ambulatory Esophageal pH Monitoring: Measures esophageal acid exposure over 24-48 hours to correlate symptoms with reflux episodes.

Analysis and Prioritization (Analyze Cues & Prioritize Hypotheses)

  • Key Issues:

    • Potential for compromised nutrition status due to dietary selection (to avoid triggering symptoms) and discomfort.

    • Acute pain due to reflux of gastric contents irritating the esophageal lining.

Planning and Implementation (Generate Solutions & Take Action)

  • Priorities: Balancing nutrition and minimizing pain.

  • **Nonsurgical Management:

    • Lifestyle Changes: Elevate the head of the bed, avoid large meals, stop smoking, avoid tight clothing.

    • Drug Therapy: Includes antacids, H_2-receptor antagonists (e.g., famotidine), proton pump inhibitors (PPIs) (e.g., omeprazole), and prokinetic agents.

    • Endoscopic Therapies: Such as Stretta procedure or EsophyX procedure to improve LES function.

  • Surgical Management: Fundoplication (e.g., Nissen fundoplication) to reinforce the LES.

Care Coordination and Transition Management

  • Educate on making appropriate dietary selections. (e.g., trigger foods).

  • Emphasize adherence to prescribed drug therapy.

  • Teach patients the signs of esophageal stricture (difficulty swallowing) and Barrett esophagus (changes in esophageal lining) to report.

  • Referral to a Registered Dietitian Nutritionist is often beneficial.

  • Suggest local support groups for ongoing management and emotional support.

Evaluation of Outcomes

  • Patient adheres to appropriate diet, medication therapy, and lifestyle modifications.

  • Patient experiences minimized or absence of pain related to GERD.

Hiatal Hernias (Diaphragmatic Hernias)

Pathophysiology

  • Also known as diaphragmatic hernias.

  • Involves the protrusion of a portion of the stomach through the esophageal hiatus of the diaphragm into the chest cavity.

  • Types: Classified into Types I through IV.

    • Sliding Hiatal Hernia (Type I): The gastroesophageal junction and part of the stomach slide up into the chest through the hiatus.

    • Paraesophageal (Rolling) Hiatal Hernia (Type II): The fundus of the stomach rolls up through the hiatus, alongside the esophagus, while the gastroesophageal junction remains in its normal position.

Assessment (Recognize Cues)

  • Many individuals are asymptomatic.

  • Others experience symptoms similar to GERD.

  • Symptoms often intensify after a meal or when lying supine.

  • **Diagnostic Assessment:

    • Barium Swallow Study with Fluoroscopy: Visualizes the stomach and esophagus as the patient swallows a contrast agent.

    • EGD: Direct visualization.

    • High-Resolution Manometry with Esophageal Pressure Topography: Measures pressure changes in the esophagus and LES function.

Interventions (Take Action)

  • **Nonsurgical Management:

    • Drug Therapy: Similar to GERD management (e.g., antacids, PPIs).

    • Nutrition Therapy: Small, frequent meals; avoid trigger foods.

    • Lifestyle Changes: Elevating the head of the bed, avoiding bending over, weight management.

  • **Surgical Management:

    • Patients may need to lose weight prior to surgery to minimize risks.

    • Laparoscopic Nissen Fundoplication: A minimally invasive surgical procedure to repair the hernia and reinforce the LES.

Care Coordination and Transition Management

  • Provide detailed instructions on nutrition modification post-surgery.

  • Recommend stool softeners or bulk laxatives to prevent straining, which could compromise the surgical repair.

  • Teach daily incisional inspection for signs of infection or complications.

  • Educate on specific signs to report to the health care provider immediately (e.g., severe pain, fever, difficulty swallowing, drainage).

  • Advise avoidance of individuals who are ill to prevent respiratory infections that could cause coughing and strain.

Esophageal Tumors

Pathophysiology

  • Some esophageal tumors can be benign, but the majority are malignant.

  • More than half of malignant esophageal tumors metastasize by the time of diagnosis.

Primary Risk Factors

  • Chronic alcohol intake.

  • Poor diet (e.g., low in fruits and vegetables, high in processed foods).

  • Obesity.

  • Smoking (both active and passive).

  • Untreated or long-standing GERD, which can lead to Barrett esophagus.

Assessment (Recognize Cues)

  • Assess for the presence of known risk factors.

  • Esophageal tumors are often referred to as