Nursing Management of Gastritis and Oral Cancer

Medical-Surgical Nursing: Coordinated Care for Patients With Oral and Esophageal Disorders

• This chapter discusses medical-surgical nursing care for patients with oral and esophageal disorders.

Stomatitis

• Pathophysiology: Inflammation and ulceration of the mouth lining.
  • Primary: Painful oral ulcers (herpes simplex, traumatic ulcers).
  • Secondary: Viral, bacterial, or fungal infections.
• Risk Factors: Viral infections, bacterial infections, fungal infections, irritants (alcohol, tobacco, mouthwash), radiation, chemotherapy, allergic reactions, vitamin deficiency, and systemic diseases.
• Medical Management - Diagnosis: Assessment of oral cavity before, during, and after chemotherapy and radiation.
• Complications: Pain, inflammation.
• Nursing Management - Assessment and analysis: Diagnosis is based on meticulous assessment. Determining the offending irritant is vital for treatment.
• Nursing Diagnoses: Acute pain, risk for infection, imbalanced nutrition, impaired oral mucosa, knowledge deficit, and impaired swallowing.
• Nursing Interventions - Assessments: Vital signs, oral mucosa, nutritional intake, weight, intake and output.
• Nursing Interventions - Actions: Aspiration precautions, administer medications as prescribed, viscous lidocaine, administer water-soluble lubricants for the lips and mouth.
• Nursing Interventions - Teaching: Mouth care after each meal, discourage use of alcohol-containing mouthwash, remove dentures, encourage regular dental check-ups, encourage saline mouth rinse every 4 hours, dietary choices.
• Nursing Management - Evaluating care outcomes: Prompt recognition of clinical manifestations, stable vital signs, stable fluid status, and stable weight.

Oral Candidiasis

• Image of oral candidiasis (white patches on the tongue) is included

Hiatal Hernia

• Pathophysiology: A portion of the stomach protrudes upward through the esophageal hiatus of the diaphragm.
  • Type 1 (Sliding): Lower esophageal sphincter (LES) is displaced.
  • Type 2 (Paraesophageal): Gastroesophageal junction (GEJ) is displaced.
• Risk Factors: Western countries, obesity, pregnancy, and smoking are risk factors
• Complications: Gastroesophageal reflux, supradiaphragmatic volvulus.
• Medical Management - Diagnosis: Upper abdominal x-ray, endoscopy, barium swallow with fluoroscopy, and Esophagogastroduodenoscopy.
• Medical Management - Medications: Antacids, proton pump inhibitors, H2-receptor antagonists, complimentary medicine.
• Surgical Management: Hernia repair.
• Nursing Management - Assessment and analysis: Lifestyle changes can help reduce clinical manifestations.
• Nursing Diagnoses: Impaired swallowing, anxiety, pain, and knowledge deficit.
• Nursing Interventions - Assessments: Dysphagia, GERD clinical manifestations, nausea and vomiting, iron-deficiency anemia.
• Nursing Interventions - Actions: Medication management, position patient supine on right side, elevate the head of the bed (HOB) after meals.
• Nursing Interventions - Teaching: Limit foods like spicy, caffeine, chocolate, carbonated, acidic, peppermint, alcohol, and medications, eat meals 2 hours before lying supine, wear nonrestrictive clothing, maintain normal weight, proper positioning after eating, and postoperative education.
• Nursing Management - Evaluating care outcomes: Being free from pain and adequate nutrition

Gastroesophageal Reflux Disease (GERD)

• Pathophysiology: Retrograde flow of gastrointestinal (GI) contents into the esophagus, causing inflammation.
• Risk Factors: Lower esophageal sphincter (LES) hypotension, loss of esophageal motility, increased compliance of the hiatal canal, increased states of gastric secretion, delayed emptying of gastric contents, obesity, pregnancy, ascites, tight belts/girdles, presence of a nasogastric tube.
• Complications: Barrett's epithelium, strictures.
• Medical Management - Diagnosis: 24-hour ambulatory esophageal pH monitoring, esophagogastroduodenoscopy, esophageal manometry.
• Medical Management - Medications: Antacids, histamine receptor antagonists, prokinetic medications, and proton pump inhibitors.
• Surgical Management: Laparoscopic Nissen fundoplication.
• Nursing Management - Assessment and analysis: Clinical manifestations are due to gastric material irritating the esophagus.
• Nursing Diagnoses: Acute/chronic pain, risk for aspiration, impaired swallowing, imbalanced nutrition.
• Nursing Interventions - Assessments: Signs of Barrett's esophagus, dental caries, water brash, eructation, flatulence/bloating, nausea, globus, pH of gastric aspirate, dysphagia.
• Nursing Interventions - Actions: Administer medications as ordered, position patient on right side with HOB elevated (6-12 inches), and provide small, frequent meals.
• Nursing Interventions - Teaching: Limit irritating foods, avoid smoking/alcohol, eat meals 2 hours before lying supine, wear nonrestrictive clothing, maintain ideal body weight.
• Nursing Management - Evaluating care outcomes: Maintain quality of life and prevent complications.

Oral Cancer

• Pathophysiology: Primarily squamous cell carcinoma.
• Clinical Manifestations: Oral bleeding, raised area on the lip/mouth, oral ulcer with poorly defined margins, mucosal lesions/nodules in oral cavity, increasing pain radiating to the neck, dysarthria, dysphagia, difficulty chewing, oral odor, regional lymph node involvement, weight loss, and poor-fitting dentures.
• Medical Management - Diagnosis: Complete blood count, chemistry profile, liver function test, CT scan, MRI, and chest x-ray.
• Medical Management - Treatment: Airway management, removal of source of irritation, radiotherapy, chemotherapy, chemoradiation, surgical removal, retinoids, beta-carotene.
• Complications: Infection, facial edema, weight loss, difficulty communicating, dysphagia, rare but severe complications (hearing loss, osteoradionecrosis, trismus, carotid artery rupture).
• Nursing Management - Assessment and analysis: Clinical manifestations affect daily functions and eating.
• Nursing Diagnoses: Risk for ineffective airway clearance, imbalanced nutrition, impaired verbal communication, acute or chronic pain, anxiety.
• Nursing Interventions - Assessments: Ability to swallow, fluid intake, nutritional intake, weight, albumin & total protein, oral mucosa irritation/infection, lymph nodes, and psychosocial adjustment.
• Nursing Interventions - Actions: Airway management, aspiration precautions, maintain emergency equipment, provide oral care, administer steroids, provide cool mist, and nutritional consult.
• Nursing Interventions - Teaching: Aspiration precautions, avoid tobacco/alcohol intake, provide nutritional education, oral hygiene, management of xerostomia, frequent sips of water/saliva substitutes.
• Nursing Management - Evaluating care outcomes: Prevention by decreasing risk factors

Esophageal Cancer

• Pathophysiology: Rapidly growing cancer. Spreads to lymph nodes within esophageal lumen. More than 50% of cases demonstrate metastasis
• Risk Factors: Barrett's esophagus, GERD, lye strictures, malnutrition (deficiencies in molybdenum, zinc, and vitamin A), esophageal diverticula, achalasia, tylosis, obesity (associated with hiatal hernia and GERD)
• Clinical Manifestations: Progressive dysphagia, hemoptysis, burning sensation in middle of chest, painful swallowing, vomiting, weight loss, anorexia, hoarseness, and melena.
• Medical Management - Diagnosis: Screening, diagnostic tests (Barium swallow, CT scan, PET scan, endoscopy, and thoracoscopy)
• Surgical Management: Esophagectomy.
• Complications: Dysphagia, strictures, dumping syndrome, stomatitis, nausea and vomiting, and diarrhea
• Nursing Management - Assessment and analysis: Manifestations are related to esophageal lumen obstruction
• Nursing Diagnoses: Impaired swallowing, imbalanced nutrition, acute/chronic pain, ineffective coping, and compromised family coping.
• Nursing Interventions - Assessments: Nausea and vomiting, painful swallowing, dysphagia, weight loss, hematocrit and hemoglobin, serum calcium levels, liver enzymes, and psychosocial adjustment.
• Nursing Interventions - Actions: Maintain HOB greater than 30 degrees, collaborate with nutritionist, provide six small meals per day, and collaborate with speech.
• Nursing Interventions - Teaching: Lines, tubes, incisions, preoperative care, coughing, deep breathing, incentive spirometry, q2 turn, early ambulation, pain management, enteral/parenteral feeding, dental screening, and postoperative education.
• Nursing Management - Evaluating care outcomes: Lifestyle choices and enhancement of quality of life.

TEN vs TPN

• TEN (Total Enteral Nutrition): Oral, nasogastric (NG), percutaneous endoscopic gastrostomy (PEG), or jejunostomy (J-) tube feedings.
• PPN (Peripheral Parenteral Nutrition): Peripheral IV or central line.
• TPN (Total Parenteral Nutrition): Central line only.

Gastritis

• Epidemiology: Chronic stress to stomach lining, caused by chronic ingestion of irritating foods, pathogens, overuse of aspirin/NSAIDs, and stress

• Pathophysiology: Prolonged irritation of the stomach lining from the mentioned causes.

• Clinical Manifestations: Epigastric pain, nausea and vomiting, decreased appetite, color changes in stool (can be dark or bloody)

• Medical Management - Diagnosis: Biopsy, upper GI x-ray series, and urea breath testing.

• Medical Management - Treatment: Supportive care (relieving clinical manifestations), and reducing the cause of discomfort.

• Surgical Management: Vagotomy and gastrectomy for severe cases.

• Nursing Management - Assessment and analysis: Epigastric pain, nausea, vomiting, decreased appetite, weight loss, color changes in stool

• Nursing Diagnoses: Acute pain, anxiety, deficient knowledge, risk for deficient fluid volume.

• Nursing Interventions - Assessments: Vital signs, history of presenting signs and symptoms, laboratory assessment (serum electrolytes), and intake and output

• Nursing Interventions - Actions: Administer IV fluids, administer medications exactly as prescribed, and report hematemesis

• Nursing Management - Evaluating outcomes: Full recovery and return of appetite

Gastroenteritis

• Pathophysiology: Inflammation of the mucous membranes of the stomach and intestinal tract due to a viral or bacterial infection.
• Clinical Manifestations: Nausea, vomiting, diarrhea, abdominal cramping, dehydration
• Fecal-oral transmission and handwashing is key to prevention

Peptic Ulcer Disease

• Pathophysiology: Damage to the gastric mucosa caused by corrosive action of gastric acid

• Clinical Manifestations: Pain triggered or worsened by eating, ulcers can cause symptoms or be asymptomatic

• Medical Management – Diagnosis: Upper GI endoscopy

• Medical Management - Treatment: Antacids, H2-receptor antagonists, Proton pump inhibitors, mucosal barrier agents.

• Surgical Management: Indicated in nonhealing and bleeding ulcers, endoscopic procedures (example: vagotomy, and pyloroplasty)

• Complications: GI hemorrhage, abdominal or intestinal infarction, perforation, penetration into attached structures, obstruction, and peritonitis

• Nursing Management - Assessment and analysis: Comprehensive physical exam to exclude other diseases

• Nursing Diagnoses: Acute or chronic pain, deficient knowledge, risk for deficient fluid volume

• Nursing Interventions - Assessments: Vital signs, gastric pH, alcohol/medication use, serum electrolytes, and pain levels

• Nursing Interventions - Actions: Administer IV fluids, as ordered, administer medications, assist with gastric lavage, prepare for endoscopy.

• Nursing Interventions - Teaching: Take medications as prescribed, avoid eating 2 hours of bedtime, avoid risk factors.

• Nursing Management - Evaluating outcomes: Increased comfort, controlled pain, tolerance of diet

Gastric Cancer

• Pathophysiology: Begins as chronic gastritis. Progresses to atrophy,intestinal metaplasia, dysplasia, then adenocarcinomas.
• Clinical Manifestations: Often asymptomatic until late disease. Indigestion, anorexia, weight loss, vague epigastric pain, vomiting, and abdominal mass.
• Medical Management - Diagnosis: Barium x-ray, endoscopy, and cytology
• Medical Management - Treatment: Antiemetics, opioid analgesics, gastric resection
• Complications (after surgery): Dumping syndrome, wound infections, leaking of anastomotic sites, strictures, and internal bleeding.
• Nursing Management - Assessment and analysis: Minimal early clinical manifestations, manifestations related to tumor growth.
• Nursing Diagnoses: Pain, anxiety, fear, nutritional imbalances, and motility issues.
• Nursing Interventions - Assessments: Physical exam, hematocrit and hemoglobin, serum electrolytes, bilirubin and alkaline phosphatase, modified oral glucose tolerance tests, comprehensive pain assessments, early dumping syndrome signs, and end of life care.
• Nursing Interventions - Actions: Small, frequent meals, verbalize feelings and concerns, prepare for surgery.
• Nursing Interventions - Teaching: Medication information, pain and precipitating factors, high-calorie/high-protein meals, nutritional supplements, main signs of dumping syndrome, and relaxation techniques
• Nursing Management – Evaluating care outcomes: Absence of infection, weight stability, reduced anxiety, adequate nutrition, pain relief, and adjusting to diagnoses

Hernias

• Pathophysiology: Protrusion of the intestines through an abdominal wall opening.
• Causes: Straining (lifting heavy objects, sudden twists/pulls), muscle strain, weight gain, and chronic coughing. Reducible vs incarcerated.
• Risk Factors: Obesity, smoking, excessive wound tension, malnutrition, pregnancy, and medications.
• Clinical Manifestations: Bulge/visible swelling (ventral, umbilical, inguinal, femoral).
• Medical Management - Diagnosis: Physical examination, and herniography.
• Surgical Management: Hernia repair, complications (strangulation of intestine, recurrences).
• Nursing Management - Assessment and analysis: Clinical manifestations are related to hernia location and type
• Nursing Diagnoses: Acute pain, and knowledge deficit
• Nursing Interventions – Assessments: Vital signs, pain, intake and output, and surgical site.
• Nursing Interventions – Actions: Deep breathing exercises, pain medications, ice packs, advance diet as tolerated
• Nursing Interventions – Teaching: Coughing, heavy lifting, pain management, observe incisions
• Nursing Management – Evaluating care outcomes: Return to normal functioning, stable vital signs, absence of infection, and normal bladder/bowel functions

Intestinal Obstruction

• Types: Mechanical (blockage), and Nonmechanical (ileus, etc)
• Problems: Blockage & distention, hypovolemia & electrolyte imbalances, and strangulation.
• Symptoms (small bowel): Pain, peristaltic waves, upper GI distention, nausea/vomiting, fluid and electrolyte imbalances, metabolic alkalosis.
• Symptoms (large bowel): Lower abdominal cramping, lower GI distention, metabolic acidosis.
• Diagnosis: Labs, ultrasound, CT scan/MRI, and endoscopy.
• Nonsurgical Management: NPO, NG tube, IV fluids, motility medications, pain management, and antibiotics.
• Surgical Management: Colon resection, exploratory laprotomy (pre-op, operative-laparascopic/open approach), and post-op NG tube

Hemorrhoids

• Pathophysiology: Swollen or dilated veins in the anorectal area, internal or external hemorrhoids
• Clinical Manifestations: 40% asymptomatic, bleeding, itching, irritation, and pain.
• Medical Management - Diagnosis: Digital examination, anoscopy, sigmoidoscopy.
• Medical Management - Treatment: Symptom relief, and medication regimens.
• Surgical Management: Rubber band ligation, bipolar, infrared and laser coagulation, sclerotherapy, cryosurgery, and hemorrhoidectomy
• Complications: Infection, pain, urinary retention, fecal impaction, damage to sphincter, bleeding, and abscess formation.
• Nursing Management - Assessment and analysis: Clinical manifestations possibly with bleeding.
• Nursing Diagnoses: Acute pain, knowledge deficit, altered bowel elimination, and risk for bleeding/fluid volume deficit.
• Nursing Interventions - Assessments: Vital signs, visual inspection of rectal area, frequency and character of bowel movements, bowel habit post-operatively, and pain level.
• Nursing Interventions - Actions: Analgesia prior to first bowel movement, local anesthetics, corticosteroids, cold packs/sitz baths, laxatives, and apply local heat.
• Nursing Interventions - Teaching: Care of surgical site, constipation prevention measures, avoid straining, avoid stimulant laxatives, nonpharmacologic pain reduction methods, and when to contact a healthcare provider.
• Nursing Management – Evaluating care outcomes: Return to normal functioning, appropriate pain management, and avoidance of constipation.

Irritable Bowel Syndrome (IBS)

• Pathophysiology: Unknown cause, abdominal pain, and altered bowel habits.
• Subtypes: IBS-D (diarrhea), IBS-C (constipation), IBS-A (alternating), and IBS-M (mixed).
• Clinical Manifestations: Diarrhea, constipation, flatulence, and abdominal pain.
• Medical Management - Diagnosis: Rome IV diagnostic criteria.
• Medical Management - Treatment: Medications, dietary modifications, and complementary/alternative therapies.
• Complications: Social isolation, spasm, constipation, diarrhea, fluid volume deficit, and hypokalemia.
• Nursing Management - Assessment and analysis: Clinical manifestations include abdominal distention and altered bowel habits.
• Nursing Diagnoses: Chronic pain, ineffective coping, and ineffective health maintenance.
• Nursing Interventions - Assessments: Vital signs, intake and output, serum electrolytes , pain levels, bowel pattern, weight, and psychosocial assessment.
• Nursing Interventions - Actions: Administer ordered IV solutions, establishing a trusting relationship, avoid foods that exacerbate symptoms, establish regular bowel routine, and implement complementary/alternative medicines.
• Nursing Interventions - Teaching: Avoid trigger foods, keep food diary, consume regular meals/water, encourage regular exercise, and smoking cessation.
• Nursing Management – Evaluating care outcomes: Stable vital signs & weight, decrease in clinical manifestations, and understanding/adherence to nutrition/activity recommendations.

Inflammatory Bowel Disease

• Pathophysiology: Unknown cause, inappropriate response, in intestinal tract resulting in inflammation.

• Clinical Manifestations: Persistent diarrhea, abdominal pain and cramps, fever, weight loss, fluid imbalance, malnutrition, mouth ulcers, and anemia

• Medical Management - Diagnosis: Colonoscopy, sigmoidoscopy, and barium enema

• Medical Management – Treatment: Fluid electrolyte management, rest, and medications

• Surgical Management: Colectomy and ostomy creation

• Complications: Perineal abscess, fistula, and strictures

• Nursing Management - Assessment and analysis: Frequent diarrhea leads to extreme fluid and electrolyte losses

• Nursing Diagnoses: Deficient fluid volume, diarrhea, imbalanced nutrition, and ineffective coping.

• Nursing Interventions - Assessments: Vital signs, nutritional intake, frequency and characteristics of stool, intake and output, daily weight, fluid and electrolyte status, and psychosocial assessments.

• Nursing Interventions - Actions: Encourage smaller, more frequent meals, encourage rest periods, establish therapeutic relationship, make referrals to interprofessional team, pain management, and meticulous skin care

• Nursing Interventions - Teaching: Importance of adequate nutrition, medications, regular follow-ups and annual colonoscopies

Diverticulitis

• Pathophysiology: Outpouching of the intestinal wall that becomes inflamed.
• Clinical Manifestations: Abdominal pain, fever, leukocytosis, and a palpable mass
• Medical Management - Diagnosis: Abdominal x-ray, CT scan, and endoscopy.
• Medical Management - Treatment: Broad-spectrum antibiotics, clear liquid diet, IV fluids, NPO and bowel rest.
• Surgical Management: Indicated for perforation, obstruction, abscess formation, and fistula.
• Complications: Perforation, microperforation, abscess, fistula formation, bowel obstruction, and bleeding.
• Nursing Management - Assessment and analysis: Clinical Manifestations related to inflammation or infection, as well as GI manifestations.
• Nursing Diagnoses: Acute pain and knowledge deficit Nursing Interventions - Assessments: Vital signs, serum potassium, intake and output, pain, and mental status.
• Nursing Interventions - Actions: Administer IV fluids, administer ordered antibiotics, use nasogastric (NG) tube for intermittent suction, and provide oral care.
• Nursing Interventions - Teaching: Dietary recommendations, avoid straining, bending, lifting, weight reduction, and complete antibiotic therapy.
• Nusring Management - Evaluating care outcomes: Free from abdominal pain, free from fever.

Appendicitis

• Pathophysiology: The opening to the appendix becomes blocked. The mucosa secretes fluid. There is venous engorgement, and restricted blood flow
• Clinical Manifestations: Periumbilical abdominal pain, anorexia, nausea, and vomiting.
• Medical Management - Diagnosis: Clinical presentation, ultrasound, and CT scan
• Surgical Management: Appendectomy.
• Complications: Rupture and sepsis
• Nursing Management - Assessment and analysis: Clinical manifestations related to inflamed appendix progressing to gangrene or rupture if untreated.
• Nursing Diagnoses: Acute pain, risk for deficient fluid volume, and knowledge deficit
• Nursing Interventions – Assessments: Vital signs, intake and output, pain, rebound tenderness, and WBC count.
• Nursing Interventions - Actions: NPO, IV fluids, prepare patient for OR, provide comfort measures, position supine with elevated HOB, and advance diet as tolerated.
• Nursing Interventions - Teaching: Turning, coughing, deep breathing, incentive spirometer, early ambulation, take full course of antibiotics, and wound care
• Nursing Management – Evaluating care outcomes: Resume normal activities, stable vital signs, CBC within normal limits, and demonstrated understanding of postoperative teaching

Colorectal Cancer

• Pathophysiology: Most are adenocarcinomas originating in glandular cells of internal organs. Metastasize to adjacent organs.
• Risk Factors: Family history, inflammatory bowel disease for 10 or more years, physical inactivity, obesity high red meat diet
• Clinical Manifestations: Pain, change in bowel habits, anemia, and fatigue
• Medical Management - Diagnosis: Colonoscopy and laboratory studies.
• Medical Management - Treatments: Chemotherapy and radiation therapy
• Surgical Management: Colectomy, hemicolectomy, and abdominoperineal resection.
• Complications: Fatigue, infection, anemia, and anastomoses
• Preoperative Patient Nursing Management - Assessment and analysis: Clinical manifestations closely associated with tumor location.
• Preoperative Patient Nursing Management - Nursing Diagnoses: Knowledge deficit, and fear
• Preoperative Patient Nursing Interventions - Assessments: Vital signs, serum electrolytes and CBC, and current knowledge of disease
• Preoperative Patient Nursing Interventions - Actions: Bowel prep, establish therapeutic relationships, and ensure surgical consent form is signed.
• Preoperative Patient Nursing Interventions - Teaching: Ostomy care, and pain management.
• Postoperative Patient Nursing Management - Assessment and analysis: Vital signs, LOC, pain, bowel sounds, and stoma (if applicable)
• Postoperative Patient Nursing Management - Nursing Diagnoses: Acute pain, potential for infection, risk for imbalanced fluid volume, knowledge deficit, and disturbed body image.
• Postoperative Patient Nursing Interventions - Assessments: Vital signs, CBC values, nausea/vomiting, intake and output, stoma, abdominal/perineal dressing, and pain.
• Postoperative Patient Nursing Interventions - Actions: IV fluids, NPO/advance diet as tolerated, NG tube, pain management, drain management, turning, coughing, deep breathing, incentive spirometry, early ambulation, perianal care
• Postoperative Patient Nursing Interventions - Teaching: Postoperative complications, and ostomy care.
• Nursing Management - Evaluating care outcomes: Stable vital signs, good CBC values, absence of infection, positive bowel sounds, demonstrated understanding, and controlled pain.