Management of Patients with Oral and Esophageal Disorders PDF

CHAPTER 39 Management of Patient with Oral and Esophageal Disorders Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort, abnormalities, or disease processes in the oral cavity can affect a person\...

CHAPTER 39 Management of Patient with Oral and Esophageal Disorders Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort, abnormalities, or disease processes in the oral cavity can affect a person\'s nutritional status. Changes in the oral cavity can influence the type and amount of food ingested as well as the degree to which food particles are properly mixed with salivary enzymes. Disorders of the mouth or tongue can interfere with speech and thus affect communication and self-image. Esophageal problems related to swallowing can also adversely affect food and fluid intake, thereby jeopardizing general health and well-being. Given the close relationship between adequate nutritional intake and the structures of the upper gastrointestinal (GI) tract (lips, mouth, teeth, pharynx, esophagus), health education can help prevent disorders associated with these structures (see Fig. 39-1). DISORDERS OF THE ORAL CAVITY Oral health is a very important component of a person\'s physical and psychological sense of well-being. Periodontal disease, which encompasses both gingivitis (inflammation of the gums) and periodontitis (which involves the soft tissue and bone supporting the teeth), is the most common cause of tooth loss among adults (Office of the Surgeon General, 2003; U.S. Department of Health and Human Services \[HHS\], 2000). From 2011 to 2012, 44.7% of adults age 30 and older in the United States had periodontitis. When this prevalence is combined with the 2009 to 2010 data, there is a 45.9% prevalence of periodontitis, which means approximately 141 million adults ages 30 and older have diagnosed periodontitis. Severe periodontitis was diagnosed in 8.9% of adults ages 30 and older, but is most prevalent among adults ages 50 and older, males, Hispanic/Latino Americans (63.5%) and non-Hispanic/Latino African Americans (59.1%), those who didn\'t graduate high school, people living below 200% of the poverty level, and current smokers (Eke, Dye, Wei, et al., 2015). Current cigarette smoking, which increases the likelihood of periodontitis by at least 50%, remains a key modifiable risk factor for periodontitis at all severity levels (Eke, Wei, Thornton-Evans, et al., 2016). Periodontal disease can be connected to a variety of other systemic dis- eases, such as cardiovascular disease, diabetes, and rheumatoid disease (American Academy of Periodontology \[AAP\], 2021). Table 39-1 reviews common abnormalities of the oral cavity, their possible causes, and nursing considerations. Figure 39-2 illustrates structures of the oral cavity. Dental Plaque and Caries Tooth decay is an erosive process that begins with the action of bacteria on fermentable carbohydrates in the mouth, which produces acids that dissolve tooth enamel. Despite the fact tooth enamel is the hardest substance in the human body, caries and periodontal disease can still occur for several reasons. Contributing factors include nutrition, soft drink consumption, and genetic predisposition. In addition, the extent of damage to the teeth may be related to the following: Presence of dental plaque, which is a gluey, gelatin-like substance that adheres to the teeth Length of time acids are in contact with the teeth Strength of acids and the ability of the saliva to neutralize them Susceptibility of the teeth to decay Dental decay begins with a small hole, usually in a fissure (a break in the tooth\'s enamel) or in an area that is hard to clean. Left unchecked, the decay extends into the dentin. Because dentin is not as hard as enamel, decay progresses more rapidly and in time, reaches the pulp of the tooth. The prevalence of dental caries in permanent teeth for adolescents ages 12 to 19 remains high at 56.8%, even though there is an increased use (48.1%) of sealants on permanent teeth in this age group. Adults ages 20 to 64 years have an 89.9% prevalence of dental caries in permanent teeth; however, only 26.1% of adults have untreated tooth decay in permanent teeth. Older adults (65 years and older) present with a 96.2% prevalence of dental caries, with 15.9% of their tooth decay untreated (Centers for Disease Control and Prevention \[CDC\], 2019). Older adults are subject to decay from drug-induced or age- related oral dryness (see Chart 39-1). Dentists can determine the extent of damage and the type of treatment needed using x-ray studies. Treatment for dental caries includes fillings, dental implants, or extraction, if necessary. In general, dental decay can occur in anyone. Prevention Measures used to prevent and control primary dental caries include applying fluoride varnish/gel (Marinho, Worthing- ton, Walsh, et al., 2015), using fluoride toothpaste, use of silver diamine fluoride compounds (Donovan, Marzola, Murphy, et al., 2018), applying dental sealants (Twetman, 2015), and ensuring community water fluoridation (HHS, 2000; HHS Federal Panel on Community Water Fluoridation, 2015). Other recommendations include implementing daily oral hygiene practices, seeking routine professional dental treatment, refraining from smoking and excessive alcohol use, making good dietary choices, and managing related systemic diseases (HHS, 2019). The inability to afford dental care is associated with a decrease in the quality of life of adults ages 45 years and older (Naavaal, Griffin, & Jones, 2019), which must be considered when assisting patients in navigating health care systems. Mouth Care Healthy teeth must be cleaned several times a day. Brushing and flossing are particularly effective in mechanically breaking up the bacterial plaque that collects around teeth. Mastication (chewing) and the normal flow of saliva also aid greatly in keeping the teeth clean. Because many ill patients do not consume adequate nutrients, they produce less saliva, which in turn reduces this natural tooth-cleaning process. The nurse may need to assume the responsibility for brushing the patient\'s teeth. Merely wiping the patient\'s mouth and teeth with a swab is ineffective. The most effective method is mechanical cleansing (brushing). If brushing is not possible, it is better to wipe the teeth with a gauze pad and then have the patient swish an antiseptic mouthwash several times before expectorating into an emesis basin. A soft, bristled toothbrush is more effective than a sponge stick. Flossing should be or foam performed daily. To prevent drying, foam the lips may be coated with a water-soluble gel Diet Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Patients who snack should be encouraged to choose less cariogenic alternatives, sound he fruits, vegetables, nuts, cheeses, or plain yogurt. Brushing after meals is recommended. Fluoridation Fluoridation of public water supplies has been found to decrease dental caries. Some areas of the country have natural fluoridation; other communities have added fluoride to public water supplies. As of 2014, 66.3% of Americans receive fluoridated water (CDC, 2020b). Studies suggest that by instituting a community water fluoridation program, tooth decay is reduced by 25% in both children and adults (CDC, 2018). Fluoridation may also be achieved by having a dentist apply a concentrated gel or solution to the teeth; adding fluoride to home water supplies; using fluoridated toothpaste or mouth rinse; or using sodium fluoride tablets, drops, or lozenges. Pit and Fissure Sealants The occlusal surfaces of the teeth have pits and fissures areas that are prone to caries. Some dentists apply a coating to and seal these areas on the primary and permanent molars to protect them from potential exposure to cariogenic processes. These sealants can last 36 to 48 months and significantly prevent tooth decay. The economic benefits of applying sealants, especially in high-risk groups, exceed the costs and provide solid evidence for their use (Donovan et al., 2018) Dental Health and Disease Studies are ongoing that show the link between oral health Stud chronic disease such as diabetes, heart disease, low birth weight, premature births, and stroke. It had long been posited that bacteria, specifically gram-negative bacteria, were the culprits that link periodontal disease to other systemic diseases, specifically coronary artery disease, including myocardial infarction and stroke. More recently, it was confirmed that these bacteria cause an inflammatory response that initites an increase in inflammatory markers such as C-reactive protein, white blood cells, and fibrinogen. These markers are associated with an increased risk of cardiovascular dis- ease. Data from short-term studies suggest that if periodontal disease is treated, systemic inflammation and endothelial dysfunction are reduced (Hegde & Awan, 2019). One study reported that thrombus aspirate and arterial blood taken from patients who had an ischemic stroke contained streptococcal bacteria. The most commonly identified Streptococcus species (found in 79% of the sample), Streptococcus mitis, is typically found in the mouth. Although a preliminary study, there is evidence that these oral bacteria may contribute to the progression of cardiovascular thrombotic events (Patrakka, Pienimäki, Tuomisto, et al., 2019). The World Health Organization (WHO) Global Oral Health Programme (2019) espouses a global focus on oral health promotion and disease prevention, with an emphasis on policy and guideline development to support equitable implementation of evidence-based practices in global com- munities. The Programme supports an emphasis on addressing modifiable risk factors (e.g., diet, nutrition, tobacco, alcohol, and oral hygiene), water sanitation, and fluoride initiatives. Initiatives recognize the impact of social, economic, political, and cultural determinants of health, and seek to integrate the existing and emerging systems that address the burden and disability that stem from oral disease (WHO, 2019). Periapical Abscess A periapical abscess, more commonly referred to as an abscessed tooth, involves a collection of pus in the apical dental periosteum (fibrous membrane supporting the tooth structure) and the tissue surrounding the apex of the tooth (where it is suspended in the jaw bone). The abscess may be acute or chronic. An acute periapical abscess arises from an infection, usually secondary to dental caries. The infection of the dental pulp extends through the apical foramen of the tooth to form an abscess around the apex. A chronic periodontal abscess occurs from a slowly progressive infectious process. In contrast to the acute form, a fully formed abscess may occur without the patient\'s knowledge. The infection eventually leads to a \"blind dental abscess,\" which is actually a periapical granuloma. It may enlarge to as much as 1 cm in diameter. It is often discovered on x-ray images and is treated by extraction or root canal therapy, often with apicoectomy (excision of the apex of the tooth root). Clinical Manifestations The abscess produces a dull, gnawing, continuous pain, often with a surrounding cellulitis and swelling of the adjacent facial structures, temperature sensitivity, and mobility of the involved tooth. The gum opposite the apex of the tooth is usually swollen on the cheek side. Swelling and cellulitis of the facial structures may make it difficult for the patient to open the mouth. There may also be a systemic response, fever, and malaise. Medical Management In the early stages of an infection, a dentist or oral surgeon may perform a needle aspiration or drill an opening into the pulp chamber to relieve pressure and pain and to provide drainage. Drainage is provided by an incision through the gingiva down to the jawbone. Purulent material escapes under pressure. This procedure may be performed in a dentist\'s office, an outpatient surgery center, or a same-day surgery department. After the inflammatory reaction has subsided, the tooth may be extracted or root canal therapy performed. Antibiotics, in the presence of overt spreading infection, and analgesics may be prescribed (Robertson, Keys, Rautemaa-Richardon, et al., 2015). Nursing Management The patient is assessed for bleeding after treatment and is instructed to use a warm saline or warm water mouth rinse to keep the area clean. The patient is also instructed to take antibiotic and analgesic agents as prescribed, to advance from a liquid diet to a soft diet as tolerated, and to keep follow-up appointments. DISORDERS OF THE JAW Abnormal conditions affecting the mandible (jaw) and the temporomandibular joint (which connects the mandible to the temporal bone at the side of the head in front of the ear) include congenital malformation, fracture, chronic dislocation, cancer, and syndromes characterized by pain and limited motion. Temporomandibular disorders and jaw surgery, a treatment common in many structural abnormalities or cancer of the jaw, are presented in this section. Temporomandibular Disorders Temporomandibular disorders are categorized as follows (National Institute of Dental and Craniofacial Research \[NIDCR\], 2018); Myofascial pain-a discomfort in the muscles control- ling jaw function and in neck and shoulder muscles Internal derangement of the joint-a dislocated jaw, a displaced disc, or an injured condyle Degenerative joint disease-rheumatoid arthritis or osteoarthritis in the jaw joint Diagnosis and treatment of temporomandibular disorders remain somewhat ambiguous, but the condition is thought to affect about 10 million people in the United States (NIDCR, 2018). Misalignment of the joints in the jaw and other problems associated with the ligaments and muscles of mastication are thought to result in tissue damage and muscle tenderness. Suggested causes include arthritis of the jaw, head injury, trauma or injury to the jaw or joint, stress, and malocclusion, although research does not support malocclusion (misalignment of bite) or associated orthodonture as a cause (NIDCR, 2018). Clinical Manifestations Patients have jaw pain ranging from a dull ache to throbbing, debilitating pain that can radiate to the ears, teeth, neck muscles, and facial sinuses. They often have restricted jaw motion and locking of the jaw. There also may be a sudden change in the way the upper and lower teeth fit together. The patient may hear clicking, popping, and grating sounds when the mouth is opened, and chewing and swallowing may be dif- ficult. Symptoms such as headaches, earaches, dizziness, and hearing problems may sometimes be related to temporomandibular disorders (Gauer & Semidey, 2015; NIDCR, 2018). Assessment and Diagnostic Findings Diagnosis is based on the patient\'s report of pain, limitations in range of motion, dysphagia (difficulty swallowing), difficulty chewing, difficulty with speech, or hearing difficulties. Magnetic resonance imaging (MRI) and other imaging studies are generally only used for severe or chronic symptoms. Medical Management Signs and symptoms improve over time for the majority of patients with temporomandibular joint disorders, with or without treatment. Conservative treatment is recommended (NIDCR, 2018). Most patients improve with a combination of simple non-invasive therapies that may include: (1) patient education on self-care-eating soft foods, icing the jaw; (2) cognitive behavior modifications-stress reduction, sleep hygiene, avoidance of extreme mandibular movement, and elimination of habits such as chewing ice; (3) physical therapy-stretching and relaxing; (4) acupuncture-highly effective with six to eight 15- to 30-minute sessions; (5) psychosocial interventions; (6) analgesics-trial of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants initially; and (7) oral appliance therapy-splints (Gauer & Semidey, 2015; NIDCR, 2018). Jaw Disorders Requiring Surgical Management Correction of mandibular structural abnormalities may require surgery involving repositioning or reconstruction of the jaw. Simple fractures of the mandible without displacement, resulting from a blow to the chin, and planned surgical interventions, as in the correction of long or short jaw syndrome, may require wiring or surgery. Jaw reconstruction may be necessary in the aftermath of trauma from a severe injury or cancer, both of which can cause tissue and bone loss. Research supports screening for concussion (see Chapter 63) with mandibular fractures associated with high-force impacts (Sobin, Kopp, Walsh, et al., 2016). Cervical spine injury must be ruled out since 2% to 10% of patients with facial fractures (up to 20% with panfacial injuries) also have a spinal injury (Pickrell, Serebrakian & Maricevich, 2017). Mandibular fractures are usually closed fractures. In the acute trauma setting, surgery providers should assess the patient\'s perception of the bite (\"bite feels normal\") for mal- occlusion, the fracture site for fragment mobility, dentition for loose or infected teeth, and sensation in the lower lip for nerve damage. When the dentition is sufficient and the fracture is isolated, maxillomandibular fixation (MMF; wiring the jaw shut) is a viable option. However, open reduction, internal fixation (ORIF) with plate fixation (insertion of one or more metal plates and screws or arch bars into the bone to approximate and stabilize the bone) is the surgery of choice (Pickrell et al., 2017). Current research revolves around the use of various types and number of reconstruction plates and fixation devices, quality of life after specific instrumentation, approach used (ORIF or endoscopic-assisted), and device choice (van den Bergh, de Mol van Otterloo, van der Ploeg, et al., 2015). Bone grafting may be performed to replace structural defects using bones from the patient\'s own ilium, ribs, or cranial sites. Nursing Management If used, MMF generally requires a short period (7 to 10 days) of a liquid diet and oral rinses followed by rehabilitation and a soft diet. After ORIF, patients are typically on a liquid or soft diet for 4 to 6 weeks to allow for healing. The most common complications are infection that may progress to osteomyelitis (infection of the bone), alignment issues or hardware failure (requiring surgical repair or MMF), and wound dehiscence (Pickrell et al., 2017). Dietary counseling is provided to ensure adequate protein intake with supplementation as needed. Oral care, including the use of medicated rinses, needs to be reinforced. To decrease the risk of complications, patients are advised to take prescribed medications and to abstain from smoking, use of electronic nicotine delivery systems (ENDS), including e-cigarettes, e-pens, e-pipes, e-hookah and e-cigars and use of alcohol and other substances. Regular follow-up with the surgeon is required to ensure healing is progressing. DISORDERS OF THE SALIVARY GLANDS The salivary glands consist of the parotid glands, one on each side of the face below the ear, the submandibular glands, located below the jawbone; the sublingual glands, in the floor of the mouth under the tongue; and the minor salivary glands in the lips, buccal mucosa, and the lining of the mouth and throat. About 1500 mL of saliva is produced daily and swallowed. The major functions of the salivary glands include lubrication, protection against harmful bacteria, and digestion. Parotitis Parotitis (inflammation of the parotid gland) is the most common inflammatory condition of the salivary glands. Inflammation of the parotid may be due to mumps (epidemic parotitis), a communicable disease caused by viral infection and most commonly affecting unvaccinated children (Grennan, 2019). People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for bacterial parotitis. The infecting organism, typically Staphylococcus aureus, travels from the mouth through the salivary duct. The onset of parotitis is sudden and associated with fever, chills, and other systemic signs of infection. The gland swells and becomes tense and tender. The patient feels pain in the ear, and swollen glands interfere with swallowing. The swelling increases rapidly, and the overlying skin soon becomes red and shiny. Medical management includes maintaining adequate nutritional and fluid intake, good oral hygiene, applying cold packs, and discontinuing medications (eg., tranquilizers, diuretic agents) that can diminish salivation. Antibiotic therapy is necessary for bacterial parotitis, and analgesics may be prescribed to control pain. If antibiotic therapy is not effective, the gland may need to be drained by a surgical procedure known as parotidectomy. This procedure may be necessary to treat chronic parotitis. The patient is advised to have any necessary dental work performed prior to surgery. Sialadenitis Sialadenitis (inflammation of the salivary glands) may be caused by dehydration, radiation therapy, stress, malnutrition, salivary gland calculi (stones, sialolithiasis), or improper oral hygiene. The inflammation is commonly associated with infection by S. aureus, which requires antibiotic therapy. In hospitalized or institutionalized patients, the infecting organ ism may be methicillin-resistant S. aureus (MRSA). Symtoms include pain, swelling, and purulent discharge. Massage hydration, warm compresses, and sialagogues (substances that trigger saliva flow like hard candyiolagogon juice) frequently cure the problem. Chronic sialadenitis is typically due to decreased salivary flow and may be treated with sialendscopy, an endoscopic procedure that allows for direct visualization of Stensen duct (diagnostic) and instillation of antibiotics, corticosteroids, or irrigation (treatment), particularly in adolescents with recurrent parotitis (Papadopoulou-Alataki, Dogantzis, Chatziavramidis, et al., 2019). Surgical drainage or excision of the gland and its duct are considered in cases of sialadenitis that are recurrent or refractory to antibiotics. Salivary Calculus (Sialolithiasis) Sialolithiasis, or salivary calculi (stones), occur in 80% of cases in the submandibular gland (Fabie, Kompelli, Naylor, et al., 2019). Calculi within the salivary gland itself may cause no symptoms unless infection arises; however, a calculus that obstructs the gland\'s duct causes swelling and sudden, local, and often colicky pain, which is abruptly relieved by a gush of saliva. On physical assessment, the gland is swollen and quite tender, the stone itself may be palpable, and may be visualized by ultrasound, non-contrast computed tomography (CT), or sialendoscopy. Salivary calculi are formed mainly from calcium phosphate. If located within the gland, the calculi are irregular and vary in diameter from 1 to 35 mm. Sialendoscopy is considered the standard in the treatment of sialothiasis, but gland- preserving incisional approaches alone may also be used for palpable stones 6 mm or larger (Fabie et al., 2019).. Litho- tripsy, a procedure that uses shock waves to disintegrate the stone, may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Lithotripsy requires no anesthesia, sedation, or analgesia. Side effects can include local hemorrhage and swelling. Gland removal may be necessary if symptoms and calculi recur repeatedly. Neoplasms Salivary gland neoplasms (tumors or growths) of almost any type may develop in the salivary gland. Malignant (cancerous) salivary gland neoplasms account for more than 0.5% of all malignancies and approximately 3% to 5% of head and neck cancers (National Cancer Institute \[NCI\], 2021d). Risk factors include prior exposure to ionizing radiation to the head and neck, older age, and specific carcinogens introduced in specific work environments (asbestos, plumbing, and wood- working). Most patients with a benign tumor present with painless swelling of the glands; patients with a malignancy tend to have neurologic symptoms (weakness or numbness of the facial nerve) and persistent facial pain (NCI, 2021d). Diagnosis is based on the health history, physical examination, and the results of fine-needle aspiration biopsy. Early-stage salivary gland tumors are usually curable with surgery alone. Dissection is carefully performed to preserve the seventh cranial nerve (facial nerve). It may not be possible to safely dissect if the tumor is extensive. Complications from surgery may involve facial nerve dysfunction and Frey syndrome. Frey syndrome, also known as auriculotemporal syndrome, involves facial sweating and flushing in the general location of the (removed) parotid gland that occurs while eating. Frey syndrome may be successfully treated with botulinum toxin type A injections (NCI, 2021d). If the salivary gland tumor is malignant, radiation therapy may follow surgery. Radiation therapy alone may be a treatment choice for tumors thought to be localized or if there is risk of facial nerve damage from surgical intervention. Chemotherapy may be considered in late stages, but due to the many different subtypes of salivary gland cancer, tumor mapping, including immunohistochemistry and genomic profiling, should be used to optimize treatment (Lassche, van Boxtel, Ligtenberg, et al., 2019). Recurrent tumors usually are more aggressive than initial tumors. CANCER OF THE ORAL CAVITY AND PHARYNX Cancers of the oral cavity and pharynx, which can occur in any part of the mouth or throat, are curable if discovered early. Risk factors for cancer of the oral cavity and pharynx include any use of any form of tobacco or nicotine (cigarette, cigar, pipe, smokeless tobacco, ENDS), excessive use of alcohol, infection with human papillomavirus (HPV), and a history of previous head and neck cancer (NCI, 2021b). Oral cancers are often associated with the combined use of alcohol and tobacco these substances have a synergistic carcinogenic effect. Patient education directed toward avoiding high-risk behaviors is critical to prevent oral cancers. In the United States, approximately 53,000 new cases of oral cavity and oropharyngeal cancer occur annually, with an estimated 10,860 deaths. Men are diagnosed with oral and oropharyngeal cancer in almost 72% of diagnosed cases (Siegel, Miller, & Jemal, 2019). Despite a rise in rates associated with HPV over the past 10 years (0.8% rise each year), patients with cancer of the oral cavity and oropharynx have a relatively stable 5-year survival rate of 65.3% (NC1, 2021b; Siegel et al., 2019). Pathophysiology Malignancies of the oral cavity are usually squamous cell carcinomas (NCI, 2021c). Any area of the oropharynx can be a site of malignant growths, but the lips, the lateral aspects of the tongue, and the floor of the mouth are most commonly affected. High-risk HPV infection is associated with about 70% of oropharyngeal cancers. Vaccination against HPV shows promise in impacting rates of head and neck cancer. A study of young adults in the United Stated found oral HPV infections (including the two high-risk, cancer-causing types 16 and 18) were 88% lower among young adults who received at least one dose of the vaccine (NCI, 2017). Clinical Manifestations Many oral cancers produce few or no symptoms in the early stages. Later, the most frequent symptom is a painless sore or lesion that bleeds easily and does not heal. Oral cancer may also present as a red or white patch (leukoplakia) in the mouth or throat. A typical lesion in oral cancer is a painless indurated (hardened) ulcer with raised edges. Depending on the location (tonsil, base of the tongue, soft palate, or pharyngeal wall), the patient may report tenderness, difficulty in chewing, swallowing, or speaking, coughing of blood-tinged sputum, trismus (limited jaw range of motion), weight loss, a neck mass, or enlarged cervical lymph nodes (NCI, 2021c). Assessment and Diagnostic Findings Diagnostic evaluation consists of an oral examination as well as an assessment of the cervical lymph nodes to detect possible metastases. Positron emission tomography-computed tomography scan (PET-CT scan), MRI, endoscopy, laryngoscopy, and biopsy, including testing of HPV status may be used to detect and guide therapy (NCI, 2021c). Human Papillomavirus Prevention HPV vaccine is generally recommended for all children ages 11 or 12 (can be started at age 9), up to the age of 26 years for women and 21 years for men. Men who have sex with men, transgender men and women, and immunocompromised people, including those with human immune deficiency virus (HIV), may receive the vaccine up to 26 years of age (CDC, 2020a). Medical Management In patients diagnosed with oropharyngeal cancer, management varies with the nature of the lesion, the preference of the provider, and patient choice. Surgical resection and chemoradiation (CRT) are associated with improved survival for all adults over age 70, including those who are positive for HPV infection (Lu, Luu, Nguyen, et al., 2019). In cancer of the lip, small lesions are usually excised liberally. Radiation therapy may be more appropriate for larger lesions involving more than one third of the lip because of superior cosmetic results. The choice depends on the extent of the lesion and what is necessary to cure the patient while preserving the best appearance. Tumors larger than 4 cm often recur. In cancer of the tongue, treatment with radiation therapy and chemotherapy may preserve function and maintain quality of life. A combination of radioactive interstitial implants (surgical implantation of a radioactive source into the tissue adjacent to or at the tumor site) and external-beam radiation may be used. Total glossectomy (removal of the tongue) remains the principal treatment of advanced stage or cancers at the base of the tongue; long-term data on functional out- comes following these procedures are being studied (Han, Kuan, Mallen-St. Clair, et al., 2019). Often, cancer of the oral cavity has metastasized through the extensive lymphatic channel in the neck region, requiring a neck dissection and reconstructive surgery of the oral cavity. Reconstructive techniques involve the use of the traditional pedicled (attached and tunneled) regional tissue flaps (graft of tissue with its own blood supply) or the current mainstay of free (cut and removed) tissue transfer most commonly obtained from the pectoralis major, vertical rectus abdominis myocutaneous, anterolateral thigh, fibula, or radial forearm. Laryngeal preservation is associated with better speech and verbal communication, but swallowing and aspiration issues remain common functional deficits with total glossectomy and free flap reconstruction (Han et al., 2019). Nursing Management The nurse assesses the patient\'s nutritional status preoperatively, and a dietary consultation may be necessary. The patient may require enteral (through the GI tract) or parenteral (intravenous \[IV\]) feedings before and after surgery to maintain adequate nutrition (see Chapter 41). The interprofessional team, including a registered dietician (RD), provides continual nutritional assessment and re-evaluation,\" Verbal communication may be impaired by radical surgery for oral cancer, especially if the larynx is removed. It is therefore vital to assess the patient\'s ability to communicate in writing before surgery. Pen and paper are provided postoperatively to patients who can use them to communicate. A communication board with commonly used words or pictures is obtained preoperatively and given after surgery to patients who cannot write so that they may point to needed items. Electronic devices, such as tablets or smartphones, may also be options for facilitating communication. The interprofessional team benefits from the input of a speech therapist, with physical and occupational therapists consulted as needed. Postoperatively, the priority for the nurse is assessing for and maintaining a patent airway. The patient may be unable to manage oral secretions, making suctioning necessary. If grafting was part of the surgery, suctioning is performed with care to prevent damage to the graft. Nurses assess the graft postoperatively for viability. Although color should be assessed (white may indicate arterial occlusion, and blue mottling may indicate venous congestion, it can be difficult to assess the graft by looking into the mouth. A Doppler ultra and to assess tissue perfusion. Depending on the extent of the sound device may be used into the mouth. Done graft site surgery, the patient may require a temporary or permanent tracheostomy after surgery (see Chapter 19). NURSING MANAGEMENT OF THE PATIENT WITH DISORDERS OF THE ORAL CAVITY The nurse caring for the patient with disorders of the oral cavity promotes mouth care, ensures adequate food and fluid intake, minimizes pain and discomfort, and prevents infection. Promoting Mouth Care Incidences of oral complications, such as infection, during cancer therapy may be decreased and less severe with the incorporation of professional oral care before and during cancer treatment. Guidelines, based on systematic review of the literature, support the implementation of multi-agent combination oral care protocols in patients undergoing head and neck chemotherapy and radiotherapy (radiation therapy) to prevent oral mucositis (OM), a painful inflammatory, typically ulcerative condition that is also referred to as stomatitis Although there are limited data, experts recognize that using saline or sodium bicarbonate rinses increases oral clearance, promotes oral hygiene, and promotes patient comfort (Hong, Gueiros, Fulton, et al., 2019). The nurse facilitates the patient rinsing or irrigating with a solution of 1/2 to 1 teaspoon of baking soda (or ¼-teaspoon salt) in 8 oz of warm water. The nurse reinforces the need to perform oral care and provides such care to patients who cannot provide it for themselves. Chlorhexidine has been studied more rigorously than other rinses and is generally not recommended for the prevention of OM, specifically not for patients undergoing head and neck radiotherapy (Hong et al., 2019). There is continued debate about the efficacy of magic mouthwash, particularly for chemotherapy-induced OM. The recipe for the mouthwash varies and frequently involves out-of-pocket expense for the patient, but most commonly contains diphenhydramine, aluminum-magnesium hydroxide, and viscous lidocaine, with intended mechanism of action to both numb and protect the mouth. More research needs to be done on OM treatment and prevention (Uberoi, Brown, & Gupta, 2019a, 2019b). Exciting developments regarding intra-oral photobiomodulation (PBM), specifically low-level laser therapy, show positive impact on the prevention of OM in patients with head and neck cancer undergoing radiotherapy with and without chemotherapy (Hong et al., 2019). If specific antimicrobial, antifungal, antibacterial, or antiviral agents are indicated (Maria, Eliopoulos, & Muanza, 2017), the nurse administers the prescribed medications and instructs the patient on how to administer the medications at home. The nurse monitors the patient\'s physical and psychological response to treatment. Xerostomia (dryness of the mouth) is a frequent sequela of oral cancer, particularly when the salivary glands have been exposed to radiation or major surgery. It is also seen in patients who are receiving psychopharmacologic agents, taking multiple medications, or using drugs recreationally; in patients who have rheumatic diseases, eating disorders (Villa, Nordio, & Gohel, 2015) or HIV infection; and in patients who cannot close the mouth and, as a result, breathe through the mouth instead of the nose. Current recommendations to treat xerostomia include sipping water, using oral mucosal lubricants (saliva substitutes topically applied), incorporating the use of newer edible saliva substitutes such as oral moisturizing jelly (OMJ), and taking medications that stimulate saliva production (Nuchit, Lam-ubol, & Paemuang, 2020). The hope is that providing oral moisture increases swallowing ability, and ultimately improves nutritional status for these patients. Ensuring Adequate Food and Fluid Intake Determination of nutritional intake goals requires consideration of the patient\'s weight, age, and level of activity. A daily calorie count may be necessary to determine the exact quantity of food and fluid ingested. This intake should include enteral feedings, oral intake, and supplements. The frequency of intake; presence of symptoms such as oral discomfort/pain, dysphagia, nausea; increased or decreased saliva or mucous production; and changes in taste or smell all impact the typically diminishing food intake seen in these patients. The social aspects of eating, reasonable expectations for the timing and amount of intake, and the importance of supportive people are all important considerations. Recommendations to navigate this challenging time include involving a registered dietician or other health care professional with specific nutritional expertise (Sandmæl, Sand, Bye, et al., 2019). The goal is to help the patient attain and maintain desirable body weight and level of energy, as well as to promote the healing of tissue. Supporting a Positive Self-Image A patient who has a disfiguring oral condition or has undergone disfiguring surgery may experience an alteration in self-image. The patient is encouraged to verbalize the perceived and actual change in body appearance and to realistically discuss changes or losses. The nurse offers support while the patient verbalizes fears and negative feelings (withdrawal, depressed mood, anger). The nurse listens attentively and determines the patient\'s needs and individualizes the plan of care. The nurse should determine the patient\'s concerns about relationships with others. Referral to support groups, a psychiatric liaison nurse, a social worker, or a spiritual advisor may be useful in helping the patient cope with anxieties and fears. The patient\'s progress toward development of positive self-esteem is documented. The nurse should be alert to signs of effective and ineffective grieving and should document emotional changes. By providing acceptance and support, the nurse encourages the patient to verbalize feelings. Minimizing Pain and Discomfort Oral lesions can be painful. Strategies to reduce pain and dis- comfort include avoiding foods that are spicy, hot, or hard (e.g., pretzels, nuts). A soft or liquid diet may be preferred. The patient is instructed about mouth care, including the use of a soft toothbrush and any prescribed rinses or topical medications. The patient may require an analgesic agent such as viscous lidocaine or opioids, as prescribed. The nurse can reduce the patient\'s fear of pain by providing information about pain control methods. Preventing Infection Leukopenia (a decrease in white blood cells) may result from radiation, chemotherapy, acquired immune deficiency syndrome (AIDS), and some medications used to treat HIV infection. Leukopenia reduces defense mechanisms, increasing the risk of infections. Malnutrition, which is also common among these patients, may further decrease resistance to infection. If the patient has diabetes, the risk of infection is further increased. Laboratory results should be evaluated frequently and the patient\'s temperature checked every 4 to 8 hours for an elevation that may indicate infection. Visitors who might transmit microorganisms are prohibited if the patient\'s immunologic system is depressed. Sensitive skin tissues are protected from trauma to maintain skin integrity and prevent infection. Aseptic technique is necessary when changing dressings. Desquamation (shedding of the epidermis) is a reaction to radiation therapy that can lead to a break in skin integrity and subsequent infection. Dry desquamation can be treated with topical lotions, but wet desquamation requires individualized treatment (see Chapter 12). Signs of wound infection (redness, swelling, drainage, tenderness) are reported to the primary provider. Antibiotics may be prescribed prophylactically. Promoting Home, Community-Based, and Transitional Care Educating Patients About Self-Care The patient who is recovering from treatment of an oral disorder is instructed about mouth care, nutrition, prevention of infection, and signs and symptoms of complications (see Chart 39-2). Methods of preparing nutritious foods that are seasoned according to the patient\'s preference and at the preferred temperature are explained to the patient and family. For some patients, it may be more convenient (but also more expensive) to use commercial baby foods than to prepare liquid and soft diets. The patient who cannot take foods orally may receive enteral or parenteral nutrition; the nurse should demonstrate administration techniques and facilitate a return demonstration by the patient and/or caregiver(s). For patients with oral cancer, instructions are provided in the use and care of any dentures. The importance of keeping dressings clean and the need for conscientious oral hygiene are emphasized. Continuing and Transitional Care The need for ongoing care in the home depends on the patient\'s condition. The patient, family members, and other health care team members responsible for home care (e.g., nurse, speech therapist, registered dietician/nutritionist, and psychologist) work together to prepare an individual plan of care. If suctioning of the mouth or tracheostomy tube is required, the necessary equipment is obtained and the patient and caregivers are taught how to use it. Considerations include the control of odors and humidification of the home to keep secretions moist. The patient and caregivers are educated to assess for obstruction, hemorrhage, and infection, as well as what actions to take if they occur. The nurse may provide physical care, monitor for changes in the patient\'s physical status (e.g., skin integrity, nutritional status, respiratory function), and assess the adequacy of pain control measures. The nurse also assesses the patient\'s and family\'s ability to manage incisions, drains, and feeding tubes and the use of recommended strategies for communication. The ability of the patient and family to accept physical, psychological, and role changes is assessed and addressed. Follow-up visits to the primary provider are important to Follow the patient\'s condition and to determine the need for modifications in treatment and general care. Because patients and their family members, as well as health care providers, tend to focus on the most obvious needs and issues, the nurse reminds the patient and family about the importance of continuing health promotion and screening practices and refers them to appropriate practitioners. The nurse also reinforces instructions in an effort to promote the patient\'s self-care and comfort. NECK DISSECTION Deaths from malignancies of the head and neck are primarily attributable to regional metastasis to the cervical lymph nodes in the neck and extra capsular spread, which is a specific char acteristic of regional metastasis where the malignant tumor in the lymph node extends into the surrounding connective tissue (Stack & Moreno, 2019). Metastasis, both regional and distant, occurs by way of the lymphatics before the primary lesion has been treated. This regional metastasis is not amenable to surgical resection and responds poorly to chemotherapy and radiation therapy. The cervical lymph nodes are classified as anterior or posterior and divided into anatomic regions nodal levels for classification (Gregoire, Ang, Budach, et al., 2014; Stack & Moreno, 2019) (see Fig. 39-3). A radical neck dissection involves removal of all cervical lymph nodes from the mandible to the clavicle and removal of the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve on one side of the neck. The associated complications include shoulder drop/dysfunction and poor cosmesis (visible neck depression). Because drop/dysfunction mortality and known complications, a radical neck dissection is now only performed when the extent and growth pattern of the cancer require aggressive the intervention. Modified radical-neck dissection, which preserves one or more of the nonlymphatic structures (internal jugular vein, sternocleidomastoid muscle, and the spinal accessory nerve) is used more often. A selective neck dissection (in comparison to a radical neck dissection or modified radical neck dissection) preserves one or more of the lymph node groups that are typically removed in a radical neck dissection. The selective neck dissection is the treatment usually used in oral cavity cancer for patients who are infected with HPV (Sabatini & Chiocca, 2019; Stack & Moreno, 2019) (see Fig. 39-4). Reconstructive techniques may be performed with a variety of grafts. A cutaneous flap (skin and subcutaneous tissue), such as the deltopectoral flap, may be used. A myocutaneous platysma flap (subcutaneous tissue, muscle, and skin) is a more frequently used graft; the pectoralis major muscle is usually used. For large grafts, a microvascular free flap may be used. This involves the transfer of muscle, skin, or bone with an artery and vein to the area of reconstruction, using microinstrumentation. Areas used for a free flap include the scapula, the radial area of the forearm, or the anterolateral thigh (Stack & Moreno, 2019). NURSING PROCESS The Patient Undergoing a Neck Dissection Assessment Preoperatively, the patient\'s physical and psychological preparation for major surgery is assessed, along with the patient\'s knowledge of the preoperative and postoperative procedures. Postoperatively, the patient is assessed for altered respiratory status, wound infection, and hemorrhage. As complications such as healing occurs, nutritional support is provided and neck range of motion is assessed to determine whether there has been a decrease in range of motion due to nerve or muscle damage. Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Lack of knowledge about preoperative and postoperative procedures Impaired airway clearance associated with obstruction by mucus, hemorrhage, or edema Acute pain associated with surgical incision Impaired tissue integrity secondary to surgery and grafting Impaired nutritional status associated with disease pro- cess or treatment Risk for situational low self-esteem associated with diagnosis or prognosis Risk for caregiver stress associated with physical and emotional effects of disease and related surgical procedure Impaired verbal communication secondary to surgical resection Impaired mobility secondary to nerve injury COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications include the following (Stack & Moreno, 2019): Hemorrhage, including hematoma formation, and rupture (\"blowout\") of the internal jugular vein (IJV) or carotid artery Chyle leak, a lymphatic leak in the thoracic duct Neurologic complications, including stroke and nerve injury (spinal accessory, marginal mandibular, vagus, phrenic, hypoglossal, lingual, brachial plexus) Planning and Goals The major goals for the patient include increased knowledge of surgical procedure and treatment plan, maintenance of respiratory status, decreased pain, viability of the graft, maintenance of adequate intake of food and fluids, effective coping strategies (for patient and caregivers), effective communication, maintenance of shoulder and neck motion, and absence of complications. Nursing Interventions PROVIDING PREOPERATIVE PATIENT EDUCATION Before surgery, the patient should be informed about the nature and extent of the surgery and what to expect in the postoperative period. Preoperative education addresses interventions that cover the entire perioperative period. As part of the informed consent process, the patient should be made aware of the potential/actual risks and benefits of the procedure as well as other treatment options, and the projected out- come if the procedure is not done. The patient is encouraged to ask questions and to express concerns about the upcoming surgery and the expected results. During this exchange, the nurse has an opportunity to assess the patient\'s coping abilities, answer questions, and develop a plan for offering assistance. A sense of mutual understanding and rapport make the postop- erative experience less traumatic for the patient. The patient\'s expressions of concern, anxieties, and fears guide the nurse in providing support postoperatively. PROVIDING GENERAL POSTOPERATIVE CARE The general postoperative nursing interventions are similar to those presented in Chapter 16 and are directed toward the identified nursing diagnoses and goals. MAINTAINING AIRWAY CLEARANCE After the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in the Fowler position to facilitate breathing and promote comfort. This position also increases lymphatic and venous drainage, facilitates swallowing, decreases venous pressure on the skin flaps, and prevents regurgitation and aspiration of stomach contents. If the patient has a tracheostomy, the nurse performs focused assessment and care of the stoma (see Chapter 19). Signs of respiratory distress, such as dyspnea, cyanosis, changes in mental status, and changes in vital signs, are assessed because they may suggest edema, hemorrhage/hematoma formation, inadequate oxygenation, or inadequate drainage. Pneumonia may occur in the postoperative phase if pulmonary secretions are not removed. To aid in the removal of secretions, coughing and deep breathing are encouraged. With the nurse supporting the neck, the patient should assume a sitting position so that excessive secretions can be coughed up and expectorated. If this is ineffective, the patient\'s respiratory tract may have to be suctioned. Care is taken to protect the suture lines during suctioning. If a tracheostomy tube is in place, suctioning is performed through the tube. The patient may also be instructed on use of Yankauer suction (tonsil-tip suction) to remove oral secretions. Humidified air or oxygen is provided through the tracheostomy to keep secretions thin. Temperature should not be taken orally. RELIEVING PAIN The nurse assesses and manages pain and the patient\'s fear of pain. Patients with head and neck cancer often report less pain than patients with other types of cancer; however, the nurse needs to be aware that each person\'s pain experience is different. The nurse works with the patient to establish reasonable pain goals and creates an interprofessional plan to meet those mutually defined goals. Patient-controlled analgesia may be prescribed for postoperative pain management (see Chapters 9 and 16). PROVIDING WOUND CARE Wound drainage tubes are usually inserted during surgery to prevent the collection of fluid subcutaneously. The drainage tubes are connected to a portable suction device (e.g., Jackson. Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Excessive drainage may be indicative of a chyle fistula or hemorrhage (see later discussion). Dressings are reinforced as needed and are observed for evidence of hemorrhage and constriction, which impair respiration and perfusion of the graft. A graft, if present, is assessed for color and temperature and for the presence of a pulse, if applicable, to determine viability. The graft should be pale pink and warm to the touch. The surgical incisions are also assessed for signs of infection (purulent, malodorous drainage), which are reported immediately. Prophylactic antibiotics may be pre- scribed in the early postoperative period. Aseptic technique is used when cleansing skin around the drains; dressings are changed as prescribed by the surgeon, usually on the second through the fifth postoperative days. Care should be taken to not apply excessive pressure to the surgical site in order to not impair flap perfusion and viability (Hudson & Carr, 2020). If radiation is planned (either with or without chemotherapy), brachytherapy catheters are inserted intraoperatively (Stack & Moreno, 2019). MAINTAINING ADEQUATE NUTRITION The interprofessional team assesses the patient\'s nutritional status preoperatively; early intervention to correct nutritional imbalances may decrease the risk of postoperative complications. Frequently, nutrition is less than optimal because of inadequate intake and nutritional support is required before surgery or the start of radiation due to the psychological stress of the cancer diagnosis, the location of the tumor(s), and diagnostic procedures. Prophylactic nutritional support using a tube feeding is common and may prevent weight loss, reduce fluid imbalances, decrease hospitalizations, and increase treatment tolerance (Sandmæl et al., 2019). Supplements that are nutritionally dense may help re-establish a positive nitrogen balance. They may be taken enterally by mouth, by a nasogastric (NG) feeding tube, or by a gastrostomy feeding tube (see later discussion). The patient who can chew may take food by mouth; the patient\'s chewing ability determines whether some diet modification (e.g., soft, puréed, or liquid foods) is necessary. Food preferences should also be discussed with the patient. Oral care before eating may enhance the patient\'s appetite, and oral care after eating is important to prevent infection and dental caries. SUPPORTING PATIENT SELF-ESTEEM AND THE NEEDS OF CAREGIVERS Preoperatively, information about the planned surgery is given to the patient and family. Any questions are answered as accurately as possible. Postoperatively, psychological nursing interventions are aimed at supporting the patient who has had a change in body image or who has major concerns related to the prognosis. The patient may have difficulty com- municating and may be concerned about having the ability to breathe and swallow normally. Head and neck cancer recovery is unique in that the patient\'s behavioral issues (e.g., HPV infection status, alcohol, smoking) often directly relate to the underlying cause of the cancer. The psychological adaptation required after a disfiguring surgery, and the social complications inherent in swallowing and speech are profound. The patient-caregiver dyad is often considered a single unit, which reinforces the need to consider both entities, as well as their interrelationship (Dri, Bressan, Cadorin, et al., 2019). The person who has had extensive neck surgery often is sensitive about their appearance. This can occur when the operative area is covered by bulky dressings, when the incision line is visible, or later after healing has occurred and the appearance of the neck and possibly the lower face has been significantly altered. If the nurse accepts the patient\'s appearance and expresses a positive, optimistic attitude, the patient is more likely to be encouraged. The patient also needs an opportunity to express fears and concerns regarding the success of the surgery and the prognosis. The American Cancer Society (ACS) may be a resource to provide a volunteer who meets with the patient either preoperatively or postoperatively and shares their own experience about the diagnosis, treatment, and recovery. The Look Good Feel Better programs of the ACS provide information about clothing and cosmetics that can be used to improve body image and self-esteem (see the Resources section at the end of this chapter). People with cancer of the head and neck frequently have used alcohol or tobacco before surgery; postoperatively, they are encouraged to abstain from these substances. Alternative methods of coping need to be explored. A referral to Alcoholics Anonymous, a smoking cessation program, and family counseling may be appropriate. PROMOTING EFFECTIVE COMMUNICATION Communication plans begin preoperatively, when the patient and family determine which method of communication will be the best postoperatively. Useful communication methods for the patient who has undergone a laryngectomy include dry-erase boards, writing materials, pictorial guides, computer aids, smart phones, tablets, and hand signals. During the post- operative period, the call bell must be readily accessible to the patient at all times. For the patient who is intubated and mechanically ventilated postoperatively, not being able to communicate well can result in anxiety, depression, and frustration, which can lead to prolonged stress and increased hospitalization (Koszalinski, Heidel, & McCarthy, 2020). (See the Nursing Research Profile in Chart 39-3.) The nurse obtains a consultation with a speech-language pathologist. Alternative speech techniques, such as a voice prosthesis or esophageal speech, may be taught by a speech- language pathologist (see Chapter 18). MAINTAINING PHYSICAL MOBILITY Excision of the sternocleidomastoid muscle and spinal accessory nerve results in weakness at the shoulder that can cause shoulder drop, which is a forward curvature of the shoulder. Many problems can be avoided with a conscientious exercise program. These exercises are usually started in collaboration with a physical therapist after the drains have been removed and the neck incision is sufficiently healed. The purpose of the exercises depicted in Figure 39-5 is to promote maximal shoulder function and neck motion after surgery. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Hemorrhage. Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. This can result in frank bleeding or the formation of a hematoma. The following measures are indicated: Vital signs are assessed frequently (every 1 to 2 hours or every 15 minutes if the patient is critical). Once the patient is stabilized, assessment is performed every 4 hours. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock (see Chapter 11 for discussion of treatment of hypovolemic shock). The patient is instructed to avoid the Valsalva maneuver to prevent stress on the graft and carotid artery. Signs of impending rupture, such as high epigastric pain or discomfort, are reported. Dressings and wound drainage are observed for excessive bleeding. If hemorrhage occurs, assistance is summoned immediately. Hemorrhage requires the continuous firm application of pressure to the bleeding site or major associated vessel. The head of the patient\'s bed should be elevated at least 30 degrees to maintain airway patency and prevent aspiration. A controlled, calm manner allays the patient\'s anxiety. The surgeon is notified immediately, because a vascular or ligature tear requires surgical intervention. Chyle Leak. A chyle leak (milklike, lymphatic fluid drainage from the thoracic duct into the thoracic cavity) may develop as a result of damage to the thoracic duct during surgery. Although not very common (3% to 5.7% of cases), this leak may be recognized during surgery (where it can be repaired immediately) or in the postoperative setting, especially when oral intake begins. If a chyle leak is suspected postoperatively, conservative measures to limit increases in intrathoracic pressure will reduce the flow of chyle fluid in the thoracic duct. Recommended interventions include inítiating enteral feeding or supporting a low fat diet focused on the intake of small- and medium-chain fatty acids (chylous fluid is formed from long-chain fatty acids). Medium-chain triglycerides/fats, like those found in coconut oil, are metabolized in the liver into ketones to provide energy without the formation of chyle. Other interventions include fluid and electrolyte replacement, activity restriction, head of bed elevation, stool softeners (to prevent straining), and occasionally, pressure dressings. Providers often prescribe octreotide, a synthetic analogue of the natural hormone somatostatin, that works primarily by inhibiting the release of gastrointestinal hormones that regulate digestion and absorption, thereby reducing lymph flow and decreasing the chyle flow (Rudrappa & Paul, 2019; Stack & Moreno, 2019). Nerve Injury. Nerve injury can occur if the spinal accessory, marginal mandibular (branch of the facial nerve), vagus, phrenic, hypoglossal, lingual, or brachial plexus nerves are severed or injured during surgery. Because lower facial paralysis may occur as a result of injury to the facial nerve, this complication is observed for and reported. The patient with nerve damage may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis, impaired tongue movement, or vagus nerve injury. Speech therapy may be indicated to assist with the problems related to nerve injury. Shoulder dysfunction is most common in radical neck dissection and often requires extensive physical rehabilitation. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. The patient and caregiver require instructions about management of the wound, the dressing, and any drains that remain in place. Patients who require oral suctioning or who have a tracheostomy may be very anxious about their care at home; the transition to home can be eased if the caregiver is given several opportunities to demonstrate the ability to meet the patient\'s needs (see Chart 39-4). The patient and caregiver are also instructed about possible complications, specifically bleeding and respiratory distress, and when to notify the primary provider. If the patient cannot take food by mouth, detailed instructions and demonstration of enteral or parenteral feedings will be required. Education in techniques of effective oral hygiene is also important. Continuing and Transitional Care. A referral for home, community-based, or transitional care may be necessary in the early period after discharge. The nurse assesses healing, ensures that feedings are being given properly, and monitors for any complications. The patient\'s adjustment to changes in physical appearance and status and ability to communicate and eat normally is also assessed. Physical and speech therapy also are likely to be continued at home. The patient is given information regarding local support groups such as \"New Voice Club,\" if indicated. The local chapter of the ACS may be contacted for information and equipment needed for the patient (see the Resources section). Evaluation Expected patient outcomes may include: 1\. Exhibits increased knowledge of course of treatment 2\. Demonstrates adequate respiratory exchange a\. Lungs are clear to auscultation b\. Breathes easily with no shortness of breath c\. Demonstrates ability to use suction effectively 3\. Verbalizes comfort and relief of pain 4\. Graft is pink and warm to touch 5\. Maintains adequate intake of foods and fluids a\. Accepts altered route of feeding b\. Is well hydrated c\. Maintains or gains weight 6\. Demonstrates ability to cope (both patient and caregivers) a\. Discusses emotional responses to the diagnosis b\. Utilizes available support 7\. Communicates effectively with caregivers and family members 8\. Attains maximal mobility a\. Adheres to physical therapy exercises b\. Attains maximal range of motion 9\. Exhibits no complications a\. Vital signs stable b\. No excessive bleeding or discharge c\. Able to move muscles of lower face and shoulders DELIVERING NUTRITION ENTERALLY Feeding via the enteric route infers that the intestines are receiving nutrients. Thus, delivering enteral nutrition refers to infusing nutritional formula feedings through a tube directly into the GI tract. The nurse plays a key role in ensuring that patients prescribed this therapy achieve nutritional balance sufficient to meet their metabolic needs. Nursing Management Administering Tube Feedings Tube feedings are given to meet nutritional requirements when oral intake is inadequate or not possible and the GI tract is functional. The feedings are delivered to the stomach, duodenum, or proximal jejunum and help preserve Gl integrity by preserving normal intestinal and hepatic metabolism. Tube feedings have several advantages over parenteral nutrition: they are lower in cost, safer, usually well tolerated by the patient, and easier to use in extended care facilities and in the patient\'s home. When possible, the physiological-ndin preference is to feed the gut. efasoduodenal or nasojejunal feeding is indicated when the esophagus and stomach need to be bypassed or when the patient is at risk for aspiration (i.e., inhalation of fluids or foods into the trachea and bronchial tree). For tube feedings longer than 4 weeks, gastrostomy or jejunostomy tubes are preferred for administration of medications or nutrition. Indications for enteral nutrition are summarized in Table 39-2. Osmolality The osmolality of normal body fluids (i.e., concentration) is approximately 300 mOsm/kg. The body attempts to keep the osmolality of the contents of the stomach and intestines at this level. Osmolality is an important consideration for patients receiving tube feedings through the duodenum or jejunum because feeding formulas with a undesirable effects. For example, when a concentrated solution high osmolality may lead to of high osmolality entering the, when a concentrate quickly of in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The patient may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, collectively termed dumping syndrome. Dumping syndrome can lead to dehydration, hypotension, and tachycardia. Patients fed by the small intestinal route vary in the degree to which they tolerate the effects of high osmolality; the nurse needs to be knowledgeable about the patient\'s formula and take steps to prevent this undesired effect. The small intestines may be able to adapt to a formula of high osmolality if it is initiated at a low hourly rate that is advanced slowly (Seres, 2019). Formulas The choice of formula to be delivered by tube feeding is influ- enced by the status of the GI tract and the nutritional needs of the patient. Formula characteristics that are considered include the chemical composition of the nutrient source (protein, carbohydrates, fat), caloric density, osmolality, fiber content, vitamins, minerals, electrolytes, and cost. Enteral formulas contain 70% to 85% free water and are not designed to meet total fluids needs (Seres, 2019). A wide variety of containers, delivery systems, and enteral pumps are available for use with tube feedings. Various tube feeding formulas are available commercially. Polymeric formulas are the most common and are composed of protein (10% to 15%), carbohydrates (50% to 60%), and fats (30% to 35%). Standard polymeric formulas are undigested and require that the patient has relatively normal digestive function and absorptive capacity. Specialty formulas may be prescribed to treat disease-specific disorders (e.g., diabetes), organ-specific disorders (e.g., renal, pulmonary, or hepatic), sepsis, or trauma, or to support wound-healing or immune-modulation. Chemically defined or pre-digested formulas contain easier-to-absorb nutrients. Modular products contain only one major nutrient, such as protein, and are used to enhance commercially prepared products. Fiber, either premíxed in or added to formulas, helps bulk the stool to decrease the occurrence of both diarrhea and constipation (McClave, Taylor, Martindale, et al., 2016). Some feedings are given as supplements, and others are given to meet the patient\'s total nutritional needs. Registered dietitians (RD), registered dietitian nutritionists (RDN), and certified nutrition support clinicians collaborate with primary providers and nurses to determine the best formula for each patient. The volume of formula delivered varies depending on the caloric density of the formula and the energy needs of the patient. The overall goal is to achieve positive nitrogen balance and weight maintenance or gain without producing discomfort or diarrhea. Administration Methods The tube feeding method chosen depends on the location of the tube in the GI tract, patient tolerance, convenience, and cost. Large-bore (larger than 12-Fr) nasogastric (NG) tubes can be uncomfortable and their usefulness for tube feedings is limited; however, they may be used for administration of short-term feedings (Mueller, 2017). Small-bore (Dobhoff) tubes that are typically inserted into the jejunum with a guide- wire and manufactured for tube feedings, are better tolerated for up to 6 weeks; however, they require diligent monitoring and frequent flushing to remain patent. Bolus and intermittent drip tube feeding methods are practical and inexpensive options for the patient receiving tube feedings who resides at home or in a long-term care facility; how- ever, these methods may be poorly tolerated in patients who are acutely ill. Bolus infusion requires dividing the total daily feeding volume into 4 to 6 feeds throughout the day. Boluses can be given into the stomach through a large (50-mL) syringe via gravity (see Fig. 39-6). The typical volume is 200 to 400 mL of feeding over a 15- to 60-minute period, but these parameters should be outlined in the provider\'s prescription (Bischoff et al., 2020; Boullata et al., 2017). Bolus feedings can be delivered as quickly as the patient can tolerate them, but are initiated slowly, increasing the rate as tolerated. With gravity feedings, raising or lowering the syringe above the abdominal wall regulates the rate of flow. The amount and flow rate is often deter- mined by the patient\'s reaction. If the patient feels full, it may be desirable to slow the delivery time or give smaller volumes more frequently. The intermittent gravity drip feeding method requires administering feedings over 30 minutes or longer at designated intervals by a reservoir enteral bag and tubing, with the flow rate regulated by a roller clamp or automated pump. Continuous feeding is the delivery of feedings incrementally by a slow infusion over long periods. Slow drip feedings are recommended for patients who are critically ill, patients at high risk for aspiration, patients at risk for intolerance (e.g., patients with pancreatitis), and for small bowel feedings (Boullata, Carrera, Harvey, et al., 2017). Enteral feeding pumps control the delivery rate of the formula (see Fig. 39-7). They allow for a constant flow rate and can infuse a viscous formula through a small-diameter feeding tube. However, they do not allow the patient as much flexibility as intermittent feedings. Portable lightweight enteral pumps are available for home use. In addition, feeding pumps have built-in alarms that signal when the bag is empty, the battery is low, or the tube is occluded. The patient and caregiver need to be aware of these alarms and know how to troubleshoot the pump. An alternative to the continuous infusion method is cyclic feeding, in which the infused feeding is given by an enteral feeding pump over 8 to 18 hours. Feedings may be infused at night to avoid interrupting the patient\'s lifestyle. Cyclic infusions may be appropriate for patients who are being weaned from tube feedings to an oral diet, for patients who cannot eat enough and need supplements, and for patients at home who need daytime hours free from the pump. Key assessment findings for patients receiving tube feedings are noted in Chart 39-5. COVID-19 Considerations Patients hospitalized with severe coronavirus disease (COVID-19) pneumonia and respiratory failure necessitating intubation and mechanical ventilation may require the delivery of enteral nutrition (see Chapter 19 for further discussion of severe COVID-19 pneumonia). Guidelines developed by the American Society for Parenteral and Enteral Nutrition (ASPEN) stipulate that enteral nutrition should be initiated for these patients within 36 hours of admission to the intensive care unit (Martindale, Patel, Taylor, et al., 2020). These guidelines should be implemented unless the decision has been made that the patient receives end-of-life palliative. Large-bore nasogastric tubes are the preferred route of delivery, these can be placed rapidly and are less prone to clogging compared to small-bore nasoduodenal or nasojejunal feeding tube. Therefore, there is less risk of contamination for nurses and other providers responsible for inserting or manipulating the feeding tubes (Martindale et al., 2020). However, inserting a nasogastric feeding tube still incurs risk. Placement of a nasogastric feeding tube can generate a cough, which can produce sputum; consequently, placing a nasogastric tube is considered an aerosol-generating procedure. When inserting a nasogastric tube in a patient with known or suspected COVID-19, whether for feeding or for decompression, the nurse should wear appropriate personal protective equipment (PPE) (see Chapter 66 for description of PPE) (Anderson, 2020). In addition, if possible, the patient\'s mouth should be covered with a mask during the procedure (Martindale et al., 2020). The feedings should be delivered as continuous rather than bolus infusions (Martindale et al., 2020). Many patients with severe COVID-19 pneumonia who are intubated and mechanically ventilated experience an improvement in their respiratory status when they are placed in the prone position (see Chapter 19); however, if they are also receiving enteral nutrition, they are at greater risk for aspiration in this position. These patients should be placed in reverse Trendelenburg, with their heads elevated 10 10 25 degrees, to minimize this risk (Martindale et al., 2020) Some experts also advocate that feedings be held for 1 hour prior to the patient being moved into the prone position, to further reduce the risk of aspiration (Anderson, 2020, Arkin, Krishnan, & Chang, 2020). Maintaining Feeding Equipment and Nutritional Balance The temperature and volume of the feeding, the flow rate, and the patient\'s total fluid intake are important factors to consider when tube feedings are given. The schedule of tube comings, including the correct quantity and frequency, is maintained. The nurse must carefully monitor the drip rate and avoid administering fluids too rapidly. For patients receiving tube feedings, measuring gastric residual volumes (GRVs) by removing gastric contents with a large syringe at routine intervals has been a commonly prescribed practice. However, the usefulness of measuring GRVs has not been validated by research; furthermore, this practice may cause clogging of gastric tubes (Boullata et al., 2017). Previously, GRV in excess of 250 to 500 mL had been thought to indicate feeding intolerance. Other indicators of feeding tolerance that the nurse needs to consider include abdominal distention, patient reports\_of discomfort, vomiting, hypoactive bowel sounds, changes in passing flatus, and presence of diarrhea (McClave et al., 2016). The most recent guidelines for assessment and provision of nutrition in the patient who is critically ill, authored by the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN), do not advocate using GRVs to monitor tolerance of enteral feedings (McClave et al., 2016). Research findings show that GRVs between 250 and 500 mL did not increase the incidence of vomiting, aspiration, or pneumonia (McClave et al., 2016). Although feedings should not routinely be held if residuals are 250 to 500 mL, measures to decrease the risk of aspiration should be implemented (Boullata et al., 2017; McClave et al., 2016). If agency protocols and policies include assessing GRV as part of routine care, research and guidelines support holding the feeding for 2 hours only if the GRV is greater than 500 mL (Boullata et al., 2017; McClave et al., 2016). Growing evidence supports moving away from routine assessment of GRVs (Seres, 2019). Maintaining tube function is an ongoing responsibility of the nurse, patient, primary provider, and caregiver. To ensure patency and to decrease the chance of bacterial growth, sludge build-up, or occlusion of the tube, at least 30 mL of water flush is recommended for adults receiving tube feedings in each of the following instances (Bischoff, Austin, Boeykens, et al., 2020; Boullata et al., 2017): Before and after intermittent tube feeding Before and after medication administration (see later discussion) After checking for gastric residuals (if required by pol- icy) and gastric pH Every 4 hours with continuous feedings When the tube feeding is discontinued or interrupted for any reason Water used to flush these tubes must be recorded as fluid intake. Although distribution (i.e., tap) or drinking (i.e., distribution and bottled) water can be used for flushes, the likelihood of contamination with pathogens must be considered. Purified (contaminant free; distillation or ultrafiltration) or sterile (purified water free of microorganisms and pyrogens) should be used for medication preparation. The use of sterile water is considered best practice for patients who are immunocompromised and for reconstitution of powdered formula (Bischoff et al., 2020; Boullata et al., 2017). Potential complications of enteral therapy are noted in Table 39-3. Providing Medications by Tube When different types of medications are prescribed, a bolus method is used for administration that is compatible with the medication\'s preparation. The feeding is paused, and the tube is flushed with at least 15 mL of water before and at least 15 mL of water after medication administration (30 mL total). Each medication should be prepared and administered separately, with a 15-mL flush provided between medications. When small-bore feeding tubes for continuous infusion are irrigated after administration of medications, a 20-mL or larger syringe is used because the pressure generated by smaller syringes could rupture the tube. Nursing judgment is required to individualize care; institutional protocols and pharmacist input should guide the primary provider\'s prescriptions regarding medication choices and route of delivery. Consideration needs to be given to preparations (tablets that can be crushed/dissolved; availability of elixirs), absorption (e.g., some medications bind to enteral feedings, location of distal end of tube in the stomach or jejunum), and the patient\'s fluid volume status (i.e., increased number of medications necessitates increases in the flush/water that is administered). Maintaining Delivery Systems Tube feeding formula is delivered to patients by either an open or a closed system. The open system is packaged as a liquid or a powder to be mixed with water that is either poured into a feeding container or given by a large syringe. The feeding container (which is hung on a pole) and the tubing used with the open system should be changed every 24 hours (Bischoff et al., 2020; Boullata et al., 2017). The open system can be used for bolus feedings, intermittent feedings, or continuous drip feedings and can be delivered by push (with a syringe and plunger), gravity (syringe with plunger removed or gravity bag with roller clamp), or pump. To avoid bacterial contamination, the formula hang time in the bag at room temperature should never exceed what the formula manufacturer recommends, which is usually no more than 4 to 8 hours. Closed delivery systems use a prefilled, sterile container of about 1 L of formula that is spiked with enteral tubing and allows a typical hang time of 24 hours at room temperature. The closed delivery system must always use a pump to control formula rate in order to avoid dispensing a large formula volume in a short period of time. Closed systems lower the risk of infection from bacterial contamination (Boullata et al., 2017) Maintaining Normal Bowel Eliminatio Patients receiving gastric or enteric tube feedings can expe- rience diarrhea or constipation. Possible causes of diarrhea include: Intolerance to enteral nutrition, related to underlying disease Malnutrition: A decrease in the intestinal absorptive area can cause diarrhea Medication therapy: Elixir-based medications often contain sorbitol, which can act as a cathartic Magnesium-acts as a cathartic Antibiotics thought to alter normal intestinal flora, allowing pathogenic bacteria to flourish Clostridium difficile (C. difficile) colitis: Can result after antibiotic use alters normal intestinal flora and pro- motes the abnormal growth of this potentially dangerous microbe; C. difficile colitis occurs most commonly in patients who are hospitalized (Read, Olson, & Calderwood, 2020) Zinc deficiency: Zinc is lost with diarrhea, and zinc deficiency can then cause continued diarrhea Concomitant lactose intolerance Concomitant hyperthyroidism Dumping syndrome: Formula is infused into the small intestine quickly or formula bypasses the stomach too readily into the small intestine and causes expansion of the intestinal wall. This leads to bloating, cramping, diarrhea, dizziness, diaphoresis, and weakness. Measures for managing the GI symptoms associated with dumping syndrome are presented in Chart 39-6. Contamination of the formula and feeding equipment with diarrhea-causing pathogens (Boullata et al., 2017) Possible causes of constipation include: Inadequate water intake: Tube feedings typically do not meet total fluid needs and additional water needs to be given. Administration of fiber-free tube feeding formulas Concomitant use of opioids Maintaining Adequate Hydration The nurse carefully monitors hydration because in many cases the patient cannot communicate the need for water. Water flushes are given every 4 hours and after feedings to prevent hypertonic dehydration. The feeding may be initially given as a continuous drip in order to help the patient develop tolerance, especially for hyperosmolar solutions. Key nursing interventions include observing for signs of dehydration (e.g., dry mucous membranes, thirst, decreased urine output); administering water routinely; and monitoring intake and output, residual volume, and fluid balance. Promoting Coping Ability The psychosocial goal of nursing care is to support and encourage the patient to accept physical changes and to con vey hope that daily progressive improvement is possible. If the patient is having difficulty adjusting to the treatment, the nurse intervenes by encouraging self-care within the parameters of the patient\'s activity level. In addition, the nurse reinforces an optimistic approach by identifying indicators of progress (daily weight trends, electrolyte balance, absence of nausea and diarrhea, improvement in plasma proteins). Promoting Home, Community-Based, and Transitional Care Educating Patients About Self-Care Patients who require long-term tube feedings may have had recent surgery, dysphagia due to a neuromuscular disease, head and neck cancer, radiation or other types of trauma to the throat, an obstruction of the upper Gl tract, GI cancer and other malignancies, GI disease (including malabsorptive syndromes), or decreased level of consciousness. For a patient to be considered for tube feeding at home, the patient should: Be medically stable and successfully tolerating at least 60% to 70% of the feeding regimen Be capable of self-care or have a caregiver willing to assume the responsibility Have access to supplies and interest in learning how to administer tube feedings at home Preparation of the patient for home administration of enteral feedings begins while the patient is still hospitalized. The nurse should educate the patient and caregiver while administering the feedings so that they can observe the mechanics and participate in the procedure, ask questions, and express any concerns. Before discharge, the nurse provides information about the equipment needed, formula purchase and storage, and administration of the feedings and water flushes (frequency, quantity, rate of instillation). Family members who will be active in the patient\'s home care are encouraged to participate in education sessions. Available printed information about the equipment, the formula, and the procedure is reviewed. Arrangements are made to obtain the equipment and formula and have it ready for use before the patient\'s discharge. Continuing and Transitional Care Referral to home, community-based, or transitional care is important so that a nurse can supervise and provide support during the first tube feedings at home. Additional visits will \^ depend on the skill and comfort of the patient or caregiver in administering the feedings. During all visits, the nurse monitors the patient\'s physical status (weight, hydration status, vital signs, activity level) and the ability of the patient and family to administer the tube feedings correctly and assess the enteral access device and site. Enteral access devices require periodic replacement, and the nurse should be sure that the patient and caregiver have the necessary information to set up these tube replacement appointments. In addition, the nurse assesses for any complications. The patient or caregiver is encouraged to record times and amounts of feedings and water flushes, bowel patterns, and any symptoms that occur. The nurse can review the record with the patient and caregiver during home visits. Gastrostomy and Jejunostomy A gastrostomy is a procedure in which an opening is created into the stomach either for the purpose of administering nutrition, fluids, and medications via a feeding tube, or for gastric decompression in patients with gastroparesis, gastroesophageal reflux disease, or intestinal obstruction. A gastrostomy is preferred over a nasally inserted tube to deliver enteral nutrition support longer than 4 to 6 weeks (Bischoff et al., 2020; Boullata et al., 2017). Gastrostomy is also preferred over nasogastric or orogastric feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely. Placement involves creation of a stoma, an artificially created opening, that houses the tube. Insertion of a percutaneous endoscopic gastrostomy (PEG) requires the services of a provider skilled in endoscopy, utilizes moderate sedation, and takes approximately 15 to 20 minutes. A lighted endoscope is inserted through the mouth into the stomach. Once in the stomach, the light indicates the location for hollow needle and guidewire insertion into the stomach. The wire is pulled back through the mouth, then the PEG tube itself is attached to the wire to guide the PEG tube as it moves into the mouth, down the esophagus, into the stomach, and out the incision in the abdominal wall. An internal fixation bolster, often called a bumper, is pulled snug against the stomach wall. An external retention disc/ phalange sits close to the abdominal surface. The tension between the external and internal fixation bolsters keeps the tube in place (see Fig. 39-8A). A radiologically inserted gastrostomy tube (RIG) can be placed fluoroscopically by a skilled provider when an endoscope cannot be passed through a strictured or obstructed esophagus. The RIG is internally sutured and held in place by an internal balloon that is inflated with a small amount of water (Anderson, 2019; Thompson, 2017). Feeding can be initiated via PEG tubes within several hours (≤4 hours) of placement. The stomal tract will take 30 to 90 days to mature, so replacement should not occur until at least 30 days after placement. Manufacturer guidelines should be followed for replacement of tubes, but deterioration or dysfunction, a ruptured balloon, stomal tract disruption, non- healing ulcers, or fistula formation may accelerate this recommended time frame. With optimal care, tubes may last 1 to 2 years; however, most policies encourage preventative maintenance that includes elective changing of the balloon gastrostomy tube every 3 to 6 months (Boullata et al., 2017). An alternative to standard gastrostomy tubes that are bulky are low-profile gastrostomy devices (see Fig. 39-8B). Specific types of low-profile gastrostomy devices include the MIC-KEY or the -Bard Button. These devices are flush with the skin, eliminate the possibility of inward tube migration, have antireflux valves to prevent gastric leakage, and do not require tape or other securement devices (Boullata et al., 2017). Patients requiring enteral nutrition support can conceal the feeding tube access site under their clothing. Low-profile gastrostomy devices require special connection tubing so they can be attached to the feeding container. Patients must be instructed to bring this connection tubing with them when traveling, going to the emergency department or hospital, or undergoing diagnostic procedures that require access into the GI tract. A jejunostomy is a surgically, endoscopically (percutaneous gastrojejunostomy or jejunal; PEJ), or radiologically placed opening into the jejunum for the purpose of administering nutrition, fluids, and medications. A jejunostomy tube is indicated when the gastric route is not accessible, or to decrease aspiration risk when the stomach is not function- ing adequately to process and empty food and fluids. These tubes either have an internal balloon or dacron cuff, or are sutured externally to secure them. Unlike the gastrostomy tubes, jejunostomy tübes should not be rotated and only last between 6 to 9 months (Anderson, 2019; Boullata et al., 2017). The small intestine can also be accessed by placing a jejunal extension tube through an existing gastrostomy tube and manipulating it through the pylorus into the small intestine endoscopically, fluoroscopically, or during a surgical procedure this is referred to as a gastrojejunostomy tube. NURSING PROCESS The Patient with a Gastrostomy or Jejunostomy Assessment The focus of the preoperative assessment is to determine the patient\'s ability to understand and cooperate with the procedure. The nurse assesses the ability of both patient and family to adjust to a change in body image and to participate medical and the patient, the caregivers, and the primary provider should discuss together. The purpose of the procedure and expected postoperative course should be explained. The patient needs to know that the feeding tube will bypass the mouth and esophagus so that liquid feedings can be given directly into the stomach or intestine. If the feeding tube is expected to be permanent, the patient should be made aware of this. If the procedure is being performed to relieve discomfort, prolonged vomiting, debilitation, or an inability to eat, the patient may find the feeding tube more acceptable. In the postoperative period, the patient\'s fluid and nutritional needs are assessed to ensure proper intake and GI function. The nurse inspects the tube for proper maintenance and the incision for any drainage, skin breakdown, or signs of infection. As the nurse evaluates patients\' responses to the change in body image and their understanding of the feeding methods, interventions are identified to help them cope with the tube and learn self-care measures. Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Impaired nutritional status Risk for infection associated with presence of wound and tube Risk for impaired skin integrity at tube insertion site Disturbed body image associated with presence of tube COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following (Anderson, 2019): Wound infection, cellulitis, and leakage GI bleeding Premature dislodgement of the tube Tube obstruction/clogging Planning and Goals The major goals for the patient may include achieving nutritional requirements, preventing infection, maintaining skin integrity, adjusting to changes in body image, and preventing complications. Nursing Interventions MEETING NUTRITIONAL NEEDS The first fluid nourishment is given soon after tube insertion and can consist of a sterile water or normal saline flush of at least 30 mL. Formula feeding can begin as prescribed, typically within 4 hours post tube insertion. The infusion rate or bolus amount given is gradually increased. If the tube has been placed for gastric drainage, it can be connected to either low intermittent suction or to a gravity drainage bag. This drainage should be measured and recorded because it is a significant indicator of GI function. A decrease in the amount of drainage may indicate that the tube can be clamped for periods of time, allowing greater freedom of movement. High output can result in significant fluid and electrolyte losses. PREVENTING INFECTION AND PROVIDING SKIN CARE For the first week after insertion, interventions are focused on prevention of stomal tract infection and promotion of incisional healing. The insertion site should be kept clean and dry using aseptic wound care daily and/or a glycerin hydrogel or glycogel dressing. It is normal to see scant serous drainage at the site for a few days post insertion. After approximately 1 week, the site (including under the external disc, if one is present) can be cleansed twice a week with soap and water and left open to air. Skin at the exit site is evaluated daily for signs of breakdown, irritation, excoriation, and the presence of drainage, bleeding or hypertrophic tissue growth or scattered, raised red papules that could indicate a yeast or candidal infection. Candida may appear in warm moist areas of the body; the area beneath the gastric tube external retention bolster is a common location for it to develop and spread. The nurse encourages the patient and family members to participate in this evaluation and in hygiene activities. If gastric contents leak and irritate the skin at the stoma site, zinc oxide-based protectants may be used. After the first week of healing, buried bumper syndrome, a severe, but rare complication, can be prevented by rotating the gastric tube (not done with jejunostomy tubes) daily and moving the tube inward 2 to 10 cm at least once a week (Bischoff et al., 2020; Boullata et al., 2017). ENHANCING BODY IMAGE Eating is a major physiologic and social function, and the patient with a gastrostomy has experienced a major change in body image. The patient is also aware that gastrostomy as a therapeutic intervention is performed only in the presence of a major, chronic, or perhaps terminal illness. It is necessary to evaluate the existing family support system because adjustment takes time and is facilitated by family acceptance. MONITORING AND MANAGING POTENTIAL COMPLICATIONS During the postoperative course, the most common complications are wound infection or cellulitis at the exit site, bleeding, leakage, excessive tightness of external retention bolster, and dislodgement. Because many patients who receive tube feedings are debilitated and have compromised nutritional status, any signs of infection are promptly reported to the primary provider so that appropriate therapy can be instituted. Bleeding from the insertion site in the stomach can also occur and should be reported promptly. The nurse closely monitors the patient\'s vital signs and observes all operative site drain- age, vomitus, and stool for evidence of bleeding. If an external retention bolster, tape, securement device, or sutures are present, they are evaluated for adequate tension and securement. Excessive tension of the external retention bolster can cause excruciating pain and will lead to skin breakdown and ulceration. The nurse should notify the primary provider if excessive pain occurs at the incision site post insertion. Dislodgement of a recently inserted tube requires immediate attention because the tract can close within 4 to 6 hours if the tube is not replaced promptly. Aspiration is a potential risk with tube dislodgment, especially with nasally inserted tubes. The head of bed for the patient should be elevated to at least 30 degrees. Careful assessment of external tube markings that could suggest drift in placement, and of the patient for signs and symptoms of fullness or nausea that might lead to gastric reflux are important strategies that may prevent aspiration (Boullata et al., 2017). Tube occlusion/clogging occurs in 23% to 35% of patients with feeding tubes and can lead to delays in feeding and medication administration (Boullata et al., 2017). Prevention is important and can be accomplished by administering adequate and frequent flushes as previously described. If a tube does become clogged, warm water may be instilled into the enteral nutrition device with a 30- to 60-mL syringe, followed by a gentle pulling and pushing on the plunger. If this method does not resolve the obstruction, an enzyme-containing commercially available declogging kit may be used or a combination of a pancreatic enzyme tablet and a bicarbonate tablet may be used (Boullata et al., 2017). PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. The patient with a gastrostomy or jejunostomy tube in the home setting must be capable of maintaining patency of the tube or have a caregiver who can do so. The nurse assesses the patient\'s level of knowledge and interest in learning about the tube, as well as an ability to understand how to flush, provide site care, and administer feedings or facilitate decompression and drainage. Education is similar to that described earlier. To facilitate self-care, the nurse encourages the patient to participate in flushing the tube, administering medications and tube feedings during hospitalization, and establishing as normal a routine as possible. Adapters are available that can be secured to the end of the tube to create a \"Y\" site for ease of flushing, suction, or medication delivery. The flushing equipment is cleaned with warm, soapy water and rinsed after each use. The tube can be marked at skin level to provide the patient with a baseline for later comparison. The patient or caregiver should be advised to monitor the tube\'s length and to notify the primary provider or home care nurse if the segment of the tube outside the body becomes shorter or longer. Continuing and Transitional Care. Referral to home, community-based, or transitional care is important to ensure initial supervision and support for the patient and caregiver. The nurse assesses the patient\'s status and progress and evaluates the care of the tube and healing status of the tube insertion site. Further instruction and supervision in the home setting may be required to help the patient and caregiver adapt to a physical environment and equipment that are different from the hospital setting (see Chart 39-7). The nurse also reviews with the patient and caregiver what complications to report and assists the patient and family in establishing as normal a routine as possible. Evaluation Expected patient outcomes may include: 1\. Achieves nutrition goals a\. Attains weight goal b\. Tolerates tube feeding prescription without nausea, emesis, cramping, abdominal pain, or fee