Nutrition and Metabolism PDF

Nutrition and Metabolism Gladys T. Cruz Assessment of Nutrition and the Digestive System Screening and Assessment of Nutritional Health Twenty- four hour dietary recall - quick and relatively easy to obtain Maintain a food diary listing all foods and beverages consumed for 1 to 3 days - i...

Nutrition and Metabolism Gladys T. Cruz Assessment of Nutrition and the Digestive System Screening and Assessment of Nutritional Health Twenty- four hour dietary recall - quick and relatively easy to obtain Maintain a food diary listing all foods and beverages consumed for 1 to 3 days - include amount - preparation - time taken Malnutrition Primary starvation occurs when adequate nutrition is not delivered to the upper GIT (famine, anorexia, mechanical obstructions of the GIT, fad diets) Secondary starvation occurs when the upper GIT fails to absorbs metabolize, or use nutrients (ischemic bowel or Crohns disease)  Chronic pancreatitis can lead to fat malabsorption and decreased absorption of fat-soluble vitamins Clients with healing may have increased vitamin C and zinc requirements Gastric surgery can impair absorption and use of vitamin B12 Physical Examination Height and Weight Body Mass Index Frame size Circumference Measurements Mouth Abdomen - cullen’s sign or a bluish periumbilical color suggests intra-abdominal bleeding and may be seen in clients with pancreatitis Diagnostic Testing: Non-invasive Tests Flat plate of the abdomen Upper GI series (barium swallow) Computed Tomography Ultrasonography Diagnostic Testing: Invasive Tests Endoscopy Gastric Analysis (for Zollinger-Ellison Syndrome) - Basal cell secretion test, a nasogastric tube is inserted and attached to suction; contents are collected every 15 minutes and then analyzed is abnormal they will proceed to: - Gastric acid stimulation test measures the amount of gastric acid produced after receiving drugs that stimulate secretion (pentagastrin and betazole) Scope Procedures Endoscopic procedures Allow direct visualization of body cavities, tissues, and organs Performed for diagnostic and therapeutic purposes Involve the use of a flexible tube that is inserted to allow visualization, biopsy, removal of abnormal tissue, and minor surgery Some procedures require a contrast medium is injected to allow visualization of structures beyond Primary Types: Arthoscopy – joint Bronschoscopy – larynx, trachea, bronchi, and alveoli Colonoscopy – anus, rectum, and colon Cystoscopy – urethra, bladder, prostate and ureters Esophagogastroduodenoscopy (EGD)- oropharnyx, esophagus, stomach and duodenum Primary Types: Endoscopic retrograde cholangiopancreatograph (ERCP) – liver, gallbladder and bile ducts Sigmoidoscopy – anus, rectum and sigmoid colon Things to consider: Age - ability to understand procedures - tolerance of the positioning Compliance with any pre-test preparation required for the procedure Things to consider: Recent food or fluid intake: - presence of food in the GIT will affect ability to visualize key structures and increase risk for complication such as aspiration Things to consider: Medications - may place client at greater risk for complications such as: Anticoagulant therapy – increased risk for bleeding Things to consider: Previous radiographic examination - use of barium may affect the examiner’s ability to view key structures Things to consider: Inadequate bowel preparation - can result in cancellation of procedures - extension of client’s NPO, leading to poor nutrition Things to consider: Electrolyte and fluid imbalances - may affect client’s ability to tolerate bowel preparation orders Nursing Interventions: Evaluate understanding of Evaluate baseline the procedure laboratories Verify consent Evaluate medical history Assess vital signs before, Position correctly during and after the procedure Assess for complications during and after the Verify allergies procedure Nursing Interventions: Determine if barium was used prior to diagnostic studies Ensure NPO for at least 6 hours prior to most endoscopic examinations Complications and Nursing Implications Oversedation Symptoms: Difficulty arousing Poor respiratory effort Evidence of hypoxemia Tachycardia Elevated or low blood pressure - should be prepared with antidote, maintain open airway, administer oxygen and monitor v/s Complications and Nursing Implications Hemorrhage Bleeding Cool clammy skin Hypotension Tachycardia Dizziness Tachypnea - monitor v/s, assess for signs of bleeding at the site Complications and Nursing Implication Aspiration Dyspnea Tachypnea Adventitious breath sounds Tachycardia Fever - notify physician immediately if the following occur Complications and Nursing Implications Perforation Chest or abdominal pain Fever Nausea Vomiting Abdominal distention - monitor diagnostic tests for sign of infection, including elevated WBC count Meeting needs of the older adults Current health status – evaluate medical history for conditions and medications that can affect client’s tolerance for recovery from the procedure Cognitive status – assess understanding of the procedure Support system – to determine if a support person will assist the client after the procedure Management of Clients with Malnutrition Protein-Energy Malnutrition A type of under nutrition, results when the body’s need for protein or energy is not supplied in adequate quantity. Classified as: -Primary when the deficits result simply from poor food intake -Secondary resulting from decreased nutrition intake or absorption Protein-Energy Malnutrition Age group at greater risks are: - With increased nutritional needs for growth, reproduction or milk production- infants, pregnant or lactating women and older adults Protein-Energy Malnutrition Secondary PEM refers to malnutrition associated with acute or chronic disease: -decreased food intake -decreased nutrient absorption -increased nutrient losses -increased nutrient requirements Protein-Energy Malnutrition Prolonged deficiencies with protein and energy can lead to the following: -Kwashiokor, which reflects primarily a chronic deficiency in protein -Marasmus, which reflects primarily a prolonged deficit in caloric supply -Marasmic kwashiorkor, which reflects both energy and a protein deficit Protein-Energy Malnutrition Prolonged deficiencies with protein and energy can lead to the following: -Kwashiorkor-like malnutrition, which has been coined to describe the abnormally low serum protein concentrations observed in previously well nourished clients during or after injury or operation Protein- Energy Malnutrition Etiology and /risk factors: - socioeconomic factors that have a negative effect on nutritional status: Social isolation Limited access to food Emotional depression Substance abuse Poverty Protein- Energy Malnutrition Pathophysiology Primary deficit is in energy balance Depletion of adipose tissue or fat stores with eventual loss of lean body tissue (muscle mass) Fatigue Protein- Energy Malnutrition Effect: The production of serum proteins, such as albumin, transferrin is reduced during acute inflammatory conditions, postoperatively, and during significant infections. Rates of protein breakdown is increased. And serum protein may shift out the vascular compartment, resulting in low serum protein concentration Protein- Energy Malnutrition Organ System Pathophysiology Clinical Manifestations Cardiac Decreased cardiac Postural hypotension muscle mass Diminished venous return Pulmonary Decreased diaphragm Inability to clear strength secretions Decreased Decreased exercise respiratory strength tolerance Decreased endurance Inability to wean from ventilator Immune system Decreased cell- Increased incidence mediated immunity and severity of Delayed cutaneous infection hypersensitivity  Protein- Energy Malnutrition Organ System Pathophysiology Clinical Manifestations Wound healing Decreased collagen Delayed wound synthesis healing Skeletal muscle Altered muscle Fatigue strength contractions Inability to perform Relations response ADLs Decreased muscle Risk of falling endurance GIT Impaired intestinal Diarrhea absorption of lipids Decreased rate of glucose absorption Decreased gastric, pancreatic and bile production Protein- Energy Malnutrition Pre-albumin -is the most sensitive indicator of protein deficiency; because of its short half-life of days -used to assess improvement in nutritional status with refeeding, and with adequate nutritional support, levels can increase 1 mg/dl/day Protein- Energy Malnutrition Medical Management: -Determine nutrient requirements -Determine route of feeding Protein- Energy Malnutrition Nursing Management -Improve nutritional intake -Increase appetite >create a pleasant environment >clear area of unsightly bedpans, urinals, suctioning equipment, and dressing supplies >ensure adequate pain reduction before meals, and avoid invasive procedures or pulmonary treatment just before a meal Protein- Energy Malnutrition Nursing Management >increased activity through regular exercise may also increase client’s appetite >stimulation of senses of taste, smell, and sight >oral hygiene to support optimal function of taste buds (use soft bristled brush, avoid alcohol-containing mouthwash Protein- Energy Malnutrition Nursing Management -Increase social interaction -Minimize sensory-perceptual deficits >make sure the client is wearing corrective lenses >arranging the food in a clock-face pattern to easy way to orient the client to the position of various foods on tray -Minimize impact of neuromuscular impairments Protein- Energy Malnutrition Nursing Management: -minimize impact of cognitive impairments -minimize fatigue -minimize risks of aspiration Feeding should take place in a calm, adequately supervised environment Place in normal eating position Food should be placed on unaffected side of the mouth Protein- Energy Malnutrition Massage the throat on the affected side to help stimulate the tactile areas that initiate the swallowing reflex Keep the suction equipment available Protein- Energy Malnutrition Medical Management with client receiving enteral nutrition: -Enteral nutrition Total enteral nutrition (TEN) or tube- feeding refers to a method of infusing nutrient solutions or formulas directly into the GI tract through tubes that enter through the nose, mouth, or abdominal wall Protein- Energy Malnutrition Medical Management with client receiving enteral nutrition: Reminder: - Daily fluid needs of the client receiving enteral nutrition must be calculated to avoid overhydration or underhydration Protein- Energy Malnutrition Medical Management with client receiving enteral nutrition: Enteral Access -Nasogastric tube -Percutaneous endoscopic gastrostomy (PEG) -Percutaneous endoscopic jejunostomy (PEJ) Protein- Energy Malnutrition Medical Management with client receiving enteral nutrition: Methods of Administration is determined by: 1. The location of the tube tip 2. The client’s tolerance Protein- Energy Malnutrition Medical Management with client receiving enteral nutrition: Methods of Administration: -Intermittent or bolus feedings, 300 to 500 ml of enteral formula is delivered several times per day -Continuous feeding are generally infused over 24 hours at rates ranging from 50 to 150ml Nursing Management of the Client Receiving Enteral Nutrition Review type of formula being used, the time, frequency, and amount of feeding and the specific indications for your client Nursing Management of the Client Receiving Enteral Nutrition Four Methods to evaluate tip location: -Aspiration: observing the fluid that is removed through a large bore feeding tube -pH paper testing: checking the pH of the fluid removed from the feeding tube Nursing Management of the Client Receiving Enteral Nutrition -Measurement: measuring and recording the length of the tube outside of the client’s nose and then before boluses or every 4-8 hours, checking the measurement -Radiography: checking the abdominal x- ray film for tube position * Auscultation is the least reliable method to evaluate the tube tip position Nursing Management of the Client Receiving Enteral Nutrition Enterostomy tube can migrate in or out if it is not properly secured at the exit site with sutures or a tube attachment device - If the tract becomes widened, formula and digestive enzymes can pass through it and excoriate the skin on the abdomen Nursing Management of the Client Receiving Enteral Nutrition Maintain Enteral Access -a dressing is required for the abdominal wall tubes -daily cleaning with mild soap and rinsing with warm water Guidelines for the Administration of Medications via an Enteral Feeding Tube If possible, administer the medication by mouth Use a liquid form of the medication if available If the medication can be crushed, crush it to a fine powder and dissolve it in 30 ml of water Do not crush enteric-coated or time- released tablets or capsules Flush the tube with 30 ml water before Guidelines for the Administration of Medications via an Enteral Feeding Tube Do not mix multiple medication or give them together Do not deliver a medication into the small intestine if it must be absorbed in the stomach, such as sucralfate or antacids Hold feedings 1 to 2 hours before and after giving a medication that might have a drug-nutrient interactions such as phenytoin Medical Management of the client receiving parenteral nutrition Components: -carbohydrates -fat emulsion -protein -fluids, electrolytes, vitamins, and trace elements *Vit. K is not contained in all commercial preparations and may be added in parenteral nutrition formula daily (1mg) Medical Management of the client receiving parenteral nutrition Other vitamins are sometimes added to the standard vitamin preparation, such as: Vit. C for wound healing Vit. B12 , thiamine, and folic acid to correct deficiencies commonly associated with alcohol abuse Medical Management of the client receiving parenteral nutrition Vascular Access Device -commonly infused in central venous circulation where the flow of blood rapidly dilutes the concentration of the solution Nursing Management of the client receiving parenteral therapy Prevent mechanical complications Example: -misplaced and occluded access devices Assess the area around the catheter insertion site for swelling that might be suggestive of a central vein thrombosis Nursing Management of the client receiving parenteral therapy Prevent metabolic complications Example: Eletrolyte disturbances, hyperglycemia, and allergic reactions PN rates should be started slowly in severely malnourished clients and electrolytes should be checked frequently before the PN rate is advanced Nursing Management of the client receiving parenteral therapy The 1st time PN is administered, blood glucose levels should be monitored every 6 hours to assess the client’s response to glucose. Allergic reactions to lipid preparations or multivitamins have been reported and usually present within 30 minutes- stop infusion Nursing Management of the client receiving parenteral therapy Prevent infectious complications -strict hand-washing and aseptic technique -Minimize manipulations of the catheter, one lumen of a multilumen catheter should be dedicated for infusion of PN -Gauze dressing every day Eating Disorder: Obesity Characterized by an excess accumulation of fat and reflects, on the most basic level, an overall positive balance between energy intake and expenditure BMI = weight (kg)/Height (m2 ) Eating Disorder: Obesity Etiology and Risk Factors: - Environmental: *The environment impacts both the energy expenditure and the energy intake sides of the energy balance equation *Individuals spend more time sitting than moving *Portion sizes of servings of food in restaurants and movie theaters have increased markedly overtime Eating Disorder: Obesity Etiology and Risk Factors - Genetic tendency - Socioeconomic factors - Ethnic disparities Eating Disorder: Obesity Associated with a series of medical co- morbidity, including DM, cardiovascular disease, hypertension, hyperlipedimia, stroke, sleep apnea, obesity hypoventilation syndrome, arthritis and other cancers Eating Disorder: Obesity Medical Management - Diet = use of meal replacement formulas or very low-calorie diet regimens to begin weight loss - Exercise = to increase energy expenditure and to facilitate weight loss - Behavior or lifestyle modification Eating Disorder: Obesity Medical Management: - Meridia (Sibutramine) An anorectic that targets neurotransmitters to reduce appetite Use with caution to clients with HPN and heart disease Habit forming – prescribed for 3-6 weeks Eating Disorder: Obesity Medical Management: - Phentermine Is a thermogenic drug that increases energy expenditure and targets neurotransmitters to reduce appetite Habit forming May induce palpitations or insomnia Eating Disorder: Obesity Medical Management: - Xenical (Orlistat) Is a peripheral lipase inhibitor that reduces digestion and absorption of fats May have loose bowel stools and flatulence and are at risk of fat-soluble vitamin deficiencies due to reduced fat absorption Eating Disorder: Obesity Surgical Management: Two approaches - gastric restrictive - restrictive plus malabsorption Eating Disorder: Obesity Gastric Restrictive Procedure - the size of the stomach is reduced by one of two procedures- the vertical banded gastroplasty or the adjustable gastric band Involve creation of a small gastric pouch with a restricted outlet to the remaining portion of the stomach Eating Disorder: Obesity Malabsorptive Procedure - gastric bypass procedure bypasses a segment of duodenum from the food stream, thus inducing malabsorption of nutrients and dumping manifestations when concentrated sugars are ingested Eating Disorder: Anorexia Nervosa and Bulimia Nervosa Anorexia nervosa is a condition of self- generated weight loss, usually seen in adolescent girls and young women, but also in middle-aged women or men - preoccupation with personal body weight and appearance - behaviors directed at thinness - physical results in extreme weight loss, amenorrhea, osteoporosis, and malnutrition Eating Disorder: Anorexia Nervosa and Bulimia Nervosa Bulimia nervosa is a less serious and entirely separate illness - clients tend to maintain a relatively normal weight, but go through periods of eating excessively (binging) and vomiting (purging) gastric contents to prevent weight gain Eating Disorder: Anorexia Nervosa and Bulimia Nervosa Etiology and Risk Factors - women are 10x more likely to be affected than men - sociocultural and environmental factors including media and peer influences, family factors including parental discord - biological factors including genetics, neurotransmitter regulation and hormonal function Eating Disorder: Anorexia Nervosa and Bulimia Nervosa Low calorie intake Prolonged starvation, shifts in fluid and electrolyte balance - Alteration in metabolism of insulin, thyroid hormones and catecholamines causing decrease in PR, BP, CO and gut motility - hypothalamus responds to the lack of nutrient with changes in pituitary function, amenorrhea and infertility Eating Disorder: Anorexia Nervosa and Bulimia Nervosa Eating Disorders: Anorexia Nervosa and Bulimia Nervosa Medical Management - severe malnutrition may cause serious fluid and electrolyte disturbances - enteral or parenteral therapy - refeeding syndrome- characterized by precipitous decreases in serum potassium, magnesium, and phosphorus levels when nutrients are administered to depleted clients Eating Disorders: Anorexia Nervosa and Bulimia Nervosa Nursing Management: - Improve body image - Improve nutritional intake 1 to 2 lbs/wk Observe and be supportive during mealtimes For bulimia, encourage to eat slowly and develop a regular exercise pattern Lactose Intolerance Insufficient lactase production occur from birth (uncommon) Secondary lactose intolerance – damage to small intestine mucosa such as infection, small bowel disease, chemotherapy, or intestinal radiation, and may be temporary  Lactose is a principal disaccharide present in milk products that requires the small intestine enzyme lactase for digestion  Milk-based foods such as aged cheeses, naturally contain less lactose, yogurts and other fermented dairy products have reduced lactose content and advantageous probiotic bacteria that have a lactase-producing ability that benefits digestion of lactose content  Patient’s diet should be assessed for adequate calcium and vitamin D sources especially for those who have eliminated dairy foods from their diets Celiac sprue Gluten-sensitive enteropathy, is a lifelong condition affecting the small intestine in which the villi morphology is damaged from the presence of gluten in the diet  Gluten is a protein found in grain products, specially wheat, rye and barley  The presence of gluten leads to villi atrophy and loss of absorptive surface Diarrhea and malabsorption of most nutrients can follow  Gluten-free versions of grain foods can replace the displaced wheat, rye and barley products. Corn, potato, rice and soy flours can be used to make alternative breads, pasta * Wheat flour products are commonly fortified with iron, folic acid and other B- complex vitamins Management of clients with Ingestive Disorders Oral Disorders Dental Decay/ Periodontal Disease Health care providers strive to preserve their client’s healthy gums and natural teeth for as long as possible for the following: - natural teeth are more functional in masticating food - effective mastication of food helps promote efficient digestion - efficient digestion of food results in healthy GI function and maintenance of general health Dental Plaque and Caries Tooth decay is an erosive process that begins with the action of bacteria on fermentable CHO in the mouth, which produces acids that dissolve tooth enamel Extent of damage depends on: - presence of dental plague - strength of the acids and the ability of the saliva to neutralize them  - length of time the acids are in contact with the teeth - susceptibility of the teeth to decay Oral Disorders Dental Decay/ Periodontal Disease Plaque is a major cause of both caries (decay) and periodontal disease The best treatment is PREVENTION - encourage to brush and floss frequently and regularly - eat a diet low in simple carbohydrates - use fluoride to increase tooth enamel resistance to bacteria - schedule regular visits to the dentist for examination, cleaning, and treatment of dental caries Oral Disorders Dental Decay/ Periodontal Disease Treatment: - drilling out cavities and filling the tooth with material to restore the tooth - extraction of the entire tooth - preservation of the tooth by root canal therapy followed by proper restoration Oral Disorders Dental Decay/ Periodontal Disease Periodontal disease, caused by plaque formation and bacterial colonization, results in gingival inflammation if the plaque is not removed by proper brushing and flossing Destroys the underlying tissues and separates the gingiva from the tooth Teeth loosen and fall out or extraction may be required Dentoalveolar Abscess or Periapical Abscess Commonly referred as abscessed tooth, involves the collection of pus in the apical dental periosteum and the tissue surrounding the apex of the tooth Management: a needle aspiration or drill an opening into the pulp chamber to relieve tension and pain and to provide drainage  Nursing management - assess for bleeding after treatment and instruct to use a warm saline or warm water rinse to keep the area clean - take antibiotics as prescribed - advance from a liquid diet to a soft diet as tolerated, and to keep follow up appointments Malocclusion Is a misalignment of the teeth of the upper and lower dental arcs when the jaws are closed Correction of malocclusion requires an orthodontist with special training, a patient who is motivated and cooperative, and adequate time  Preventive orthodontics may be started at age 5 years if malocclusion is diagnosed early Management - to realign teeth, orthodontist gradually forces the teeth into a new location by using wires or plastic bands  Nursing Management - practice meticulous oral hygiene Oral Disorders Mucositis Mucositis or stomatitis, an inflammation of the soft tissues of the oral cavity Caused by: - mechanical trauma, such as injury - chemical trauma, such as drugs used for cancer Oral Disorders Mucositis Primary mucositis includes aphthous ulcer (canker sore), herpes simplex and Vincent’s angina Secondary mucositis results when a client’s lowered resistance allows an opportunistic infection to develop Oral Disorders Mucositis Systemic disorders that can affect the oral mucous membranes include: - allergies - bone marrow disorders - nutritional disorders - immunodeficiency disorders - chemotherapy, radiation therapy or immunosuppressive therapy Oral Disorders Mucositis Type Cause Clinical Prevention Manifestation and Treatment s Aphthous ulcer Herpes simplex Varies in size; If allergic (canker sore) virus, stress, usually small cause, avoid allergies, painful eggs, citrus endocrine ulcerations on foods, disorders, soft tissue of chocolate, trauma, vitamin tongue, lips, shellfish, nuts, deficiency and buccal and milk mucosa; products superficial with raised borders Oral Disorders Mucositis Type Cause Clinical Prevention Manifestation and Treatment s Herpes simplex May lie Clear vesicular Very contagious virus (cold sore) dormant; lesions in oral during vesicular activated by cavity rupture and ulcerative stress or to form painful stages infection ulcerations Treat pain with resembling oral and topical canker sores analgesics Heavy white Start acyclovir coating on tongue Oral Disorders Mucositis Type Cause Clinical Prevention Manifestation and Treatment s Vincent’ Acute bacterial Sudden onset: Removal of s angina infection of gingiva erythema and devitalized caused by resident oral ulceration and tissues, rest, flora, fusiform bacteria, ulceration of improved oral and spirochetes gingivae hygiene, bland Precipitating factors: spreading to diet, vitamins poor hygiene, orophrarynx increased age, Manifestations: malnutrition, lack of foul taste, pain, rest and sleep, local choking tissue damage, and sensation, fever, debilitating disease thick Oral Disorders Candidiasis Candidiasis (moniliasis, thrush) is a secondary infection caused by an overgrowth of the organism Candida albicans, a yeast-like fungus that is part of the normal flora of the oral cavity. Assessment reveals white patches on the tongue, palate, and buccal mucosa “milk curds” lesions Oral Disorders Candidiasis Medical Management: - antifungal agents, either nystatin troches or liquid to “swish and spit” or systemic therapy with fluconazole - topical or oral analgesics, such as acetaminophen or ibuprofen, may also be administered to reduce pain - commercial mouthwashes should be avoided because of high alcohol content - a liquid pureed diet may be necessary Oral Disorders Tumors of the Oral Cavity (Benign Tumors of the Oral Cavity) Fibromas (fibrous tissue), lipomas (fatty tissue), neurofibromas (nerve fiber tissue), hemangiomas (collection of blood vessels) Primarily occupying space and causing pressure Oral Disorders Premalignant Tumors of the Oral Cavity (Leukoplakia) A potentially precancerous, yellow-white or gray-white lesion, may occur in any region of the mouth Men are affected 2x than women; smoking Results from chronic irritation of mucosa by physical, chemical, or thermal factors Oral Disorders Premalignant Tumors of the Oral Cavity (Leukoplakia) Risk factors: Physical factors (poorly fitting dentures, broken teeth, cheek nibbling, and poor alignment of the mandible and maxilla Chemical and thermal factors (tobacco, marijuana, excessively hot food and beverages Human papillomavirus (HPV) *Topical calcipotriol (Dovanex) and topical (retin A) Oral Disorders Premalignant Tumors of the Oral Cavity (Erythroplakia) Red, velvety appearing patch that commonly indicates early squamous cell carcinoma Ages 50 to 60; appears equally in men and women Oral Disorders Malignant Tumors of the Oral Cavity Associated with long term alcohol consumption and tobacco and marijuana use Health promotion include avoid excessive tobacco, alcohol, and very hot drinks and foods Encourage to have meticulous oral hygiene, eat well balanced diet and use sunscreen during exposure to sunlight Oral Disorders Malignant Tumors of the Oral Cavity (Basal Cell Carcinoma) The second most common oral cancer, occurs primarily on the lips Starts with a small scab that develop into an ulcer with a characteristic pearly border Occurs as a result of excessive exposure to sunlight, tending to occur in fair-skinned individuals Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) Is a malignant growth arising from tiny flat squamous cells that line mucous membranes Primary cause is chronic irritation of the mucous lining of the mouth and oral cavity with overuse of alcohol, marijuana, and tobacco Manifestation: a sore or lesion in the oral cavity that does not heal; mild irritation of the tongue, sore throat, trouble with wearing dentures, or pain in the tongue or ear Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) Medical Management Inhibit tumor growth - radiation therapy - chemotherapy Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) Nursing Management of the Medical Client: Assessment: - painful ulcer - difficulty in swallowing, white or red patches on the oral mucosa - bleeding in the mouth - enlarged lymph nodes in the neck - pain referred to the ear, foul odor, and hoarseness Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) Impaired oral mucous membrane - frequent oral hygiene and avoid oral irritants - provide comfort Palifermin (Kepivance), a keratinocyte growth factor, before radiation therapy or chemotherapy may reduce the severity of mucositis Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) Imbalanced Nutrition: Less than Body Requirements - administering an analgesic 30 to 45 minutes before a meal can decrease the pain associated with eating - provide oral care before and after meals to remove debris and minimize oral odors - relieve mouth dryness (xerostamia) - chewing sugarless gum or sucking on sugar-free sour hard candy will increase saliva production - oral rinses with cool water to reduce dryness Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) Surgical Management Ranges from local excision of small tumors to extensive surgery for invasive tumors - xeroform gauze is placed over the skin graft and sutured into place - because of packing and edema, tracheostomy tube is placed until oral airway is patent - NPO for 7 to 10 days, NG feeding to provide nutrition Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) A radical neck dissection is an extensive procedure that involves removal of all tissue under the skin, from the jaw down the clavicle, and from the anterior border of the trapezius muscle to the midline Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) Nursing Management of the Surgical Client : Risk for injury - maintain airway Tracheostomy is place to help prevent respiratory difficulty from edema of oral and pharyngeal structures Pulse oximetry to determine oxygenation sufficiency Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) - provide wound care After dressing and packing is removed, oral rinses every 4 hours to remove debris and promote healing Oral hygiene and suctioning are not usually implemented until healing has begun Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) - monitor for bleeding > Monitor for possible bleeding; can be massive because of the large vessels that supply the mouth and oral area Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) : Imbalanced Nutrition: Less than body requirements - administer supplemental nutrition - discuss eating modification  Decrease sensation in the oral cavity after surgery  Assess swallowing carefully before eating begins  Avoid putting food directly on surgical resection site  After meals, perform oral hygiene to remove particles that may cause problems with the incision Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) : Impaired Verbal Communication - promote alternate forms of communication Picture board, gestures or whatever is easy for the client to communicate Help client to avoid social isolation Oral Disorders Malignant Tumors of the Oral Cavity (Squamous Cell Carcinoma) - relieve anxiety Help client who cannot express needs, concern and feelings Check on clients frequently to reduce anxiety and loneliness Disorders of the Salivary Glands The parotid gland is the largest salivary gland opening into the oral cavity Parotitis is an inflammation of the parotid glands As secretions of the salivary gland diminish, oral bacteria have an opportunity to invade the gland and multiply Disorders of the Salivary Glands Interventions: - administer antibiotics - increase saliva production with the use of sialogogues such as lemon drops - keeping the client well hydrated - stopping anticholinergic medications - analgesics and warm compresses to alleviate pain - if no improvement in 2 to 3 days, CT is required to rule out abscess, lesion or sialolith Sialadenitis Inflammation of the salivary gland Caused by dehydration, radiation therapy, stress, malnutrition, salivary gland calculi (stones), or improper oral hygiene Symptoms include: pain, swelling, and purulent discharge Antibiotics to treat infections Disorders of the Salivary Glands Calculi Stones or calculi, may form in the salivary glands from inactivity and/or the precipitation of salts Occurs commonly in the submaxillary glands, because of the longer length of duct and production of viscous alkaline secretions Intervention: - local excision Disorders of the Salivary Glands Tumors Pain occurs when expansion within the capsule of the gland creates pressure on the sensory nerves Intervention: - surgical excision - radiation therapy if its highly malignant Disorders of the Jaw Temporomandibular disorders Categories: - myofascial pain – a discomfort in the muscles controlling 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 Clinical Manifestations: - pain that radiate to the ears, teeth, neck muscles and facial sinuses - often have restricted jaw motion and locking of the jaw  - may hear clicking and grating noises and chewing and swallowing may be difficult Management - stress management may be helpful to reduce grinding and clenching of teeth - range of motion exercises - pain management measures - a bite plate or splint (plastic guard worn over the upper and lower teeth) may be worn to protect teeth from grinding Surgical Management - rigid plate fixation (insertion of metal plates and screws into the bone to approximate and stabilize the bone)  - bone grafting to replace structural defects using bones from the patient’s own ilium, ribs or cranial sites Nursing Management - with rigid fixation (not to chew food in the first 1 to 4 weeks after surgery; liquid diet and diet counseling should be obtained to ensure optimal caloric and protein intake Cancer of the Oral Cavity Caused by smoking, alcohol intake and ingestion of smoked meats; chronic irritation by a warm pipe stem or prolonged exposure to the sun and wind may predispose a person to lip cancer  Clinical Manifestations - painless sore or mass that will not heal - a typical lesion in oral cancer is a painless indurated (hardened) ulcer with raised edges - ulcer of the oral cavity that does not heal in 2 weeks should be examined through biopsy  - as cancer progress patient may complain of tenderness; difficulty in chewing, swallowing, or speaking, coughing of blood-tinged sputum; or enlarged cervical lymph nodes Medical Management Cancer of the lip - small lesions are excised - larger lesions are treated by radiation therapy Cancer of the tongue - treated with radiation and chemotherapy to preserve organ function and maintain quality of life  If cancer spread to lymph nodes, neck dissection may be performed Nursing Management Promote mouth care - xerostamia = increase fluid intake and use humidifier during sleep = use of synthetic saliva - stomatitis = extraction of teeth before radiation to prevent infection  Ensuring adequate food and fluid intake - recommends changes in the consistency of foods and the frequency of eating - goals is to help attain and maintain desirable body weight and level of energy to promote healing of tissue  Supporting a positive self-image Minimizing pain and discomfort - avoid foods that are spicy, hot or hard - provide with viscous lidocaine as prescribe  Promoting effective communication Preventing infection Disorders of the Esophagus Dysphagia (difficulty in swallowing) involves the sensation of food sticking in the back of the throat or upper esophagus Odynophagia (painful swallowing) caused by obstructive or motility problems Disorders of the Esophagus Dysphagia Caused by Mechanical Obstruction - include congenital defects, cancer and acquired condition such as hiatal hernia - may be accompanied by weight loss and cachexia Disorders of the Esophagus Dysphagia Caused by cardiovascular abnormalities - vascular dysphagia includes enlarged heart, an aortic aneurysm, and calcification of the descending aorta Disorders of the Esophagus Dysphagia Caused by Neurologic Diseases - stroke, multiple sclerosis, poliomyelitis, and amyotrophic lateral sclerosis Disorders of the Esophagus Dysphagia Other causes - food caught in the esophagus - relieved by drinking liquids to force the impacted bolus through the narrow segment or by retching to dislodge the food Disorders of the Esophagus Regurgitation Regurgitation is the ejection of small amounts of chyme or gastric juice from the mouth without antecedent nausea Caused by incompetent lower esophageal sphincter (LES) Contributing factors include abnormal motor activity, increased abdominal pressure, and sphincter abnormality Disorders of the Esophagus Regurgitation Occurs in achalasia, pylorospasm, lesions proximal to the cardia, hiatal hernia, reflux esophagitis, and esophageal ulcer or cancer. Disorders of the Esophagus Acute Pain Pain may result from alterations of the mucosa from reflux disease, radiation, or viral infection Pain is describes as sharp, constricting, sticking, crushing, stabbing, or knife-like Can be triggered by a cold or carbonated beverages or by solid food passing through the esophagus Disorders of the Esophagus Heartburn or Pyrosis Also known as indigestion or dyspepsia Commonly experienced with obesity, postural changes, gulping of food or liquids, with pregnancy, or ingestion of alcohol Manifestation are relieved by standing or eructating (belching) Disorders of the Esophagus Achalasia Is a motor disorder characterized by progressively incomplete relaxation of the lower esophageal sphincter (LES), and progressive, eventually complete loss of peristalsis in the esophageal body Common in ages 20s and 30s and appears equally often in men and women Frequently treated for gastroesophageal reflux disease (GERD) before the diagnosis of achalasia is made Disorders of the Esophagus Achalasia Etiology and Risk Factors - loss of nerve endings and loss of hormones The sphincter may become so impaired that the lower esophagus and stomach are visualized as one cavity instead of two entities Manifestations include heartburn and dysphagia for solids Disorders of the Esophagus Achalasia Characterized by impaired motility of the lower 2/3 of the esophagus LES fails to relax normally with swallowing Inadequate functioning occurs because nerve impulses cannot pass through the esophagus or sympathetic receptors are absent from the LES Disorders of the Esophagus Achalasia Clinical Manifestations: - Early stages: substernal pain because of spasms of the esophagus or may be unable to eructate - The client may regurgitate undigested food eaten many hours earlier as well as large amounts of mucus that have been stimulated by esophageal irritation - URTI, emotional disturbances, overeating, obesity, and pregnancy may exacerbate the problem Disorders of the Esophagus Achalasia Diagnostic Tests - barium swallow Disorders of the Esophagus Achalasia There is no medical or surgical therapy that will restore normal esophageal sphincter function Dilation of LES = may be performed by a gastroenterologist or a surgeon and may be regarded as either a surgical or a medical procedure Under fluoroscopic guidance, a firm balloon is inflated to a predetermined diameter, thus tearing some of the fibers of the LES Disorders of the Esophagus Achalasia Major complication of balloon dilation is mediastinal tear Dilation is used to correct esophageal spasms and stricture Disorders of the Esophagus Achalasia Administer medication: > Calcium channel blockers are potent smooth muscle relaxants that may help in treatment of achalasia > Botulism toxin is injected endoscopically to paralyze the muscle (used in elderly) but repeated treatment decreases the effect because of the development of antibodies by the client Disorders of the Esophagus Achalasia Modify diet: Small frequent feedings ease the passage of food, and semisoft, warm foods are better tolerated than cold, hard foods Should avoid hot, spicy, iced food, alcohol and tobacco Chew food to add saliva to the mixture for lubrication and to allow the bolus to pass more easily from the esophagus Disorders of the Esophagus Achalasia Alternate positions: Arch the back while swallowing After eating, should remain in upright by standing or sitting Avoid restrictive or tight clothing which may increase esophageal pressure and regurgitation Sleep with head elevated to prevent nocturnal reflux of food Disorders of the Esophagus Achalasia Nursing Management: - Imbalanced nutrition: less than body requirements A gastrostomy feeding can be used to provide adequate nutritional support - Acute pain Relieved through antacids, histamine H2- receptors and proton pump inhibitors Disorders of the Esophagus Achalasia Surgical Management: Esophagomyotomy (Heller’s procedure) the surgeon enlarges the vestibule by incising the circular fibers down to the mucosa over the entire length of the LES A major complication is severe reflux esophagitis Disorders of the Esophagus Achalasia Nursing Management of the Surgical Client: - Deficient knowledge Teach about esophageal dilation Client should take long slow breaths during passage of the bougie Explain esophagomyotomy The possibility of a thoracotomy approach being used to reach the esophagus requires instruction concerning chest tubes Disorders of the Esophagus Achalasia - Imbalanced nutrition: less than body requirements Maintain feeding tube (if gastric return is more than 150 ml or twice the hourly rate, hold the feeding for 1 hour and repeat aspiration before continuing the feeding - Risk for impaired skin integrity Provide feeding tube care Disorders of the Esophagus Achalasia - Risk for injury Monitor for complication Maintain chest tubes Disorders of the Esophagus Diffuse Spasm - is a motor disorder of the esophagus - cause is unknown but associated with stressful situation - common in women and usually in middle age Disorders of the Esophagus Diffuse Spasm Clinical Manifestations: - difficulty or pain on swallowing and by chest pain similar to that of coronary artery spasm Diagnostic Findings: - esophageal manometry – measures the motility of the esophagus, indicates that simultaneous contractions of the esophagus occur irregularly Disorders of the Esophagus Diffuse Spasm Management: - sedatives and long-acting nitrates to relieve pain - calcium channel blockers - small, frequent feedings and a soft diet to decrease the esophageal pressure and irritation that lead to spasm Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Is a chronic condition with frequent exacerbations that may result in significant morbidity over time if not appropriately managed Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Due to brain stem function, Swallowing Relaxes LES mediated by vagus nerve  Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Common triggers for LES relaxation Medications affecting the function of the Consumption of food Lifestyle and social LES include like caffiene, alcohol, habits such as anticholinergics, beta peppermint, spicy or alcoholism, smoking, blockers, estrogen, fried foods, chocolate high-fat diet and progesterone, Ca and tomatoes obesity channel blockers, and nitrates Delayed gastric Pregnancy and lying motility due to DM, recumbent position scleroderma, multiple when stomach is full sclerosis and Parkinson’s disease Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Older men have 3 to 5 times risk of developing Barrett’s esophagus and adenocarcinoma of the esophagus Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Preventive Measures: Cease smoking Reduce ingestion of high-fat, acidic, and caffeine- or chocolate-containing food or beverages Eat small meals and increasing dietary protein Losing weight Elevate head of bed when sleeping Avoid lifting, straining, bending, and tight or constrictive clothing Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Pathophysiology High pressure prevents reflux, but permits the passage of food and liquids LES relaxes, pressure decreases and reflux of stomach contents into the lower esophagus occurs Delayed gastric emptying may contribute to reflux by increasing gastric volume and pressure Decreased salivation and buffering from salivary bicarbonate may contribute to impaired clearing of acid reflux from the esophagus Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Pathophysiology Frequent or prolonged reflux results in inflammation of the esophageal mucosa (esophagitis) Three Levels: - non-erosive esophagitis (NERD) - erosive esophagitis - Barrett’s esophagus Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Clinical Manifestations: Subjective data: heartburn, epigastric pain, retrosternal burning, odynophagia, dysphagia, acid regurgitation, water brash (release of salty secretions in the mouth), eructation (belching), and hoarseness Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Less typical manifestations - recurrent laryngitis, sore throat, cough, wheezing, and loss of dental enamel Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Severe Clinical Manifestations: - pain may radiate at the back, neck, or jaw - pain occurs 30 to 60 minutes after meals, relieved with antacids or fluids other than water Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Diagnostic: Esophagogastroduodenoscopy (EGD) - indicated with clients not responding to medication - client high risk with Barrett’s esophagus - indicated if manifestation includes GI bleed, early satiety, weight loss, severe pain, choking, and chest pain Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Medical Management Decrease reflux with medications - avoid anticholinergic drugs, calcium-channel blockers, biphosphonates, and theophylline because it decreases LES pressure, delay gastric emptying, or irritate the esophagus Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Medical Management Medications for GERD - antacids 1 hour before and 2 to 3 hours after each meal to buffer neutralize gastric acid secretions and soothe the mucosal lining - H2-receptors should be given an hour before or after antacids; decrease gastric acid secretions Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Medical Management Decrease reflux with lifestyle and diet changes - restrict the diet to small frequent feedings to decrease the amount of food in the stomach - drink adequate fluids at meals to assist food passage - eat slowly and chew thoroughly to add saliva to the food - avoid eating and drinking for 3 hours before retiring to prevent the common problem of nocturnal reflux Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Medical Management - elevate the head of the bed 6 to 8 inches to prevent nocturnal reflex - lose weight, if overweight, to decrease the gastroesophageal pressure gradient - avoid tobacco, salicylates, and phenylbutazone, which may exacerbate esophagitis Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Medical Management Endoluminal gastroplication - a therapy for symptomatic GERD - works be creating plications, or pleats, at the LES Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Nursing Management Assess manifestations - if the client has an inadequate response to H2 receptor antagonists or if manifestations intensify, a proton pump inhibitor is prescribed as they provide more complete control of acid secretion by inhibiting the hydrogen and potassium ATPase enzyme system in the gastric parietal cell Disorders of the Esophagus Gastroesophageal Reflux Disease (GERD) Nursing Management - PPI therapy is initiated immediately because of the superior healing rate of the drug class - Metoclopramide (Reglan), an antiemetic and cholinergic drug, because it increases LES pressure stimulating the smooth muscle of the GI tract and increases the rate of gastric emptying Disorders of the Esophagus Hiatal Hernia Also called diaphragmatic hernia Is a herniation of a part of the stomach into the thoracic cavity through an enlarged esophageal hiatus in the diaphragm Disorders of the Esophagus Hiatal Hernia Two major types of hernias: - sliding hernias (type I) The upper stomach and the gastroesophageal junction are displaced upward into the thorax - rolling or paraesophageal hernias (type II) The gastroesophageal junction stays below the diaphragm, but all or part of the stomach pushes through into the thorax Disorders of the Esophagus Hiatal Hernia Etiology and Risk Factors Hernias are related to muscle weakness in the esophageal hiatus, which loosens the esophageal supports and allows the lower portion of the stomach to rise into the thorax - muscle weakness caused by aging, trauma, congenital muscle weakness, surgery, or anything that increases intra-abdominal pressure such as lifting, coughing, pregnancy and obesity Disorders of the Esophagus Hiatal Hernia Pathophysiology Involves protrusion of part of the stomach through a weakness in the diaphragm Regurgitation and motor dysfunction cause the manifestations Sliding hiatal hernia problem is reflux while in rolling hiatal hernia the LES remains below the diaphragm and reflux is not a problem Disorders of the Esophagus Hiatal Hernia Clinical Manifestations Heartburn 30 to 60 minutes after meals Substernal pain Chest pain similar to angina Pain usually worse when patient is lying down *Barium swallow with fluoroscopy Disorders of the Esophagus Hiatal Hernia Surgical Management Nissen fundoplication involves suturing the fundus around the esophagus - an increase in pressure or volume in the stomach closes the cardia and blocks reflux into the esophagus Disorders of the Esophagus Hiatal Hernia Surgical Management Hill operation narrows the esophageal opening and anchors the stomach and distal esophagus to the median arcuate ligament (posterior gastropexy) - the procedure reinforces the sphincter and recreates the gastroesophageal valve Disorders of the Esophagus Hiatal Hernia Surgical Management Belsey (Mark IV) repair consists of plication of the anterior and lateral aspects of the stomach onto the distal esophagus Disorders of the Esophagus Hiatal Hernia Nursing Management of the Surgical Client Postoperative Assessments - clients have an NG tube to avoid stomach distention - prevent respiratory complications - prevent gas-bloat syndrome > Fluids are usually resumed after 24 hours, and diet is progressively advanced as tolerated when peristalsis returns Disorders of the Esophagus Hiatal Hernia Nursing Management of the Surgical Client Small, frequent meals are provided to avoid overloading the stomach After fundoplication if the wrap of the fundus is too tight, causing bloating and an ability to eructate Clients should avoid carbonated beverages and gas-producing foods Disorders of the Esophagus Diverticula Is a sac-like outpouching in one or more layers of the esophagus Disorders of the Esophagus Diverticula Food ingested Trapped in diverticulum May regurgitate later Disorders of the Esophagus Diverticula Zenker (esophageal pulsion) most common, which occurs above the upper esophageal sphincter - associated with coordination of the pahrynx during swallowing - occurs more often in men than in women Epiphrenic diverticulum occurs just above the LES and is associated with failure of the LES to relax, and increased amplitude of esophageal contractions Disorders of the Esophagus Diverticula Etiology and Risk Factors Causes of Congenital Weakness: Congenital defect, esophageal trauma, scar tissue, or inflammation Two categories of diverticula: Traction and pulsion Disorders of the Esophagus Diverticula Etiology and Risk Factors Traction diverticulum – the esophageal mucosa has pulled outward from the esophagus; commonly found in the middle esophagus Pulsion diverticulum – the esophageal mucosa has pushed outward through a defect in the esophageal musculature; commonly found in upper esophagus Disorders of the Esophagus Diverticula Pathophysiology Food trapped in diverticulum may cause local abscess Infected diverticula, is at risk for esophageal perforation because the mucosa is without protection of the normal esophageal muscle layer Disorders of the Esophagus Diverticula Clinical Manifestations Complains of intermittent or constant difficulty swallowing Zenker’s pouch enlarges, manifestations progress to aspiration of fluids and regurgitation of food into the mouth Epiphrenic diverticula may lead to regurgitation of large amounts of accumulated fluid when recumbent Disorders of the Esophagus Diverticula Clinical Manifestations Halithosis, a sour taste in the mouth, and coughing because of irritation of the trachea from regurgitated food Disorders of the Esophagus Diverticula Diagnostic Procedure Barium swallow to locate diverticulum Esophageal manometry to determine the presence of an associated motility disorder in epiphrenic diverticulum *Endoscopy is contraindicated because endoscope may perforate the diverticulum Disorders of the Esophagus Diverticulum Medical Management Small, frequent meals of semisoft foods often facilitate passage of food Take note of which foods ease or worsen the manifestations Raise the head of the bed for 2 hours after meals Sleep with head elevated to prevent reflux Avoid constrictive clothing and vigorous exercise after eating Disorders of the Esophagus Diverticulum Surgical Management Zenker’s diverticulum – cervical approach Diverticula located lower the esophagus – thoracic approach *diverticulum is excised and the esophageal mucosa is re-anastomosed Disorders of the Esophagus Diverticulum Nursing Management of the Surgical Client Provide teaching – explain preparation of NPO and NG insertion Maintain NG tube - do not irrigate or reposition the NG tube (can perforate the esophagus or stomach - assess for manifestation of esophageal perforation such as chest pain, fever, and subcutaneous emphysema Disorders of the Esophagus Diverticulum Nursing Management of the Surgical Client Promote comfort Disorders of the Esophagus Esophageal Cancer Etiology and Risk Factors Cigarette smoking and alcohol consumption HPV Chronic reflux of gastric contents results in squamous epithelium to columnar epithelium Other risk factors include obesity, ingestion of smoked meats and poor nutritional intake of vitamins A and C and minerals such as magnesium, selenium, and zinc Disorders of the Esophagus Esophageal Cancer Pathophysiology Normal Esophagus is lined with squamous epithelium, which is continuous until it reaches the gastroesophageal junction At the junction, columnar tissues lines the esophagus Disorders of the Esophagus Esophageal Cancer Pathophysiology Slow-growing tissue changes or dysplasia occurs Classified as polypoid (projects into the lumen, obstructing the lumen if undetected), ulcerative (raised and may expand into the mucosa, elevating until obstructive) or infiltrative (expand locally and rapidly, causing wall thickening and narrowing of the lumen) Disorders of the Esophagus Esophageal Cancer Pathophysiology Esophagus has no serosal layer, tumors are allowed to spread to adjacent tissues and lymphatic nodes early Metastasis is wide and quick because of the rich lymphatic supply; common sites are liver, lung, pleura, and kidneys Disorders of the Esophagus Esophageal Cancer Clinical Manifestations Dysphagia is progressive - becomes constraint and manifestations of obstruction appear - increase in salivation, mucus in the throat, nocturnal aspiration, regurgitation and an inability to swallow even liquids There may be pain in epigastric and sternal area Disorders of the Esophagus Esophageal Cancer Medical Management Inhibit tumor growth (Karnosfsky performance scale) Radiation therapy to reduce tumor size and slows tumor growth - may cause stenosis of the esophagus, treatment is administered 6 to 8 weeks to minimize the effect Chemotherapy Disorders of the Esophagus Esophageal Cancer Medical Management Photodynamic therapy - client receives an injection of light-sensitive drug (photofrin), which is followed 2 days later with special fiberoptic probe with a light-bearing tip placed in the esophagus The light activates the photofrin and kills only cancer cells Disorders of the Esophagus Esophageal Cancer Medical Management Maintain nutrition - gastrostomy or jejunostomy feeding - proper positioning to prevent regurgitation after meal - elevate head 30 degrees always Disorders of the Esophagus Esophageal Cancer Nursing Management Nutrition: Less than body requirements - monitor client’s nutritional status, including measurement of daily weight, I and O, calories consumed - assess skin around feeding tube for impairment of skin integrity caused by leakage of gastric juices - wash the skin with soap and dry thoroughly twice a day - apply protective ointment such as zinc oxide or karaya gum Disorders of the Esophagus Esophageal Cancer Nursing Management Impaired swallowing - can easily choke on saliva and mucous secretions and must spit frequently or drool; wiping can cause irritation - taught self-suctioning - assist in frequent oral care to prevent oral lesions and oral infections Disorders of the Esophagus Esophageal Cancer Nursing Management Risk for ineffective coping - provide emotional support Disorders of the Esophagus Esophageal Cancer Surgical Management Esophageal dilation - to treat strictures and obstruction Prosthesis or stent - to maintain patency, but can perforate the esophagus if it becomes dislodge or the tumor size increases Disorders of the Esophagus Esophageal Cancer Surgical Management Prophylactic surgery (the lower third of the esophagus is removed) Esophagectomy - removal of all part of the esophagus; replaced with dacron graft; performed via thoracotomy Disorders of the Esophagus Esophageal Cancer Surgical Management Esophagogastrostomy - resection of the lower portion of the esophagus and anastomosis to the stomach Esophagoenterostomy - resected and replaced with a segment of the descending colon Disorders of the Esophagus Esophageal Cancer Nursing Management of a Surgical Client Improve nutritional status before surgery Provide preoperative teaching Maintain airway Maintain fluid and electrolyte balance - monitor drainage (bloody to greenish yellow) - NPO for 4 to 5 days Disorders of the Esophagus Vascular Disorders Varices due to portal hypertension Disorders of the Esophagus Trauma Chemical burns (ingestions of acids or alkalis, sometimes highly spiced foods), thermal burns (extremely hot liquids), presence of foreign bodies, and injuries from external forces such as endoscopic equipment The Lord is my Shepherd…I shall not want… Psalm 23:1