Part 2 Management of Patients With Oral and Esophageal Disorders

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Part 2Management of PatientsWith Oral
andEsophageal Disorders

• 2ed Years Student, 2ed Semester
• Miss Iman shaweesh
• January 2008

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Disorders of the TeethDENTAL 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. The extent of damage
  to the teeth depends on the following

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• The presence of dental plaque
• The strength of the acids and the ability of the
  saliva to neutralize them
• The length of time the acids are in contact with
  the teeth
• The susceptibility of the teeth to decay

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Prevention

• Measures used to prevent and control dental
  caries include practicing effective mouth care,
  reducing the intake of starches and
• sugars (refined carbohydrates), applying fluoride
  to the teeth or
• drinking fluoridated water, refraining from
  smoking, controlling diabetes, and using pit and
  fissure sealants

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Disorders of the Lips, Mouth, and Gums
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Abnormalities of the Mouth
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Abnormalities of the Gums
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Gerontologic Considerations

• Many medications taken by the elderly cause dry
  mouth, which is uncomfortable, impairs
  communication, and increases the risk of oral
  infection. These medications include the
  following
• Diuretics
• Antihypertensive medications
• Anti-inflammatory agents
• Antidepressant medications

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Gerontologic Considerations

• Poor dentition can exacerbate problems of aging,
  such as
• Decreased food intake
• Loss of appetite
• Social isolation
• Increased susceptibility to systemic
  infection
• (from periodontal disease)
• Trauma to the oral cavity secondary to
  thinner,
• less vascular oral mucous membranes

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DENTOALVEOLAR ABSCESSOR PERIAPICAL ABSCESS

• more commonly referred to as an abscessed,
  involves the 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 has two forms acute
  and chronic. Acute periapical abscess is usually
  secondary to a suppurative pulpitis (a
  pus-producing inflammation of the dental pulp)

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Clinical Manifestations

• The abscess produces a dull, gnawing, continuous
  pain, often with a surrounding cellulitis and
  edema of the adjacent facial structures, 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.

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Management

• In the early stages of an infection, a dentist or
  dental surgeon
• may perform a needle aspiration or drill an
  opening into the pulp chamber to relieve tension
  and pain and to provide drainage.
• After the inflammatory reaction has subsided, the
  tooth may be extracted or root canal therapy
  performed. Antibiotics may be prescribed.

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Nursing Management

• The nurse assesses the patient for bleeding after
  treatment and instructs the patient to use a warm
  saline or warm water mouth rinse to keep the area
  clean.
• The patient is also instructed to take
  antibiotics
• and analgesics as prescribed,
• to advance from a liquid diet
• to a soft diet as tolerated, and to keep
  follow-up appointments.

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Disorders of the Jaw

• Temporomandibular disorders are categorized as
  follows (National Oral Health Information)
• Myofascial paina discomfort in the muscles
  controlling jaw function and in neck and shoulder
  muscles
• Internal derangement of the jointa dislocated
  jaw, a displaced disc, or an injured condyle
• Degenerative joint diseaserheumatoid arthritis
  or osteoarthritis in the jaw joint

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Disorders of the Salivary Glands

• Parotitis (inflammation of the parotid gland) is
  the most common inflammatory condition of the
  salivary glands, although inflammation can occur
  in the other salivary glands as well. Mumps
  (epidemic parotitis), a communicable disease
  caused by viral infection and most commonly
  affecting children, is an inflammation of a
  salivary gland, usually the parotid.

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SIALADENITIS

• (inflammation of the salivary glands) may be
  caused by dehydration, radiation therapy, stress,
  malnutrition, salivary gland calculi (stones), or
  improper oral hygiene. The inflammation is
  associated with infection by S. aureus,
  Streptococcus viridans, or pneumococcus.

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SALIVARY CALCULUS (SIALOLITHIASIS)

• Sialolithiasis, or salivary calculi (stones),
  usually occurs in the submandibular gland.
  Salivary gland ultrasonography or sialography
  (x-ray studies filmed after the injection of a
  radiopaque substance into the duct) may be
  required to demonstrate obstruction of the duct
  by stenosis. Salivary calculi are formed mainly
  from calcium
• phosphate.

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Cancer of the Oral Cavity

• Cancers of the oral cavity, which can occur in
  any part of the mouth or throat, are curable if
  discovered early. These cancers are associated
  with the use of alcohol and tobacco.
• Cancer of the oral cavity accounts for less than
  2 of all cancer deaths in the United States. Men
  are afflicted more often than women.

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Pathophysiology

• Malignancies of the oral cavity are usually
  squamous cell cancers. Any area of the oropharynx
  can be a site for malignant growths, but the
  lips, the lateral aspects of the tongue, and the
  floor of the mouth are most commonly affected.

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Clinical Manifestations

• Many oral cancers produce few or no symptoms in
  the early stages. Later, the most frequent
  symptom is a painless sore or mass that will not
  heal. A typical lesion in oral cancer is a
  painless
• indurated (hardened) ulcer with raised edges.
  Tissue from any ulcer of the oral cavity that
  does not heal in 2 weeks should be examined
• through biopsy.

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Medical Management

• Surgical resection, radiation therapy,
  chemotherapy, or a combination of these therapies
  may be effective. In cancer of the lip, small
  lesions are usually excised liberally larger
  lesions involving more than one third of the lip
  may be more appropriately treated by radiation
  therapy because of superior cosmetic results.

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• If the cancer has spread to the lymph nodes, the
  surgeon may perform a neck dissection. Surgical
  treatments leave a less functional tongue
  surgical procedures include hemiglossectomy
  (surgical removal of half of the tongue) and
  total glossectomy (removal of the tongue).
• Often cancer of the oral cavity has metastasized
  through the extensive lymphatic channel in the
  neck region

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Neck Dissection

• Malignancies of the head and neck include those
  of the oral cavity, oropharynx, hypopharynx,
  nasopharynx, nasal cavity,paranasal sinus, and
  larynx (Fig)
• These cancers account for fewer than 5 of all
  cancers. Depending on the location and stage,
  treatment may consist of radiation therapy,
  chemotherapy, surg or a combination of these
  modalities.

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• 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 muscle on one side of the neck.

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Group Discussion

• Nursing Management
• NURSING PROCESS THE PATIENT WITH CONDITIONS OF
  THE ORAL CAVITY
• Neck Dissection
• NURSING PROCESS THE PATIENT UNDERGOING A NECK
  DISSECTION

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Disorders of the Esophagus

• The esophagus is a mucus-lined, muscular tube
  that carries food from the mouth to the stomach.
  It begins at the base of the pharynx and ends
  about 4 cm below the diaphragm. Its ability to
  transport food and fluid is facilitated by two
  sphincters. The upper esophageal sphincter, also
  called the hypopharyngeal sphincter, is located
  at thejunction of the pharynx and the esophagus.
  The lower esophageal sphincter, also called the
  gastroesophageal sphincter, is located at the
  junction of the esophagus and the stomach.

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Dysphagia

• (difficulty swallowing) is the most common
  symptom of esophageal disease. This symptom may
  vary from an uncomfortable
• feeling that a bolus of food is caught in the
  upper esophagus (before it eventually passes into
  the stomach) to acute pain
• on swallowing (odynophagia).

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Achalasia

• is absent or ineffective peristalsis of the
  distal esophagus accompanied by failure of the
  esophageal sphincter to relax in response to
  swallowing. Narrowing of the esophagus just above
  the stomach results in a gradually increasing
  dilation of the esophagus in the upper chest.
  Achalasia may progress slowly and occurs most
  often in people 40 years of age or older.

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Clinical Manifestations

• The primary symptom of achalasia is difficulty in
  swallowing both liquids and solids. The patient
  has a sensation of food sticking in the lower
  portion of the esophagus. As the condition
  progresses, food is commonly regurgitated, either
  spontaneously or intentionally by the patient to
  relieve the discomfort produced by prolonged
  distention of the esophagus by food that will not
  pass into the stomach. The patient may also
  complain of chest pain and heartburn
• (pyrosis).

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Assessment and Diagnostic Findings

• X-ray studies show esophageal dilation above the
  narrowing at the gastroesophageal junction.
  Barium swallow, computed tomography
• (CT) of the esophagus, and endoscopy may be used
  for diagnosis however, the diagnosis is
  confirmed by manometry, a process in which the
  esophageal pressure is measured by a radiologist
  or gastroenterologist.

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Management

• The patient should be instructed to eat slowly
  and to drink fluids with meals. As a temporary
  measure, calcium channel blockers and nitrates
  have been used to decrease esophageal pressure
  and improve swallowing.
• Achalasia may be treated conservatively by
  pneumatic dilation to stretch the narrowed area
  of the esophagus (Fig. 35-6). Pneumatic dilation
  has a high success rate.

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Achalasia may be treated surgically by
esophagomyotomy
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DIFFUSE SPASM

• spasm is a motor disorder of the esophagus. The
  cause is unknown, but stressful situations can
  produce contractions of the esophagus. It is more
  common in women and usually manifests in middle
  age.
• characterized by difficulty or pain on
  swallowing (dysphagia, odynophagia) and by chest
  pain similar to that of coronary artery spasm.

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Assessment and Diagnostic Findings

• Esophageal manometry, which measures the motility
  of the esophagus and the pressure within the
  esophagus, indicate that simultaneous
  contractions of the esophagus occur irregularly.
  Diagnostic x-ray studies after ingestion of
  barium show separate areas of spasm.

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Management

• Conservative therapy includes administration of
  sedatives and long-acting nitrates to relieve
  pain. Calcium channel blockers have also been
  used to manage diffuse spasm. Small, frequent
• feedings and a soft diet are usually
  recommended to decrease the esophageal pressure
  and irritation that lead to spasm.

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HIATAL HERNIA

• The esophagus enters the abdomen through an
  opening in the diaphragm and empties at its lower
  end into the upper part of the stomach. Normally,
  the opening in the diaphragm encircles the
  esophagus tightly, and the stomach lies
  completely within the abdomen. In a condition
  known as hiatus (or hiatal) hernia, the opening
  in the diaphragm through which the esophagus
  passes becomes enlarged, and part of the upper
  stomach tends to move up into the lower portion
  of the thorax.

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There are two types of hiatal hernias sliding
and paraesophageal

• Sliding, or type I, hiatal hernia occurs when the
  upper stomach and the gastroesophageal junction
  (GEJ) are displaced upward and slide in and out
  of the thorax (Fig. 35-8A). About 90 of patients
  with esophageal hiatal hernia have a sliding
  hernia.
• A paraesophageal hernia occurs when all or part
  of the stomach pushes through the diaphragm
  beside the esophagus

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Clinical Manifestations

• may have heartburn, regurgitation, and dysphagia,
  but at least 50 of patients are asymptomatic.
  Sliding hiatal hernia is often implicated in
  reflux. The patient with a paraesophageal hernia
  usually feels a sense of fullness after eating or
  may be asymptomatic.

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Assessment and Diagnostic Findings

• Diagnosis is confirmed by
• x-ray studies,
• barium swallow,
• and fluoroscopy.

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Management

• Management for an axial hernia includes frequent,
  small feedings that can pass easily through the
  esophagus. The patient is advisednot to recline
  for 1 hour after eating, to prevent reflux or
  movement of the hernia, and to elevate the head
  of the bed on 4- to 8-inch (10- to 20-cm) blocks
  to prevent the hernia from sliding upward.
  Surgery is indicated in about 15 of patients.

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Management

• Medical and surgical management of a
  paraesophageal hernia is similar to that for
  gastroesophageal reflux however, paraesophageal
  hernias may require emergency surgery to correct
  torsion (twisting) of the stomach or other body
  organ that leads to restriction of blood flow to
  that area.

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DIVERTICULUM

• A diverticulum is an outpouching of mucosa and
  submucosa that protrudes through a weak portion
  of the musculature. Diverticula may occur in one
  of the three areas of the esophagusthe
  pharyngoesophageal or upper area of the
  esophagus, the midesophageal area, or the
  epiphrenic or lower area of the esophagus or
  they may occur along the border of the esophagus
  intramurally.

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• The most common type of diverticulum, which is
  found three times more frequently in men than in
  women, is Zenkers diverticulum (also known as
  pharyngoesophageal pulsion diverticulum or a
  pharyngeal pouch). It occurs posteriorly through
  the cricopharyngeal muscle in the midline of the
  neck. It is usually seen in people older than 60
  years of age.

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Clinical Manifestations

• include difficulty swallowing, fullness in the
• neck, belching, regurgitation of undigested
  food, and gurglingnoises after eating.
• The diverticulum, or pouch, becomes filled with
  food or liquid. When the patient assumes a
  recumbent position, undigested food is
  regurgitated, and coughing may be caused by
  irritation of the trachea.
• Halitosis and a sour taste in the mouth are also
  common because of the decomposition of food
  retained in the diverticulum.

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Assessment and Diagnostic Findings

• A barium swallow may be performed to determine
  the exact nature and location of a diverticulum.
• Manometric studies are often performed for
  patients with epiphrenic diverticula to rule out
  a motor disorder.
• Esophagoscopy usually is contraindicated because
  of the danger of perforation of the diverticulum,

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Management

• Because pharyngoesophageal pulsion diverticulum
  is progressive,the only means of cure is surgical
  removal of the diverticulum. During surgery, care
  is taken to avoid trauma to the common carotid
  artery and internal jugular veins.
• Food and fluids are withheld until x-ray studies
• show no leakage at the surgical site. The
  diet begins with liquids and progresses as
  tolerated.

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PERFORATION

• The esophagus is not an uncommon site of injury.
  Perforation may result from stab or bullet wounds
  of the neck or chest, trauma from motor vehicle
  crash, caustic injury from a chemical burn
  (described later), or inadvertent puncture by a
  surgical instrument during examination or
  dilation.

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Clinical Manifestations

• The patient has persistent pain followed by
  dysphagia. Infection,
• fever, leukocytosis, and severe hypotension may
  be noted. In
• some instances, signs of pneumothorax are
  observed.

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Assessment and Diagnostic Findings

• Diagnostic x-ray studies and fluoroscopy are used
  to identify the site of the injury.

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Management

• Because of the high risk of infection,
  broad-spectrum antibiotic therapy is initiated.
  A nasogastric tube is inserted to provide suction
  and to reduce the amount of gastric juice that
  can reflux into the esophagus and mediastinum.
  Nothing is given by mouth nutritional needs are
  met by parenteral nutrition. Parenteral nutrition
  is preferred to gastrostomy because the latter
  might cause reflux into the esophagus. Surgery
  may be necessary to close the wound, and
  postoperative nutritional support then becomes a
  primary concern.

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CHEMICAL BURNS

• Chemical burns of the esophagus may be caused by
  undissolved medications in the esophagus. This
  occurs more frequently in the elderly than it
  does among the general adult population. A
  chemical burn may also occur after swallowing of
  a battery, which may release caustic alkaline.
  Chemical burns of the esophagus occur most often
  when a patient, either intentionally or
  unintentionally, swallows a strong acid or base

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RX

• Esophagoscopy and barium swallow- to determine
  the extent and severity of damage.
• The patient is NPO, and IV fluids adm
• A NGT may be inserted by the physician.
• Vomiting and gastric lavage are avoided to
  prevent further exposure of the esophagus to the
  caustic agent.

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RX

• The use of corticosteroids to reduce inflammation
  and minimize subsequent scarring and stricture
  formation is of questionable value.
• The value of the prophylactic use of antibiotics
  for these patients has also been questioned
• For strictures that do not respond to dilation,
  surgical management is necessary.

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GASTROESOPHAGEAL REFLUX DISEASE

• Some degree of gastroesophageal reflux (back-flow
  of gastric or duodenal contents into the
  esophagus) is normal in both adults and children.
  Excessive reflux may occur because of an
  incompetent lower esophageal sphincter, pyloric
  stenosis, or a motility disorder. The incidence
  of reflux seems to increase with aging.

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Clinical Manifestations(GERD)

• pyrosis (burning sensation in the esophagus),
• dyspepsia (indigestion), regurgitation,
• dysphagia or odynophagia (difficulty swallowing,
• pain on swallowing), hypersalivation, and
  esophagitis. The symptoms may mimic those of a
  heart attack.

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Assessment and Diagnostic Findings(GERD)

• Diagnostic testing may include an endoscopy or
  barium swallow to evaluate damage to the
  esophageal mucosa.
• Ambulatory 12- to 36-hour esophageal pH
  monitoring is used to evaluate the degree
• of acid reflux.
• Bilirubin monitoring (Bilitec) is used to measure
• bile reflux patterns.

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Management (GERD)

• Management begins with teaching the patient to
  avoid situations that decrease lower esophageal
  sphincter pressure or cause esophageal
  irritation.
• The patient is instructed to eat a low-fat diet
• to avoid caffeine, tobacco, beer, milk, foods
  containing peppermint or spearmint, and
  carbonated beverages to avoid eating or drinking

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Management (GERD)

• 2 hours before bedtime to maintain normal body
  weight to avoid tight-fitting clothes to
  elevate the head of the bed on 6- to 8-inch (15-
  to 20-cm) blocks and to elevate the upper body
  on pillows.
• If reflux persists, the patient may be given
  medications such as antacids or histamine
  receptor blockers. Proton pump inhibitors
  (medications that decrease the release of gastric
  acid,

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Management (GERD)

• Surgical management involves a fundoplication
  (wrapping of a portion of the gastric fundus
  around the sphincter area of the esophagus).
  Fundoplication may be performed by laparoscopy.

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CANCER OF THE ESOPHAGUS

• USA carcinoma of the esophagus occurs more than
  three times as often in men as in women. It is
  seen more frequently in African Americans than in
  Caucasians and usually occurs in the fifth decade
  of life. Cancer of the esophagus has a much
  higher incidence in other parts of the world,
  including China and northern Iran

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• cancer of the esophagus has been associated with
  ingestion of alcohol and with the use of tobacco.
  There seems to be an association between GERD and
  adenocarcinoma of the esophagus. People with
  Barretts esophagus (which is caused by chronic
  irritation of mucous membranes due to reflux of
  gastric and duodenal contents) have a higher
  incidence

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Pathophysiology

• Esophageal cancer is usually of the squamous cell
  epidermoid type however, the incidence of
  adenocarcinoma of the esophagus is increasing in
  the United States.
• Tumor cells may spread beneath the esophageal
  mucosa or directly into, through, and beyond the
  muscle layers into the lymphatics.

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Clinical Manifestations

• Symptoms include dysphagia, initially with solid
  foods and eventually with liquids a sensation of
  a mass in the throat painful swallowing
  substernal pain or fullness and, later,
  regurgitation of undigested food with foul breath
  and hiccups.

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• As the tumor progresses and the obstruction
  becomes more complete, even liquids cannot pass
  into the stomach. Regurgitation of food and
  saliva occurs, hemorrhage may take place, and
  progressive loss of weight
• Later symptoms include substernal pain,
  persistent hiccup, respiratory difficulty, and
  foul breath. The delay between the onset of early
  symptoms and the time when the patient seeks
  medical advice is often 12 to 18 months.

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Assessment and Diagnostic Findings

• new endoscopic techniques are being studied for
  screening and diagnosis of esophageal cancer,
  currently diagnosis is confirmed most often by
  EGD with biopsy and brushings.
• Endoscopic ultrasound or mediastinoscopy
• is used to determine whether the cancer has
  spread to the nodes and other mediastinal
  structures.

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Medical Management

• If esophageal cancer is found at an early stage,
  treatment goals may be directed toward cure
  however, it is often found in late stages, making
  relief of symptoms the only reasonable goal of
  therapy.
• Treatment may include surgery, radiation,
  chemotherapy, or a combination of these
  modalities,

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• Standard surgical management includes a total
  resection of the esophagus (esophagectomy) with
  removal of the tumor plus a wide tumor-free
  margin of the esophagus and the lymph nodes in
  the area.
• When tumors occur in the cervical or upper
  thoracic area, esophageal continuity may be
  maintained by free jejunal graft transfer, in
  which the tumor is removed and the area is
  replaced with a portion of the jejunum (Fig).

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• A segment of the colon may be used, or the
• stomach can be elevated into the chest and the
  proximal section of the esophagus anastomosed to
  the stomach.
• Tumors of the lower thoracic esophagus are more
  amenable to surgery than are tumors located
  higher in the esophagus, and gastrointestinal
  tract integrity is maintained by anastomosing the
  lower esophagus to the stomach.

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• Surgical resection of the esophagus has a
  relatively high mortality rate because of
  infection, pulmonary complications, or leakage
  through the anastomosis.
• Postoperatively, the patient will have a
  nasogastric tube in place that should not be
  manipulated. The patient is given nothing by
  mouth until x-ray studies confirm that
• the anastomosis is secure and not leaking.

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Nursing Management

• Intervention is directed toward improving the
  patients nutritional and physical condition in
  preparation for surgery, radiation therapy, or
  chemotherapy.
• A program to promote weigh gain based on a
  high-calorie and high-protein diet, in liquid or
  soft form, is provided if adequate food can be
  taken by mouth.

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Nursing Management

• informed about the nature of the postoperative
  equipment that will be used, including that
  required for closed chest drainage, nasogastric
  suction, parenteral fluid therapy, and gastric
  intubation.
• After recovering from the effects of anesthesia,
  the patient is placed in a low Fowlers position,
  and later in a Fowlers position, to assist in
  preventing re- flux of gastric secretions.

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Nursing Management

• The patient is observed carefully
  for-regurgitation and dyspnea. A common
  postoperative complication is aspiration
  pneumonia.
• If jejunal grafting has been performed, the nurse
  checks for graft viability hourly for at least
  the first 12 hours. To make the graft visible,

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Nursing Management

• Moist gauze covers the external portion of the
  graft. The gauze is removed briefly to assess the
  graft for color and to assess for the presence of
  a pulse by means of Doppler ultrasonography.
• The nasogastric tube is removed 5 to 7 days after
  surgery, and a barium swallow is performed to
  assess for any anastomotic leak before the
  patient is allowed to eat.

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Nursing Management

• Once feeding begins, the nurse encourages the
  patient to swallow small sips of water and,
  later, small amounts of pureed food.
• After each meal, the patient remains upright for
  at least 2 hours to allow the food to move
  through the gastrointestinal tract.
• If radiation is part of the therapy, the
  patients appetite is further depressed and
  esophagitis may occur.

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thanks