Management of Patients With Oral and Esophageal Disorders.pdf

7/28/2019 Management of Patients With Oral and Esophageal Disorders.pdf

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Disorders of the Teeth

DENTAL PLAQUE AND CARIES

Tooth decay is an erosive process that begins

with the action of bacteria on fermentablecarbohydrates in the mouth, which produces acids

that dissolve tooth enamel.

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The extent of damage to the teeth

depends on the following:

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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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 oralinfection. 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 ABSCESS OR

PERIAPICAL ABSCESS

More commonly referred to as an abscessed

tooth, involves the collection of pus in the apical

dental periosteum (fibrous membrane supporting

the tooth structure) and the tissue surroundingthe 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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Acute periapical abscess is usually secondary to a suppurative

pulpitis (a pus-producing inflammation of the dental pulp)

that arises from an infection extending from dental caries.

The infection of the dental pulp extends through the apical

foramen of the tooth to form an abscess around the apex.

Chronic dentoalveolar abscess is a slowly progressive

infectious process. It differs from the acute form in that the

process may progress to a fully formed abscess without the

patients knowing it.

The infection eventually leads to a blind dental abscess,

which is really a periapical granuloma. It may enlarge to asmuch as 1 cm in diameter. It is often discovered on x-ray

films and is treated by extraction or root canal therapy, often

with apicectomy (excision of the apex of the tooth root).

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Clinical Manifestations

A dull, gnawing, continuous pain,

Surrounding cellulitis

Edema of the adjacent facial structures, Mobility of the involved tooth.

Gum opposite the apex of the tooth isusually swollen on the cheek side.

Swelling and cellulitis of the facial structuresmay make it difficult for the patient to openthe 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 torelieve 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 aftertreatment and instructs the patient to use a warm

saline or warm water mouth rinse to keep the areaclean.

The patient is also instructed to take antibiotics

and analgesics as prescribed,

To advance from a liquid diet to a soft diet astolerated, and to keep follow-up appointments.

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Disorders of the Jaw:

Temporomandibular disordersare categorized as follows (National Oral Health

Information)

Myofascial paina discomfort in the musclescontrolling jaw function and in neck and shouldermuscles

Internal derangement of the jointa dislocatedjaw, a displaced disc, or an injured condyle

Degenerative joint diseaserheumatoid arthritisor osteoarthritis in the jaw joint

Diagnosis and treatment of temporomandibulardisorders remain somewhat ambiguous

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Clinical Manifestations Patients have pain ranging from a dull ache to

throbbing, debilitating pain that can radiate tothe ears, teeth, neck muscles, and facial sinuses.

They often have restricted jaw motion andlocking of the jaw.

They may hear clicking and grating noises, andchewing and swallowing may be difficult.

Depression may occur in response to thesesymptoms.

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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, althoughinflammation can occur in the other salivary glands aswell.

Mumps (epidemic parotitis), a communicable diseasecaused by viral infection and most commonly affectingchildren, is an inflammation of a salivary gland, usuallythe parotid.

Elderly, acutely ill, or debilitated people with decreasedsalivary flow from general dehydration or medications

are at high risk The infecting organisms travel from the mouth through

the salivary duct. The organism is usuallyStaphylococcus aureus (except in mumps)

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S & S The onset of this complication is sudden, with an

exacerbation of both the fever and the symptoms of theprimary condition.

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.

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Management Preventive measures are essential and include advising

the patient to have necessary dental work performedbefore surgery.

In addition, maintaining adequate nutritional and fluid

intake, good oral hygiene, and discontinuingmedications (eg, tranquilizers, diuretics) that candiminish salivation may help prevent the condition.

If parotitis occurs, antibiotic therapy is necessary.

Analgesics may also be prescribed to control pain. If antibiotic therapy is not effective, the gland may need

to be drained by a surgical procedure known asparotidectomy.

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SIALADENITIS Inflammation of the salivary glands may be caused

by dehydration, radiation therapy, stress,malnutrition, salivary gland calculi (stones), orimproper oral hygiene.

The inflammation is associated with infection by S.aureus, Streptococcus viridans, or pneumococcus.

Symptoms include pain, swelling, and purulentdischarge.

Antibiotics are used to treat infections.

Massage, hydration, and corticosteroids frequentlycure the problem.

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SALIVARY CALCULUS (SIALOLITHIASIS)

Sialolithiasis, or salivary calculi (stones), usuallyoccurs in the submandibular gland.

Salivary gland ultrasonography or sialography (x-raystudies filmed after the injection of a radiopaque

substance into the duct) may be required todemonstrate obstruction of the duct by stenosis.

Salivary calculi are formed mainly from calciumphosphate.

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Cancer of the Oral Cavity

Cancers of the oral cavity, which can occur in anypart of the mouth or throat, are curable if discoveredearly.

These cancers are associated with the use of alcohol

and tobacco. The combination of alcohol and tobacco seems to

have a synergistic carcinogenic effect.

About 95% of cases of oral cancer occur in people

older than 40 years of age, but the incidence isincreasing in men younger than age 30 because of theuse of smokeless tobacco, especially snuff

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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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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 excisedliberally; 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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Medical Management

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 metastasizedthrough 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 acombination of these modalities.

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A radical neck dissection involves removal of all

cervical lymph nodes from the mandible to theclavicle and removal of the sternocleidomastoid

muscle, internal jugular vein, and spinal accessory

muscle on one side of the neck.

Modified radical neck dissection, which preserves on

or more of the nonlymphatic structures, is used more

often.

A selective neck dissection (in comparison to a radicaldissection) preserves one or more of the lymph node

groups, the internal jugular vein, the

sternocleidomastoid muscle, and the spinal accessory

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Read on your own!!! 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 symptomof 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 thestomach) to acute pain on swallowing

(odynophagia).

Obstruction of food (solid and soft) and even liquids

may occur anywhere along the esophagus.

Often the patient can indicate that the problem is

located in the upper, middle, or lower third of the

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Achalasia

is absent or ineffective peristalsis of the distalesophagus accompanied by failure of theesophageal sphincter to relax in response toswallowing.

Narrowing of the esophagus just above thestomach results in a gradually increasingdilation of the esophagus in the upper chest.

Achalasia may progress slowly and occurs mostoften in people 40 years of age or older.

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Assessment and Diagnostic Findings

X-ray studies show esophageal dilation abovethe narrowing at the gastroesophagealjunction.

Barium swallow, computed tomography

CT of the esophagus, and endoscopy may beused for diagnosis; however, the diagnosis isconfirmed by manometry, a process in which

the esophageal pressure is measured by aradiologist or gastroenterologist.

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Management

The patient should be instructed to eat slowlyand to drink fluids with meals.

As a temporary measure, calcium channel

blockers and nitrates have been used to decreaseesophageal pressure and improve swallowing.

Achalasia may be treated conservatively by

pneumatic dilation to stretch the narrowed areaof the esophagus this has a high success rate.

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Achalasia may be treated surgically by

esophagomyotomy

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DIFFUSE SPASM This 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 manifestsin 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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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 ofsedatives 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 anopening in the diaphragm and empties at itslower end into the upper part of the stomach.

Normally, the opening in the diaphragm

encircles the esophagus tightly, and thestomach lies completely within the abdomen.

In hiatus (or hiatal) hernia, the opening in thediaphragm through which the esophagus passes

becomes enlarged, and part of the upperstomach tends to move up into the lowerportion 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).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 theesophagus

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Heartburn,

Regurgitation

Dysphagia

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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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 theesophagus.

The patient is advised not 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 fromsliding upward.

Surgery is indicated in about 15% of patients.

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Management

Medical and surgical management of aparaesophageal hernia is similar to that forgastroesophageal reflux; however,paraesophageal hernias may require emergency

surgery to correct torsion (twisting) of thestomach or other body organ that leads torestriction of blood flow to that area.

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DIVERTICULUM

A diverticulum is an outpouching of mucosa andsubmucosa 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 esophagusor 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 aspharyngoesophageal 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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Difficulty swallowing, Fullness in the neck,

Belching,

Regurgitation of undigested food

Gurgling noises after eating.

The diverticulum, or pouch, becomes filled with foodor liquid. When the patient assumes a recumbent

position, undigested food is regurgitated, andcoughing may be caused by irritation of the trachea.

Halitosis and a sour taste in the mouth are alsocommon because of the decomposition of food

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A barium swallow may be performed to determine theexact nature and location of a diverticulum.

Manometric studies are often performed for patientswith 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 isprogressive, 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 astolerated.

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PERFORATION

The esophagus is not an uncommon site ofinjury.

Perforation may result from stab or bullet

wounds of the neck or chest, trauma frommotor 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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The patient has persistent pain followed bydysphagia. Infection, fever, leukocytosis, and

severe hypotension may be noted.

In some instances, signs of pneumothorax areobserved.

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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-spectrumantibiotic therapy is initiated.

A nasogastric tube is inserted to provide suction and toreduce the amount of gastric juice that can reflux intothe esophagus and mediastinum.

Nothing is given by mouth; nutritional needs are metby parenteral nutrition.

Parenteral nutrition is preferred to gastrostomybecause the latter might cause reflux into the

esophagus. Surgery may be necessary to close the wound, and

postoperative nutritional support then becomes aprimary concern.

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CHEMICAL BURNS

Chemical burns of the esophagus may be caused byundissolved 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

The use of corticosteroids to reduceinflammation and minimize subsequentscarring 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

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GASTROESOPHAGEAL REFLUX DISEASE

Some degree ofgastroesophageal reflux (back-flowof gastric or duodenal contents into the esophagus) is

normal in both adults and children.

Excessive reflux may occur because of anincompetent lower esophageal sphincter, pyloric

stenosis, or a motility disorder.

The incidence of reflux seems to increase with aging.

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(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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(GERD)

Diagnostic testing may include an endoscopy or barium

swallow to evaluate damage to the esophageal mucosa.

Ambulatory 12- to 36-hour esophageal pH monitoringis 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 thepatient to avoid situations that decreaselower 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 orspearmint, and carbonated beverages;

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Management (GERD)

Avoid eating or drinking 2 hours beforebedtime;

Maintain normal body weight;

Avoid tight-fitting clothes;

Elevate the head of the bed on 6- to 8-inch (15-to 20-cm) blocks; and

Elevate the upper body on pillows.

If reflux persists, the patient may be givenmedications such as antacids or histaminereceptor blockers. Proton pump inhibitors(medications that decrease the release of

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Management (GERD) Surgical management involves a

fundoplication - wrapping of a portion of the

gastric fundus around the sphincter area of theesophagus.

Fundoplication may be performed by

laparoscopy.

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CANCER OF THE ESOPHAGUS

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 oflife.

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 beenassociated with ingestion of alcohol andwith the use of tobacco.

There seems to be an association betweenGERD and adenocarcinoma of theesophagus.

People with Barretts esophagus (which iscaused by chronic irritation of mucousmembranes due to reflux of gastric andduodenal contents) have a higher

incidence 70


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Pathophysiology

Esophageal cancer is usually of the squamouscell 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 thelymphatics.

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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 becomesmore complete, even liquids cannot pass into thestomach.

Regurgitation of food and saliva occurs, hemorrhagemay take place, and progressive loss of weight

Later symptoms include substernal pain, persistenthiccup, respiratory difficulty, and foul breath.

The delay between the onset of early symptoms and

the time when the patient seeks medical advice isoften 12 to 18 months.

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New endoscopic techniques are being studied forscreening and diagnosis of esophageal cancer,currently diagnosis is confirmed most often by EGDwith biopsy and brushings.

Endoscopic ultrasound or mediastinoscopy is used todetermine whether the cancer has spread to the nodesand other mediastinal structures.

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Medical Management

If esophageal cancer is found at an earlystage, treatment goals may be directedtoward cure; however, it is often found in

late stages, making relief of symptoms theonly reasonable goal of therapy.

Treatment may include surgery, radiation,

chemotherapy, or a combination of thesemodalities,

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Management

Standard surgical management includes a totalresection 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 theproximal section of the esophagus

anastomosed to the stomach.

Tumors of the lower thoracic esophagus aremore 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 improvingthe patients nutritional and physicalcondition 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 ifadequate food can be taken by mouth.

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Nursing Management

informed about the nature of the postoperativeequipment 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 reflux

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 graftvisible,

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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 bymeans 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 isallowed to eat.

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Nursing Management Once feeding begins, the nurse encourages the patient

to swallow small sips of water and, later, smallamounts of pureed food.

After each meal, the patient remains upright for atleast 2 hours to allow the food to move through thegastrointestinal tract.

If radiation is part of the therapy, the patients appetiteis further depressed and esophagitis may occur.

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