Chapter 46: Management of Patients With Oral and Esophageal Disorders – Flashcards

b) dysphagia. This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain on swallowing.

d) Surgical removal of the diverticulum Because Zenker's diverticulum is progressive, the only means of cure is surgical removal of the diverticulum.

c) Omeprazole (Prilosec) Proton-pump inhibitors include omeprazole (Prilosec) and lansoprazole (Prevacid). Ranitidine (Zantac) is a histamine-2 antagonist; sucralfate (Carafate) is a cytoprotective agent; cisapride (Propulsid) is a gastrointestinal motility agent.

b) Chronic irritation of the esophagus is a known risk factor. In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men as in women. It is seen more frequently in African Americans than in Caucasian Americans. It usually occurs in the fifth decade of life.

b) Fowler's The patient should be placed in the Fowler's position to facilitate expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

b) Yellow-green secretions It is normal to observe a small amount of dark blood when the client first returns from the operating room, but then the drainage should promptly return to the yellow green of normal gastric secretions. Dark blood would initially be present after surgery but should promptly return to the yellow green of normal gastric secretions. This is an unexpected observation. You would expect to see yellow green of normal gastric secretions.

d) Approximately 80 to 120 mL. Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.

c) Give high-protein, semiliquid foods A major goal for a client with esophageal cancer is adequate or improved nutrition and eventually stable weight. Because he has difficulty in swallowing, the nurse should ensure that the client receives soft foods or high-calorie, high-protein semiliquid foods to get improved nutrition. Providing oral liquids alone will not provide improved nutrition. Using a straw leads to bloating and should be avoided. Providing liquid supplements are used in between meals, not as meals. Encouraging small, frequent meals will give improved nutrition to a client who does not have any difficulty in swallowing.

c) many oral cancers produce no symptoms in the early stages. The most frequent symptom of oral cancer is a painless sore that does not heal. The patient may complain of tenderness, and difficulty with chewing, swallowing, or speaking as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

d) Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute. A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is anitfungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.

a) Staphylococcus aureus People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcus aureus (except in mumps).

d) Arterial thrombosis A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.

d) Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

a) Proton pump inhibitors. Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.

d) Sialadenitis Sialadenitis is the inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

d) Insertion of nasogastric (NG) tube An NG tube may be inserted by the medical team. Vomiting and gastric lavage are avoided to prevent further exposure of the esophagus to the caustic agent. The patient is given nothing by mouth, and IV fluids are administered.

d) Pyrosis Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain on swallowing is termed odynophagia.

d) High epigastric pain and/or discomfort The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not require reporting to the physician.

a) Avoid all sweets. c) Gradually progress to five or six small meals daily, with each feeding providing protein, fat, and complex carbohydrate. Restrict total amount to less than one cup. Initially, the stomach will be about the size of an egg, stretching slowly over time to about the size of a cup. Sweets will trigger the symptoms associated with dumping syndrome. Take fluids between meals to prevent dumping syndrome and delay gastric emptying. Avoid commonly problematic foods, such as doughy breads, pasta, rice, skins and seeds of fruits and vegetables, nuts, and popcorn.

d) altered oral mucous membranes. Not drinking anything by mouth can result in drying of the oral mucous membranes and a coated, furrowed tongue. The risk for altered oral mucous membranes applies to an individual who is NPO. Being NPO is unrelated to physical injury. Being NPO is unrelated to ineffective social interaction. This is too short for a time frame to be concerned about decreased nutritional intake.

b) Encourage the client to eat meals with family or friends. c) Provide a soft, mechanical diet. d) Ask family to bring home-cooked favorite foods of the client. Clients who experience chemotherapy and radiation for esophageal cancer may have a depressed appetite and, thus, lose weight. Having the client socialize during mealtimes with family or friends will make eating more enjoyable. The client will better tolerate a soft, mechanical diet and home-cooked foods that are favorites. Supplements such as Boost and Ensure may promote vagotomy syndrome (dumping syndrome). The client is to sit upright for at least 2 hours after eating.

a) Follow-up medical appointment b) Follow-up dental appointment c) Oral hygiene d) Use of humidification Discharge teaching for a patient after oral surgery includes oral hygiene, follow-up dental and medical appointments, and the use of humidification to keep secretions moist.

c) Prepare for nasogastric irrigations. Hemorrhage with peptic ulcer disease is initially handled through cold saline lavage via nasogastric tube. Increasing the IV rate is not a nursing measure. Administering oxygen is not indicated unless the client is experiencing respiratory difficulties. While having hematemesis, the head of the bed would remain elevated to avoid risk for aspiration.

b) Take long, slow breaths During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.

b) Assessing lung sounds Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after as esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.

b) Glucagon Glucagon is administered before removing a foreign body because it relaxes the smooth muscle of the esophagus, thereby facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Insulin and epinephrine would not assist with foreign body removal.

b) Remove source of acid secretion. In a vagotomy, the vagus nerve is severed to decrease stimulation of gastric acid secretion. A delay in gastric emptying can be experienced after a vagotomy but is not the intended outcome. A portion of the stomach is removed to reduce acid by removing the source of acid secretion. Clients may experience dumping syndrome as a result of this surgery, which can result in malabsorption and anemia. Pernicious anemia can be an adverse effect of this surgery.

a) Parotid The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.

c) Take measures to prevent spreading the lesion to other people. A chancre is a primary lesion of syphilis and very contagious. It is important to instruct the client about ways to prevent spreading the lesion to others. Other nursing considerations include cold soaks to the lip, good mouth care (brushing and flossing), and administration of antibiotics as prescribed.

d) Make a notation on the call light system that the client cannot speak. The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.

c) Replace the nasogastric tube if the tube becomes dislodged. d) Verify rhythm on the cardiac monitoring system. e) Assess lung sounds every 4 hours and prn. Following recovery from anesthesia for a surgical resection of an esophageal tumor, the client is placed in the Fowler's position. A common postoperative complication is aspiration pneumonia. The nurse assesses for this complication by assessing lung sounds. The nurse monitors the drainage in the closed chest drainage system. Because of irritation of the vagus nerve, the nurse assesses for the complication of atrial fibrillation. The nurse does not replace the nasogastric tube if it becomes dislodged.

a) Stomatitis c) Kaposi's sarcoma Kaposi's sarcoma appears first on the oral mucosa as a red, purple, or blue lesion that is associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy, as well as HIV infection. Krythoplakia is caused by a nonspecific inflammation, and candidiasis is caused by fungus.

d) Boerhaave syndrome Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker's diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

d) Zenker's diverticulum The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).

d) metoclopramide The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa, which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

a) Aphthous stomatitis Aphthous stomatitis is characterized by a shallow ulcer with a white or yellow center and red border, often on the inner lip and cheek or on the tongue. It begins with a burning or tingling sensation and slight swelling, and is painful, usually lasting 7 to 10 days. Aphthous ulcers are associated with HIV infection. Kaposi's sarcoma and hairy leukoplakia also are found in clients who are HIV positive. Kaposi's sarcoma is marked by red, purple, or blue lesions on the oral mucosa; hairy leukoplakia is characterized by white patches with rough hair-like projections typically on the lateral border of the tongue. A chancre is a reddened, circumscribed lesion that ulcerates and becomes crusted--it is a primary lesion of syphilis.

a) Insert an intravenous (IV) catheter for administration of IV fluids. b) Maintain nothing by mouth status. c) Assess respiratory status every 4 hours and prn. e) Administer medication for report of pain. The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. The nurse will administer medication for pain and assess respiratory status. The client will be NPO, and IV fluids will be administered. Vomiting is avoided to prevent additional trauma from the caustic agent.

c) Buccal mucosa next to the upper molars The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.