Management of Patients with Oral and Esophageal Disorders Flashcards
Describe the nursing management of patients with abnormalities of the oral cavity, jaw, and salivary glands, including cancer of the oral cavity and disorders of the esophagus.
Nursing management includes assessment of oral hygiene, pain management, nutritional support, airway protection, patient education on self-care, monitoring for complications, and coordination with an interprofessional team.
Describe the nursing management of the patient receiving enteral nutrition support.
Monitor tube placement, assess for complications such as aspiration or infection, ensure adequate hydration and nutrition, provide skin care around the tube site, and educate the patient and caregivers on proper feeding techniques.
Use the nursing process as a framework for care of the patient undergoing neck dissection, having a gastrostomy or jejunostomy feeding tube placed, or with noncancerous disorders of the esophagus.
Assessment includes airway patency, nutritional status, and wound healing. Nursing interventions focus on pain management, prevention of infection, emotional support, and rehabilitation planning. Evaluation includes monitoring for complications and ensuring adequate nutrition and communication strategies.
What are the nursing concepts related to patients with oral and esophageal disorders?
Elimination, Nutrition
Define achalasia.
Absent or ineffective peristalsis (wavelike contraction) of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing.
What is the focus of the assessment and diagnostic findings for temporomandibular joint disorders?
Diagnosis is based on the patient’s report of pain, limitations in range of motion, dysphagia (difficulty swallowing), difficulty chewing, difficulty with speech, or hearing difficulties.
What imaging studies are used for severe or chronic symptoms of temporomandibular joint disorders?
Magnetic resonance imaging (MRI) and other imaging studies.
What type of treatment is recommended for temporomandibular joint disorders?
Conservative treatment is recommended.
What are some noninvasive therapies for temporomandibular joint disorders?
Patient education on self-care—eating soft foods, icing the jaw; cognitive behavior modifications—stress reduction, sleep hygiene, avoidance of extreme mandibular movement, and elimination of habits such as chewing ice; physical therapy—stretching and relaxing; acupuncture—highly effective with six to eight 15- to 30-minute sessions; psychosocial interventions; analgesics—trial of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants initially; oral appliance therapy—splints.
What should surgery providers assess in the acute trauma setting for mandibular fractures?
The patient’s perception of the bite (“bite feels normal”) for malocclusion; the fracture site for fragment mobility; dentition for loose or infected teeth; sensation in the lower lip for nerve damage.
What is a viable option for mandibular fractures when the dentition is sufficient and the fracture is isolated?
Maxillomandibular fixation (MMF; wiring the jaw shut) is a viable option.
What is the surgery of choice for mandibular fractures?
Open reduction, internal fixation (ORIF) with plate fixation (insertion of one or more metal plates and screws or arch bars into the bone to approximate and stabilize the bone).
What can be used to replace structural defects in mandibular fractures?
Bone grafting may be performed to replace structural defects using bones from the patient’s own ilium, ribs, or cranial sites.
What does the nurse assess preoperatively for a patient with a mandibular fracture?
The nurse assesses the patient’s nutritional status preoperatively, and a dietary consultation may be necessary.
What type of feeding may the patient require before and after surgery for a mandibular fracture?
The patient may require enteral (through the GI tract) or parenteral (intravenous [IV]) feedings before and after surgery to maintain adequate nutrition.
What does the interprofessional team provide for a patient with a mandibular fracture?
The interprofessional team, including a registered dietician (RD), provides continual nutritional assessment and reevaluation.
How can verbal communication be impaired after radical surgery for oral cancer?
Verbal communication may be impaired by radical surgery for oral cancer, especially if the larynx is removed.
What should be assessed to assist patient communication after radical surgery for oral cancer?
It is therefore vital to assess the patient’s ability to communicate in writing before surgery.
What can be provided postoperatively to patients who can use them to communicate?
Pen and paper are provided postoperatively to patients who can use them to communicate.
What is obtained preoperatively and given after surgery to patients who cannot write?
A communication board with commonly used words or pictures.
What are other options for facilitating communication for patients who cannot write?
Electronic devices, such as tablets or smartphones.
What health care professional’s input is important for impaired communication in patients after radical surgery for oral cancer?
The interprofessional team benefits from the input of a speech therapist, with physical and occupational therapists consulted as needed.
What are the nursing responsibilities for a patient with disorders of the oral cavity?
The nurse caring for the patient with disorders of the oral cavity: promotes mouth care, ensures adequate food and fluid intake, minimizes pain and discomfort, prevents infection.
How can incidences of oral complications during cancer therapy be decreased?
Incidences of oral complications, such as infection, during cancer therapy may be decreased and less severe with the incorporation of professional oral care before and during cancer treatment.
What do guidelines support the implementation of for patients undergoing head and neck chemotherapy and radiotherapy?
Guidelines, based on systematic review of the literature, support the implementation of multi-agent combination oral care protocols in patients undergoing head and neck chemotherapy and radiotherapy to prevent oral mucositis (OM), a painful inflammatory, typically ulcerative condition that is also referred to as stomatitis.
What is the effect of saline or sodium bicarbonate rinses for the oral cavity?
Experts recognize that using saline or sodium bicarbonate rinses increases oral clearance, promotes oral hygiene, and promotes patient comfort.
How are saline or sodium bicarbonate rinses prepared?
The nurse facilitates the patient rinsing or irrigating with a solution of ½ to 1 teaspoon of baking soda (or ¼-teaspoon salt) in 8 oz of warm water.
Is chlorhexidine recommended for the prevention of oral mucositis?
Chlorhexidine has been studied more rigorously than other rinses and is generally not recommended for the prevention of OM, specifically not for patients undergoing head and neck radiotherapy.
Is magic mouthwash effective for chemotherapy-induced oral mucositis?
There is continued debate about the efficacy of magic mouthwash, particularly for chemotherapy-induced OM.
What should the patient and/or caregiver be able to state at the completion of education regarding home care for a patient with an oral disorder?
State the impact of the oral disorder and treatment on communication and other physiologic functioning, ADLs, IADLs, body image, roles, relationships, and spirituality. Identify modification of home environment, interventions, and strategies (e.g., utilizing durable medical equipment, employing a home health aide) used in safely adapting to changes in structure or function and promote effective recovery and rehabilitation. Describe ongoing therapeutic regimen, including diet and activities to perform (e.g., oral care, suctioning) and to limit or avoid (e.g., oral foods if NPO).
What are the major goals for the patient undergoing surgery for disorders of the oral cavity?
Increased knowledge of surgical procedure and treatment plan, maintenance of respiratory status, decreased pain, viability of the graft, maintenance of adequate intake of food and fluids, effective coping strategies (for patient and caregivers), effective communication, maintenance of shoulder and neck motion, absence of complications.
What should preoperative education address for a patient undergoing surgery for disorders of the oral cavity?
Preoperative education addresses interventions that cover the entire perioperative period.
What is part of the informed consent process for a patient undergoing surgery for disorders of the oral cavity?
As part of the informed consent process, the patient should be made aware of the potential/actual risks and benefits of the procedure as well as other treatment options, and the projected outcome if the procedure is not done.
What should the nurse assess during the exchange with the patient before surgery for disorders of the oral cavity?
During this exchange, the nurse has an opportunity to assess the patient’s coping abilities, answer questions, and develop a plan for offering assistance.
How does oral care before eating impact a patient with disorders of the oral cavity?
Oral care before eating may enhance the patient’s appetite, and oral care after eating is important to prevent infection and dental caries.
What information is provided to the patient and family preoperatively for disorders of the oral cavity?
Preoperatively, information about the planned surgery is given to the patient and family. Any questions are answered as accurately as possible.
What are the psychological nursing interventions aimed at postoperatively for disorders of the oral cavity?
Postoperatively, psychological nursing interventions are aimed at supporting the patient who has had a change in body image or who has major concerns related to the prognosis.
What behavioral issues often directly relate to the underlying cause of head and neck cancer?
The patient’s behavioral issues (e.g., HPV infection status, alcohol, smoking) often directly relate to the underlying cause of the cancer.
What does the psychological adaptation require after a disfiguring surgery, and the social complications inherent in swallowing and speech?
The psychological adaptation required after a disfiguring surgery, and the social complications inherent in swallowing and speech are profound.
What should the patient and/or caregiver be able to identify at the completion of education regarding home care for a patient recovering from neck surgery?
Name the procedure that was performed and identify any permanent changes in anatomic structure or function as well as changes in communication, ADLs, IADLs, roles, body image, relationships, and spirituality. Identify modification of home environment, interventions, and strategies (e.g., utilizing durable medical equipment, employing a home health aide) used in safely adapting to changes in structure or function and promote effective recovery and rehabilitation. Describe ongoing therapeutic regimen, including diet and activities to perform (e.g., oral care, suctioning) and to limit or avoid (e.g., lifting weights, driving a car, contact sports).
What are the expected patient outcomes after neck surgery?
Exhibits increased knowledge of course of treatment. Demonstrates adequate respiratory exchange. Lungs are clear to auscultation. Breathes easily with no shortness of breath. Demonstrates ability to use suction effectively.
When is nasoduodenal or nasojejunal feeding indicated?
Nasoduodenal or nasojejunal feeding is indicated when the esophagus and stomach need to be bypassed or when the patient is at risk for aspiration (i.e., inhalation of fluids or foods into the trachea and bronchial tree).
When are gastrostomy or jejunostomy tubes preferred for tube feedings?
For tube feedings longer than 4 weeks, gastrostomy or jejunostomy tubes are preferred for administration of medications or nutrition.
What is the osmolality of normal body fluids?
Approximately 300 mOsm/kg.
What may occur when a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts?
When a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The patient may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, collectively termed dumping syndrome.
What can dumping syndrome lead to?
Dehydration, hypotension, and tachycardia.
How can the small intestines adapt to a formula of high osmolality?
The small intestines may be able to adapt to a formula of high osmolality if it is initiated at a low hourly rate that is advanced slowly.
What are practical and inexpensive options for the patient receiving tube feedings who resides at home or in a long-term care facility?
Bolus and intermittent drip tube feeding methods.
How is bolus infusion administered?
Bolus infusion requires dividing the total daily feeding volume into 4 to 6 feeds throughout the day. Boluses can be given into the stomach through a large (50-mL) syringe via gravity.
What factors are important to consider when tube feedings are given?
The temperature and volume of the feeding, the flow rate, and the patient’s total fluid intake are important factors to consider when tube feedings are given.
How often should the feeding be paused, and the tube flushed with water before and after medication administration via tube?
The feeding is paused, and the tube is flushed with at least 15 mL of water before and at least 15 mL of water after medication administration (30 mL total).
What size syringe should be used to irrigate small-bore feeding tubes for continuous infusion after administration of medications?
When small-bore feeding tubes for continuous infusion are irrigated after administration of medications, a 20-mL or larger syringe is used because the pressure generated by smaller syringes could rupture the tube.
What strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding?
Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.
What are the interventions for the first week after gastrostomy or jejunostomy tube insertion?
For the first week after insertion, interventions are focused on prevention of stomal tract infection and promotion of incisional healing.
How often should the insertion site be kept clean and dry for the first week after gastrostomy or jejunostomy tube insertion?
The insertion site should be kept clean and dry using aseptic wound care daily and/or a glycerin hydrogel or glycogel dressing.
After approximately 1 week, how should the gastrostomy or jejunostomy tube site be cleansed?
After approximately 1 week, the site (including under the external disc, if one is present) can be cleansed twice a week with soap and water and left open to air.
After the first week of healing, how can buried bumper syndrome be prevented?
After the first week of healing, buried bumper syndrome, a severe, but rare complication, can be prevented by rotating the gastric tube (not done with jejunostomy tubes) daily and moving the tube inward 2 to 10 cm at least once a week.
What is the patient with a gastrostomy or jejunostomy tube in the home setting must be capable of?
The patient with a gastrostomy or jejunostomy tube in the home setting must be capable of maintaining patency of the tube or have a caregiver who can do so.
What should the patient and/or caregiver be able to do at the completion of education regarding home care for a patient receiving tube feeding?
Name the procedure that was performed and identify any permanent changes in anatomic structure or function as well as changes in ADLs, IADLs, roles, relationships, and spirituality. State what types of changes are needed (if any) to maintain a clean home environment and prevent infection. State how to contact the primary provider, the team of home care professionals overseeing care, and tube feeding supply vendor.
What does the nurse perform in a patient with a foreign body in the esophagus?
The nurse performs an initial and ongoing respiratory (airway-focused) assessment of a patient with a foreign body in the esophagus.
What medication may be injected IV because of its relaxing effect on the esophageal muscle?
Glucagon, because of its relaxing effect on the esophageal muscle, may be injected IV (a 1-mg dose).
What is used to remove the impacted food or object from the esophagus?
A flexible endoscope and retrieval devices (e.g., forceps, graspers) may be used to remove the impacted food or object from the esophagus.
What requires special consideration for foreign bodies in the esophagus?
Foreign bodies such as short-blunt objects, long objects, sharp-pointed objects, disc batteries, magnets, coins, or narcotic packets require special consideration.
What decisions are made regarding the best course of action for a foreign body in the esophagus?
Decisions regarding the best course of action consider the likelihood of the object passing on its own (blunt, nontoxic objects), the patient’s condition (airway maintenance), the length of time the obstruction has been present (typical intervention occurs within 24 hours), and the type of foreign object that is impacted.
Are ingested drug packets removed by endoscopy?
For example, ingested drug packets are not removed by endoscopy for fear of packet rupture; no intervention or surgical intervention are recommended in these cases.
How do chemical burns of the esophagus most often occur?
Chemical burns of the esophagus occur most often when a patient, either intentionally (67%; typically adults) or unintentionally (33%; typically children), swallows a strong acid or base, with alkaline agents being the most common.
What may an acute chemical burn of the esophagus be accompanied by?
An acute chemical burn of the esophagus may be accompanied by severe burns of the lips, mouth, and pharynx, with pain on swallowing. Breathing difficulties due to either edema of the throat or a collection of mucus in the pharynx may occur.
What should the patient be closely monitored for when they have an acute chemical burn of the esophagus?
The patient needs to be closely monitored for: tracheoesophageal fistula, perforation of large vessels, mediastinitis, vocal cord paralysis, tracheal stenosis or tracheomalacia, aspiration pneumonia, empyema, lung abscess, pneumothorax, spondylodiscitis, strictures.
What is an example of an antacid/acid neutralizing agent?
Calcium carbonate, Aluminum hydroxide, magnesium hydroxide, and simethicone.
What is a key nursing consideration for antacids/acid neutralizing agents?
Potential risk of gastric acid suppression is the loss of protective flora and an increased risk of infection, especially Clostridium difficile.
What does the health history reveal for nonemergency symptoms of esophageal disorders?
For nonemergency symptoms, a complete health history may reveal the nature of the esophageal disorder.
What is included in the health history for nonemergency symptoms of esophageal disorders?
The nurse asks about the patient’s: appetite, discomfort with swallowing, pain, other symptoms that occur regularly, such as regurgitation, nocturnal regurgitation, eructation (belching), pyrosis, substernal pressure, a sensation that food is sticking in the throat, a feeling of fullness after eating a small amount of food, nausea, vomiting, or weight loss.
What does the nurse determine regarding appearance and assessment of a patient with nonemergency symptoms of esophageal disorders?
The nurse determines whether the patient appears emaciated and auscultates the patient’s chest to assess for pulmonary complications.
What are the nursing diagnoses for esophageal disorders?
Impaired nutritional intake associated with difficulty swallowing. Risk for aspiration associated with difficulty swallowing or tube feeding. Acute pain associated with difficulty swallowing, ingestion of an abrasive agent, tumor, or frequent episodes of gastric reflux. Lack of knowledge about the esophageal disorder, diagnostic studies, medical management, surgical intervention, and rehabilitation.
What is the patient advised regarding excessive use of over-the-counter antacids?
The patient is advised that excessive use of over-the-counter antacids can cause rebound acidity. Antacid use should be directed by the primary provider, who can recommend the daily, safe dose needed to neutralize gastric juices and prevent esophageal irritation.
How should treatment interventions be evaluated for esophageal disorders?
Treatment interventions must be evaluated continually, and the patient is given sufficient information to participate in care and diagnostic tests.
What should the patient be instructed regarding endoscopic diagnostic methods for esophageal disorders?
If endoscopic diagnostic methods are used, the patient is instructed regarding the moderate sedation that will be used during the procedure. If outpatient procedures are performed with the use of moderate sedation, someone must be available to drive the patient home after the procedure.
What should the patient and/or caregiver be able to do at the completion of education regarding home care for a patient with an esophageal disorder?
State the impact of the esophageal disorder and treatment on physiologic functioning, ADLs, IADLs, body image, roles, relationships, and spirituality. Identify modification of home environment, interventions, and strategies (e.g., utilizing durable medical equipment, employing a home health aide) used in safely adapting to changes in structure or function and promote effective recovery and rehabilitation. Describe ongoing therapeutic regimen, including diet and activities to perform (e.g., suctioning) and to limit or avoid (e.g., oral foods if NPO).
What is the immediate postoperative care for patients undergoing surgery for esophageal disorders similar to?
Immediate postoperative care is similar to that provided for patients undergoing thoracic surgery.
What position should the patient be placed in after recovering from anesthesia after surgery for esophageal disorders?
After recovering from the effects of anesthesia, the patient is placed in a low Fowler position, and later in a Fowler position, to help prevent reflux of gastric secretions.
What is a common postoperative complication after surgery for esophageal disorders?
A common postoperative complication is aspiration pneumonia.
What is avoided due to the risk of aspiration after surgery for esophageal disorders?
Chest physiotherapy is avoided due to the risk of aspiration.
What is the patient monitored for to detect any elevation that may indicate aspiration or seepage of fluid through the operative site into the mediastinum?
The patient’s temperature.
What is evidence of an early esophageal leak?
Drainage from the cervical neck wound, usually saliva.
What is the patient also monitored for postoperatively?
The patient is also monitored for a postoperative chylothorax (accumulation of chyle/lymphatic fluid in the pleural cavity), which would require pleural drainage.
Define achalasia.
Absent or ineffective peristalsis (wavelike contraction) of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing.
What are some assessment and diagnostic findings for temporomandibular joint disorders?
Diagnosis is based on the patient’s report of pain, limitations in range of motion, dysphagia (difficulty swallowing), difficulty chewing, difficulty with speech, or hearing difficulties. Magnetic resonance imaging (MRI) and other imaging studies are generally only used for severe or chronic symptoms.
What is the recommended medical management for temporomandibular joint disorders?
Conservative treatment is recommended, including: Patient education on self-care—eating soft foods, icing the jaw. Cognitive behavior modifications—stress reduction, sleep hygiene, avoidance of extreme mandibular movement, and elimination of habits such as chewing ice. Physical therapy—stretching and relaxing. Acupuncture—highly effective with six to eight 15- to 30-minute sessions. Psychosocial interventions. Analgesics—trial of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants initially. Oral appliance therapy—splints.
In the acute trauma setting, what should surgery providers assess in the patient with mandibular fractures?
Patient’s perception of the bite (“bite feels normal”) for malocclusion. The fracture site for fragment mobility. Dentition for loose or infected teeth. Sensation in the lower lip for nerve damage.
When is maxillomandibular fixation (MMF) a viable option for mandibular fractures?
When the dentition is sufficient and the fracture is isolated.
What is the surgery of choice for mandibular fractures?
Open reduction, internal fixation (ORIF) with plate fixation.
What does ORIF involve?
Insertion of one or more metal plates and screws or arch bars into the bone to approximate and stabilize the bone.
When might bone grafting be performed in the management of mandibular fractures?
To replace structural defects using bones from the patient’s own ilium, ribs, or cranial sites.
What is the role of the nurse in caring for the patient with mandibular fractures?
Assess the patient’s nutritional status preoperatively, and a dietary consultation may be necessary.
What type of feeding might the patient with mandibular fractures require before and after surgery to maintain adequate nutrition?
Enteral (through the GI tract) or parenteral (intravenous [IV]) feedings.
Who provides continual nutritional assessment and reevaluation for the patient with mandibular fractures?
The interprofessional team, including a registered dietician (RD).
How might verbal communication be impaired in the patient with mandibular fractures?
By radical surgery for oral cancer, especially if the larynx is removed.
What should be assessed regarding communication in the patient with mandibular fractures?
The patient’s ability to communicate in writing before surgery.
What should be provided postoperatively to patients who can use writing to communicate?
Pen and paper.
What should be obtained preoperatively and given after surgery to patients who cannot write so that they may point to needed items?
A communication board with commonly used words or pictures.
What electronic devices may be options for facilitating communication in patients with mandibular fractures?
Tablets or smartphones.
Besides the other members of the interprofessional team, who else benefits from the input of a speech therapist?
Physical and occupational therapists.
What are the nursing goals for the patient with disorders of the oral cavity?
The nurse caring for the patient with disorders of the oral cavity: Promotes mouth care. Ensures adequate food and fluid intake. Minimizes pain and discomfort. Prevents infection.
In what ways can incidences of oral complications during cancer therapy be decreased?
With the incorporation of professional oral care before and during cancer treatment.
What do guidelines support in patients undergoing head and neck chemotherapy and radiotherapy to prevent oral mucositis (OM)?
The implementation of multi-agent combination oral care protocols.
What do experts recognize that using saline or sodium bicarbonate rinses increases?
Oral clearance and oral hygiene, and promotes patient comfort
The nurse facilitates the patient rinsing or irrigating with a solution of BLANK in 8 oz of warm water.
½ to 1 teaspoon of baking soda (or ¼-teaspoon salt)
Should Chlorhexidine be generally recommended for the prevention of OM?
No, specifically not for patients undergoing head and neck radiotherapy
Is there continued debate about the efficacy of magic mouthwash, particularly for chemotherapy-induced OM?
Yes
In Chart 39-2 HOME CARE CHECKLIST: The Patient with an Oral Disorder, what should the patient and/or caregiver be able to state at the completion of education?
The impact of the oral disorder and treatment on communication and other physiologic functioning, ADLs, IADLs, body image, roles, relationships, and spirituality. Identify modification of home environment, interventions, and strategies (e.g., utilizing durable medical equipment, employing a home health aide) used in safely adapting to changes in structure or function and promote effective recovery and rehabilitation. Describe ongoing therapeutic regimen, including diet and activities to perform (e.g., oral care, suctioning) and to limit or avoid (e.g., oral foods if NPO).
What are the major goals for the patient undergoing surgery for an oral disorder?
Increased knowledge of surgical procedure and treatment plan. Maintenance of respiratory status. Decreased pain. Viability of the graft. Maintenance of adequate intake of food and fluids. Effective coping strategies (for patient and caregivers). Effective communication. Maintenance of shoulder and neck motion. Absence of complications.
What should preoperative education address for the patient undergoing surgery for an oral disorder?
Interventions that cover the entire perioperative period
What should the patient be made aware of as part of the informed consent process prior to surgery for an oral disorder?
The potential/actual risks and benefits of the procedure as well as other treatment options, and the projected outcome if the procedure is not done
What should the patient be encouraged to do prior to surgery for an oral disorder?
Ask questions and to express concerns about the upcoming surgery and the expected results
What does a sense of mutual understanding and rapport make less traumatic for the patient?
The postoperative experience
What do the patient’s expressions of concern, anxieties, and fears guide the nurse in providing?
Support postoperatively
What determines whether some diet modification is necessary for the patient who can chew?
The patient’s chewing ability
What should also be discussed with the patient in addition to chewing ability and necessary diet modifications?
Food preferences
When may oral care enhance the patient’s appetite?
Before eating
When is oral care important to prevent infection and dental caries?
After eating
What are the psychological nursing interventions aimed at postoperatively for the patient undergoing surgery for an oral disorder?
Supporting the patient who has had a change in body image or who has major concerns related to the prognosis
Why is head and neck cancer recovery unique?
Because the patient’s behavioral issues (e.g., HPV infection status, alcohol, smoking) often directly relate to the underlying cause of the cancer
After a disfiguring surgery, what is often considered a single unit?
The patient–caregiver dyad
In Chart 39-4 HOME CARE CHECKLIST: The Patient Recovering from Neck Surgery, what should the patient and/or caregiver be able to do at the completion of education?
Name the procedure that was performed and identify any permanent changes in anatomic structure or function as well as changes in communication, ADLs, IADLs, roles, body image, relationships, and spirituality. Identify modification of home environment, interventions, and strategies (e.g., utilizing durable medical equipment, employing a home health aide) used in safely adapting to changes in structure or function and promote effective recovery and rehabilitation. Describe ongoing therapeutic regimen, including diet and activities to perform (e.g., oral care, suctioning) and to limit or avoid (e.g., lifting weights, driving a car, contact sports).
Identify modification of home environment, interventions, and strategies used in safely adapting to changes in structure or function and promote effective recovery and rehabilitation.
Utilizing durable medical equipment, employing a home health aide
Describe ongoing therapeutic regimen, including diet and activities to perform and to limit or avoid.
Oral care, suctioning, lifting weights, driving a car, contact sports
In Chart 39-4 HOME CARE CHECKLIST: The Patient Recovering from Neck Surgery, what should the patient and/or caregiver be able to do at the completion of education?
Identify foods or therapies necessary to meet caloric needs and dietary needs (e.g., change in consistency, seasoning limitations, supplements, enteral or parenteral therapy). Participate in prescribed therapy (e.g., speech therapy, PT, OT) to promote recovery and rehabilitation. Demonstrate the use of tracheostomy care and suctioning if indicated. Demonstrate use of humidification if indicated. Demonstrate effective oral hygiene. Demonstrate care of incision and drains.
In Chart 39-4 HOME CARE CHECKLIST: The Patient Recovering from Neck Surgery, what should the patient and/or caregiver be able to do at the completion of education?
State the name, dose, side effects, frequency, and schedule for all medications. Describe approaches to controlling pain (e.g., take analgesics as prescribed; use nonpharmacologic interventions). Identify possible complications (e.g., bleeding, respiratory distress) and interventions. Relate how to reach primary provider with questions or complications. State time and date of follow-up medical/dental appointments, therapy, and testing. Identify sources of support (e.g., friends, relatives, faith community, cancer support, caregiver support). Identify the need for health promotion, disease prevention, and screening activities.
The patient is given information regarding local support groups such as BLANK, if indicated.
“New Voice Club”
What are the expected patient outcomes following surgery for oral disorders?
Exhibits increased knowledge of course of treatment. Demonstrates adequate respiratory exchange. Lungs are clear to auscultation. Breathes easily with no shortness of breath. Demonstrates ability to use suction effectively.
When is nasoduodenal or nasojejunal feeding indicated?
When the esophagus and stomach need to be bypassed. When the patient is at risk for aspiration (i.e., inhalation of fluids or foods into the trachea and bronchial tree).
For tube feedings longer than BLANK, gastrostomy or jejunostomy tubes are preferred for administration of medications or nutrition.
4 weeks
What is the osmolality of normal body fluids?
Approximately 300 mOsm/kg
What may occur when a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts?
The small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The patient may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, collectively termed dumping syndrome.
What can dumping syndrome lead to?
Dehydration, hypotension, and tachycardia
What does the nurse need to be knowledgeable about regarding the patient’s tube feeding formula?
The patient’s formula and take steps to prevent this undesired effect
How may the small intestines be able to adapt to a formula of high osmolality?
If it is initiated at a low hourly rate that is advanced slowly
What are practical and inexpensive options for the patient receiving tube feedings who resides at home or in a long-term care facility?
Bolus and intermittent drip tube feeding methods
Why may bolus and intermittent drip tube feeding methods be poorly tolerated in some patients?
Patients who are acutely ill
How does bolus infusion work?
Requires dividing the total daily feeding volume into 4 to 6 feeds throughout the day. Boluses can be given into the stomach through a large (50-mL) syringe via gravity.
What is the typical volume of a bolus feeding?
200 to 400 mL of feeding
Over what period of time should a bolus feeding be delivered?
Over a 15- to 60-minute period
How can the rate of flow be regulated with gravity feedings?
Raising or lowering the syringe above the abdominal wall
What is the intermittent gravity drip feeding method?
X
In Chart 39-5 ASSESSMENT: Assessing Patients Receiving Tube Feedings, what assessment findings should the nurse be alert for?
Tube placement, patient’s position (head of bed elevated > 30 degrees), and formula flow rate. Patient’s ability to tolerate the formula; observe for fullness, bloating, distention, nausea, vomiting, and stool pattern. Clinical responses, as noted in laboratory findings (blood urea nitrogen, serum protein, prealbumin, electrolytes, kidney function, hemoglobin, hematocrit). Signs of dehydration (dry mucous membranes, thirst, decreased urine output). Amount of formula actually taken in by the patient. Elevated blood glucose level, decreased urinary output, sudden weight gain, and periorbital or dependent edema. Signs of infection (to avoid infection, replace any formula given by an open system every 4 to 8 hours with fresh formula; change tube feeding container and tubing every 24 hours). Signs of complications (if suspected, check gastric residual volume before each feeding or, in the case of continuous feedings, every 4 hours; return the aspirate to the stomach). Intake and output. Weekly weights. Recommendations made on dietitian consult.
What are important factors to consider when tube feedings are given?
The temperature and volume of the feeding, the flow rate, and the patient’s total fluid intake
The nurse must carefully monitor the drip rate and avoid administering fluids too BLANK.
Rapidly
Why has measuring gastric residual volumes (GRVs) by removing gastric contents with a large syringe at routine intervals been a commonly prescribed practice for patients receiving tube feedings?
X
Is the usefulness of measuring GRVs validated by research?
No
What may measuring GRVs cause?
Clogging of gastric tubes
What had GRV in excess of 250 to 500 mL been thought to indicate previously?
Feeding intolerance
What do other indicators of feeding tolerance that the nurse needs to consider include?
Abdominal distention, patient reports of discomfort, vomiting, hypoactive bowel sounds, changes in passing flatus, and presence of diarrhea
Do the most recent guidelines for assessment and provision of nutrition in the patient who is critically ill advocate using GRVs to monitor tolerance of enteral feedings?
No
What do research findings show regarding GRVs between 250 and 500 mL?
Did not increase the incidence of vomiting, aspiration, or pneumonia
What measures should be implemented if residuals are 250 to 500 mL?
Measures to decrease the risk of aspiration
If agency protocols and policies include assessing GRV as part of routine care, research and guidelines support holding the feeding for 2 hours only if the GRV is greater than BLANK mL.
500
Is there growing evidence supporting moving away from routine assessment of GRVs?
Yes
Where are potential complications of enteral therapy noted?
Table 39-3
When different types of medications are prescribed, what method is used for administration that is compatible with the medication’s preparation?
A bolus method
The feeding is BLANK, and the tube is flushed with at least BLANK of water before and at least BLANK of water after medication administration (BLANK total).
Paused, 15 mL, 15 mL, 30 mL
How should each medication be prepared and administered?
Separately, with a 15-mL flush provided between medications
When small-bore feeding tubes for continuous infusion are irrigated after administration of medications, a BLANK syringe is used because the pressure generated by smaller syringes could rupture the tube.
20-mL or larger
What is required to individualize care?
Nursing judgment
What should guide the primary provider’s prescriptions regarding medication choices and route of delivery?
Institutional protocols and pharmacist input
What considerations need to be given to medication preparations?
Tablets that can be crushed/dissolved; availability of elixirs
What considerations need to be given to absorption?
Some medications bind to enteral feedings, location of distal end of tube in the stomach or jejunum
What considerations need to be given to the patient’s fluid volume status?
Increased number of medications necessitates increases in the flush/water that is administered
What is refeeding syndrome caused by?
Rapid shifts in intracellular and extracellular electrolytes
In Chart 39-6 Preventing Dumping Syndrome, what strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding?
Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time.
For the first week after insertion, interventions are focused on prevention of BLANK and promotion of BLANK.
Stomal tract infection, incisional healing
The insertion site should be kept BLANK using BLANK daily and/or a BLANK.
Clean and dry, aseptic wound care, glycerin hydrogel or glycogel dressing
After approximately 1 week, how should the site (including under the external disc, if one is present) be cleansed?
Twice a week with soap and water and left open to air
Skin at the exit site is evaluated daily for signs of breakdown, irritation, excoriation, and the presence of drainage, bleeding or hypertrophic tissue growth or scattered, raised red papules that could indicate a BLANK.
Yeast or candidal infection
Where may Candida appear?
Warm moist areas of the body; the area beneath the gastric tube external retention bolster is a common location for it to develop and spread
If gastric contents leak and irritate the skin at the stoma site, what may be used?
Zinc oxide–based protectants
After the first week of healing, how can buried bumper syndrome be prevented?
By rotating the gastric tube (not done with jejunostomy tubes) daily and moving the tube inward 2 to 10 cm at least once a week
Where can the procedural guidelines for declogging a feeding tube be found?
thepoint.lww.com/Brunner15e
In promoting home, community-based, and transitional care for the patient with a gastrostomy or jejunostomy tube, what must be assessed?
The patient’s level of knowledge and interest in learning about the tube, as well as an ability to understand how to flush, provide site care, and administer feedings or facilitate decompression and drainage
To facilitate self-care, the nurse encourages the patient to participate in BLANK during hospitalization, and establishing as normal a routine as possible.
Flushing the tube, administering medications and tube feedings
In Chart 39-7 HOME CARE CHECKLIST: The Patient Receiving Tube Feeding, what should the patient and/or caregiver be able to do at the completion of education?
Name the procedure that was performed and identify any permanent changes in anatomic structure or function as well as changes in ADLs, IADLs, roles, relationships, and spirituality. State what types of changes are needed (if any) to maintain a clean home environment and prevent infection. State how to contact the primary provider, the team of home care professionals overseeing care, and tube feeding supply vendor.
In Chart 39-7 HOME CARE CHECKLIST: The Patient Receiving Tube Feeding, what should the patient and/or caregiver be able to do at the completion of education?
List emergency phone numbers. State how to obtain medical supplies and carry out dressing changes, site care, and other prescribed regimens. Demonstrate how to perform site care. Demonstrate how to prepare tube feeding. Demonstrate how to deliver tube feeding via prescribed method (e.g., bolus method, intermittent drip method, continuous feeding).
In Chart 39-7 HOME CARE CHECKLIST: The Patient Receiving Tube Feeding, what should the patient and/or caregiver be able to do at the completion of education?
When indicated, demonstrate how to operate, disconnect, and clean the tube feeding pump. When indicated, demonstrate tube maintenance functions. Flush before and after bolus and intermittent feeding and medication administration. Flush every 4 hours with continuous feeding. Flush once daily if tube is not being used.
In Chart 39-7 HOME CARE CHECKLIST: The Patient Receiving Tube Feeding, what should the patient and/or caregiver be able to do at the completion of education?
Demonstrate how to record all fluid intake and output. Identify a plan for operation of tube feeding pump during a power outage or other emergency. State the name, dose, side effects, frequency, and schedule for all medications. Demonstrate medication preparation and administration via bolus method, with flushing before, after and between medications.
In Chart 39-7 HOME CARE CHECKLIST: The Patient Receiving Tube Feeding, what should the patient and/or caregiver be able to do at the completion of education?
Identify possible tube feeding complications and interventions. Relate how to reach primary provider with questions or complications. State time and date of follow-up appointments and testing. State understanding of community resources and referrals (if any). Identify the need for health promotion (e.g., weight reduction, smoking cessation, stress management), disease prevention and screening activities.
What is the Quality and Safety Nursing Alert for a patient with a foreign body in the esophagus?
The nurse performs an initial and ongoing respiratory (airway-focused) assessment of a patient with a foreign body in the esophagus. Intubation may be required to protect the airway.
What effect does Glucagon have on the esophageal muscle, and how is it administered?
Relaxing effect, may be injected IV (a 1-mg dose).
What may be used to remove the impacted food or object from the esophagus?
A flexible endoscope and retrieval devices (e.g., forceps, graspers).
What requires special consideration regarding foreign bodies such as short-blunt objects, long objects, sharp-pointed objects, disc batteries, magnets, coins, or narcotic packets?
X
For ingested drug packets, are they removed by endoscopy?
No, for fear of packet rupture; no intervention or surgical intervention are recommended in these cases.
Where is the endoscopic procedure usually performed and by whom?
In the endoscopy suite or clinic by the gastroenterologist under moderate sedation.
How often do chemical burns of the esophagus occur intentionally vs unintentionally?
Intentionally (67%; typically adults). Unintentionally (33%; typically children).
What is the most common cause of chemical burns of the esophagus?
Swallowing a strong acid or base, with alkaline agents being the most common.
What may acute chemical burn of the esophagus be accompanied by?
Severe burns of the lips, mouth, and pharynx, with pain on swallowing.
What should the patient with a chemical burn of the esophagus be closely monitored for?
Tracheoesophageal fistula, perforation of large vessels, mediastinitis, vocal cord paralysis, tracheal stenosis or tracheomalacia, aspiration pneumonia, empyema, lung abscess, pneumothorax, spondylodiscitis, and strictures.
How should antacids/acid neutralizing agents be taken and what class do they belong to?
Without food but with water 1 h prior to meals, therapeutic and pharmacologic class—Antacid.
What is a potential risk of gastric acid suppression?
The loss of protective flora and an increased risk of infection, especially Clostridium difficile.
What should other medications be taken in relation to antacids/acid neutralizing agents?
2 h before or after this medication.
What are some key nursing considerations for antacids/acid neutralizing agents?
Many drug–drug interactions (e.g., digoxin, phenytoin, warfarin), may cause constipation or nausea.
For nonemergency symptoms, what may a complete health history reveal?
The nature of the esophageal disorder.
What questions should the nurse ask when taking a history regarding a potential esophageal disorder?
The patient’s appetite; Has it remained the same, increased, or decreased? Is there any discomfort with swallowing? If so, does it occur only with certain foods? Is it associated with pain? Does a change in position affect the discomfort? The patient is asked to describe the pain; Does anything aggravate it? Are there any other symptoms that occur regularly, such as regurgitation, nocturnal regurgitation, eructation (belching), pyrosis, substernal pressure, a sensation that food is sticking in the throat, a feeling of fullness after eating a small amount of food, nausea, vomiting, or weight loss? Are the symptoms aggravated by emotional upset?
If the patient reports any symptoms of esophageal disorder, what should the nurse ask about?
When they occur, their relationship to eating, and factors that relieve or aggravate them (e.g., position change, belching, antacids, vomiting; Bickley, 2016).
What else should this history include questions about?
Past or present causative factors, such as infections and chemical, mechanical, or physical irritants; alcohol and tobacco use; and the amount of daily food intake.
What should the nurse determine during the physical exam?
Whether the patient appears emaciated.
What should the nurse auscultate to assess for pulmonary complications?
The patient’s chest.
Based on the assessment data, what nursing diagnoses may be made?
Impaired nutritional intake associated with difficulty swallowing. Risk for aspiration associated with difficulty swallowing or tube feeding. Acute pain associated with difficulty swallowing, ingestion of an abrasive agent, tumor, or frequent episodes of gastric reflux. Lack of knowledge about the esophageal disorder, diagnostic studies, medical management, surgical intervention, and rehabilitation.
The patient is advised that excessive use of over-the-counter antacids can cause BLANK.
Rebound acidity.
Antacid use should be directed by the primary provider, who can recommend the BLANK needed to neutralize gastric juices and prevent esophageal irritation.
Daily, safe dose.
BLANK are given as prescribed to decrease gastric acid irritation.
H2-antagonists or PPIs (more commonly).
What does nursing interventions include when preparing the patient for diagnostic tests, treatments, and possible surgery?
Reassuring the patient and explaining the procedures and their purposes.
In instances of trauma to the esophagus, is the emotional and physical preparation for treatment more difficult?
Yes, because of the short time available and the circumstances of the injury.
If endoscopic diagnostic methods are used, what is the patient instructed regarding?
The moderate sedation that will be used during the procedure.
If outpatient procedures are performed with the use of moderate sedation, what must there be?
Someone available to drive the patient home after the procedure.
In Chart 39-8 HOME CARE CHECKLIST: The Patient with an Esophageal Disorder, what should the patient and/or caregiver be able to do at the completion of education?
State the impact of the esophageal disorder and treatment on physiologic functioning, ADLs, IADLs, body image, roles, relationships, and spirituality. Identify modification of home environment, interventions, and strategies (e.g., utilizing durable medical equipment, employing a home health aide) used in safely adapting to changes in structure or function and promote effective recovery and rehabilitation. Describe ongoing therapeutic regimen, including diet and activities to perform (e.g., suctioning) and to limit or avoid (e.g., oral foods if NPO).
In Chart 39-8 HOME CARE CHECKLIST: The Patient with an Esophageal Disorder, what should the patient and/or caregiver be able to do at the completion of education?
Identify possible complications (e.g., difficulty swallowing, pain, respiratory distress) and interventions. Relate how to reach primary provider with questions or complications. State time and date of follow-up medical appointments, therapy, and testing. Identify sources of support (e.g., friends, relatives, faith community, cancer support, caregiver support). Identify the need for health promotion, disease prevention, and screening activities.
Immediate postoperative care for the patient with an esophageal disorder is similar to that provided for patients undergoing BLANK.
Thoracic surgery.
Following surgery for an esophageal disorder, it is not uncommon for patients to have a BLANK and be placed in an BLANK.
Tracheostomy, intensive care unit or step-down unit.
After recovering from the effects of anesthesia, in what position is the patient placed following surgery for an esophageal disorder?
A low Fowler position, and later in a Fowler position, to help prevent reflux of gastric secretions.
What is the patient observed carefully for following surgery for an esophageal disorder?
Regurgitation and dyspnea.
What is a common postoperative complication following surgery for an esophageal disorder?
Aspiration pneumonia.
How is aspiration pneumonia prevented post-op after surgery for an esophageal disorder?
Vigorous pulmonary plan of care that includes incentive spirometry. Sitting up in a chair. If necessary, nebulizer treatments. Chest physiotherapy is avoided due to the risk of aspiration.
Why is the patient’s temperature monitored post-op following surgery for an esophageal disorder?
To detect any elevation that may indicate aspiration or seepage of fluid through the operative site into the mediastinum, which would indicate an esophageal leak.
What is evidence of an early esophageal leak following surgery for an esophageal disorder?
Drainage from the cervical neck wound, usually saliva.
How is an esophageal leak treated following surgery for an esophageal disorder?
Typically, no treatment other than maintaining NPO status and parenteral or enteral support is warranted.
What else is the patient monitored for following surgery for an esophageal disorder?
A postoperative chylothorax (accumulation of chyle/lymphatic fluid in the pleural cavity), which would require pleural drainage.
