chapter 35 management of patients with oral and esophageal disorders

Copyright © 2008 Lippincott Williams & Wilkins.

Chapter 35Management of Patients With Oral

and Esophageal Disorders

Chapter 35Management of Patients With Oral

and Esophageal Disorders


Disorders of the Jaw and Salivary GlandsDisorders of the Jaw and Salivary Glands

• Temporomandibular disorders:

– Myofascial pain

– Internal derangement of joint

– Degenerative joint disease

• Fractures (of bone)

• Parotitis

• Sialadenitis

• Sialolithiasis

• Neoplasms


Disorders of the Teeth Disorders of the Teeth

• Dental plaque

• Dental caries

• Periapical abscess

• Malocclusion


Promotion of Oral Health (See Chart 35-2)Promotion of Oral Health (See Chart 35-2)

• Effective mouth care, including regular brushing and flossing

• Reduce intake of starches and sugars, and maintain good nutrition.

• Fluoride application or fluorinated water

• Refrain from smoking and alcohol.

• Control diabetes.

• Regular dental care


Disorders of the Lips, Mouth, and Gums (See Table 35-1)Disorders of the Lips, Mouth, and Gums (See Table 35-1)

• Lips

– Actinic cheilitis

– Herpes simplex 1 (“cold sore”)

– Chancre

• Mouth

– Leukoplakia, hairy leukoplakia, lichen planus

– Candidiasis

– Stomatitis

• Gums: gingivitis, periodontitis


Oral CancerOral Cancer

• Risk factors

– Tobacco use, including smokeless tobacco

– Alcohol

• Increased incidence in men, persons over age 40, and African-Americans

• Usually a squamous cell cancer

• May occur in any area, but lips, lateral tongue, and floor of the mouth are most frequently affected


ManifestationsManifestations

• Painless mass or sore that does not heal

• Any lesion that is present more than 2 weeks or that does not heal should be examined and biopsied.

• Later manifestations include tenderness; difficulty in chewing, swallowing, or speaking; coughing up blood-tinged sputum; and enlarged cervical lymph nodes.


Medical Management Medical Management

• Surgical resection

• Radiation therapy

• Chemotherapy


Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Assessment

Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Assessment• Health history: include symptoms related to oral

problems, oral hygiene and dental care, use of tobacco and alcohol, and eating and nutrition

• Inspect and palpate the structures of the mouth and neck.


Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: DiagnosisNursing Process: The Care of the Patient with Cancer of the Oral Cavity: Diagnosis

• Impaired oral mucous membranes

• Imbalanced nutrition

• Disturbed body image

• Fear of pain and social isolation

• Pain

• Impaired verbal communication

• Risk for infection

• Deficient knowledge


Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: PlanningNursing Process: The Care of the Patient with Cancer of the Oral Cavity: Planning

• Goals may include improved condition of the oral mucosa, improved nutritional intake, positive self-image, relief of pain, identification of alternative methods of communication, prevention of infections, and understanding of disease process.


Impaired Oral Mucous MembranesImpaired Oral Mucous Membranes

• Preventive oral care

• Dental care prior to surgery or radiation therapy

• Frequent gentle brushing and flossing, or if patient cannot tolerate brushing, use of mouthwashes and other methods of cleaning and rinsing

• Patient education related to oral hygiene

• Encourage fluid intake to reduce dry mouth

• Use of synthetic saliva such as Oral Balance or a saliva production stimulant such as Salagen


Imbalanced NutritionImbalanced Nutrition

• Assess nutritional requirements and dietary patterns.

• Assess patient preferences and take into account social and cultural factors when encouraging and recommending dietary intake.

• A calorie count may be needed to assess if intake is meeting needs.

• Dietary consult


Other InterventionsOther Interventions

• Support a positive self-image:

– Encourage patient to verbalize.

– Listen and offer acceptance and support.

– Referral to support group, psychiatric liaison, or spiritual advisor

• Pain

– Avoid hot, spicy, or hard foods.

– Oral care

– Viscous xylocaine or other pain medications


Other InterventionsOther Interventions

• Promote effective communication:

– Assess patient’s writing ability preop.

– Plan communication preop.

– Communication board or pencil and paper

– Speech therapy

• Prevent infection:

– Assess for signs and symptoms of infections.

– Appropriate wound and skin care

• Patient teachingSee Chart 35-4


Radical Neck Dissection and Selective Radical Neck DissectionRadical Neck Dissection and Selective Radical Neck Dissection


Nursing Process: The Care of the Patient with a Radical Neck Dissection: Assessment

Nursing Process: The Care of the Patient with a Radical Neck Dissection: Assessment• Assess knowledge.

• Assess for risks for potential complications.

• Postoperatively, the patient will need careful monitoring and assessment:

– Airway and breathing

– Pain

– Potential bleeding and wound drainage system

– Other


Nursing Process: The Care of the Patient with a Radical Neck Dissection- PlanningNursing Process: The Care of the Patient with a Radical Neck Dissection- Planning

• Major goals include patient participation in the treatment plan, maintenance of respiratory status, attainment of comfort, absence of infection, viability of graft, maintenance of adequate nutrition and fluid intake, effective coping strategies, effective communication, maintenance of neck and shoulder motion, and absence of complications.


Nursing Process: The Care of the Patient with a Radical Neck Dissection: DiagnosisNursing Process: The Care of the Patient with a Radical Neck Dissection: Diagnosis

• Knowledge deficiency

• Ineffective airway

• Acute pain

• Impaired tissue integrity

• Imbalanced nutrition

• Impaired physical mobility secondary to nerve injury


Collaborative Problems/Potential ComplicationsCollaborative Problems/Potential Complications

• Hemorrhage

• Chyle fistula

• Nerve injury


Maintaining the AirwayMaintaining the Airway

• Frequent assessment

• Place in Fowler’s position.

• Encourage coughing and deep breathing.

• If patient has a tracheostomy, provide tracheostomy care as required.


Patient Education (See Chart 35-6)Patient Education (See Chart 35-6)

• Patient should be aware of the extent and nature of the surgery and what to expect in the postoperative period.

• Patient and family will require postoperative teaching related to self-care and home management:

– Sign and symptoms to report

– Wound care, dressings and drains if present

– Diet and medications

– Exercises and activity

• Speech therapy, support resources, and follow-up care


Impaired Tissue IntegrityImpaired Tissue Integrity

• Suctioning should be done with great care to protect suture lines.

• Support the head and neck when moving the patient.

• Assess wound drainage system and empty as required.

• Assess dressings, wound, and graft condition.


Imbalanced NutritionImbalanced Nutrition

• Assess nutritional state preoperatively and intervene early to prevent nutritional problems.

• Encourage high-density, high-quality intake.

• Diet may need to be modified to liquid diet, or to soft, puréed, and liquid foods.

• Consider patient preferences and cultural considerations in food selection.

• Provide oral care before and after eating.

• Nasogastric or gastrostomy feedings may be required.


Disorders of the EsophagusDisorders of the Esophagus

• Dysphagia

• Achalasia

• Diffuse spasm

• Hiatal hernia

• Perforation

• Foreign bodies

• Chemical burns

• GERD (gastroesophageal reflux disease)

• Esophageal cancer


Treatment of Achalasia: Pneumatic Dilation Treatment of Achalasia: Pneumatic Dilation


Sliding Esophageal and Paraesophageal HerniaSliding Esophageal and Paraesophageal Hernia


Esophageal Reconstruction with Free Jejunal TransferEsophageal Reconstruction with Free Jejunal Transfer

chapter 35 management of patients with oral and esophageal disorders

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