GI System Lecture 2

Learning Objectives:
At the end of this lecture, you will be able to:
1. Use the nursing process as a framework for care of
patients with conditions of the oral cavity.
2. Describe the relationship of dental hygiene and dental
problems to nutrition.
JOFRED M. MARTINEZ, RN

3. Describe the nursing management of patients with
abnormalities of the lips, gums, teeth, mouth, and
salivary glands.
patients with cancer of the oral cavity.
5. Identify the physical and psychosocial long-term
needs of patients with oral cancer.
patients undergoing neck dissection.
patients with conditions of the esophagus.
Learning Objectives (Cont’d.):

8. Describe the various conditions of the esophagus and
their clinical manifestations and management.
Learning Objectives (Cont’d.):

DENTAL PLAQUE AND CARIES
Tooth decay is an erosive process that begins with the
action of bacteria on fermentable carbohydrates in the
mouth, which produces acids that dissolve tooth enamel.
The extent of damage to the teeth depends on the
following:
• The presence of dental plaque
• The strength of the acids and the ability of the saliva to
neutralize them
• Length of time the acids are in contact with the teeth
• The susceptibility of the teeth to decay
Disorders of the Teeth

• Dental decay begins with a small hole, usually in a
fissure or in an area that is hard to clean.
• Left unchecked, the affected area penetrates the
enamel into the dentin.
• When the blood, lymph vessels, and nerves are
exposed, they become infected and an abscess may
form, either within the tooth or at the tip of the root.
• Soreness and pain usually occur with an abscess.
• As the infection continues, the patient’s face may swell,
and there may be pulsating pain.

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

PATIENT EDUCATION
• Brush teeth using a soft toothbrush at least two times
daily.
• Floss at least once daily.
• Use an antiplaque mouth rinse.
• Visit a dentist at least every 6 months, or when you
have a chipped tooth, a lost filling, an oral sore that
persists longer than 2 weeks, or a toothache.
• Avoid alcohol and tobacco products, including
smokeless tobacco.
• Maintain adequate nutrition and avoid sweets.
• Replace toothbrush at first signs of wear, usually every
2 months.

DENTOALVEOLAR ABSCESS / PERIAPICAL ABSCESS
• Periapical abscess, more commonly referred to as an
abscessed tooth, involves the collection of pus in the
apical dental periosteum and the tissue surrounding the
apex of the tooth.
• The abscess has two forms:
 Acute periapical abscess is usually secondary to a
suppurative pulpitis that arises from an infection
extending from dental caries.
 Chronic dentoalveolar abscess, a slowly progressive
infectious process. This eventually leads to a “blind
dental abscess,” which is really a periapical granuloma.

CLINICAL MANIFESTATIONS
• The abscess produces a dull, gnawing, continuous
pain, often with a surrounding cellulitis and edema of
the adjacent facial structures, and mobility of the
involved tooth.
• The gum opposite the apex of the tooth is usually
swollen on the cheek side.
• In well-developed abscesses, there may be a systemic
reaction, fever, and malaise.

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

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

MALOCCLUSION
• Malocclusion is a misalignment of the teeth of the upper
and lower dental arcs when the jaws are closed.
Malocclusion can be inherited or acquired.
• Malocclusion makes the teeth difficult to clean and can
lead to decay, gum disease, and excess wear on
supporting bone and gum tissues.

MANAGEMENT
• Correction of malocclusion requires an orthodontist with
special training, a patient who is motivated and
cooperative, and adequate time.
• Most treatments begin when the patient has shed the
last primary tooth and the last permanent successor has
erupted, usually at about 12 or 13 years of age, but
treatment may occur in adulthood.
• Preventive orthodontics may be started at age 5 years if
malocclusion is diagnosed early.

MANAGEMENT
• To realign the teeth, the orthodontist gradually forces
the teeth into a new location by using wires or plastic
bands (braces).
• In the final phase of treatment, a retaining device is
worn for several hours each day to support the tissues
as they adjust to the new alignment of the teeth.

NURSING MANAGEMENT
• The patient must practice meticulous oral hygiene, and
the nurse encourages the patient to persist in this
important part of the treatment.
• An adolescent undergoing orthodontic correction who is
admitted to the hospital for some other problem may
have to be reminded to continue wearing the retainer.

Disorders of the Jaw
TEMPOROMANDIBULAR DISORDERS
Temporomandibular disorders are categorized as follows:
(National Oral Health Information Clearinghouse, 2000)
• Myofascial pain—a discomfort in the muscles
controlling jaw function and in neck and shoulder
muscles
• Internal derangement of the joint—a dislocated jaw, a
displaced disc, or an injured condyle
• Degenerative joint disease—rheumatoid arthritis or
osteoarthritis in the jaw joint

• Patients have pain ranging from a dull ache to
throbbing, debilitating pain that can radiate to the ears,
teeth, neck muscles, and facial sinuses.
• They often have restricted jaw motion and locking of the
jaw.
• They may hear clicking and grating noises, and
chewing and swallowing may be difficult.
• Depression may occur in response to these symptoms.

ASSESSMENT AND DIAGNOSTIC FINDINGS
• Diagnosis is based on the patient’s subjective
symptoms of pain, limitations in range of motion,
dysphagia, difficulty chewing, difficulty with speech, or
hearing difficulties.
• Magnetic resonance imaging, x-ray studies, and an
arthrogram may be performed.

MANAGEMENT
• Patient education in stress management may be helpful
(to reduce grinding and clenching of teeth).
• Occasionally, a bite plate or splint may be worn to
protect teeth from grinding; however, this is a short-term
therapy.
• Patients may also benefit from range-of-motion
exercises. Pain management measures may include
nonsteroidal anti-inflammatory drugs (NSAIDs), with the
possible addition of opioids, muscle relaxants, or mild
antidepressants.

SURGICAL MANAGEMENT
• Correction of mandibular structural abnormalities may
require surgery involving repositioning or reconstruction
of the jaw.
• Rigid plate fixation (insertion of metal plates and screws
into the bone to approximate and stabilize the bone) is
the current treatment of choice in many cases of
mandibular fracture and in some mandibular
reconstructive surgery procedures.
• Bone grafting may be performed to replace structural
defects using bones from the patient’s own ilium, ribs,
or cranial sites. Rib tissue may also be harvested from
cadaver donors.

NURSING MANAGEMENT
• The patient who has had rigid fixation should be
instructed not to chew food in the first 1 to 4 weeks after
surgery.
• A liquid diet is recommended, and dietary counseling
should be obtained to ensure optimal caloric and
protein intake.

Disorders of the Salivary Glands
PAROTITIS
• Parotitis is the most common inflammatory condition of
the salivary glands.
• Mumps (epidemic parotitis), a communicable disease
caused by viral infection and most commonly affecting
children, is an inflammation of a salivary gland, usually
the parotid.
• Elderly, acutely ill, or debilitated people with decreased
salivary flow from general dehydration or medications
are at high risk for parotitis.
• The organism is usually Staphylococcus aureus (except
in mumps).

• The onset of this complication is sudden, with an
exacerbation of both the fever and the symptoms of the
primary 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.

PREVENTIVE MEASURES
• Advising the patient to have necessary dental work
performed before surgery.
• Maintaining adequate nutritional and fluid intake, good
oral hygiene, and discontinuing medications (eg,
tranquilizers, diuretics) that can diminish salivation may
help prevent the condition.

MANAGEMENT
• 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 as
parotidectomy.

SIALADENITIS
• Sialadenitis may be caused by dehydration, radiation
therapy, stress, malnutrition, salivary gland calculi
(stones), or improper oral hygiene.
• The inflammation is associated with infection by S.
aureus, Streptococcus viridans, or pneumococcus.
• In hospitalized or institutionalized patients the infecting
organism may be methicillin-resistant S. aureus
(MRSA).

• Symptoms include pain, swelling, and purulent
discharge.
MANAGEMENT
• Antibiotics are used to treat infections.
• Massage, hydration, and corticosteroids frequently cure
the problem.
• Chronic sialadenitis with uncontrolled pain is treated by
surgical drainage of the gland or excision of the gland
and its duct.

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

• Calculi within the salivary gland itself cause no
symptoms unless infection arises; however, a calculus
that obstructs the gland’s duct causes sudden, local,
and often colicky pain, which is abruptly relieved by a
gush of saliva.
• On physical assessment, the gland is swollen and quite
tender, the stone itself can be palpable, and its shadow
may be seen on x-ray films.

MANAGEMENT
• The calculus can be extracted fairly easily from the duct
in the mouth.
• Occasionally lithotripsy, a procedure that uses shock
waves to disintegrate the stone, may be used instead of
surgical extraction for parotid stones and smaller
submandibular stones. Lithotripsy requires no
anesthesia, sedation, or analgesia. Side effects can
include local hemorrhage and swelling.
• Surgery may be necessary to remove the gland if
symptoms and calculi recur repeatedly.

NEOPLASMS
• Tumors occur more often in the parotid gland.
• The incidence of salivary gland tumors is similar in men
and women.
• Risk factors include prior exposure to radiation to the
head and neck.
• Diagnosis is based on the health history and physical
examination and the results of fine needle aspiration
biopsy.

MANAGEMENT
• The common procedure involves partial excision of the
gland, along with all of the tumor and a wide margin of
surrounding tissue.
• If the tumor is malignant, radiation therapy may follow
surgery.
• Radiation therapy alone may be a treatment choice for
tumors that are thought to be contained or if there is risk
of facial nerve damage from surgical intervention.
• Chemotherapy is usually used for palliative purposes.
Local recurrences are common, and the recurrent
growth usually is more aggressive than the original.

Cancer of the Oral Cavity
• Cancers of the oral cavity, which can occur in any part
of the mouth or throat, are curable if discovered early.
• These cancers are associated with the use of alcohol
and tobacco.
• About 95% of cases of oral cancer occur in people older
than 40 years of age, but the incidence is increasing in
men younger than age 30 because of the use of
smokeless tobacco, especially snuff.
• Chronic irritation by a warm pipe stem or prolonged
exposure to the sun and wind may predispose a person
to lip cancer. Predisposing factors for other oral cancers
are dietary deficiency, and ingestion of smoked meats.

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.

• 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 ulcer with raised edges. Tissue
from any ulcer of the oral cavity that does not heal in 2
weeks should be examined through biopsy.
• As the cancer progresses, the patient may complain of
tenderness; difficulty in chewing, swallowing, or
speaking; coughing of blood-tinged sputum; or enlarged
cervical lymph nodes.

• Diagnostic evaluation consists of an oral examination as
well as an assessment of the cervical lymph nodes to
detect possible metastases.
• Biopsies are performed on suspicious lesions (those that
have not healed in 2 weeks).
• High-risk areas include the buccal mucosa and gingiva for
people who use snuff or smoke cigars or pipes.
• For those who smoke cigarettes and drink alcohol, high-
risk areas include the floor of the mouth, the ventrolateral
tongue, and the soft palate complex (soft palate, anterior
and posterior tonsillar area, uvula, and the area behind the
molar and tongue junction).

MEDICAL MANAGEMENT
• Management varies with the nature of the lesion, the
preference of the physician, and patient choice.
• Surgical resection, radiation therapy, chemotherapy, or
a combination of these therapies may be effective.
• In cancer of the lip, small lesions are usually excised
liberally; larger lesions involving more than one third of
the lip may be more appropriately treated by radiation
therapy because of superior cosmetic results.
• Tumors larger than 4 cm often recur.

• Cancer of the tongue may be treated with radiation
therapy and chemotherapy to preserve organ function
and maintain quality of life.
• A combination of radioactive interstitial implants and
external beam radiation may be used.
• 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 and total
glossectomy.

• Often cancer of the oral cavity has metastasized
through the extensive lymphatic channel in the neck
region, requiring a neck dissection and reconstructive
surgery of the oral cavity.
• A common reconstructive technique involves use of a
radial forearm free flap.

NURSING MANAGEMENT (PRE-OP)
• The nurse assesses the patient’s nutritional status
preoperatively, and a dietary consultation may be
necessary.
• The patient may require enteral (through the intestine)
or parenteral (intravenous) feedings before and after
surgery to maintain adequate nutrition.
• If a radial graft is to be performed, an Allen test on the
donor arm must be performed to ensure that the ulnar
artery is patent and can provide blood flow to the hand
after removal of the radial artery.

NURSING MANAGEMENT (POST-OP)
• Postoperatively, the nurse assesses for a patent airway.
The patient may be unable to manage oral secretions,
making suctioning necessary.
• If grafting was included in the surgery, suctioning must
be performed with care to prevent damage to the graft.
• The graft is assessed postoperatively for viability.
Although color should be assessed (white may indicate
arterial occlusion, and blue mottling may indicate
venous congestion), it can be difficult to assess the graft
by looking into the mouth.

NURSING MANAGEMENT (POST-OP)
• A Doppler ultrasound device may be used to locate the
radial pulse at the graft site and to assess graft
perfusion.

The Patient with Conditions in the Oral Cavity
ASSESSMENT
• The history includes questions about the patient’s
normal brushing and flossing routine; frequency of
dental visits; awareness of any lesions or irritated areas
in the mouth, tongue, or throat; recent history of sore
throat or bloody sputum; discomfort caused by certain
foods; daily food intake; use of alcohol and tobacco,
including smokeless chewing tobacco; and the need to
wear dentures or a partial plate.
NURSING PROCESS:

ASSESSMENT
• A careful physical assessment follows the health history.
Both the internal and the external structures of the
mouth and throat are inspected and palpated.
• Dentures and partial plates are removed to ensure a
thorough inspection of the mouth.
• The examination can be accomplished by using a bright
light source and a tongue depressor.
• Gloves are worn to palpate the tongue and any
abnormalities.

LIPS
• The examination begins with inspection of the lips for
moisture, hydration, color, texture, symmetry, and the
presence of ulcerations or fissures.
• The lips should be moist, pink, smooth, and symmetric.
• The patient is instructed to open the mouth wide; a
tongue blade is then inserted to expose the buccal
mucosa for an assessment of color and lesions.

GUMS
• The gums are inspected for inflammation, bleeding,
retraction, and discoloration.
• The odor of the breath is also noted.
• The hard palate is examined for color and shape.
TONGUE
• The dorsum of the tongue is inspected for texture, color,
and lesions.
• A thin white coat and large, vallate papillae in a “V”
formation on the distal portion of the dorsum of the
tongue are normal findings.

TONGUE
• The patient is instructed to protrude the tongue and
move it laterally.
• Any lesions of the mucosa or any abnormalities
involving the frenulum or superficial veins on the
undersurface of the tongue are assessed for location,
size, color, and pain.
• The patient is told to tip the head back, open the mouth
wide, take a deep breath, and say “ah.” This briefly
allows a full view of the tonsils, uvula, and posterior
pharynx

TONGUE
• These structures are inspected for color, symmetry, and
evidence of exudate, ulceration, or enlargement.
• The neck is examined for enlarged lymph nodes
(adenopathy).

NURSING DIAGNOSES
• Impaired oral mucous membrane related to a pathologic
condition, infection, or chemical or mechanical trauma
(eg,medications, ill-fitting dentures)
• Imbalanced nutrition, less than body requirements,
related to inability to ingest adequate nutrients
secondary to oral or dental conditions
• Disturbed body image related to a physical change in
appearance resulting from a disease condition or its
treatment
• Pain related to oral lesion or treatment

NURSING DIAGNOSES
• Impaired verbal communication related to treatment
• Risk for infection related to disease or treatment
• Deficient knowledge about disease process and
treatment plan

PLANNING AND GOALS
• The major goals for the patient may include improved
condition of the oral mucous membrane, improved
nutritional intake, attainment of a positive self-image,
relief of pain, identification of alternative communication
methods, prevention of infection, and understanding of
the disease and its treatment.

NURSING INTERVENTIONS
PROMOTING MOUTH CARE
• The nurse reinforces the need to perform oral care and
provides such care to patients who are unable to
provide it for themselves.
• If a bacterial or fungal infection is present, the nurse
administers the appropriate medications and instructs
the patient in how to administer the medications at
home.
• The nurse monitors the patient’s physical and
psychological response to treatment.

XEROSTOMIA
• The patient is advised to avoid dry, bulky, and irritating
foods and fluids, as well as alcohol and tobacco.
• The patient is also encouraged to increase intake of
fluids and to use a humidifier during sleep.
• The use of synthetic saliva, a moisturizing antibacterial
gel may be helpful.

STOMATITIS OR MUCOSITIS
• Prophylactic mouth care is started when the patient
begins receiving treatment.
• If a patient receiving radiation therapy has poor
dentition, extraction of the teeth before radiation
treatment in the oral cavity is often initiated to prevent
infection.
• Many radiation therapy centers recommend the use of
fluoride treatments for patients receiving radiation to the
head and neck.

ENSURING ADEQUATE FOOD AND FLUID INTAKE
• The patient’s weight, age, and level of activity are
recorded to determine whether nutritional intake is
adequate.
• The nurse recommends changes in the consistency of
foods and the frequency of eating, based on the
disorder and the patient’s preferences.
• The goal is to help the patient attain and maintain
desirable body weight and level of energy, as well as to
promote the healing of tissue.

SUPPORTING A POSITIVE SELF-IMAGE
• The patient is encouraged to verbalize the perceived
change in body appearance and to realistically discuss
actual changes or losses.
• The nurse offers support while the patient verbalizes
fears and negative feelings (withdrawal, depression,
anger).
• Referral to support groups, a social worker, or a spiritual
advisor may be useful in helping the patient to cope with
anxieties and fears.

SUPPORTING A POSITIVE SELF-IMAGE
• Emphasizing that the patient’s worth is not diminished
by a physical change in a body part can be a helpful
approach.
• The nurse should be alert to signs of grieving and
should record emotional changes.
• By providing acceptance and support, the nurse
encourages the patient to verbalize feelings.

MINIMIZING PAIN AND DISCOMFORT
• Avoiding foods that are spicy, hot, or hard.
• The patient is instructed about mouth care.
• It may be necessary to provide the patient with an
analgesic such as viscous lidocaine or opioids, as
prescribed.
• The nurse can reduce the patient’s fear of pain by
providing information about pain control methods.

PROMOTING EFFECTIVE COMMUNICATION
• Pen and paper are provided postoperatively to patients
who can use them to communicate.
• A communication board with commonly used words or
pictures is obtained preoperatively and given after
surgery to patients who cannot write so that they may
point to needed items.
• A speech therapist is also consulted postoperatively.

PREVENTING INFECTION
• Laboratory results should be evaluated frequently and
the patient’s temperature checked every 4 to 8 hours for
an elevation that may indicate infection.
• Visitors who might transmit microorganisms are
prohibited because the patient’s immunologic system is
depressed.
• Sensitive skin tissues are protected from trauma to
maintain skin integrity and prevent infection.

PREVENTING INFECTION
• Aseptic technique is necessary when changing
dressings. adequate nutrition is helpful in preventing
infection.
• Signs of wound infection are reported to the physician.
Antibiotics may be prescribed prophylactically.

EVALUATION
EXPECTED PATIENT OUTCOMES
1. Shows evidence of intact oral mucous membranes
a. Is free of pain and discomfort in the oral cavity
b. Has no visible alteration in membrane integrity
c. Identifies and avoids foods that are irritating.
2. Describes measures that are necessary for preventive
mouth care
a. Complies with medication regimen
b. Limits or avoids use of alcohol and tobacco
3. Attains and maintains desirable body weight

EVALUATION
4. Has a positive self-image
a. Verbalizes anxieties
b. Is able to accept change in appearance and modify
self concept accordingly
5. Attains an acceptable level of comfort
a. Verbalizes that pain is absent or under control
b. Avoids foods and liquids that cause discomfort
c. Adheres to medication regimen

EVALUATION
6. Has decreased fears related to pain, isolation, and the
inability to cope
a. Accepts that pain will be managed if not eliminated
b. Freely expresses fears and concerns
7. Is free of infection
a. Exhibits normal laboratory values
b. Is afebrile
c. Performs oral hygiene after every meal and at
bedtime
8. Acquires information about disease process and
course of treatment

Neck Dissection
• Malignancies of the head and neck include those of the
oral cavity, oropharynx, hypopharynx, nasopharynx,
nasal cavity, paranasal sinus, and larynx.
• Depending on the location and stage, treatment may
consist of radiation therapy, chemotherapy, surgery, or a
combination of these modalities.
• A radical neck dissection involves removal of all cervical
lymph nodes from the mandible to the clavicle and
removal of the sternocleidomastoid muscle, internal
jugular vein, and spinal accessory muscle on one side
of the neck.

Neck Dissection
• Modified radical neck dissection, which preserves one
or more of the nonlymphatic structures, is used more
often.
• A selective neck dissection preserves one or more of
the lymph node groups, the internal jugular vein, the
sternocleidomastoid muscle, and the spinal accessory
nerve.
• Reconstructive techniques may be performed with a
variety of grafts.

Neck Dissection
(A) A classic radical neck dissection in which the sternocleidomastoid and
smaller muscles are removed. The selective neck dissection (B) is similar but
preserves the sternocleidomastoid muscle, internal jugular vein, and spinal
accessory nerve. The wound is closed (C), and portable suction drainage
tubes are in place.

The Patient Undergoing Neck Dissection
ASSESSMENT
• Preoperatively, the patient’s physical and psychological
preparation for major surgery is assessed, along with
his or her knowledge of the preoperative and
postoperative procedures.
• Postoperatively, the patient is assessed for
complications such as altered respiratory status, wound
infection, and hemorrhage.
• As healing occurs, neck range of motion is assessed to
determine whether there has been a decrease in range
of motion due to nerve or muscle damage.
NURSING PROCESS:

NURSING DIAGNOSIS
• Deficient knowledge about preoperative and
postoperative procedures
• Ineffective airway clearance related to obstruction by
mucus, hemorrhage, or edema
• Acute pain related to surgical incision
• Risk for infection related to surgical intervention
secondary to decreased nutritional status, or
immunosuppression from chemotherapy or radiation
therapy

NURSING DIAGNOSIS
• Impaired tissue integrity secondary to surgery and
grafting
related to disease process or treatment
• Situational low self-esteem related to diagnosis or
prognosis
• Impaired verbal communication secondary to surgical
resection
• Impaired physical mobility secondary to nerve injury

PLANNING AND GOALS
• The major goals for the patient include participation in
the treatment plan, maintenance of respiratory status,
absence of infection, viability of the graft, maintenance
of adequate intake of food and fluids, effective coping
strategies, attainment of comfort, effective
communication, and absence of complications.

PROVIDING PREOPERATIVE PATIENT EDUCATION
PROVIDING GENERAL POSTOPERATIVE CARE
MAINTAINING THE AIRWAY
RELIEVING PAIN
PROVIDING WOUND CARE
MAINTAINING ADEQUATE NUTRITION
SUPPORTING COPING MEASURES
PROMOTING EFFECTIVE COMMUNICATION
MAINTAINING PHYSICAL MOBILITY

MONITORING AND MANAGING POTENTIAL COMPLICATIONS
HEMORRHAGE
• Vital signs are assessed.
• The patient is instructed to avoid the Valsalva maneuver
• Signs of impending rupture, such as high epigastric
pain or discomfort, are reported.
• Dressings and wound drainage are observed for
excessive bleeding.

HEMORRHAGE
• Hemorrhage requires the continuous application of
pressure to the bleeding site or major associated
vessel.
• A controlled, calm manner will allay the patient’s
anxiety.
• The surgeon is notified immediately, because a vascular
or ligature tear requires surgical intervention.

CHYLE FISTULA
• A chyle fistula may develop as a result of damage to the
thoracic duct during surgery.
• The diagnosis is made if there is excess drainage which
has a 3% fat content and a specific gravity of 1.012 or
greater.
• Treatment of a small leak (500 mL or less) includes
application of a pressure dressing and a diet of medium
chain fatty acids or parenteral nutrition.
• Surgical intervention to repair the damaged duct is
necessary for larger leaks.

NERVE INJURY
• Nerve injury can occur if the cervical plexus or spinal
accessory nerves are severed during surgery.
• If the superior laryngeal nerve is damaged, the patient
may have difficulty swallowing liquids and food because
of the partial lack of sensation of the glottis.
• Speech therapy may be indicated to assist with the
problems related to nerve injury.

Disorders of the Esophagus
DYSPHAGIA
• Dysphagia is the most common symptom of esophageal
disease.
• This symptom may vary from an uncomfortable feeling
that a bolus of food is caught in the upper esophagus to
odynophagia.
• There are many pathologic conditions of the
esophagus, including motility disorders (achalasia,
diffuse spasm), gastroesophageal reflux, hiatal hernias,
diverticula, perforation, foreign bodies, chemical burns,
benign tumors, and carcinoma.

ACHALASIA
• Achalasia is absent or ineffective peristalsis of the distal
esophagus, accompanied by failure of the esophageal
sphincter to relax in response to swallowing.
• Achalasia may progress slowly and occurs most often in
people 40 years of age or older.

• The primary symptom of achalasia is difficulty in
swallowing both liquids and solids.
• As the condition progresses, food is commonly
regurgitated, either spontaneously or intentionally by
the patient to relieve the discomfort produced by
prolonged distention of the esophagus by food that will
not pass into the stomach.
• The patient may also complain of chest pain and
heartburn. Pain may or may not be associated with
eating.

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

MANAGEMENT
• The patient should be instructed to eat slowly and to
drink fluids with meals.
• As a temporary measure, calcium channel blockers and
nitrates have been used to decrease esophageal
pressure and improve swallowing.
• Injection of botulinum toxin (Botox) to quadrants of the
esophagus via endoscopy has been helpful because it
inhibits the contraction of smooth muscle.
• If these methods are unsuccessful, pneumatic (forceful)
dilation or surgical separation of the muscle fibers may
be recommended.

MANAGEMENT
• Achalasia may be treated surgically by
esophagomyotomy.
• Although patients with a history of achalasia have a
slightly higher incidence of esophageal cancer, long-
term follow-up with esophagoscopy for early detection
has not proved beneficial.

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

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

HIATAL HERNIA
• In hiatus hernia, the opening in the diaphragm through
which the esophagus passes becomes enlarged, and
part of the upper stomach tends to move up into the
lower portion of the thorax.
• Hiatal hernia occurs more often in women than men.
• 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.

HIATAL HERNIA
• About 90% of patients with esophageal hiatal hernia
have a sliding hernia.
• A paraesophageal hernia occurs when all or part of the
stomach pushes through the diaphragm beside the
esophagus.
• Paraesophageal hernias may be further classified as
types II, III, or IV, depending on the extent of herniation,
with type IV having the greatest herniation.

COMPLICATIONS
• Malformation
• Muscle weakness of the esophageal hiatus
• Esophageal shortening
• Obesity
• Strangulation

• Diagnosis is confirmed by x-ray studies, barium
swallow, and fluoroscopy.
MANAGEMENT
• Management for an axial hernia includes frequent,
small feedings that can pass easily through the
esophagus.
• 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 from sliding upward.

MANAGEMENT
• Surgical repair may be needed if symptoms persist after
instituting dietary and medical management:
• Surgery is more common for large paraesophageal
hernias.
• The most common technique is the laparoscopic Nissen
fundoplication (LNF).

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

• The most common type of diverticulum, which is found
three times more frequently in men than in women, is
Zenker’s diverticulum. 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.
• Other types of diverticula include midesophageal,
epiphrenic, and intramural diverticula.
• Midesophageal diverticula are uncommon. Symptoms
are less acute, and usually the condition does not
require surgery.

• Epiphrenic diverticula are usually larger diverticula in
the lower esophagus just above the diaphragm. They
are thought to be related to the improper functioning of
the lower esophageal sphincter or to motor disorders of
the esophagus.
• Intramural diverticulosis is the occurrence of
numerous small diverticula associated with a stricture in
the upper esophagus.

• Symptoms experienced by the patient with a
pharyngoesophageal pulsion diverticulum include
difficulty swallowing, fullness in the neck, belching,
regurgitation of undigested food, and gurgling noises
after eating.
• When the patient assumes a recumbent position,
undigested food is regurgitated, and coughing may be
caused by irritation of the trachea.
• Halitosis and a sour taste in the mouth are also
common because of the decomposition of food retained
in the diverticulum.

• Symptoms produced by midesophageal diverticula are
less acute.
• One third of patients with epiphrenic diverticula are
asymptomatic, and the remaining two thirds complain of
dysphagia and chest pain.
• Dysphagia is the most common complaint of patients
with intramural diverticulosis.

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

MANAGEMENT
• Because pharyngoesophageal pulsion diverticulum is
progressive, the only means of cure is surgical removal
of the diverticulum.
• The sac is dissected free and amputated flush with the
esophageal wall.
• In addition to a diverticulectomy, a myotomy of the
cricopharyngeal muscle is often performed to relieve
spasticity of the musculature, which otherwise seems to
contribute to a continuation of the previous symptoms.
• Postoperatively, the patient may have a nasogastric
tube inserted at the time of surgery.

MANAGEMENT
• The surgical incision must be observed for evidence of
leakage from the esophagus and a developing fistula.
• Food and fluids are withheld until x-ray studies show no
leakage at the surgical site.
• The diet begins with liquids and progresses as tolerated.
• Surgery is indicated for epiphrenic and midesophageal
diverticula only if the symptoms are troublesome and
becoming worse.
• Treatment consists of a diverticulectomy and long
myotomy. Intramural diverticula usually regress after the
esophageal stricture is dilated.

PERFORATION
• Perforation may result from stab or bullet wounds of the
neck or chest, trauma from motor vehicle crash, caustic
injury from a chemical burn, or inadvertent puncture by
a surgical instrument during examination or dilation.
• The patient has persistent pain followed by dysphagia.
• Infection, fever, leukocytosis, and severe hypotension
may be noted.
• In some instances, signs of pneumothorax are
observed.

• Diagnostic x-ray studies and fluoroscopy are used to
identify the site of the injury.
MANAGEMENT
• Because of the high risk of infection, broad-spectrum
antibiotic therapy is initiated.
• A nasogastric tube is inserted to provide suction and to
reduce the amount of gastric juice that can reflux into
the esophagus and mediastinum.
• Nothing is given by mouth; nutritional needs are met by
parenteral nutrition.

• Surgery may be necessary to close the wound, and
postoperative nutritional support then becomes a
primary concern.
• Depending on the incision site and the nature of
surgery, the postoperative nursing management is
similar to that for patients who have had thoracic or
abdominal surgery.

FOREIGN BODIES
• Swallowed foreign bodies may injure the esophagus or
obstruct its lumen and must be removed.
• Pain and dysphagia may be present, and dyspnea may
occur as a result of pressure on the trachea.
• The foreign body may be identified by x-ray film.
Glucagon, because of its relaxing effect on the
esophageal muscle, may be injected intramuscularly.
• An endoscope may be used to remove the impacting
food or object from the esophagus.

FOREIGN BODIES
• A mixture consisting of sodium bicarbonate and tartaric
acid may be used to increase intraluminal pressure by
the formation of a gas.
• Caution must be used with this treatment because there
is risk of perforation.

CHEMICAL BURNS
• Chemical burns of the esophagus may be caused by
undissolved medications in the esophagus.
• This occurs more frequently in the elderly than it does
among the general adult population.
• Chemical burns of the esophagus occur most often
when a patient, either intentionally or unintentionally,
swallows a strong acid or base.
• An acute chemical burn of the esophagus may be
accompanied by severe burns of the lips, mouth, and
pharynx, with pain on swallowing.

CHEMICAL BURNS
• There may be difficulty in breathing due to either edema
of the throat or a collection of mucus in the pharynx.
• The patient, who may be profoundly toxic, febrile, and in
shock, is treated immediately for shock, pain, and
respiratory distress.
• Esophagoscopy and barium swallow are performed as
soon as possible to determine the extent and severity of
damage.

MANAGEMENT
• The patient is given nothing by mouth, and intravenous
fluids are administered.
• A nasogastric tube may be inserted by the physician.
• Vomiting and gastric lavage are avoided to prevent
further exposure of the esophagus to the caustic agent.
• The use of corticosteroids to reduce inflammation and
minimize subsequent scarring and stricture formation is
of questionable value.
• The value of the prophylactic use of antibiotics for these
patients has also been questioned.

MANAGEMENT
• After the acute phase has subsided, the patient may
need nutritional support via enteral or parenteral
feedings.
• The patient may require further treatment to prevent or
manage strictures of the esophagus.
• Dilation by balloon may be sufficient, but dilation
treatment may need to be repeated periodically.

GASTROESOPHAGEAL REFLUX DISEASE
• refers to a group of conditions that cause reflux of
gastric and duodenal contents back to the esophagus
CAUSES:
• idiopathic incompetent lower esophageal sphincter
• pregnancy
• obesity
• surgical removal lower esophagus due to cancer
• ascites
• hiatal hernia

CAUSES
• Insufficient closure of lower esophageal sphincter
• Gastric distention
• Hiatal hernia
• Lifestyle
Smoking, Dietary factors (including high-fat diet; increased intake
of caffeine, chocolate, alcohol, and spicy foods; and excessively
large meals)
• Medications
NSAIDs and some drugs to treat cardiovascular conditions
(nitrates, calcium-channel blockers) place a person at risk for
developing GERD

• dysphagia
• odynophagia
• pyrosis
• dyspepsia
• regurgitation
• dysphagia or odynophagia
• hypersalivation, and esophagitis
• hoarseness, throat clearing or sore throat

• Ambulatory pH monitoring to measure the frequency
and duration of reflux episodes
• Barium swallow to show structural abnormalities and
reflux of barium from stomach into esophagus.
• Endoscopy to directly visualize tissue erythema, fragility,
or erosion and detect esophageal cancer or Barrett’s
esophagus.
• Esophageal manometry to measure pressure of
esophageal wave motility and identify LES pressure
sufficiency.
• Bilirubin monitoring (Bilitec) is used to measure bile
reflux patterns.

MANAGEMENT
Treatment of GERD aims to reduce reflux of gastric juices
and abdominal pressure.
Dietary management includes:
• Losing weight if obese
• Eating a low-fat, high-protein diet
• Limiting or avoiding chocolate, fatty foods, and mints
• Eating small frequent meals (4 to 6 a day)
• Avoiding carbonated beverages
• Avoiding meals within 3 hours of going to bed

MANAGEMENT
• Avoiding spicy and high-acid foods
• Avoiding alcohol, especially late at night before
bedtime.
• Increasing fluid intake.
Other changes include:
• Discontinuing of NSAIDs, as ordered by physician.
• Elevating head of the bed 6 to 12 inches or more.
• Stopping smoking to improve.
• Avoiding constrictive clothing.

MANAGEMENT
Drug therapy includes:
• Proton-pump inhibitors - such as omeprazole
(Prilosec), lansoprazole (Prevacid), esomeprazole
(Nexium), and pantoprazole (Protonix)
• H2-receptor blockers - such as nizatidine (Axid),
ranitidine (Zantac), and famotidine (Pepcid)
• Antacids - such as aluminum magnesium
combinations (Mylanta, Maalox)
• Mucosal barrier fortifiers - such as sucralfate
(Carafate) to protect the mucosal barrier.

MANAGEMENT
Invasive treatments include:
• Endoscopic intervention to tighten the LES and prevent
reflux.
• Laparoscopic Nissen fundoplication (LNF) is the most
common procedure.

COMPLICATIONS
Long-term untreated GERD causes acidic burning of
tissue, leading to:
• Esophagitis (erosion and ulceration of epithelium of
esophagus).
• Stricture (narrowing of esophagus caused by scar
tissue) can lead to swallowing difficulties.
• Barrett’s esophagus (a precancerous change in the
tissue of the esophagus) can lead to esophageal
cancer.

BARRETT’S ESOPHAGUS
• It is believed that long-standing untreated GERD may
result in a condition known as Barrett’s esophagus.
• This has been identified identified as a precancerous
condition that, if left untreated, can result in
adenocarcinoma of the esophagus, which has a poor
prognosis.
• It is more common among middle-aged white men;
however, the incidence is increasing among women
and among African Americans.

• An esophagogastroduodenoscopy (EGD) is performed.
• This usually reveals an esophageal lining that is red
rather than pink.
• Biopsies are taken, and the cells resemble those of the
intestine.

MANAGEMENT
• Monitoring varies depending on the amount of cell
changes.
• Some physicians may recommend a repeat EGD in 6
to 12 months if there are minor cell changes.
• Medical and surgical management is similar to that for
GERD.

BENIGN TUMORS OF THE ESOPHAGUS
• Benign tumors can arise anywhere along the
esophagus. The most common lesion is a leiomyoma,
which can occlude the lumen of the esophagus.
• Most benign tumors are asymptomatic and are
distinguished from cancerous lesions by a biopsy.
• Small lesions are excised during esophagoscopy;
lesions that occur within the wall of the esophagus may
require treatment via a thoracotomy.

CANCER OF THE ESOPHAGUS
• Chronic irritation is a risk factor for esophageal cancer.
There seems to be an association between GERD and
adenocarcinoma of the esophagus.
• People with Barrett’s esophagus (which is caused by
chronic irritation of mucous membranes due to reflux of
gastric and duodenal contents) have a higher incidence
of esophageal cancer.

PATHOPHYSIOLOGY
• Esophageal cancer is usually of the squamous cell
epidermoid type.
• Tumor cells may spread beneath the esophageal
mucosa or directly into, through, and beyond the
muscle layers into the lymphatics.
• In the latter stages, obstruction of the esophagus is
noted, with possible perforation into the mediastinum
and erosion into the great vessels.

Many patients have an advanced ulcerated lesion of the
esophagus before symptoms are manifested.
Symptoms include:
• dysphagia, initially with solid foods and eventually with
liquids
• sensation of a mass in the throat
• painful swallowing
• substernal pain or fullness
• regurgitation of undigested food with foul breath and
hiccups

• As the tumor progresses and the obstruction becomes
more complete, even liquids cannot pass into the
stomach.
• Regurgitation of food and saliva occurs, hemorrhage
may take place, and progressive loss of weight and
strength occurs from starvation.
• Later symptoms include substernal pain, persistent
hiccup, respiratory difficulty, and foul breath.

• Diagnosis is confirmed most often by EGD with biopsy
and brushings.
• Bronchoscopy usually is performed, especially in
tumors of the middle and the upper third of the
esophagus, to determine whether the trachea has been
affected and to help determine whether the lesion can
be removed.
• Endoscopic ultrasound or mediastinoscopy is used
to determine whether the cancer has spread to the
nodes and other mediastinal structures.

MEDICAL MANAGEMENT
• Treatment may include surgery, radiation,
chemotherapy, or a combination of these modalities,
depending on the extent of the disease.
• Standard surgical management includes a total
resection of the esophagus (esophagectomy) with
removal of the tumor plus a wide tumor-free margin of
the esophagus and the lymph nodes in the area.
• When tumors occur in the cervical or upper thoracic
area, esophageal continuity may be maintained by free
jejunal graft transfer.

MEDICAL MANAGEMENT
• 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.
• Palliative treatment may be necessary to keep the
esophagus open, to assist with nutrition, and to control
saliva.
• Palliation may be accomplished with dilation of the
esophagus, laser therapy, placement of an
endoprosthesis (stent), radiation, or chemotherapy.

The Patient with Conditions in the Esophagus
ASSESSMENT
• The nurse asks about 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?
• Does anything aggravate it?
NURSING PROCESS:

ASSESSMENT
• Are there any other symptoms that occur regularly, such
as regurgitation, nocturnal regurgitation, eructation,
heartburn, substernal pressure, a sensation that food is
sticking in the throat, a feeling of becoming full after
eating a small amount of food, nausea, vomiting, or
weight loss?
• Are the symptoms aggravated by emotional upset?
NURSING PROCESS:

ASSESSMENT
• This history also includes questions about past or
present causative factors, such as infections and
chemical, mechanical, or physical irritants.
• The nurse determines whether the patient appears
emaciated and auscultates the patient’s chest to
determine whether pulmonary complications exist.
NURSING PROCESS:

NURSING DIAGNOSES
related to difficulty swallowing
• Risk for aspiration related to difficulty swallowing or to
tube feeding
• Acute pain related to difficulty swallowing, ingestion of
an abrasive agent, tumor, or frequent episodes of
gastric reflux
• Deficient knowledge about the esophageal disorder,
diagnostic studies, medical management, surgical
intervention, and rehabilitation

PLANNING AND GOALS
• The major goals for the patient may include attainment
of adequate nutritional intake, avoidance of respiratory
compromise from aspiration, relief of pain, and
increased knowledge level.

• ENCOURAGING ADEQUATE NUTRITIONAL INTAKE
• DECREASING RISK OF ASPIRATION
• RELIEVING PAIN
• PROVIDING PATIENT EDUCATION
• PROMOTING HOME AND COMMUNITY-BASED
CARE

EVALUATION
1. Achieves an adequate nutritional intake
a. Eats small, frequent meals
b. Drinks water with small servings of food
c. Avoids irritants
d. Maintains desired weight
2. Does not aspirate or develop pneumonia
a. Maintains upright position during feeding
b. Uses oral suction equipment effectively

EVALUATION
3. Is free of pain or able to control pain within a tolerable
level
a.Avoids large meals and irritating foods
b.Takes medications as prescribed and with adequate
fluids, and remains upright for at least 10 minutes
after taking medications
c. Maintains an upright position after meals for 1 to 4
hours
d.Reports that there is less eructation and chest pain

EVALUATION
4. Increases knowledge level of esophageal condition,
treatment, and prognosis
a. States cause of condition
b. Discusses rationale for medical or surgical
management and diet or medication regimen
c. Describes treatment program
d. Practices preventive measures so injuries are
avoided

GI System Lecture 2

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