MANAGEMENT OF PATIENTS WITH ORAL AND ESOPHAGEAL DISORDERSPresented by:

Jomar P. Ronquillo, RN, MANc

NORMAL ANATOMY OF A TOOTH

NORMAL ANATOMY OF A TOOTH

DENTAL PLAQUE AND CARIES

• TOOTH DECAY:

• An erosive process that begins with the action of bacteria in the mouth

DENTAL PLAQUE AND CARIES

• DENTAL PLAQUE:

• A gluey, gelatin-like substance that adheres to the teeth.

DENTAL PLAQUE AND CARIES

• Dental decay begins with a small hole• Enamel gets penetrated and the dentin as

well• Pulp is also affected• Abscess• Pain and soreness• Facial swelling• DIAGNOSTICS:• TREATMENT: Fillings, Implant, extraction

DENTAL PLAQUE AND CARIES

• PREVENTION: – Effective mouth care– Diet– Fluoridation– Smoking cessation– Sealants

DENTOALVEOLAR ABSCESS OR PERIAPICAL ABSCESS

• Involves the collection of pus in the apical dental periosteum and the tissue surrounding the apex of the tooth.

• Has two forms: Acute and chronic• CLINICAL MANIFESTATIONS:

– Dull, gnawing, continuous pain– Facial edema– Systemic reaction

DENTOALVEOLAR ABSCESS OR PERIAPICAL ABSCESS

• MANAGEMENT:– Aspiration / Incision and drainage– Tooth extraction– Root canal therapy

• NURSING MANAGEMENT:– WOF bleeding– Mouth care– Medications

MALOCCLUSION

• Misalignment of the teeth in the upper and lower dental arcs

• Can be inherited or acquired• Can be corrected early with orthodontics

TEMPOROMANDIBULAR DISORDERS

• Categories:– Myofascial pain– Internal derangement of the joint– Degenerative joint disease

• CLINICAL MANIFESTATIONS:– Radiating dull, throbbing pain– Restricted jaw motion– Clicking/grating noise– Difficulty swallowing

• POSSIBLE CAUSES:– Arthritis, trauma, stress, malocclusion

TEMPOROMANDIBULAR DISORDERS

• MANAGEMENT:– Stress management– ROM– Pain management– Bite plate or splint

• SURGICAL MANAGEMENT:– Rigid plate fixation (trauma)– Bone grafting

• NURSING MANAGEMENT:– No chewing post surgery– Liquid diet

DISORDERS OF THE SALIVARY GLANDS

• PAROTITIS:– Inflammation of the parotid gland– Elderly, the acutely ill and the debilitated are

at high risk– Pain in the ear, swollen glands, red shiny

skin– Antibiotics, adequate nutrition,

discontinuing meds that affect salivation, parotidectomy

DISORDERS OF THE SALIVARY GLANDS

• SIALADENITIS:– Inflammation of the salivary glands– Causes: Dehydration, radiation, stress,

malnutrition, salivary gland calculi, improper oral hygiene

– Organisms:– Pain, swelling, purulent drainage– Antibiotics, massage, hydration and steroids,

surgical drainage

DISORDERS OF THE SALIVARY GLANDS

• SIALOLITHIASIS:– Occurs in the submandibular gland– Formed from calcium phosphate– Can arise in the gland itself or in the ducts– Lithotripsy or surgery

DISORDERS OF THE ESOPHAGUS

• The esophagus is a mucus-lined muscular tube from the mouth to the stomach

• Has two sphincters

DISORDERS OF THE ESOPHAGUS

• DYSPHAGIA:– Most common symptom of esophageal disease– Possible causes: achalasia, diffuse spasm,

GERD, hiatal hernias, diverticula, perforation, foreign bodies, tumors, carcinoma

• ACHALASIA:– MANIFESTATIONS:

• Difficulty swallowing• Regurgutation• Chest pain• Pyrosis• Secondary pulmonary complications

DISORDERS OF THE ESOPHAGUS

• ACHALASIA:– ASSESSMENT AND DX FINDINGS:

• Esophageal dilatation• Barium swallow• CT scan• Endoscopy• Manometry

– MANAGEMENT:• Eat slowly and drink fluids• Calcium channel blocker• Botulinum toxin injection• Pneumatic dilation and surgery• Esophagomyotomy

DISORDERS OF THE ESOPHAGUS

• DIFFUSE SPASM– A motor disorder of the esophagus– Cause is unknown, stress is possible– Most common in women– CLINICAL MANIFESTATIONS:

• Dysphagia, odynophagia• Chest pain

– ASSESSMENT AND DX FINDINGS:• Irregular contractions of the esophagus on

manometry• Xray

– MANAGEMENT:• Sedatives, nitrates, calcium channel

blocker, small frequent meals, soft diet, and surgeries same as achalasia

HIATAL HERNIA

• A condition wherein the opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the stomach tends to move up in the lower portion of the thorax

• Occurs more often in women than in men• Two types: Sliding and Paraesophageal

HIATAL HERNIA

HIATAL HERNIA

• CLINICAL MANIFESTATIONS:– Heartburn, regurgitation, reflux (sliding type),

dysphagia– Sense of fullness (paraesophageal type)– Complication: Hemorrhage, obstruction,

strangulation

• ASSESSMENT AND DX FINDINGS:– X-ray, barium swallow, fluoroscopy

HIATAL HERNIA

• MANAGEMENT:– Small frequent feedings– Management to prevent reflux:

• No reclining 1 hour post eating• Elevate HOB

– Surgery– Management techniques for Paraesophageal

hernia are similar to GERD, but may also necessitate emergency surgery

DIVERTICULUM

• Is an outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature

• May occur in one of the three areas of the esophagus (PME) or may occur along the border of the esophagus intramurally

• Zenker’s diverticulum, most common type

DIVERTICULUM

• CLINICAL MANIFESTATIONS:– Zenker’s Diverticulum: Difficulty swallowing,

fullness in the neck, belching, regurgitation, gurgling noises after eating

– Halitosis and a sour taste– Dysphagia and chest pain (Epiphrenic type)– Dysphagia (Intramural type)

• ASSESSMENT AND DX FINDINGS:– Barium swallow– Manometric disorders for epiphrenic type– Esophagoscopy?– Blind NGT insertion?

DIVERTICULUM

• MANAGEMENT:– Surgical removal of the diverticulum (Zenker’s

type) and myotomy of cricopharyngeal muscle– NGT insertion POST OP– Surgical ncision monitoring– NPO until clear in Xray– DIET: liquid to DAT

PERFORATION

• May result from stab or bullet wounds of neck or chest, MVC, caustic injury or inadvertent puncture

• CLINICAL MANIFESTATIONS:– Persistent pain, dysphagia– Infxn, fever, leukocytosis, severe hypotension– Pneumothorax

PERFORATION

• ASSESSMENT AND DX FINDINGS:– X-ray studies, fluoroscopy

• MANAGEMENT:– Broad-spectrum antibiotics– NGT– NPO, parenteral nutrition– Surgery

• Nursing management is similar to that for patients who have had thoracic or abdomial surgery

FOREIGN BODIES

• Swallowed foreign object may injure the esophagus or obstruct its lumen

• Pain and dysphagia• X-ray (diagnosis)• Glucagon administration• Endoscopy and dilation

CHEMICAL BURNS

• May be caused by undissolved medications in the esophagus, swallowing of strong acid or base, batteries, etc

• More common in the elderly• Pain, difficulty breathing, shock,

respiratory distress• DIAGNOSIS: Esophagoscopy and barium

swallow

CHEMICAL BURNS

• MANAGEMENT:– NGT, NPO, lavage, corticosteroids and

antibiotics– Nutritional support– Bougienage– Esophagectomy and colon interpostion

MALLORY-WEISS TEAR

• A Mallory-Weiss tear occurs in the mucous membrane where the esophagus connects to the stomach, causing bleeding.

• Unusual• Causes: Any condition that leads to long

term or forceful vomiting, coughing, retching, epileptic convulsions

• Results in vomiting or bright red vomitus, melena or hematochezia

• DIAGNOSIS: Endoscopy

MALLORY-WEISS TEAR

• MANAGEMENT:– Usually supportive but may require endoscopy,

surgery, cauterization, epinephrine injection, embolization, high gastrostomy

GASTROESOPHAGEAL REFLUX DISEASE

• Causes: incompetent LES, pyloric stenosis, or motility disorders

• Incidence increases with aging• CLINICAL MANIFESTATIONS:

– Pyrosis– Dyspepsia– Regurgitation– Dysphagia– Odynophagia– Hypersalivation– Esophagitis

GASTROESOPHAGEAL REFLUX DISEASE

• ASSESSMENT AND DX FINDINGS:– Endoscopy– Barium swallow– Ambulatory 12- to 36 hour esophageal pH

monitoring– Bilirubin monitoring

GASTROESOPHAGEAL REFLUX DISEASE

• MANAGEMENT:– Teach patient to avoid situations that decrease

LES sphincter pressure or cause esophageal irritation:• Diet:• Eating in relation to bedtime:• Normal body weight, maintain• Clothing:• HOB elevation:

– Medications:• Antacids• Histamine receptor blockers• PPI’s• Prokinetic agents

GASTROESOPHAGEAL REFLUX DISEASE

• SURGICAL MANAGEMENT:– Fundoplication

BARRETT’S ESOPHAGUS

• A precancerous condition of the esophagus commonly associated with longs-standing GERD

• CLINICAL MANIFESTATIONS:– Symptoms of GERD

• ASSESSMENT AND DX FINDINGS:– EGD

• MANAGEMENT:– Monitoring– Medical and surgical management are similar

to that for GERD

MANAGEMENT OF PATIENTS WITH GASTRIC AND DUODENAL ULCERS

GASTRITIS

– A common GI problem– Can be chronic or acute

• Acute Gastritis:– Dietary indescretion– Overuse of certain medications– Excessive alcohol intake– Bile reflux– Radiation therapy– Ingestion of strong acid or alkali– May be a sign of an acute systemic infxn

GASTRITIS

• CHRONIC GASTRITIS:– Can be caused by benign or malignant ulcers– Helicobacter pylori– Autoimmune diseases– Dietary factors

• PATHOPHYSIOLOGY:– Edema and hyperemia– Decreased secretion– Superficial erosion– Hemorrhage

GASTRITIS

• CLINICAL MANIFESTATIONS:– Acute form:

• Abd. Discomfort• Headache• Lassitude• N & V• Anorexia• Hiccuping

– Chronic form:• Anorexia• Heartburn• Belching, n & v, sour taste• Vitamin B12 deficiency

GASTRITIS

• ASSESSMENT AND DX FINDINGS:– Achlorhydria/Hypochlorhydia to

Hyperchlorhydia– Endoscopy, upper GI radiographic studies,,

histologic exam, Diagnostic measures for H-Pylori

GASTRITIS

• MEDICAL MANAGEMENT:– Refrain from alcohol or food until sx subsides– Control of bleeding– Diluting/neutralizing offending agent (Ingestion

of acid and alkalis)– Emetics and lavage– NGT– Gastric resection– CHRONIC GASTRITIS: Diet modification,

Promoting rest, reduce stress, pharmacologic therapy,

NURSING PROCESS AND THE PARIENT WITH GASTIRITIS

• ASSESSMENT:– Patient History

• Ask about the presenting signs and symptoms

• 72 dietary recall• Any methods used to treat the symptoms

• NURSING DIAGNOSIS:– Anxiety related to treatment– Imbalanced nutrition, less than body

requirements, related to inadequate intake– Risk for imbalanced fluid volume related to

insufficient fluid loss subsequent to vomiting– Deficient knowledge– Acute pain

NURSING PROCESS AND THE PARIENT WITH GASTIRITIS

• PLANNING AND GOALS:– Reduced anxiety– Avoidance of irritating foods– Fluid balance– Relief of pain– Dietary management

• NURSING INTERVENTIONS:– Reduce anxiety– Optimal nutrition– Promote fluid balance– Relieve pain

NURSING PROCESS AND THE PARIENT WITH GASTIRITIS

• EVALUATION:– Exhibits less anxiety– Avoids eating irritating foods or drinking

carbonated beverages– Maintains fluid balance– Adheres to medical regimen– Maintains appropriate weigh– Reports less pain

GASTRIC AND DUODENAL ULCERS

• A peptic ulcer is an excavation that forms in the mucosal wall of the stomach, in the pylorus, and duodenum, or in the esophagus.

• Depth of erosion is variable• Occurs mostly in people between 40 and

60 y/o• Results from infection with H. Pylori• Excessive secretion of HCL may also be

the cause

GASTRIC AND DUODENAL ULCERS

• DUODENAL VS. GASTRIC ULCER:• INCIDENCE:• SIGNS AND SYMPTOMS:• MALIGNANCY POSSIBILITY:• RISK FACTORS:

GASTRIC AND DUODENAL ULCERS

• Risk factor: Familial tendency, use of NSAIDs, Alcohol ingestion, excessive smoking, Zollinger-Ellison syndrome

• PATHOPHYSIOLOGY:– Erosion is caused either by increased activity of

pepsin and HCL or decreased resistance of the mucosa

– ZES is suspected in unresponsive peptic ulcer– STRESS ULCERS can also be the cause:

• Ischemia, increased acid and pepsin production, reflux

– Cushing’s and Curlings’s types

GASTRIC AND DUODENAL ULCERS

• CLINICAL MANIFESTATIONS:– May be asymptomatic– Dull, gnawing pain/burning sensation in the

midepigastiric area or in the back– Eating usually relieves pain– Pyrosis– Vomiting, constipation, diarrhea, bleeding

GASTRIC AND DUODENAL ULCERS

• ASSESSMENT AND DX FINDINGS:– Physical findings– Upper GI barium study– Endoscopy– Stool analysis– Biopsy, and histology with culture– Urea breath test

GASTRIC AND DUODENAL ULCERS

• MEDICAL MANAGEMENT:– PHARMACOLOGIC:

• Antibiotics (TAMCB)• Proton-pump inhibitors (OLR)• Bismuth salts• H2 receptor antagonists (CRFN)• Octreotide• Cytoprotective agents

– Stress reduction and rest– Dietary modification

GASTRIC AND DUODENAL ULCERS

• MEDICAL MANAGEMENT:• Vagotomy with or without pyloroplasty

– Vagotomy• Truncal• Selective• Proximal gastric vagotomy

• Billroth I and Billroth II

NURSING PROCESS AND PEPTIC ULCER

• ASSESSMENT:– Chief complaint

• Ask about the nature of the pain– 72 hour dietary recall– Lifestyle habits– Vital signs– Physical exam

NURSING PROCESS AND PEPTIC ULCER

• NURSING DIAGNOSIS:– Acute pain related to the effect of gastric acid

secretion on damaged tissue– Imbalanced nutrition related to changes in diet

• Potential Complications:– H– P– P– P

NURSING PROCESS AND PEPTIC ULCER

• GOALS:– Relief of pain– Reduced anxiety– Nutrition maintenance– Absence of complications

NURSING PROCESS AND PEPTIC ULCER

• NURSING INTERVENTIONS:– Relieving pain

• Avoid caffeine and aspirin• Relaxation techniques

NURSING PROCESS AND PEPTIC ULCER

• NURSING INTERVENTIONS:– Reducing anxiety

NURSING PROCESS AND PEPTIC ULCER

• NURSING INTERVENTIONS:– Monitoring and managing potential

complications:• HEMORRHAGE

– Usually manifested by:– Monitor the patient for signs of

hypotension– Monitor Hgb and Hct

NURSING PROCESS AND PEPTIC ULCER

• NURSING INTERVENTIONS:– Monitoring and managing potential

complications:• HEMORRHAGE

– Treat the bleeding!– Replacing blood that was lost

» IV line, CVP insertion, blood component therapy

– NG Tube insertion» Monitoring» Lavage

– IFC and monitoring UO– Proper positioning

NURSING PROCESS AND PEPTIC ULCER

• NURSING INTERVENTIONS:– Monitoring and managing potential

complications:• HEMORRHAGE

– Transendoscopic coagulation– Selective embolization

NURSING PROCESS AND PEPTIC ULCER

• NURSING INTERVENTIONS:– Monitoring and managing potential

complications:• PERFORATION AND PENETRATION

– Perforation S/sx:» Intractable pain radiating to the right

shoulder» Tender, rigid, board-like abdomen» Vomiting, htn, tachycardia, fainting

– Penetration S/Sx:» Back and epigastric pain

– Surgery– Post Op: Monitoring

NURSING PROCESS AND PEPTIC ULCER

• NURSING INTERVENTIONS:– Monitoring and managing potential

complications:• PYLORIC OBSTRUCTION (GOO):

– S/Sx: Nausea and vomiting, constipation, epigastric fullness, weightloss

– Management: Insertion of Ng Tube– Upper GI endoscopy– Balloon dilatation of the pylorus– Surgery: Vagotomy, antrectomy,

gestrojejunostomy and vagotomy

MORBID OBESITY

• Morbid obesity is the term applied to people who are more than two times their ideal body weight or whose body mass index (BMI) exceeds 30 kg/m²

• 100 pounds greater than the ideal body weight

MORBID OBESITY

• Patients with morbid obesity are at highest risk for health complications!

MORBID OBESITY

• MEDICAL MANAGEMENT:– Weightloss diet with behavioral modification

and exercise– Treatment of depression– PHARMACOLOGIC:

• Sibutramine HCL (Meridia)• Orlistat (Xenical)

– SE: Sibutramine increases BP; Orlistat Increases BM, decreases absorption of some vitamins

MORBID OBESITY

• MEDICAL MANAGEMENT:– Surgery:

• BARIATRIC SURGERY:– Jejunoileal bypass– Gastric bypass– Vertical banded gastroplasty

GASTRIC BYPASS

GASTRIC BYPASS

VERTICAL BANDED GASTROPLASTY

MORBID OBESITY

• NURSING MANAGEMENT:– General postop care similar to that for a patient

recovering from a gastric resection– Provide 6 small feedings– Encourage fluid intake– Teach patients signs of dehydration– Discuss dietary instructions:

• Do not overeat!

GASTRIC CANCER

• Incidence: MEN>WOMEN• Japan has higher incidence• Diet: Significant factor• Other factors:

– Chronic inflammation of the stomach– Pernicious anemia– Achlorhydria– Gastric ulcers– H. Pylori infection– Genetics

GASTRIC CANCER

• CLINICAL MANIFESTATIONS:– Early stages: Asymptomatic– Early symptoms seldom definitive:

• Pain relived with antacids– Progressive: Anorexia, dyspepsia, weightloss,

abdominal pain, constipation, anemia, nausea and vomiting

GASTRIC CANCER

• MEDICAL MANAGEMENT:– REMOVAL OF THE TUMOR– Gastrectomy (Total/subtotal)– Chemotherapy– Radiation therapy

PATIENTS UNDERGOING GASTRIC SURGERY

• ASSESSMENT:– Pt. and family knowledge– Patient’s nutritional status– Assess for presence of bowel sounds– Palpate the abdomen– Assess for complication postop

PATIENTS UNDERGOING GASTRIC SURGERY

• NURSING DIAGNOSIS:– Anxiety related ton surgical intervention– Acute pain related to surgical incision– Deficient knowledge about surgical procedures

and postoperative course– Imbalanced nutrition, less than body

requirements, related to poor nutrition before surgery and altered GI system after surgery

PATIENTS UNDERGOING GASTRIC SURGERY

• NURSING INTERVENTIONS:– Relieve anxiety– Relieve pain

• Analgesics• No sedation!• Maintain NG tube

– Resume enteral intake– Recognize obstacles to adequate nutrition:

• Dysphagia and gastric retention• Bile reflux• Dumping syndrome• Vitamin and mineral deficiencies

MANAGEMENT OF PATIENTS WITH INTESTINAL AND RECTAL DISORDERS

ABNORMALITIES OF FECAL ELIMINATION

CONSTIPATION

CONSTIPATION

• Is a term used to describe an abnormal infrequency or irregularity of defecation, abnormal hardening of stools that makes their passage difficult and sometimes painful, a decrease in stool volume, or retention of stool for a prolonged period.

CONSTIPATION

• Causes:– Medications: Tranquilizers, anticholinergics,

antidepressants, opiods– Rectal or anal disorders: Hemorrhoids– Obstruction– Metabolic, neurologic and neuromuscular

conditions (DM, Hirschsprung’s dse, parkinson’s, MS)

– Endocrine disorders– IBS, diverticular dse– Immobility– Dietary habits

CONSTIPATION

• CLINICAL MANIFESTATIONS:– Abdominal distention– Borborygmus– Pain and pressure– Decreased appetite– Headache– Fatigue– Indigestion– Straining at stool– Small, hard, dry stools

CONSTIPATION

• COMPLICATIONS:– Hypertension– Fecal impaction– Hemorrhoids and fissures– Megacolon

CONSTIPATION

• MEDICAL MANAGEMENT:– Education– Bowel habit training– Increase fiber and OFI– Judicious use of laxatives:

• Psyllium hydrophilic mucilloid (Metamucil)• Magnesium OH• Mineral oil• Bisacodyl (Dulcolax)

ABNORMALITIES OF FECAL ELIMINATION

DIARRHEA

DIARRHEA

• Increased frequency of bowel movements, increased amount of stool, and altered consistency of stool.

• Frequent causes:– IBS– IBD– Lactose intolerance– Medications, endocrine disorders, infection

• Can be acute or chronic

DIARRHEA

• TYPES:– Secretory– Osmotic– Mixed

• CLINICAL MANIFESTATIONS:– Increased frequency and fluid content of stools– Abdominal cramps– Distention– Intestinal rumbling– Anal spasms and tenesmus– S/sx of dehydration

DIARRHEA

• The characteristic of the stools can tell the location of the g.i. problem

• DIAGNOSTIC TESTS:– CBC– Urinalysis– Stool exam– Endoscopy– Barium enema

DIARRHEA

• COMPLICATIONS:– Potential for cardiac dysrhythmia

• NURSING INTERVENTIONS:– Monitoring through physical assessment – Bed rest– Increased OFI– No intake of foods that increase intestinal

motility– Administer antidiarrheal meds: Diphenoxylate

and loperamide– Perianal hygiene

FECAL INCONTINENCE

FECAL INCONTINENCE

• The involuntary passage of stool from the rectum

• Possible causes:– Trauma– Neurologic disorders– Infection– Radiation treatment– Fecal impaction– Pelvic floor relaxation– Laxative abuse– Advancing age

FECAL INCONTINENCE

What are the clinical manifestations?

FECAL INCONTINENCE

FECAL INCONTINENCE

FECAL INCONTINENCE

FECAL INCONTINENCE

FECAL INCONTINENCE

FECAL INCONTINENCE

• ASSESSMENT AND DIAGNOSTIC FINDINGS:– Rectal exams– Endoscopic examinations– X-ray– Barium enema– Computed tomography scans– Anorectal manometry– Transit studies

FECAL INCONTINENCE

• MEDICAL MANAGEMENT:– No specific cure– Biofeedback therapy– Bowel training programs– Surgery

FECAL INCONTINENCE

• NURSING MANAGEMENT:– Take health history– Bowel training program– Encourage meticulous skin hygiene– Facilitate use of internal or external

incontinence devices

IRRITABLE BOWEL SYNDROME (IBS)

IRRITABLE BOWEL SYNDROME (IBS)

• It is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any detectable organic cause.

• Various factors are associated with the syndrome:– Heredity, stress, diet high in fat, smoking and

alcohol consumption

IRRITABLE BOWEL SYNDROME (IBS)