Management of Patients With Oral and Esophageal Disorders
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Transcript of Management of Patients With Oral and Esophageal Disorders
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)