1. Care of Patients with Esophageal Problems
Chapter 57
Care of Patients with Esophageal Problems
Reflux of gastric acid up into the esophagus through the LES in GERD.

2. Gastroesophageal Reflux Disease
Esophageal assessment
Evidence-based information
Noninvasive diagnostic procedures
Antacids, histamine antagonists
Priority nursing interventions

3. Hiatal Hernia
Comparison of the normal stomach and sliding and paraesophageal (rolling) hiatal hernias.

4. Hiatal Hernia Priorities of care Pre-, intra-, postoperative care
Collaboration of interdisciplinary team
Nutritional needs
Community resources

5. Other Esophageal D/O Types Common assessment data Diagnostic testing
Esophageal tumors
Esophageal diverticula
Esophageal trauma
Common assessment data
Diagnostic testing
Surgical vs. nonsurgical management
Psychosocial concerns
Patient teaching

6. Case Study
A 59-year-old man was admitted to the hospital with dysphagia, stating that he has been having more difficulty swallowing food, even when he has chewed it thoroughly and drinks plenty of water. A CT scan shows an area for a possible esophageal tumor. The patient undergoes a biopsy and is awaiting results.
The patients asks, “What am I going to do if this is cancer?” What is the most appropriate nursing response?
“You will have surgery to remove it.”
“I would choose to get radiation.”
“The doctor will go over the options with you.”
“You sound as if you are concerned about the biopsy results.”
ANS: D
Asking the patient about his biopsy results addresses his feelings and provides an atmosphere where he is invited to continue expressing his concerns. Suggesting treatment options does not address the patient’s feelings and is not within the scope of the nurse’s role. Deferring to the physician does not address the patient’s concerns.

7. Case Study
(cont’d)
The patient’s history includes smoking cigarettes since he was 17 and drinking 3 to 6 beers per day. He says that he feels fearful and anxious about the results of the biopsy. He asks how this could have happened to him and what the chances are that the tumor will be cancerous. What is the nurse’s best response?
The two primary risk factors for squamous cell esophageal tumors are tobacco use and heavy alcohol intake. The most common symptom of esophageal cancer is difficulty swallowing which is progressive. Although esophageal tumors can be benign, they are usually malignant.

8. Case Study
(cont’d)
Later that afternoon, the biopsy is positive for malignancy and the tumor is small and localized. He will receive photodynamic therapy (PDT).
Which teaching points about this therapy should the nurse be sure to include? (Select all that apply.)
PDT can be used as a cure for small, localized tumors.
An oral porfimer sodium (Photofrin) will be given.
A fiberoptic probe will be inserted to activate the Photofrin 2 days after you receive it.
Photofrin will destroy cancer cells and some healthy cells.
Avoid exposure to sunlight for 1 to 3 months after treatment.
ANS: A, C, E
The Photofrin is given by injection, not orally. The Photofrin destroys only cancer cells.

9. Case Study
(cont’d)
Which intervention should be implemented after the photodynamic therapy?
Assess the patient for chest pain frequently.
Encourage the patient to walk outside on warm sunny days.
Instruct the patient to avoid dietary fiber because of the side effect of diarrhea.
Immediately post-procedure, encourage the patient to consume meat protein for healing.
ANS: A
Side effects of the procedure include nausea, fever, and constipation, as well as photosensitivity. Immediately after the procedure, the patient will follow a clear liquid diet for 3 to 6 days, followed by full liquids as tolerated.

10. Case Study
(cont’d)
On assessment, tissue particles in the patient’s sputum are noted.
What is the nurse’s interpretation of this finding?
The esophagus is breaking down; the oncologist should be notified immediately.
A respiratory infection has developed; the provider should be called.
The patient has aspirated; the Rapid Response Team should be called.
An expected response is occurring; documentation and patient teaching should be performed.
ANS: D
It is important to teach the patient that after PDT, tissue particles may be released from the tumor site and be present in the sputum.

11. Audience Response System Questions
Chapter 57
Audience Response System Questions 11

12. Question 1
The patient with a long history of osteoarthritis is at risk for developing gastroesophageal reflux disease (GERD) if he or she:
Weighs 220 pounds
Frequently takes NSAIDs for pain
Consumes foods with calcium supplementation
Has limited physical mobility
Answer: B
Rationale: Some drugs can cause GERD, such as oral contraceptives, anticholinergic agents, sedatives, NSAIDs (e.g., ibuprofen), nitrates, and calcium channel blockers. The possibility of eliminating those drugs causing reflux should be explored with the health care provider. Obesity is a nonspecific risk factor for developing GERD. Limited mobility can decrease gastric emptying, and patients with GERD are encouraged to sit upright after meals to decrease reflux.

13. Question 2
A priority nursing intervention in the care of a patient with a hiatal hernia is:
Providing nutrition education
Promoting regular exercise
Providing medication education
Instructing the patient on signs and symptoms of intestinal strangulation
Answer: A
Rationale: The most important role of the nurse in caring for a patient with a hiatal hernia is health teaching, specifically nutrition management to include weight loss. Education for prescribed medications is an important nursing function, as well as education for signs and symptoms of infection if the patient has a rolling hiatal hernia.

14. Question 3
Which assessment variable requires immediate intervention post esophagectomy?
Blood pressure of 170/88
Respiratory rate of 28
Temperature of 38.1° C
Pain assessment of 6 on a scale of 0-10
Answer: B
Rationale: Respiratory care is the highest postoperative priority for patients having an esophagectomy. For those who had traditional surgery, intubation with mechanical ventilation is needed for at least the first 16 to 24 hours. Pulmonary complications include atelectasis and pneumonia. The risk for postoperative pulmonary complications is increased in the patient who has received preoperative radiation. Once the patient is extubated, begin deep breathing, turning, and coughing every 1 to 2 hours. Assess the patient for decreased breath sounds and shortness of breath every 1 to 2 hours. Provide incisional support and adequate analgesia for effective coughing. Blood pressure may be elevated as a sympathetic response to decreased ventilation; temperature may indicate postoperative atelectasis and/or possible infection; and pain should be treated once the airway is secured.