1. Chapter 35 Management of Patients With Oral and Esophageal Disorders

2. Disorders of the Jaw and Salivary Glands
Temporomandibular disorders:
Myofascial pain
Internal derangement of joint
Degenerative joint disease
Fractures (of bone)
Parotitis
Sialadenitis
Sialolithiasis
Neoplasms

3. Disorders of the Teeth Dental plaque Dental caries Periapical abscess
Malocclusion

4. Promotion of Oral Health (See Chart 35-2)
Effective mouth care, including regular brushing and flossing
Reduce intake of starches and sugars, and maintain good nutrition.
Fluoride application or fluorinated water
Refrain from smoking and alcohol.
Control diabetes.
Regular dental care

5. Disorders of the Lips, Mouth, and Gums (See Table 35-1)
Actinic cheilitis
Herpes simplex 1 (“cold sore”)
Chancre
Mouth
Leukoplakia, hairy leukoplakia, lichen planus
Candidiasis
Stomatitis
Gums: gingivitis, periodontitis

6. Oral Cancer Risk factors Tobacco use, including smokeless tobacco
Alcohol
Increased incidence in men, persons over age 40, and African-Americans
Usually a squamous cell cancer
May occur in any area, but lips, lateral tongue, and floor of the mouth are most frequently affected

7. Manifestations Painless mass or sore that does not heal
Any lesion that is present more than 2 weeks or that does not heal should be examined and biopsied.
Later manifestations include tenderness; difficulty in chewing, swallowing, or speaking; coughing up blood- tinged sputum; and enlarged cervical lymph nodes.

8. Medical Management
Surgical resection
Radiation therapy
Chemotherapy

9. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Assessment
Health history: include symptoms related to oral problems, oral hygiene and dental care, use of tobacco and alcohol, and eating and nutrition
Inspect and palpate the structures of the mouth and neck.

10. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Diagnosis
Impaired oral mucous membranes
Imbalanced nutrition
Disturbed body image
Fear of pain and social isolation
Pain
Impaired verbal communication
Risk for infection
Deficient knowledge

11. Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Planning
Goals may include improved condition of the oral mucosa, improved nutritional intake, positive self-image, relief of pain, identification of alternative methods of communication, prevention of infections, and understanding of disease process.

12. Impaired Oral Mucous Membranes
Preventive oral care
Dental care prior to surgery or radiation therapy
Frequent gentle brushing and flossing, or if patient cannot tolerate brushing, use of mouthwashes and other methods of cleaning and rinsing
Patient education related to oral hygiene
Encourage fluid intake to reduce dry mouth
Use of synthetic saliva such as Oral Balance or a saliva production stimulant such as Salagen

13. Imbalanced Nutrition
Assess nutritional requirements and dietary patterns.
Assess patient preferences and take into account social and cultural factors when encouraging and recommending dietary intake.
A calorie count may be needed to assess if intake is meeting needs.
Dietary consult

14. Other Interventions Support a positive self-image:
Encourage patient to verbalize.
Listen and offer acceptance and support.
Referral to support group, psychiatric liaison, or spiritual advisor
Pain
Avoid hot, spicy, or hard foods.
Oral care
Viscous xylocaine or other pain medications

15. Other Interventions Promote effective communication:
Assess patient’s writing ability preop.
Plan communication preop.
Communication board or pencil and paper
Speech therapy
Prevent infection:
Assess for signs and symptoms of infections.
Appropriate wound and skin care
Patient teaching See Chart 35-4

16. Radical Neck Dissection and Selective Radical Neck Dissection

17. Nursing Process: The Care of the Patient with a Radical Neck Dissection: Assessment
Assess knowledge.
Assess for risks for potential complications.
Postoperatively, the patient will need careful monitoring and assessment:
Airway and breathing
Pain
Potential bleeding and wound drainage system
Other

18. Nursing Process: The Care of the Patient with a Radical Neck Dissection- Planning
Major goals include patient participation in the treatment plan, maintenance of respiratory status, attainment of comfort, absence of infection, viability of graft, maintenance of adequate nutrition and fluid intake, effective coping strategies, effective communication, maintenance of neck and shoulder motion, and absence of complications.

19. Nursing Process: The Care of the Patient with a Radical Neck Dissection: Diagnosis
Knowledge deficiency
Ineffective airway
Acute pain
Impaired tissue integrity
Imbalanced nutrition
Impaired physical mobility secondary to nerve injury

20. Collaborative Problems/Potential Complications
Hemorrhage
Chyle fistula
Nerve injury

21. Maintaining the Airway
Frequent assessment
Place in Fowler’s position.
Encourage coughing and deep breathing.
If patient has a tracheostomy, provide tracheostomy care as required.

22. Patient Education (See Chart 35-6)
Patient should be aware of the extent and nature of the surgery and what to expect in the postoperative period.
Patient and family will require postoperative teaching related to self-care and home management:
Sign and symptoms to report
Wound care, dressings and drains if present
Diet and medications
Exercises and activity
Speech therapy, support resources, and follow-up care

23. Impaired Tissue Integrity
Suctioning should be done with great care to protect suture lines.
Support the head and neck when moving the patient.
Assess wound drainage system and empty as required.
Assess dressings, wound, and graft condition.

24. Imbalanced Nutrition
Assess nutritional state preoperatively and intervene early to prevent nutritional problems.
Encourage high-density, high-quality intake.
Diet may need to be modified to liquid diet, or to soft, puréed, and liquid foods.
Consider patient preferences and cultural considerations in food selection.
Provide oral care before and after eating.
Nasogastric or gastrostomy feedings may be required.

25. Disorders of the Esophagus
Dysphagia
Achalasia
Diffuse spasm
Hiatal hernia
Perforation
Foreign bodies
Chemical burns
GERD (gastroesophageal reflux disease)
Esophageal cancer

26. Treatment of Achalasia: Pneumatic Dilation

27. Sliding Esophageal and Paraesophageal Hernia

28. Esophageal Reconstruction with Free Jejunal Transfer