Interventions for Interventions for clients with oral cavity clients with oral cavity problems, esophageal, problems, esophageal, stomack and intestinal stomack and intestinal disordersdisorders

Painful inflammation & ulceration of the mouth Painful inflammation & ulceration of the mouth as a result ofas a result of

InfectionInfection Vitamin deficiencyVitamin deficiency Systemic diseaseSystemic disease MedicationsMedications TraumaTrauma Food allergyFood allergy

Clinical findings vary by causeClinical findings vary by cause Dry mouthDry mouth Ulcerations/lesionsUlcerations/lesions FissuresFissures Bacterial or fungal growthBacterial or fungal growth PainPain OdorOdor

StomatitisStomatitis

Oral TumorsOral TumorsPre Malignant LesionsPre Malignant Lesions

LeukoplakiaLeukoplakia ErythroplakiaErythroplakia

Oral lesions that do not Oral lesions that do not heal, especially in heal, especially in clients who smoke clients who smoke tobacco, use “snuff”, tobacco, use “snuff”, alcohol use, sun alcohol use, sun exposure exposure

Slowly developing changes Slowly developing changes in the oral mucous in the oral mucous membranes characterized membranes characterized by thickened, white, firmly by thickened, white, firmly attached patches that are attached patches that are slightly raised and sharply slightly raised and sharply circumscribed.circumscribed.

Related to factors that Related to factors that cause oral mucous cause oral mucous membrane irritation (i.e. membrane irritation (i.e. poorly fitting dentures, poorly fitting dentures, smoking)smoking)

Cannot be removed when Cannot be removed when scraped unlike scraped unlike candidalcandidal infectioninfection

Most common oral lesion Most common oral lesion among adultsamong adults

ErythroplakiaErythroplakia Red, velvety mucosal lesions on the surface of the oral Red, velvety mucosal lesions on the surface of the oral

mucosamucosa Higher degree of malignant transformation in erythroplakia Higher degree of malignant transformation in erythroplakia

than in leukoplakiathan in leukoplakia Commonly found on the floor of the mouth, tongue, palate, Commonly found on the floor of the mouth, tongue, palate,

and mandibular mucosaand mandibular mucosa Erythroplakia is a general term for red, flat, or eroded velvety Erythroplakia is a general term for red, flat, or eroded velvety

lesions that develop in the mouth. In this image, a squamous lesions that develop in the mouth. In this image, a squamous cell carcinoma is surrounded by a margin of erythroplakia.cell carcinoma is surrounded by a margin of erythroplakia.

Most common oral malignancy: can be found on the lips, Most common oral malignancy: can be found on the lips, tongue, buccal mucosa, and oropharynxtongue, buccal mucosa, and oropharynx

Highly associated with aging, tobacco use, and alcohol Highly associated with aging, tobacco use, and alcohol ingestioningestion

Tumor, node, metastasis classification system for tumors of Tumor, node, metastasis classification system for tumors of the lips and oral cavitythe lips and oral cavity

Squamous Cell CarcinomaSquamous Cell Carcinoma

Basal Cell CarcinomaBasal Cell Carcinoma Occurs primarily on the lipsOccurs primarily on the lips Lesion is asymptomatic and resembles a raised scab; Lesion is asymptomatic and resembles a raised scab;

evolves into ulcer with a raised pearly borderevolves into ulcer with a raised pearly border Aggressively involves the skin of the face, but does not Aggressively involves the skin of the face, but does not

metastasize metastasize Major etiologic factor is exposure to sunlightMajor etiologic factor is exposure to sunlight

Kaposi’s SarcomaKaposi’s Sarcoma Malignant lesion arising in blood vesselsMalignant lesion arising in blood vessels Usually painlessUsually painless Raised purple nodule or plaqueRaised purple nodule or plaque Found on the hard palate, gums, tongue, or tonsilsFound on the hard palate, gums, tongue, or tonsils Most often associated with AIDSMost often associated with AIDS

Acute SialadenitisAcute Sialadenitis Inflammation of a salivary gland, caused by infectious Inflammation of a salivary gland, caused by infectious

agents, irradiation, or immunologic disordersagents, irradiation, or immunologic disorders InterventionsInterventions

HydrationHydration Application of warm compressesApplication of warm compresses Massage of the glandMassage of the gland Use of saliva substituteUse of saliva substitute Use of sialagoguesUse of sialagogues

Salivary Gland TumorsSalivary Gland Tumors Relatively rare among oral tumorsRelatively rare among oral tumors Often associated with radiation of the head and neck areasOften associated with radiation of the head and neck areas Assessment: ability to wrinkle brow, raise eyebrows, squeeze Assessment: ability to wrinkle brow, raise eyebrows, squeeze

eyes shut, wrinkle nose, pucker lips, puff out cheeks, and eyes shut, wrinkle nose, pucker lips, puff out cheeks, and grimace or smilegrimace or smile

Treatment of choice: surgical excision of the parotid glandTreatment of choice: surgical excision of the parotid gland

Esophageal DisordersEsophageal Disorders

Gastroesophageal reflux diseaseGastroesophageal reflux disease Hiatal herniaHiatal hernia Esophageal cancerEsophageal cancer Esophageal diverticulaEsophageal diverticula Esophageal stricturesEsophageal strictures AchalasiaAchalasia Esophageal varicesEsophageal varices

Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease

Occurs as a result of the backward flow (reflux) of Occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagusgastrointestinal contents into the esophagus

Reflux esophagitis characterized by acute symptoms of Reflux esophagitis characterized by acute symptoms of inflammationinflammation

Esophageal reflux occurs when gastric volume or intra-Esophageal reflux occurs when gastric volume or intra-abdominal pressure is elevated, the sphincter tone of the abdominal pressure is elevated, the sphincter tone of the lower esophageal sphincter is decreased, or it is lower esophageal sphincter is decreased, or it is inappropriately relaxed.inappropriately relaxed.

Clinical ManifestationsClinical Manifestations DyspepsiaDyspepsia RegurgitationRegurgitation Hypersalivation or water brashHypersalivation or water brash Dysphagia and odynophagiaDysphagia and odynophagia Others manifestations: chronic cough, Others manifestations: chronic cough,

asthma, atypical chest pain, eructation asthma, atypical chest pain, eructation (belching), flatulence, bloating, after (belching), flatulence, bloating, after eating, nausea and vomitingeating, nausea and vomiting

Hiatal HerniaHiatal Hernia

Hiatal HerniaHiatal Hernia

Protrusion of the stomach through the Protrusion of the stomach through the esophageal hiatus of the diaphragm into the esophageal hiatus of the diaphragm into the thoraxthorax

Sliding hernia most common, occurring Sliding hernia most common, occurring when esophagogastric junction and a when esophagogastric junction and a portion of the fundus of the stomach slide portion of the fundus of the stomach slide upward through the esophageal hiatus into upward through the esophageal hiatus into the thoraxthe thorax

Rolling hernia: fundus rolls into the thorax Rolling hernia: fundus rolls into the thorax beside the esophagusbeside the esophagus

HeartburnHeartburn RegurgitationRegurgitation Pain Pain DysphagiaDysphagia BelchingBelching Worsening symptoms after eating or Worsening symptoms after eating or

when in recumbent positionwhen in recumbent position

AssessmentAssessment

Surgical ManagementSurgical Management Operative proceduresOperative procedures Preoperative carePreoperative care Postoperative carePostoperative care

Respiratory careRespiratory care Nasogastric tube managementNasogastric tube management Nutritional care for complications of surgery including gas Nutritional care for complications of surgery including gas

bloat syndrome and aerophagia (air swallowing)bloat syndrome and aerophagia (air swallowing)

AchalasiaAchalasiaClinical ManifestationsClinical Manifestations

Symptoms Dysphagia

Most common symptom Globus sensation Substernal chest pain

During/after a meal Halitosis

Inability to belch GERD Regurgitation Weight loss

Esophageal DilationEsophageal Dilation Metal stents used to keep the esophagus open for longer Metal stents used to keep the esophagus open for longer

durationsdurations Complications: bleeding, signs of perforation, chest and Complications: bleeding, signs of perforation, chest and

shoulder pain, elevated temperature, subcutaneous shoulder pain, elevated temperature, subcutaneous emphysema, hemoptysisemphysema, hemoptysis

Passage of progressively larger sizes of esophageal bougies Passage of progressively larger sizes of esophageal bougies using polyurethane balloons on a catheterusing polyurethane balloons on a catheter

EsophagomyotomyEsophagomyotomy Surgical procedure for achalasia is done to facilitate the Surgical procedure for achalasia is done to facilitate the

passage of food.passage of food. Laparoscopic approach is most common.Laparoscopic approach is most common. For long-term refractory achalasia, the surgeon may attempt For long-term refractory achalasia, the surgeon may attempt

excising the affected portion of the esophagus with or excising the affected portion of the esophagus with or without replacement of a segment of colon or jejunum.without replacement of a segment of colon or jejunum.

Esophageal TumorsEsophageal Tumors Esophageal tumors can Esophageal tumors can

be benign or malignant.be benign or malignant. Barrett’s esophagus is Barrett’s esophagus is

ultimately malignant.ultimately malignant. Clinical manifestations Clinical manifestations

include dysphagia, include dysphagia, odynophagia, odynophagia, regurgitation, vomiting, regurgitation, vomiting, foul breath, chronic foul breath, chronic hiccups, pulmonary hiccups, pulmonary complications, chronic complications, chronic cough, and cough, and hoarseness.hoarseness.

Surgical ManagementSurgical Management Esophagectomy: the removal of all or part of the esophagusEsophagectomy: the removal of all or part of the esophagus Esophagogastrostomy: the removal of part of the esophagus Esophagogastrostomy: the removal of part of the esophagus

and proximal stomachand proximal stomach Minimally invasive esophagectomy Minimally invasive esophagectomy Extensive preoperative care Extensive preoperative care Operative proceduresOperative procedures

DiverticulaDiverticula Sacs resulting from the herniation of esophageal mucosa and Sacs resulting from the herniation of esophageal mucosa and

submucosa into surrounding tissuesubmucosa into surrounding tissue Zenker’s diverticulum most commonZenker’s diverticulum most common Diet therapy for size and frequency of mealsDiet therapy for size and frequency of meals Surgical managementSurgical management

Esophageal TraumaEsophageal Trauma

Trauma to the esophagus can result from Trauma to the esophagus can result from blunt injuries, chemical burns, surgery or blunt injuries, chemical burns, surgery or endoscopy, or stress of protracted endoscopy, or stress of protracted vomiting.vomiting.

Nothing is administered by mouth; broad-Nothing is administered by mouth; broad-spectrum antibiotics are given.spectrum antibiotics are given.

Surgical management requires resection of Surgical management requires resection of part of the esophagus with a gastric pull-part of the esophagus with a gastric pull-through and repositioning or replacement through and repositioning or replacement by a bowel segment.by a bowel segment.

Interventions for Interventions for clients with stomack clients with stomack and intestinal and intestinal disordersdisorders

Stomach DisturbancesStomach Disturbances GastritisGastritis Peptic Ulcer DiseasePeptic Ulcer Disease Gastric SurgeryGastric Surgery Zollinger-Ellison SyndromeZollinger-Ellison Syndrome Dumping SyndromeDumping Syndrome

GastritisGastritis

Gastritis is defined as inflammation of Gastritis is defined as inflammation of the gastric mucosa; two types:the gastric mucosa; two types: Acute gastritisAcute gastritis Chronic gastritisChronic gastritis

Type A gastritisType A gastritis Type B gastritisType B gastritis Atrophic gastritisAtrophic gastritis

Helicobacter pylori, Escherichia coli Helicobacter pylori, Escherichia coli can cause gastritis.can cause gastritis.

Peptic Ulcer DiseasePeptic Ulcer Disease

PUD is a mucosal lesion of the stomach or duodenum as a PUD is a mucosal lesion of the stomach or duodenum as a result of gastric mucosal defenses impaired and no longer result of gastric mucosal defenses impaired and no longer able to protect the epithelium from the effects of acid and able to protect the epithelium from the effects of acid and pepsin.pepsin.

Acid, pepsin, and Acid, pepsin, and Helicobacter pylori Helicobacter pylori infection play an infection play an important role in the development of gastric ulcers.important role in the development of gastric ulcers.

Duodenal UlcersDuodenal Ulcers Most duodenal ulcers occur in the first portion of Most duodenal ulcers occur in the first portion of

the duodenum.the duodenum. Duodenal ulcers present as deep, sharply Duodenal ulcers present as deep, sharply

demarcated lesions that penetrate through the demarcated lesions that penetrate through the mucosa and submucosa into the muscularis mucosa and submucosa into the muscularis propria.propria.

Differentiating Gastric Differentiating Gastric and Duodenal Ulcersand Duodenal Ulcers

Gastric UlcerGastric Ulcer Increase of pain with Increase of pain with

eating, antacids eating, antacids 30min30min

HematemesisHematemesis

Duodenal UlcerDuodenal Ulcer Relief with food, Relief with food,

antacids 90min-3hrantacids 90min-3hr Pain awakens at Pain awakens at

nightnight MelenaMelena

Stress UlcersStress Ulcers Acute gastric mucosa lesions occurring after an Acute gastric mucosa lesions occurring after an

acute medical crisis or traumaacute medical crisis or trauma Associated with head injury, major surgery, burns, Associated with head injury, major surgery, burns,

respiratory failure, shock, and sepsis.respiratory failure, shock, and sepsis. Principal manifestation: bleeding caused by gastric Principal manifestation: bleeding caused by gastric

erosionerosion

Complications of UlcersComplications of Ulcers

Hemorrhage—hematemesisHemorrhage—hematemesis Perforation—a surgical emergencyPerforation—a surgical emergency Pyloric obstruction—manifested by vomiting Pyloric obstruction—manifested by vomiting

caused by stasis and gastric dilationcaused by stasis and gastric dilation Intractable disease—the client no longer Intractable disease—the client no longer

responds to conservative management, or responds to conservative management, or recurrences of symptoms interfere with ADLsrecurrences of symptoms interfere with ADLs

Drug TherapyDrug Therapy

Four primary goals for drug therapy:Four primary goals for drug therapy: Provide pain reliefProvide pain relief Eradicate Eradicate H. pylori H. pylori infectioninfection Heal ulcerationsHeal ulcerations Prevent recurrencePrevent recurrence

Diet TherapyDiet Therapy

Diet therapy may be directed toward Diet therapy may be directed toward neutralizing acid and reducing neutralizing acid and reducing hypermotility. hypermotility.

A bland, nonirritating diet is recommended A bland, nonirritating diet is recommended during the acute symptomatic phase.during the acute symptomatic phase.

Avoid bedtime snacks.Avoid bedtime snacks. Avoid alcohol and tobacco.Avoid alcohol and tobacco.

Irritable Bowel Syndrome Irritable Bowel Syndrome (IBS)(IBS)

TreatmentTreatment

Education—teaching the client to avoid problem Education—teaching the client to avoid problem stimulantsstimulants

Diet therapy—elimination of offending or upsetting Diet therapy—elimination of offending or upsetting foodsfoods

Drug therapy—bulk-forming laxatives, antidiarrheal Drug therapy—bulk-forming laxatives, antidiarrheal agents, anticholinergic agents, tricyclic agents, anticholinergic agents, tricyclic antidepressants, and 5-HTantidepressants, and 5-HT4 4 agonists.agonists.

Stress management based on the client’s current Stress management based on the client’s current

and ongoing stressorsand ongoing stressors Complementary and alternative therapies used to Complementary and alternative therapies used to

reduce symptoms and discomfort reduce symptoms and discomfort

HerniationHerniation Weakness in the abdominal muscle wall through Weakness in the abdominal muscle wall through

which a segment of bowel or other abdominal which a segment of bowel or other abdominal structure protrudesstructure protrudes

Types of hernia include:Types of hernia include: Indirect inguinal Indirect inguinal Direct inguinal Direct inguinal Femoral Femoral Umbilical Umbilical Incisional or ventral Incisional or ventral

Colorectal CancerColorectal Cancer

ColorectalColorectal refers to the colon and the refers to the colon and the rectum, which together make up the large rectum, which together make up the large intestine.intestine.

95% of cancers of the colon or rectum are 95% of cancers of the colon or rectum are adenocarcinomas.adenocarcinomas.

EtiologyEtiology Genetic considerationsGenetic considerations Personal factorsPersonal factors Dietary factorsDietary factors Inflammatory bowel diseaseInflammatory bowel disease

Clinical ManifestationsClinical Manifestations

Rectal bleeding, hematochezia, passage of red Rectal bleeding, hematochezia, passage of red blood via the rectumblood via the rectum

AnemiaAnemia Change in stool textureChange in stool texture Mass in abdomenMass in abdomen

Laboratory AssessmentLaboratory Assessment

Hemoglobin and hematocrit values Hemoglobin and hematocrit values usually decreasedusually decreased

Fecal occult blood testFecal occult blood test Possible elevation of Possible elevation of

carcinoembryonic antigencarcinoembryonic antigen Radiographic assessmentRadiographic assessment Other diagnostic assessmentsOther diagnostic assessments

Intestinal ObstructionIntestinal Obstruction Mechanical obstructionMechanical obstruction Nonmechanical obstruction, known as paralytic Nonmechanical obstruction, known as paralytic

ileusileus Strangulated obstruction resulting from tumors, Strangulated obstruction resulting from tumors,

hernias, fecal impactions, strictures, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis, vascular intussusception, volvulus, fibrosis, vascular disorder, and adhesionsdisorder, and adhesions

Clinical Manifestations of Clinical Manifestations of Mechanical ObstructionMechanical Obstruction

Midabdominal pain or crampingMidabdominal pain or cramping VomitingVomiting ObstipationObstipation DiarrheaDiarrhea Alteration in bowel pattern and stoolAlteration in bowel pattern and stool Abdominal distentionAbdominal distention BorborygmiBorborygmi Abdominal tendernessAbdominal tenderness

Clinical Manifestations of Clinical Manifestations of Nonmechanical ObstructionNonmechanical Obstruction

Constant diffuse discomfortConstant diffuse discomfort Abdominal distentionAbdominal distention Decreased to absent bowel soundsDecreased to absent bowel sounds VomitingVomiting Obstipation Obstipation

AssessmentAssessment Laboratory assessmentLaboratory assessment Radiographic assessmentRadiographic assessment EndoscopyEndoscopy Barium enemaBarium enema Computed tomographyComputed tomography

HemorrhoidsHemorrhoids Unnaturally swollen or distended veins in the anorectal Unnaturally swollen or distended veins in the anorectal

regionregion Internal hemorrhoidsInternal hemorrhoids External hemorrhoids External hemorrhoids Nonsurgical managementNonsurgical management Surgical management: hemorrhoidectomySurgical management: hemorrhoidectomy