Chapter 45: Management of Patients With Oral and Esophageal Disorders

While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?

80-120ml Wound drainage tubes are usually inserted during surgery to prevent the collection of fluid subcutaneously. The drainage tubes are connected to a portable suction device (e.g., Jackson-Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.

The nurse is performing an assessment for a patient who presents to the clinic with a lip lesion. The lesion is erythemic, is fissuring, and has white hyperkeratosis. What does the nurse suspect that these findings are characteristic of?

Actinic cheilitis Actinic cheilitis is an irritation of the lips associated with scaling, crusting, fissure; white overgrowth of horny layer of epidermis (hyperkeratosis).

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?

Assess lung sounds bilaterally All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply.

Avoid beer, especially in the evening Elevate the HOB on 6-8in blocks Elevate the upper body on pillows Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

Avoid coffee and alcoholic beverages To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Chancre A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.

Which is the primary symptom of achalasia?

Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?

Diuretics Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the client's risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?

Dysphagia Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).

A client is in the initial stages of oral cancer diagnosis and is frightened about the side effects of treatment and subsequent prognosis. The client has many questions regarding this type of cancer and asks where oral cancer typically occurs. What is the nurse's response?

Floor of the mouth Malignant growths can be found anywhere in the oral cavity, but cancers usually occur on the lips, sides of the tongue, or floor of the mouth.

What are the functions of saliva?

Lubrication Protection against harmful bacteria Digestion The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question?

Metoclopramide The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route?

Nasogastric intubation The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland?

Parotid The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.

A client with oral cancer reports dryness of the mouth. What is the nurse's best response?

Provide humidifier for the client to use while sleeping Dryness of the mouth (xerostomia) is a frequent sequeala of oral cancer. While explaining this to the client provides information, it does nothing to help solve the problem. The nurse should encourage this client to increase intake of fluids to 2000 to 3000 mL per day. Providing a humidifier will assist in moisturizing the oral cavity. The client needs to be instructed to avoid dry, bulking, and irritating foods and fluids.

Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus?

Pyrosis Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain on swallowing is termed odynophagia.

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding?

Sialadenitis. Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiaisis Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.

A patient has been diagnosed with Zenker's diverticulum. What treatment does the nurse anticipate educating the patient about?

Surgical removal of the diverticulum Because Zenker's diverticulum is progressive, the only means of cure is surgical removal of the diverticulum.

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.

Which of the following is the most common type of diverticulum?

Zenker's diverticulum The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).

A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate?

Achalasia Achalasia is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. The main symptom is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus.

A patient has been NPO for two days anticipating surgery which has been repeatedly delayed. In addition to risks of nutritional and fluid deficits, the nurse determines that this patient is at the greatest risk for:

Altered oral mucous membranes Not drinking anything by mouth can result in drying of the oral mucous membranes, compromising their integrity. Being NPO is unrelated to physical injury or ineffective social interaction. Confusion is unlikely to result from the client's NPO status.

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?

"Ill eat small frequent meals that are high in fiber." In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To minimize intra-abdominal pressure and decrease gastric reflux, the client should eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver). Eating three large meals daily would increase intra-abdominal pressure, possibly worsening the hiatal hernia. The client should avoid spicy foods, alcohol, and tobacco because they increase gastric acidity and promote gastric reflux. To minimize intra-abdominal pressure, the client shouldn't recline after meals, lift heavy objects, or bend.

Achalasia

failure of the lower esophagus sphincter muscle to relax

An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries?

Exhibiting hemoglobin A1C of 8.2 Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse?

A canker sore of the oral soft tissues Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease?

Avoid eating or drinking 2 hours before bedtime The client should not recline with a full stomach. The client should be instructed to avoid caffeine, beer, milk, and foods containing peppermint or spearmint, and to eat a low-fat diet. The client should be instructed to elevate the head of the bed on 6- to 8-inch blocks.

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client?

Brush and floss daily The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.

A nurse inspects the Stensen duct of the parotid gland to determine inflammation and possible obstruction. What area in the oral cavity would the nurse examine?

Buccal mucosa next to the upper molars

A patient is experiencing painful, inflamed, and swollen gums, and when brushing the teeth, the gums bleed. What common disease of the oral tissue does the nurse understand these symptoms indicate?

Gingivitis Gingivitis is a gum disease that results in painful, inflamed, swollen gums that bleed in response to light contact.

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician?

High epigastric pain and or discomfort The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.

Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply.

Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium)

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?

Metoclopramide (Reglan) Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid), nizatidine (Axid), or ranitidine (Zantac). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.

The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate?

Notify the physician The presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.

The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply.

Oral hygiene Follow up dental appointment Follow up medical appointment Use of humidification Discharge teaching for a client after oral surgery includes oral hygiene, follow-up dental and medical appointments, and the use of humidification to keep secretions moist.

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?

Place the client in Fowlers All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.

A nurse practitioner, who is treating a patient with GERD, knows that responsiveness to this drug classification is validation of the disease. The drug classification is:

Proton pump inhibitors Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.

The client has a chancre on the lips. What instruction should the nurse provide?

Take measures to prevent spreading the lesion to other people A chancre is a primary lesion of syphilis and very contagious. It is important to instruct the client about ways to prevent spreading the lesion to others. Other nursing considerations include cold soaks to the lip, good mouth care (brushing and flossing), and administration of antibiotics as prescribed.