Chapter 54: Care of Patients with Esophageal Problems

A client with gastroesophageal reflux disease has undergone a laparoscopic Nissen fundoplication (LNF). What will the nurse include in postoperative home care instructions? A. "Consume carbonated beverages if you experience stomach upset." B. "Remain on a soft diet for about a week and avoid raw fruits and vegetables." Correct C. "You may resume running and weight lifting if you wish." D. "You may stop taking your anti-reflux medications after 1 week."

After LNF, clients should be taught to remain on a soft diet for 1 week. Carbonated beverages should be avoided. Clients may walk, but should avoid heavy lifting. Anti-reflux medications should be taken for 1 month after the procedure.

The nurse is caring for a client with a hiatal hernia who had an open fundoplication yesterday. Which task does the nurse delegate to unlicensed assistive personnel (UAP)? A. Using a pillow to support the incision when the client coughs Correct B. Adjusting the position of the nasogastric (NG) tube C. Assessing the level of postoperative pain using a 0-to-10 scale D. Giving the client sips of water once bowel sounds are heard

Assisting a client to cough is a task within the education and skill level of UAP. NG tube maintenance, pain assessment, and assessment of bowel sounds require more knowledge of the potential complications associated with this surgical procedure, and are actions best performed by licensed nursing staff.

The nurse is working with the dietitian to plan a menu for a client who has persistent difficulty swallowing. What is a suitable breakfast selection for this client? A. Scrambled eggs and toast B. Oatmeal and orange juice C. Puréed fruit and English muffin D. Cream of wheat and applesauce Correct

Both cream of wheat and applesauce are foods of semi-solid consistency and are appropriate for this client. The client who is having difficulty swallowing should be given semi-solid foods and thickened liquids. Toast would not be appropriate, and orange juice would have to be thickened before it is given to this client. An English muffin would be inappropriate for this client because it is not a semi-solid food.

The nurse is reviewing orders for a client with possible esophageal trauma after a car crash. Which request does the nurse implement first? A. Give total parenteral nutrition (TPN) through a central venous catheter. B. Administer cefazolin (Kefzol) 1 g intravenously. C. Obtain a computed tomography (CT) scan of the chest and abdomen. D. Keep the client nothing by mouth (NPO) for possible surgery. Correct

Clients with possible esophageal tears should be NPO until diagnostic testing is completed, because leakage of anything taken orally into the sterile mediastinum could occur. In addition, esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing. TPN is prescribed to provide calories and protein for wound healing; although this is important, it is not a priority for the nurse to implement first. Antibiotics may be requested to prevent possible infection, but this is not the priority. A CT of the chest and abdomen will be needed, but is not the nurse's initial action.

A client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea? A. Ensure that the client takes adequate amounts of fluids with meals. Incorrect B. Advance the diet to solid food and encourage eating as much as possible at meals. C. Give the client a dose of magnesium hydroxide (Milk of Magnesia) after each meal. D. Encourage the client to take fluids between meals rather than with meals. Correct

Diarrhea is believed to be the result of vagotomy syndrome and can be managed by taking fluids between meals rather than with meals. For this client, fluids with meals can lead to the development of diarrhea immediately after eating. The client may not be physically ready to advance to a solid diet. The client should eat six to eight small meals daily. Magnesium hydroxide is a magnesium-based antacid that can cause diarrhea.

The nurse is caring for a client diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the health care provider will request which medication to manage diarrhea? A. Loperamide (Imodium) Correct B. Mesalamine (Pentasa) C. Minocycline (Minocin) D. Pantoprazole (Protonix)

Diarrhea is thought to be the result of vagotomy syndrome, which develops as a result of interruption of vagal fibers to the abdominal viscera during surgery. It can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide. Mesalamine is used to treat clients with mild to moderate ulcerative colitis. Minocycline is an antibiotic used for treatment of infection. Pantoprazole is used to treat gastroesophageal reflux disease.

The nurse is assessing a client with gastroesophageal reflux disease (GERD). Which findings does the nurse expect to observe? (Select all that apply.) A. Blood-tinged sputum B. Dyspepsia Correct C. Excessive salivation D. Flatulence Correct E. Regurgitation Correct

Dyspepsia, also known as heartburn, is one of the main symptoms of GERD. Flatulence is common after eating, as well as regurgitation (backward flow into the throat) of food and fluids. Blood-tinged sputum and excessive salivation are not symptoms of GERD.

The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a client diagnosed with esophageal cancer. Which instruction to the client is the highest priority? A. Place food at the back of the mouth as you eat. Correct B. Do not be overly concerned with tongue or lip movements. C. Before swallowing, tilt the head back to straighten the esophagus. D. Do not attempt to reach food particles that are on the lips or around the mouth.

Placing food at the back of the mouth when eating will help the client avoid aspirating. Both tongue movements and sealing of the lips should be monitored in this client. The client's head should be tilted forward in the chin-tuck position. The client should be able to reach food particles on her or his lips and around the mouth with the tongue.

The nurse is caring for a client with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the client about porfimer sodium? (Select all that apply.) A. Avoid sunlight for 2 weeks. Incorrect B. Cover all exposed body areas. Correct C. Follow a clear liquid diet for 3 to 5 days after the procedure. Correct D. Monitor for hypertension. E. Tissue particles may be found in the sputum. Correct

Porfimer sodium causes photosensitivity, and sunglasses and protective clothing covering all exposed body areas are essential. A clear liquid diet should be followed for 3 to 5 days after the procedure and then should be advanced to full liquids as tolerated. The client should be warned that tissue particles may be released from the tumor site and may be present in the sputum. Sunlight should be avoided for 1 to 3 months. Side effects are rare and may include nausea, fever, and constipation. Hypertension is not a side effect of porfimer sodium.

A client who has been diagnosed recently with esophageal cancer states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response? A. "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it." B. "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed." Correct C. "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much." D. "You need to talk to your doctor about your concerns. The doctor may recommend that you join a support group for cancer survivors." Incorrect

Suggesting that the client invite people over for a meal provides psychosocial support to the client and assists the client in finding a solution to the problem. Telling the client not to worry about it or to call the provider is evasive and unhelpful; it is used to placate the client and does not address the client's concerns. The client should use problem-solving and coping skills before resorting to the use of medication.

A client has been diagnosed with mild gastroesophageal reflux disease and asks the nurse about nonpharmacologic treatments to prevent symptoms. What does the nurse tell this client? A. "Avoid caffeine-containing foods and beverages." Correct B. "Eat three meals each day and avoid snacking between meals." C. "Peppermint lozenges help to reduce stomach upset." D. "Sleep on your left side with a pillow between your knees."

Teach the client to limit or eliminate foods that decrease lower esophageal sphincter (LES) pressure and that irritate inflamed tissue, causing heartburn, such as peppermint, chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. Large meals increase the volume of and pressure in the stomach and delay gastric emptying. Remind the client to eat four to six small meals each day rather than three large ones. Peppermint decreases LES pressure and increases the risk of symptoms. Clients should be taught to elevate the head by 6 to 12 inches for sleep to prevent nighttime reflux.

A client has been diagnosed with terminal esophageal cancer. The client is interested in obtaining support from hospice, but expresses concern that pain management will not be adequate. What is the nurse's best response? A. "Haven't you received adequate pain management in the hospital?" B. "Would you like me to get a nurse from hospice to come talk with you?" Correct C. "Do you want me to call the hospital chaplain to explain hospice to you?" D. "Talk to your health care provider about hospice services."

The best way to alleviate the client's concerns would be to have a hospice nurse talk with the client and answer any questions. Suggesting that the client has had adequate pain management sounds defensive. Referring the client to the chaplain or the health care provider is evasive and attempts to shift responsibility away from the nurse.

The nurse prepares a teaching session regarding lifestyle changes needed to decrease the discomfort associated with a client's hiatal hernia. Which change does the nurse recommend to this client? A. Eat only two or three meals daily. B. Sleep flat in a left side-lying position. C. Drink tea instead of coffee. D. Avoid working while bent over the computer. Correct

The client should avoid working while bent over because this position presses on the diaphragm, causing discomfort. The client with a hiatal hernia should eat four to six meals a day. The head of the client's bed should be elevated approximately 6 inches. Both tea and coffee should be eliminated from this client's diet because of the caffeine content.

The nurse is observing a co-worker who is caring for a client with a nasogastric tube following esophageal surgery. Which actions by the co-worker require the nurse to intervene? (Select all that apply.) A. Checking tube placement every 12 hours Correct B. Keeping the bed flat Correct C. Placing the client upright when taking sips of water D. Providing mouth care every 8 hours Correct E. Securing the tube

The nasogastric tube should be checked every 4 to 8 hours. The head of the bed should be elevated at least 30 degrees. Oral hygiene should be provided every 2 to 4 hours. The client should be placed upright when taking sips or small amounts of water to prevent choking and to allow observation of the client for dysphagia. The tube should be secured to prevent dislodgment.

A client in the outpatient clinic tells the nurse about experiencing heartburn and nighttime coughing episodes. Which action does the nurse take first? A. Teach the client about antacid effects and side effects. B. Ask the client about medications and dietary intake. Correct C. Suggest that the client sleep with the head elevated 6 inches. D. Tell the client to avoid drinking alcohol late in the evening. Incorrect

The nurse's initial action should be further assessment of the client's risk factors for gastroesophageal reflux disease. Before suggesting interventions or beginning client teaching, the nurse must elicit more information about the client's symptoms. The nurse needs additional data before telling the client to avoid drinking alcohol late in the evening.

Which of these assigned clients does the nurse assess first after receiving the change-of-shift report? A. Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography (CT) scan in 30 minutes B. Adult with gastroesophageal reflux disease (GERD) who is describing epigastric pain at a level of 6 (0-to-10 pain scale) C. Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright-red drainage from the nasogastric (NG) tube Correct D. Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as-needed (PRN) basis Incorrect

The presence of blood in NG drainage is an unexpected finding 2 days after esophagogastrectomy and requires immediate investigation. The young adult scheduled for a CT scan, the adult with GERD, and the older adult with an ileus are all stable and do not require the nurse's immediate attention.

The nurse is reviewing the medication history for a client diagnosed with gastroesophageal reflux disease who has been prescribed esomeprazole (Nexium) once daily. The client reports that the drug doesn't completely control the symptoms. The nurse contacts the provider to discuss which intervention? A. Adding a second proton pump inhibitor medication B. Increasing the dose of esomeprazole Incorrect C. nging to a twice-daily dosing regimen Correct D. Switching to omeprazole (Prilosec)

The proton pump inhibitors are usually effective when given once daily, but can be given twice daily if symptoms are not well controlled. Adding a second medication, increasing the dose, or switching to another proton pump inhibitor is not recommended.

A client with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide? A. Teaching family members how to determine whether the client is obtaining adequate nutrition B. Assessing lung sounds for possible aspiration when the client is swallowing clear liquids C. Reminding the client to use the chin-tuck technique each time the client attempts to swallow Correct D. Instructing family members about symptoms that may indicate a need to call the provider

The role of a home health aide when caring for a client with swallowing difficulty includes reinforcement of previously taught swallowing techniques. Client teaching and providing instructions to family members are not within the scope of practice of a home health aide and should be done by the nurse. Likewise, assessment is part of the nursing process and should be done by a nurse.

A client is being discharged after a minimally invasive esophagectomy. Which teaching point does the nurse consider to be of the highest priority during the predischarge teaching session? A. Instruct the client to eat three meals daily. B. Emphasize the importance of lying down after meals. C. Encourage the client to ask his or her health care provider for antidepressant medication. D. Report the presence of fever and a swollen, painful neck incision. Correct

Wound management and prevention of infection are major concerns because the client who has had an esophagectomy typically has multiple drains and incisions. The client should eat six to eight small meals daily, and should sit up after meals to encourage satisfactory swallowing. The client's coping skills should be assessed, as well as his or her level of anxiety and/or depression, before antidepressant medication is prescribed.