Assessment of the Gastro-Intestinal System.
Interventions for Clients with Oral Cavity Problems
After you have successfully completed this chapter, you should be able to:
· Identify pertinent abdominal history questions
· Obtain a pertinent abdominal history
· Perform an abdominal physical assessment
· Document abdominal assessment findings
· Identify actual/potential health problems stated as nursing
· diagnoses
· Differentiate betweeormal and abnormal findings
The abdominal assessment provides information about a variety of systems because every system, with the exception of the respiratory system, is found within the abdomen. The stomach, small and large intestines, liver, gallbladder, pancreas, spleen, kidneys, ureters, bladder, aortic vasculature, spine, uterus and ovaries, or spermatic cord are all located in the abdomen. Not only does assessment of the abdomen enable you to obtain valuable information about the functioning of the gastrointestinal (GI), cardiovascular, reproductive, neuromuscular, and genitourinary systems; it can also provide vital information about the health status of every other system.
Anatomy and Physiology Review
Before you begin your assessment, an understanding of the anatomy and physiology of abdominal structures is essential. You must be able to recognize normal structures before you can identify abnormal findings. Recognizing the structures will enable you to perform the assessment accurately, and understanding the physiology will guide your assessment and allow you to interpret your findings.
Structures and Functions
The major system assessed in the abdominal examination is the GI or digestive system. The digestive system is responsible for the ingestion and digestion of food,absorption of nutrients, and elimination of waste products. The primary structures of the digestive system (Fig. 17.1) include the mouth, pharynx, esophagus, stomach, small intestines (duodenum, jejunum, and ileum), large intestines (cecum, colon [ascending, transverse, descending, and sigmoid]), and rectum.These main structures of the digestive system form a hollow tube that is actually outside the internal environment of the body even though it is located inside the body.This tube, referred to as the alimentary canal or the gastrointestinal tract, begins at the mouth and ends at the anus. The digestive system also contains accessory organs that aid in the digestion of food. The accessory organs of the digestive system include the salivary glands (parotid, submandibular, and sublingual), liver, gallbladder, and pancreas.
The Digestive Process
The digestive process consists of mechanical digestion, the breakdown of food through chewing, peristalsis, and churning; and chemical digestion, the breakdown of food through a series of metabolic reactions with enzymes. The digestive process begins in the mouth, where food is taken in and masticated. The bolus of food is then swallowed into the esophagus, where it is propelled slowly via peristaltic contraction to the stomach. In the stomach, the food bolus is churned, breaking it down further into smaller particles and mixing it with digestive juices and hydrochloric acid that is produced by the stomach.The food bolus becomes chyme and progresses down into the first portion of the small intestine, called the duodenum. In the duodenum, pancreatic juices and bile are secreted in the chyme. The food then enters the jejunum and ileum, where nutrients are absorbed into the circulatory system. Food particles that are not absorbed by the small intestines proceed into the large intestine, where they are eventually excreted as feces.
Additional Abdominal Structures
Along with the organs of the digestive system, the abdomen also contains the spleen; the urinary tract including the bladder, kidneys, and ureters; the uterus and ovaries; the aorta; and the iliac, renal, and femoral arteries. The uterus and ovaries are covered in Chapter 18,Assessing the Female Genitourinary System.The other abdominal organs are shown in Figure 17.2. The abdominal cavity has a serous membrane called the peritoneum, which covers the organs and holds them in place.The peritoneum contains a parietal layer that lines the walls of the abdomen and the visceral pleura, which coats the outer surface of the organs. A small amount of fluid between these membranes allows them to move smoothly within the cavity.
Interaction With Other Body Systems
The GI system requires the proper functioning of the nervous, endocrine, respiratory, cardiovascular, integumentary, and musculoskeletal systems in order to operate at its full capacity.
The Integumentary and Musculoskeletal Systems
The digestive system is protected and supported by the musculoskeletal and integumentary systems.The musculoskeletal system also assists with ingestion, mastication, deglutition (swallowing) of food,and eventual defecation of its byproducts.
The Respiratory and Cardiovascular Systems
The respiratory and cardiovascular systems provide the oxygeeeded for the digestive organs to function.The respiratory system gets oxygen for the cells of the body and rids the body of carbon dioxide. All the cells in the body, including those of the digestive system, need oxygen to function appropriately.The cardiovascular system circulates the oxygen-rich blood to all the cells in the body.Any decrease in oxygen to the cells of the digestive system affects organ function. For example, if blood flow to the bowel is disrupted,a bowel infarct can occur, causing the bowel to stop functioning.
The Neurological System
The neurological system plays an important role in digestion. When the body is in a parasympathetic response, or the “rest and repair” phase, the neurological system releases acetylcholine, the neurotransmitter for the parasympathetic system. In relation to the digestive system, acetylcholine stimulates the secretion of digestive juices and increases peristalsis. The opposite is true for the sympathetic response. The sympathetic system is stimulated at times of physical or psychological stress.When this system is stimulated, a “fight or flight” response occurs, causing the release of norepinephrine,which produces a decrease in peristalsis and secretion of digestive juices.Therefore, the digestive system functions to its maximum capacity when it receives parasympathetic responses from the peripheral nervous system.
The Endocrine System
The secretion of digestive juices also depends on the proper functioning of the pancreas, an organ that has both endocrine and exocrine functions. The endocrine function is to release insulin, glucagon, and gastrin into the bloodstream to assist in carbohydrate metabolism. The exocrine function is to secrete bicarbonate and pancreatic enzymes into the duodenum to aid in the digestion of proteins, fats, and carbohydrates.
Performing the Abdominal Assessment
Assessment of the abdomen involves obtaining a complete health history and performing a physical examination. As you assess the patient, be watchful for signs and symptoms of actual and potential problems involving the different organs and structures in the abdomen.
Health History
The health history precedes the physical examination and involves interviewing the patient about his or her perception of his or her health status.The health history interview includes a broad range of questions so that possible problems associated with each of the systems of the abdomen may be identified. Remember that information collected as part of the health history may uncover problems related to systems outside the abdomen (e.g., myocardial infarction [MI]). If time is an issue and you are unable to perform a complete health history, perform a focused history on the abdomen.
Biographical Data
Gathering biographical information can provide valuable insights about the patient’s health status in several ways. Certain age groups are at greater risk for problems in the GI system. For example, infants and toddlers have a higher incidence of hernias than older children. Preschoolers are more likely to get parasitic infections, and teenagers may have abdominal symptoms as a result of pregnancy, sexually transmitted diseases (STDs),eating disorders like anorexia nervosa or bulimia, and infectious mononucleosis. Appendicitis occurs more frequently in children and teenagers than it does in adults. Older adults commonly develop problems with digestion, absorption, metabolism, and elimination because of changes caused by the aging process.Women aged 65 and over are commonly diagnosed with hiatal hernia, constipation, and diverticulosis. Certain diseases occur more frequently in some races and cultures (see previous section).You will need to ask additional health history questions to determine whether symptoms of these diseases are present so that appropriate screening measures can be performed, if necessary. The potential for exposure to environmental and occupational hazards can also be discovered in the biographical data. Where a person lives or works may raise questions about environmental hazards such as lead exposure in children (from inhalation of lead-based paint dust in older houses) or occupational health hazards such as chemical exposure (arsenic, benzene).
Current Health Status
If your patient has an abdominal complaint, investigate this first. Common chief complaints involving the body systems in the abdomen include:
· Lymphatic: Swelling, lymph node tenderness.
· Digestive: Anorexia, bruising, constipation, diarrhea, distension, dysphagia, epigastric burning, gastric reflux, indigestion, jaundice, nausea, vomiting, pain, weight changes.
· Reproductive: Cramping,nausea,pain,vomiting,weight gain.
· Neurological: Pain.
· Cardiovascular: Pain.
· Urinary: Edema, pain, problems with urination (burning, frequency).
The most common abdominal complaints—pain, changes in weight, changes in bowel habits (constipation, diarrhea), indigestion, nausea, and vomiting—are analyzed in the subsequent text,using the PQRST format. The nature and intensity of the symptoms dictate the order and extent of questioning during the symptom analysis.
Symptom Analysis
Symptom analysis tables for all the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book.
Abdominal Pain
The most common complaint related to the abdomen, pain is often classified as visceral, parietal, or referred.
Visceral pain results from distension of the intestines or stretching of the solid organs. It is often described as burning, cramping, diffuse, and poorly localized.
Parietal pain results from inflammation of the parietal peritoneum. The pain is usually severe, localized, and aggravated by movement.
Referred pain is felt at a site away from the site of origin. Impulses from the internal organs and structures that share nerve pathways inside the central nervous system explain the nature of referred pain. Acute abdominal pain (“acute abdomen”) may indicate a life-threatening abdominal condition that requires immediate medical intervention. In this situation, you should assess the patient’s vital signs to determine whether she or he is in imminent danger.Vital signs provide information about the possibility of cardiac irregularities and reveal symptoms of shock and signs of an infectious process such as peritonitis. In addition, you need to prioritize the symptom assessment questions to elicit the most essential information.The order of symptom assessment becomes RTQSP.
Pain Location
The location of the pain is often diagnostically significant. Some disorders have classic signs located in specific regions of the abdomen. For instance, pain in the umbilical region may indicate an abdominal aortic aneurysm or early appendicitis. Abdominal problems may also cause referred pain to the chest, so chest pain can indicate either an abdominal problem or a cardiac event. Patients with a gastric ulcer can have pain in the upper epigastric region left of midline, which is also the location for angina and MI. Patients with gastroesophageal reflux disease (GERD) may have chest pain that radiates to the back, neck, or jaw, which also mimics an MI. Patients with a hiatal hernia may complain of substernal chest pain and difficulty breathing, especially after a meal.
Note location of pain by quadrant or region:
Pain in shoulder: Ruptured spleen, ectopic pregnancy, Pancreatitis.
Pain in scapula: Cholelithiasis, MI, angina, biliary colic, pancreatitis.
Pain in thighs, genitals, lower back: Renal problems, ureteral colic.
Pain in lower and middle back: Abdominal aortic aneurysm. Recognizing the relationship between the location of the pain and the possible health problem has important implications for immediate nursing assessment and care of the patient.
Change in Bowel Patterns
Alterations in bowel movements are associated with a variety of GI disorders, such as malabsorption disorders, irritable bowel syndrome, cancer, infections (viral, bacterial, parasitic), food intolerance, and reactions to medications, as well as non-GI disorders.To determine whether a patient is having health problems that affects bowel function, first establish a baseline by asking general questions about bowel habits, such as: “How often do you have bowel movements? Do you have any problems with your bowels, such as straining, pain, constipation, or diarrhea?” Then ask more specific questions to help identify the origin of the problem.
Bowel patterns range from two movements per day to two or three per week. Identify the color of the stool:
Black, tarry: Upper GI bleeding.
Red, bloody: Lower GI bleeding.
Clay colored: Increased bile in obstructive jaundice.
Weight Change
Weight change may indicate diseases in many body systems, reflect unhealthy behaviors, or even reveal a normal state such as pregnancy. Weight changes can be a sign of GI disease, cancer, congestive heart failure with fluid retention, metabolic or endocrine disorders, unhealthy lifestyles, major depressive disorder, and eating disorders. A careful analysis of this symptom provides data that allow the nurse to distinguish between medical and behavioral problems causing the weight change.Weight changes of 2 to
Indigestion
Indigestion—also called dyspepsia or pyrosis—is a frequent abdominal complaint that is usually described as “heartburn.”This burning sensation is usually worse after eating a meal. Acid from the stomach flows into the lower esophagus, causing the burning sensation. GERD has heartburn as its chief symptom, but the epigastric dis- tress occurs more frequently, lasts longer, and has more severe symptoms than indigestion. Heartburn is also a common complaint in both gastric ulcer and duodenal ulcer disease and gallbladder disease. Indigestion that increases when the person is lying flat may indicate a hiatal hernia or GERD. Indigestion associated with belching (eructation) and flatulence suggests cholecystitis
Nausea
Nausea is caused by stresses on the stomach wall or esophagus. Distension, alterations in peristalsis, negative olfactory stimulation, inner ear problems, or medications can also cause nausea. Many GI medical conditions have nausea as an assessment finding.
Vomiting
During vomiting, peristalsis is reversed and the esophageal sphincter opens to allow the contents of the stomach to be ejected.The involuntary emptying of stomach contents is caused by irritation of the stomach lining caused by chemicals, trauma, or distension; stimulation of the vomiting center in the brain (medulla); and head injury. Some GI conditions that cause vomiting are intestinal obstruction, peptic ulcer, viral or bacterial infection, and appendicitis.A person with repeated vomiting is always at risk for fluid and electrolyte problems.
Past Health History
This section of the health history involves asking questions about childhood and adult illnesses, injuries, hospitalizations, allergies, immunizations, and medications that can affect the abdominal structures. Remember to document specific dates in the patient’s record.
Family History
Questioning about diseases in the patient’s family enables you to identify those that the patient may be at risk for because of genetic predisposition.Then you can help the patient plan lifestyle changes that will help prevent those diseases and promote health.
Review of Systems
A disruption in the systems contained in the abdominal cavity can cause problems in many other areas of the body. The problem in another body system depends on which organ of the abdomen is involved. For example, liver problems may cause malaise, nausea and vomiting, bruising, jaundice, and fluid in the abdomen. This is one reason why taking a careful review of systems (ROS) is so important. Another reason is that the ROS might reveal that the primary health problem does not originate in the abdomen.Instead,you may uncover medical illnesses that have abdominal symptoms. So be sure to keep an open mind about the nature of the patient’s health problem and not conclude that it lies in the GI system simply because he or she has abdominal complaints. Instead, assess each system methodically until you have collected all the data.
Psychosocial Profile
The psychosocial profile describes your patient’s lifestyle and habits. How your patient eats, exercises, rests, and copes with the stresses of every day has an impact on the health of the GI system.
Anatomical Mapping
Anatomical mapping helps pinpoint the location of findings during the abdominal assessment. There are three ways to identify the location of these findings: anatomical landmarks, the four-quadrant method,and the nine regions of the abdomen.
Anatomical Landmarks
Anatomical structures are used as landmarks to help you describe abdominal findings.The following landmarks are used: xiphoid process of the sternum; costal margin; midline (down the center of the abdomen); umbilicus; anterior-superior iliac spine; inguinal ligament (Poupart’s); and superior margin of the pubic bone (Figs. 17.3 and 17.4).
Four-Quadrant Method
Another way to mark the location of your findings is by the four-quadrant method.To use this method,draw imaginary lines separating the abdomen into four quadrants, with one line at the midline and the other horizontal at the umbilicus.These lines should intersect at the umbilicus. The aorta and the spine are located midline in the abdomen.The uterus and bladder,when enlarged,may be palpable midline in the abdomen (Fig. 17.5).
Nine Regions of the Abdomen
The third way to document the location of your findings is to separate the abdomen into nine regions, similar to a tic-tac-toe grid.The first two lines are vertical at the right and left midclavicular lines to the middle of the inguinal ligaments.The second two lines are horizontal beginning at the lower edge of the costal margin and at the anterior- superior iliac spine of the iliac bones (Fig. 17.6).
Physical Assessment
Now that you have completed the subjective part of your examination,proceed to the objective part.The purpose of the physical assessment is to identify normal structures and functions as well as actual and potential health problems. Just as all the organs of the body are interrelated,so are the assessments. Assessment findings in other body areas can also indicate problems with abdominal organs. So your assessment should begin with a general survey and a head-to-toe scan to detect clues that may indicate an abdominal problem.
Approach
Perform the abdominal examination in a warm, private environment.Have your patient empty her or his bladder before the examination, so that you do not mistake a full bladder for a mass.Ask the patient to lie supine with her or his arms at the sides.Warm both your stethoscope and your hands before proceeding with the examination,and remember to work from the right side of your patient. Once your patient is comfortable, expose the abdomen from the lower thorax to the iliac crests.
Other things to remember include:
1. Explain what you will be doing during the examination.
2. Have adequate lighting so that you can visualize the abdomen without difficulty.
3. Observe the patient’s face for signs of discomfort.
4. Perform the examination slowly and avoid quick movements.
5. Make sure that your fingernails are short, to prevent injuring the patient during palpation.
6. Distract the patient with questions or conversation.
You will use all four techniques of physical assessment to examine the abdomen. However, the sequence is inspection, auscultation, percussion, and palpation. During an abdominal examination, it is important to auscultate before percussion and palpation because the manipulation that occurs with these techniques may increase the frequency of bowel sounds.
Performing a General Survey
Before physically assessing the abdomen, perform a general survey, observing the patient’s overall appearance. Using your inspection skills, note nutritional status, emotional status, body habitus, and any changes that might relate to the abdomen. Begin by taking vital signs, height, and weight. Changes in vital signs may alert you to a serious medical problem.
Vital sign changes and related abdominal problems include:
1. Hypertension: Abdominal aortic aneurysm or dissection, renal infarction, glomerulonephritis, vasculitis, or abdominal pain.
2. Orthostatic hypotension: Hypovolemia (fluid or bloodloss).
3. Fever: GI infection,peritonitis, pelvic infection,cholangitis.
4. Pulse deficit: Aortic dissection or aneurysm.
5. Hypotension/bradycardia: Hypotension may indicate shock associated with ruptured abdominal aortic aneurysm.Vasovagal reaction is caused by bearing down or straining with a bowel movement. The decrease in pulse and BP is a result of decreased blood return to the heart and therefore decreased cardiac output. In addition to taking vital signs, be alert for signs that may indicate underlying abdominal problems. For example, note:
6. Facial expression: Is it appropriate? If your patient complains of pain, does her or his nonverbal behavior reflect this? For example, is she or he grimacing?
7. Posture: Does your patient assume a particular posture for comfort? For example, is he or she splinting a section of the abdomen, guarding an area of the abdomen, or drawing the knees up to his or her chest? Patients with acute appendicitis often flex their legs, because lying supine often increases the intensity of pain. Does pain seem to increase with movement?
8. Weight/nutritional status: Is your patient malnourished and underweight or overweight? Severely thin patients may have an eating disorder. Overweight patients may have underlying cardiovascular or renal disease as a result of fluid retention. Gross abnormalities such as abdominal distension warrant further investigation.
Performing a Head-to-Toe Physical Assessment
An abdominal assessment reflects many different systems. Therefore, next examine the patient for specific changes that may indicate underlying pathology and might have an impact on the structures of the abdomen.
Performing an Abdominal Assessment
After you have completed your general survey and headto- toe assessment, focus on the abdomen. Begin with inspection and proceed with auscultation, percussion, and palpation. Next, examine each structure separately. As you proceed with the assessment, try to visualize the underlying structures.
Inspection
Inspect the abdomen for size,shape,and symmetry.Look at it from different angles.Check color,surface characteristics, contour, and surface movements. Look for lesions, striae, or scars.
Striae, also known as lineas albicantes or stretch marks, are streaks of light-colored skin that occur after rapid skin stretching.Observe the location of the umbilicus and note any visible veins on the abdomen.Then, have the patient take a deep breath and bear down to assess for bulges that may indicate a hernia or organomegaly. Assess for distension—any unusual stretching of the abdominal wall. If present, determine if it is generalized or in one area. Fluid and gas usually result in generalized, symmetrical distension, whereas anything solid, such as a fetus, mass, tumor, or stool, results in asymmetrical distension. Sometimes distension is difficult to assess, so ask the patient if her or his abdomen looks or feels any different from normal. A concrete way to measure abdominal distention is to measure abdominal girth and compare measurements daily. Measurements should be taken at the umbilicus for consistency. Also inspect the abdomen for any visible aortic pulsations, peristalsis,and respiratory pattern.Slight aortic pulsations and respiratory movements are readily seen in adult patients. Visualization of peristaltic waves may be seen in infants and small children, but this usually indicates a problem if seen in an adult. (See Inspection of the Abdomen.)
Auscultation
Begin auscultating the abdomen by placing the warmed diaphragm of the stethoscope gently in one quadrant. Proceed in an organized fashion,listening in several areas in all four quadrants. Use the diaphragm to listen for bowel sounds, which sound like high-pitched gurgles or clicks that last from 1 to several seconds. They are assessed to determine bowel motility and peristalsis.
Peristalsis is the progressive wavelike movements of the digestive tract that move gastric contents through the tract.There will be 5 to 30 clicks per minute, or bowel sounds occurring every 5 to 15 seconds on an average adult patient. If bowel sounds are hypoactive, listen over the ileocecal valve to the right of the umbilicus.
Listen for vascular sounds with the bell of the stethoscope. These sounds include bruits, venous hums, and friction rubs.Apply the bell of the stethoscope lightly on the abdomen. Listen over the aorta in the epigastric region,over the renal, iliac, and femoral arteries. Listen for dilation of a tortuous vessel.Also listen over the epigastric region and liver and around the umbilicus for a venous hum—a soft, low-pitched humming noise with a systolic and diastolic component. Last, listen over the liver and spleen, along the right and left costal margins, for friction rubs.These are grating sounds that increase with inspiration and indicate peritoneal irritation (Fig. 17.7).
Percussion
Percussion is a technique used to assess the presence of fluid, air, organs, or masses in the abdominal cavity. Indirect or mediate percussion is best for assessing the abdomen.Always ask the patient if he or she has abdominal pain, and percuss painful areas last. Percuss all four quadrants, listening for tympany and dullness (Fig. 17.8)
Tympany is the most common finding and indicates the presence of gas. Dullness can also be heard when percussing organs, masses, or fluid. Percussion is also valuable for determining organ size and tenderness.The following methods are used for estimating the size of the liver, spleen, and bladder and for assessing kidney tenderness.
Assessing Liver Size
To help you locate the lower edge of the liver where it is difficult to percuss, use the scratch test: Place your stethoscope over the right upper quadrant (RUQ) above the liver, and with one finger of your other hand, lightly scratch the abdomen starting in the RLQ and moving up toward the liver. When the scratching sound in your stethoscope becomes magnified, you have reached the liver border.
The liver span test gives you an estimate of the size of the liver at the midclavicular line. To assess the upper border of the liver, start at the right midclavicular line at the third intercostal space over lung tissue and percuss down until you hear resonance change to dullness over the liver (around the fifth to seventh intercostal space). Place a mark where the dullness begins. The upper border of the liver usually begins at the fifth to seventh intercostal space.To determine the lower border of the liver, start at the right midclavicular line at the level of the umbilicus and percuss upward until tympany turns to dullness (usually at the sternal border). Mark this area with a pen. Measure the distance between the two marks—this is the liver span.The normal liver span at the midclavicular line is 6 to
. Assessing Spleen Size
Percussion is also helpful in estimating the size of the spleen. Three methods are used. The first method is to percuss from the left midclavicular line along the costal margin to the left midaxillary line. If you hear tympany, splenomegaly is unlikely. Dullness in the area of the anterior axillary line to the midaxillary line is a sign of spleen enlargement. A second method of assessing splenomegaly is to percuss at the lowest intercostal space at the left anterior axillary line (Fig. 17.9).
Ask the patient to take a deep breath and percuss again.Tympany is normal, but with splenomegaly, the tympany turns into dullness on inspiration. The third method is to percuss from the third to the fourth intercostal space slightly posterior to the left midaxillary line, and percuss downward until dullness is heard instead of tympany or resonance. Dullness of the normal spleen will be noted around the ninth to the eleventh rib.
Assessing Bladder Size
To percuss the bladder for distension, begin at the symphysis pubis and percuss upward to the umbilicus, noting any dullness. Normally, an empty bladder does not rise above the symphysis pubis.
Assessing Kidney Tenderness
Fist or blunt percussion can be used to assess the kidneys for tenderness. Assess the kidneys at the costovertebral angle (CVA). Posteriorly, identify the CVA where the end of the rib cage meets the spine. Place the palm of your nondominant hand over the CVA, and strike that hand with the fist of your other hand.Repeat on the other side. Tenderness upon blunt percussion at the costovertebral angle is positive CVA tenderness.
Palpation
You will use both light and deep palpation to assess the abdomen. Begin with light palpation to put your patient at ease. Light palpation is useful in assessing surface characteristics and identifying areas of tenderness. If the patient has identified an area of pain, examine that area last. Otherwise, the patient may tense her or his muscles, affecting the accuracy of your assessment.
Perform light palpation in all four quadrants, using your fingertips. Press down 1 to
To palpate for muscle guarding, perform light palpation over the rectus muscles of the abdomen.The normal response is easy palpation of the muscle. If guarding is present, determine if it is voluntary or involuntary by placing a pillow under the patient’s knees and asking him or her to take several slow, deep breaths. Palpate the rectus abdominis muscles on expiration.The patient cannot voluntarily tense this muscle during expiration, so if involuntary guarding is present, you will feel a boardlike rigidity that indicates peritonitis.
Deep palpation is used to assess organs, masses, and tenderness. It can be done using a manual or bimanual technique.To perform single-handed deep palpation, use the distal portion of your fingertips and depress 4 to
Assessing Abdominal Structures
While assessing the abdomen, you will need to examine specific abdominal structures. The following section describes the examination of these structures and explains the difference betweeormal and abnormal findings.
Abdominal Aorta
To palpate the abdominal aorta, place your fingers in the epigastric portion of the abdomen and slightly toward the patient’s left midclavicular line.Palpate for aortic pulsations. You can also assess the width of the aorta by placing one hand on each side of the aorta.
Liver
To palpate the liver,place your right hand at the patient’s right midclavicular line under the costal margin. Place your left hand posteriorly on the patient’s right eleventh to twelfth rib and press upward to elevate the liver toward the abdominal wall. Have the patient inhale and exhale deeply while you press your right hand gently but deeply in and up during inspiration. The hooking technique is another way to palpate the liver.Place your hands over the right costal margin and hook your fingers over the edge. Have the patient take a deep breath and feel for the liver’s edge as it drops down on inspiration, then rises up over your fingers during expiration. (See Palpating the Liver.)
Spleen
To palpate the spleen, stand on the patient’s right side, place your left hand under the left CVA, and pull upward to move the spleen anteriorly. Place your right hand under the left anterior costal margin and have the patient take a deep breath in and out. During exhalation, press inward along the left costal margin and try to palpate the spleen. (See Palpating the Spleen.)
Kidneys
To assess the left kidney, stand on the patient’s right side and place your left hand in the left CVA of her or his back. Place your right hand at the left anterior costal margin. Have the patient take a deep breath, then press your hands together to “capture” the kidney. As the patient exhales, lift your left hand and palpate the kidney with your right hand. To assess the right kidney, remain on the patient’s right side and place your right hand on the right posterior CVA and your left hand on the patient’s right anterior costal margin.When the patient exhales, palpate the kidney. (SeePalpating the Kidneys.)
Bladder
Palpate the bladder in the hypogastric area up to the umbilicus, using deep palpation. (See Palpating the Bladder.)
Inguinal Lymph Nodes
Using the pads of your fingers, palpate just below the inguinal ligament for the superficial superior (also called the horizontal) inguinal lymph nodes and along the inner aspect of upper thigh for the superficial inferior (also called the vertical) inguinal lymph nodes.
If nodes are palpable, note size, shape, mobility, consistency, and tenderness (See Palpating Inguinal Lymph Nodes.).
Interventions for Clients with Oral Cavity Problems
Learning Objectives
After studying this chapter, you should be able to:
1. Develop a teaching plan for clients who have stomatitis.
2. Explain the common causes of malignant oral tumors.
3. Identify common nursing diagnoses for clients with oral cancer.
4. Prioritize postoperative care for clients undergoing surgery for oral cancer.
5. Develop a teaching plan for community-based care of clients with oral cancer.
Oral cavity disorders can severely impact speech, nutrition, body image, and overall quality of life. Nurses play an important role in maintaining and restoring oral cavity health in their clients through nursing interventions and client education. Chart 54-1 lists ways for clients to maintain a healthy oral cavity.
STOMATITIS
OVERVIEW
Stomatitis is characterized by painful, single or multiple ul-cerations of the oral mucosa that appear as inflammation and denudation of the oral mucosa, impairing the protective lining of the mouth. These ulcerations are commonly referred to as canker sores. Although the terms stomatitis and mucositis may be used interchangeably, stomatitis is contained in the oral cavity, and mucositis may be more generalized throughout the mucous membranes. The ulceration causes pain, and open areas predispose the individual to bleeding and infection. Although infection remains the most life-threatening complication of stomatitis, pain is the most common complaint (Eilers, 1997). Mild erythema (redness) may respond to topical treatments, whereas extensive stomatitis may require treatment with opioid analgesics.
Stomatitis is classified according to the cause of the inflammation. Primary stomatitis includes aphmous stomatitis, herpes simplex stomatitis, and traumatic ulcers. Secondary stomatitis generally results from infection by opportunistic viruses or bacteria, particularly in clients with immunosup-pressive disorders.
Pathophysiology
The oral mucosa is a protective lining of stratified, squamous, and nonkeratinizing epithelium that extends from the mouth at the junction of the lips to the oropharynx (throat). Inflammatory processes induced by infectious agents, allergy, vitamin deficiency, systemic disease, or antineoplastic drugs cause injury to oral cavity membranes. Cells that are damaged by the inflammatory process slough off, leading to an ulcerated oral mucosa. The ulcerations formed are painful, and bleeding results secondary to erosion of oral mucous membranes (Eilers, 1997).
Etiology
Stomatitis can result from infection, allergy, vitamin deficiency, systemic disease, chemotherapy, or radiation. Infectious agents, such as bacteria and viruses, may have a role in the development of recurrent aphthous stomatitis. L-forms of streptococcus bacteria have been isolated from aphthous ulcers. Although viruses have not been successfully cultured from aphthous lesions, recurrent lesions have been associated with latent zoster or cytomegalovirus (CMV).
The implication that certain foods trigger allergic responses that result in the formation of aphthous ulcers remains controversial. Foods such as coffee, potatoes, cheese, nuts, citrus fruits, and gluten may be precipitating factors. In some cases, strict elimination diets have resulted in the improvement of ulcers. Deficiencies in vitamin B12, folate, and iron associated with malnutrition can contribute to the formation of stomatitis.
Systemic diseases such as human immunodeficiency virus (HIV) infection and chronic renal failure can also predispose a person to stomatitis. Approximately 50% of first-degree relatives of individuals with aphthous ulcers also have the disease, suggesting a genetic link to stomatitis (Woo & Sonis, 1996). Treatment of disease states such as cancer can predispose an individual to the development of painful stomatitis or mucositis. Thirty-nine to fifty percent of clients undergoing chemotherapy or radiation to the head and neck for cancer re port experiencing stomatitis (Hyland, 1997).
CLIENT EDUCATION GUIDE Maintaining a Heaithy Oral Cavity
• Perform a self-examination of your mouth every month;
report any unusual finding.
• Be sure to eat a balanced diet.
Brush and floss your teeth every day. Set a routine and keep to it.
• Manage your stress as much as possible; learn how to
maintain your emotional health.
• Avoid contact with agents that may cause inflammation
of the mouth, such as mouthwashes that contain alcohol.
• If possible, avoid medications that may cause inflamma
tion of the mouth or reduce the flow of saliva.
• Be aware of any changes in the occlusion of your teeth,
mouth pain, or swelling; seek medical attention promptly.
• See your dentist regularly; have problems attended to
promptly.
” If you wear dentures, make sure they are in good repair and fit properly.
The severity of stomatitis is related to the type and dose of therapy, as well as to client-related factors, such as pretreatment oral health (Eilers, 1997). (See Chapter 25 for nursing care of the client undergoing radiation and chemotherapy.)
The symptoms of stomatitis range in severity from a dry, painful mouth to open ulcerations, predisposing the client to infection. Mouth ulcerations can alter nutritional status as a result of difficulty with food ingestion or swallowing. When severe, stomatitis and the edema that can accompany it have the potential to impact airway integrity.
Incidence/Prevalence
Aphthous stomatitis is the most common oral lesion treated by primary care providers. It has been found to affect more than 50% of the population and is especially common in
WOMEN’S HEALTH CONSIDERATIONS A hormonal influence has been suggested in relation to women and aphthous stomatitis. Women generally have a higher prevalence of the disorder, with an increased incidence of oral ul-ceration during the luteal phase of the menstrual cycle. A moderation or absence of lesions during pregnancy has been attributed to increased steroid levels (Peterson & Baughman, 1996).
Primary Stomatitis
■APHTHOUS STOMATITIS
Aphthous stomatitis is a noninfectious inflammatory condition of the oral mucosa. Aphthous ulcers are categorized as minor, major, or herpetiform. Eighty percent of aphthous lesions are minor ulcers, measuring less than
HERPES SIMPLEX STOMATITIS
The herpes simplex virus (HSV) is responsible for the devel-; opment of primary herpes simplex stomatitis, also called acute herpetic stomatitis. The uniformly sized vesicles occur most often on the tongue, palate, and buccal and labial mu-cosae. The vesicles rupture soon after appearing, leaving painful, ulcerated areas surrounded by erythematous margins. The lesions at this stage are similar to aphthous ulcers. The ulcerated areas heal in 10 to 14 days. The mucosal vesicles are generally accompanied by acute inflammation of the gingiva, occasionally with herpetic lesions. The tongue has a characteristic white coating, and the client complains of a foul breath. Primary HSV infection is characterized by symptoms of generalized infection, including malaise, fever, and lym-phadenopathy.
HSV enters injured oral mucosal tissue, where it replicates in the cells of the dermis and epidermis, resulting in primary HSV infection. Although stomatitis caused by HSV can occur as either a primary or secondary (recurrent) infection, secondary infections are more common. Two types of HSV have been identified: HSV type 2, which causes genital lesions (discussed in Chapter 77), and HSV type 1, which is responsible for nongenital lesions.
HSV infection is extremely common. Primary herpetic stomatitis is usually contracted in childhood but may be seen in adults. Immunocompromised clients tend to experience more severe and extensive HSV infections.
VINCENT’S STOMATITIS
Vincent’s stomatitis, or acute necrotizing stomatitis, is an acute bacterial infection of the gingiva characterized by erythema, ulceration, and necrosis of the gingival margins. The gingival papillae between the teeth appear worn away and raw. The gin-givae often bleed spontaneously or from mild irritation, such as chewing. Clients complain of severe pain; foul breath; thick, ropy secretions; and increased salivation. Systemic clinical manifestations can include malaise, poor appetite, and occasionally, enlargement of cervical lymph nodes.
The disease has a sudden onset and is related to a decreased resistance of tissues to normal oral bacterial flora. Systemic etiologic factors that decrease tissue resistance include poor nutrition, leukemia, and severe infections such as pyelonephritis. Poor oral hygiene and extreme emotional stress have been suggested as contributing factors.
Necrotizing gingivitis occurs primarily in adults, and the incidence seems to increase with aging. Older adults have an increased susceptibility to infections because of decreased immunocompetence.
TRAUMATIC ULCERS
Oral trauma is thought to be the most common precipitating factor in the development of recurrent aphthous stomatitis (Peterson & Baughman, 1996). Traumatic ulcers can develop at the site of an injury. Traumatic insults, such as injuries from dental procedures, cheek biting, and hot foods, can lead to ul-ceration. Such injuries can also allow the entry of bacteria, resulting in secondary infection.
Traumatic ulcers are commonly found in clients with mal-occlusion, ill-fitting dentures, or broken teeth and in those who habitually bite their oral mucosa. In addition, individuals with recurrent aphthous stomatitis are predisposed to developing additional ulcers at the site of a traumatic injury.
Secondary Stomatitis
LICHEN PLANUS
Lichen planus is an inflammatory mucocutaneous disease involving both the skin and the oral mucous membranes. The lesions may be active or in remission, with external lesions affecting the extremities and the genitalia. Symmetric white oral lesions of various patterns appear on the tongue and buc-cal and labial mucosae. Eighty percent of all lichen planus lesions are bilateral, appearing on the buccal mucosa (Burkhart, Burkes, & Burker, 1997). The remaining 20% are localized to the tongue or lips.
The etiology of the disease is unknown, but recent developments indicate that there may be a cell-mediated immune response involved in the progression of the lesions. Disease states such as diabetes and hypertension may invoke lichenoid reactions from the medications used to treat these conditions. Oral lichen planus may also be associated with hepatitis C infection (Bagan et al., 1998). Local irritants and trauma are contributing factors associated with the progression of lichenoid lesions. There has been conflicting evidence suggesting stress as a mediator of lichen planus. In addition, the chronic inflammatory nature of lichen planus may prove to be a risk factor for oral cancer.
Lichen planus affects 1 % to 2% of the population, occurring more often in women than in men and occurring most often in clients ages 40 to 50 years (Burkhart, Burkes, & Burker, 1997). It occurs in all races, with variations in severity among the racial groups. Although the oral lesions themselves are often asymptomatic, an erosive form of the disor der can cause pain that interferes with speech and swallowing. The diagnosis of lichen planus is confirmed through tissue biopsy.
CANDIDIASIS (MONILIASIS)
In oral candidiasis, white plaquelike lesions appear on the tongue, palate, pharynx, and buccal mucosa (Figure 54-1). When these patches are wiped away, the underlying surface appears red and sore (Sheff, 1999). Clients rarely complain of actual pain but describe the lesions as dry or hot.
Candida albicans is part of the normal flora of the oral cavity. Candidiasis, also called moniliasis, is a fungal infection resulting from an overgrowth of this normal flora. With recurrent candidiasis, as with all secondary stomatitis, a causative systemic disorder should be sought. Antibiotic therapy destroys the normal flora that usually prevent fungal infections; thus candidiasis can occur in clients receiving long-term antibiotic therapy. Candidiasis of the oral cavity is common in clients undergoing immunosuppressive therapy (chemotherapy, radiation, steroid therapy, or antirejection medication). For example, chemotherapy affects the rapidly dividing cells of the oral mucosa, leading to ulcerations that have a propensity to become infected secondary to a decreased immune response. Candidiasis is also very common among HIV-infected individuals, becoming increasingly likely as CD4+ cell counts fall (Klaus & Grodesky, 1998).
CONSIDERATIONS FOR OLDER ADULTS
Older adults are especially at high risk for candidiasis because aging causes a decrease in immune function. The risk increases for clients who are diabetic, malnourished, or under emotional stress. Older adults who wear dentures may use soft denture liners that provide comfort but can also be colonized by C. albicans, contributing to denture stomatitis (Dixon, Breeding, & Faler, 1999).
COLLABORATIVE MANAGEMENT
Assessment
HISTORY
The nurse collects information concerning possible etiologic factors, such as recent infections, a history of stomatitis, nutritional compromise, oral hygiene habits, oral trauma, stress, or immunocompromise. A medication history should also be collected. The nurse records the course of the current outbreak and ascertains if episodes of stomatitis are recurrent. The client is asked if the lesions interfere with swallowing or eating.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
While examining the oral cavity, the nurse wears nonsterile gloves for protection against infection. Adequate lighting, including a flashlight or penlight, and a tongue blade facilitate the examination. The nurse assesses the oral cavity for lesions, coating, cracking, and fissures. Characteristics of the lesions are described in terms of location, size, shape, color, and drainage. Any odors that may be present are noted and described. If lesions are noted along the pharynx, and if the client reports dysphagia or pain on swallowing, the nurse should suspect that the lesions may extend farther down the esophagus. Additional diagnostic testing may be required. The physical examination may also include examination of the cervical and submandibular lymph nodes for swelling. Any elevation in temperature is noted.
LABORATORY ASSESSMENT
Laboratory tests are usually not needed. However, serum albumin, vitamin B12, folate, and iron levels may be obtained if nutritional status appears to be compromised. A complete blood count may reveal the presence of infection, neutrope-nia, or anemia. A Tzank smear can assist in distinguishing between herpatic and aphthous ulcers. Fluid from herpetic vesicles in herpes simplex stomatitis may be obtained for viral culture. Bacterial culture of exudate from the oral mucosa validates Vincent’s stomatitis or secondary infection. A potassium hydroxide slide preparation or a routine culture and Gram stain can help identify Candida organisms.
Interventions
Interventions for stomatitis are aimed toward the promotion of oral health through scrupulous oral hygiene and careful food selection.
ORAL HYGIENE. The nurse or assistive nursing personnel uses a soft-bristled toothbrush or disposable foam swabs (toothettes) to stimulate gums and clean the oral cavity. The nurse encourages frequent rinsing of the mouth with any of the following: sodium bicarbonate solution, warm saline, or hydrogen peroxide solution. The client should avoid commercial mouthwashes because they have a high alcohol content, causing a burning sensation in irritated or ulcerated oral mucosa.
The nurse instructs the client to increase mouth care to every 2 hours and twice at night if the stomatitis is not controlled. Frequent gentle mouth care enhances debridement of ulcerated lesions and can prevent superinfections. Frequent oral care also promotes a general feeling of well-being. Chart 54-2 lists measures for special oral care.
DRUG THERAPY. Anti-infective agents, including antibiotics and antifungals, may be necessary for control of infection in the client with stomatitis. The nurse administers anti-infectives as ordered and provides instruction on how to take them. The health care provider prescribes systemic antibiotics severe recurrent or Vincent’s stomatitis. Investigations have linked recurrent aphthous stomatitis to strains of L-streptococci. Tetracycline syrup 250 mg/10 mL four times a day for 10 days may be prescribed. The client rinses for 2 minutes and swallows the syrup, thus obtaining both topical and systemic therapy. Chlorhexidine, an oral rinse, can be beneficial in preventing infection, since it is active against numerous bacteria and fungi. However, chlorhexidine prepared in the
Antibiotics are of little value in viral or fungal stomatitis unless a secondary infection is present. Systemic antibiotics are ineffective for lichen planus and are not recommended.
A regimen of intravenous (IV) acyclovir (Zovirax) is usually prescribed for immunocompromised clients who contract herpes simplex stomatitis. Acyclovir is typically administered to clients with normal renal function at a dose of 5 mg/kg, infused at a constant rate over a 1-hour period every 8 hours for 7 days. Clients with competent immune systems may be given acyclovir in oral or topical form.
For clients with oral candidal infection, an antifungal agent is prescribed, such as nystatin (Mycostatin, Nadostine) oral suspension 600,000 units four times daily for 7 to 10 days. The nurse teaches the client to swish the solution around in the mouth before swallowing. Oral troches (lozenges) may also be effective. Clients who are taking inhaled steroids should be advised to use a spacer to decrease the amount of medication left in the mouth. In addition, the client should rinse the mouth with warm water after using inhalers, to rinse away any deposited drug (Shuster, 1998). Systemic steroids can be of benefit in long-standing lichen planus.
ANALGESICS. Interventions for clients with stomatitis should include pain control, because pain is consistently present during an outbreak. The nurse performs a comprehensive assessment of pain that includes the following: location, characteristics, onset and duration, frequency, quality, intensity, severity, and precipitating factors.
Topically applied agents or oral analgesics temporarily relieve severe oral pain (Table 54-1). Agents containing 20% benzocaine provide temporary pain relief and can be applied to the affected areas three to four times daily. Fifteen millilitres of 2% viscous lidocaine every 3 hours (maximum of 8 doses per day) can be used as a gargle or mouthwash. The health care provider often prescribes topical swishes for herpes simplex stomatitis and lichen planus. These suspensions can be offered in frozen form; the numbing effects of the cold provide longer analgesia. Topical corticosteroids
are indicated for aphthous ulcers, lichen planus, and the lesions of primary herpes simplex virus (HSV) infection. Triamcinolone cream is applied with the finger or a cottontipped applicator, or the corticosteroid can be injected directly into the lesion. Occasionally, systemic approaches to pain relief need to be employed. For moderate to severe stomatitis, around-theclock administration of combinations of opioid and nonopioid analgesics, such as acetaminophen and codeine, is recommended. If the pain is unrelieved, or if the stomatitis is severe, morphine may be used until healing occurs. Any time a client receives an intervention for pain, the nurse monitors the effectiveness of the pain control measures through an ongoing assessment of the pain experience.
TUMORS
OVERVIEW
Oral cavity tumors can be benign, premalignant, or malignant. Whether benign or malignant, tumors of the oral cavity impact many daily functions. Activities such as swallowing, chewing, and speaking can be affected. Pain accompanying the tumor can also impose limitations on daily activities and self-care. Oral cavity tumors affect body image, especially if treatment involves removal of the tongue or part of the mandible, or requires a tracheostomy.
Premalignant Lesions
LEUKOPLAKIA
Leukoplakia presents as slowly developing changes in the oral mucous membranes that are characterized by thickened, white, firmly attached patches. These patches appear slightly raised and sharply circumscribed. Leukoplakial lesions undergo malignant transformation in approximately 3% to 6% of cases (Olsen, 1999). Although leukoplakia can be found anywhere on the oral mucosa, lesions on the lips or tongue are more likely to progress to malignancy. Leukoplakia results from mechanical factors that cause long-term oral mucous membrane irritation, such as poorly fitting dentures, chronic cheek nibbling, or broken or poorly repaired teeth. In addition, oral hairy leukoplakia can be found in clients with HIV infection. The use of tobacco products has also been implicated in the development of leukoplakia, which is sometimes referred to as “smoker’s patch.” Oral leukoplakia can be confused with oral candidal infection. However, unlike candidal infection, leukoplakia cannot be removed by scraping. Leukoplakia is the most common oral lesion among adults; it affects 3% of the population and accounts for 18% of all oral lesions (Shugars & Patton, 1997). Oral hairy leukoplakia is an early manifestation of HIV infection and is highly correlated with progression from HIV infection to acquired immunodeficiency syndrome (AIDS). Leukoplakia not associated with HIV infection is more often seen in people over age 40. Men have twice the incidence of leukoplakia that women have, but this ratio is changing because increasing numbers of women are smoking.
ERYTHROPLAKIA
Erythroplakia presents as a red, velvety mucosal lesion on the surface of the oral mucosa. There is a higher degree of malignant transformation in erythroplakia than in leukoplakia. As such, these lesions should be regarded with suspicion and analyzed by biopsy. Erythroplakia is most commonly found on the floor of the mouth, tongue, palate, and mandibular mucosa. Erythroplakia can be difficult to distinguish from inflammatory or immune reactions.
Malignant Tumors
SQUAMOUS CELL CARCINOMA
PATHOPHYSIOLOGY. More than 90% of oral cancers are squamous cell carcinomas that begin on the surface of the epithelium. Over a period of many years, premalignant (or dysplastic) changes begin. Cells begin to vary in size and shape; alterations in the thickness of the lining of the epithelium develop, resulting in atrophy. These tumors usually grow slowly, and the lesions may be large before the onset of symptoms unless ulceration is present. Mucosal erythroplasia is the earliest sign of oral carcinoma. Oral lesions that appear as red, raised, eroded areas are suspicious for carcinoma. The American Joint Committee on Cancer has devised the TNM classification system for tumors of the lip and oral cavity (Table 54-2). Each lesion is defined by the following:
T—the size or degree of penetration of the tumor
N—the presence, size, number, and location of involved cervical lymph nodes
M—the presence of distant metastasis (spread)
ETIOLOGY. Squamous cell carcinoma is the most common oral malignancy. Squamous cell carcinomas can be found on the lips, tongue, buccal mucosa, and oropharynx. The major risk factors in the development of oral cancers are increasing age, tobacco use, and alcohol ingestion. Ninetyfive percent of all oral cancers occur in people over 40 years of age. Tobacco use in any form (e.g., smoking or chewing tobacco) can increase the risk of cancer by 5% to 25%. The use of smokeless tobacco has nearly tripled in the last 20 years. This form of tobacco contains carcinogens and large quantities of nicotine, which can lead to nicotine addiction. Alcohol ingestion can potentate the carcinogenic effects of tobacco. An increased rate of oral carcinoma is found in individuals with certain occupations, such as textile workers, plumbers, and coal and metal workers. Additional factors, such as sun exposure, poor dietary habits, poor oral hygiene, and infection with the human papillomavirus (HPV), require further research. Common signs and symptoms of oral carcinoma include unusual lumps or thickening of the buccal mucosa, or red or white patches appearing on the gums, tongue, or oral mucous membranes. Cancers of the lip are strongly associated with chronic exposure to the sun and often present as a sore that fails to heal. Soreness, pain, or a burning sensation may also be present. In later stages, the client may experience difficulty chewing or swallowing. Advanced cancers of the tongue can cause pain that radiates to the ear. Cervical lymph nodes may become enlarged, hardened, and fixed secondary to metastatic invasion.
INCIDENCE/PREVALENCE. Carcinomas of the oral cavity account for approximately 6% of all cancers diagnosed each year in the
(Parkin, Pisani, & Ferlay, 1999).
CULTURAL CONSIDERATIONS
African Americans have a higher rate of oral carcinoma than Caucasians (Shugars & Patton, 1997). The relative 5-year survival rate for Caucasians with cancer of the oral cavity or pharynx is 55%, compared with a relative 5-year survival rate of 32% for African Americans with oral cancer (National Cancer Institute, 1999). Higher mortality rates from oral cancer have been associated with limited access to health care.
BASAL CELL CARCINOMA
Basal cell carcinoma of the oral cavity occurs primarily on the lips. The lesion is asymptomatic and resembles a raised scab. With time, the lesion evolves into a characteristic ulcer with a raised pearly border. Basal cell carcinomas do not metastasize but can aggressively involve the skin of the face. The major etiologic factor in basal cell carcinoma is exposure to sunlight.
Basal cell carcinoma occurs as a result of the failure of basal cells to mature into keratinocytes. It is the second most common type of oral cancer but is much less common than squamous cell carcinoma.
CULTURAL CONSIDERATIONS
Clients who work outdoors or who sunbathe excessively, especially Caucasians with fair skin, are more likely to have basal cell carcinomas.
KAPOSI’S SARCOMA
Kaposi’s sarcoma is a malignant lesion arising in blood vessels. Kaposi’s sarcoma is usually painless and appears as a raised purple nodule or plaque. In the mouth the hard palate is the most common site of Kaposi’s sarcoma, but it can also be found on the gums, tongue, or tonsils. It is most often associated with AIDS. (See Chapter 22 for a complete discussion of Kaposi’s sarcoma.)
INCIDENCE/PREVALENCE. Carcinomas of the oral cavity account for approximately 6% of all cancers diagnosed each year in the
COLLABORATIVE MANAGEMENT
Assessment
■ HISTORY
A priority for nurses in the prevention and detection of oral cancers is the identification of high-risk groups. Individuals at high risk for developing oral cancer tend to use large amounts of alcohol and tobacco and are over 40 years of age. The nurse asks about occupation and exposure to known oral carcinogens or irritants, such as sunlight or other source of ultraviolet radiation. A family history of cancer and a history of previous oral cancer alert health care providers to be especially observant for signs of cancer.
The nurse assesses the client’s routine oral hygiene regimen and use of dentures or oral appliances, which might add to discomfort or mechanically irritate the mucosa. The client should be asked about bleeding, which might indicate an ulcerative lesion. The nurse determines the status of the client’s past and current appetite and nutritional state, including difficulty with chewing or swallowing. A continuing trend of weight loss may be related to metastasis, heavy alcohol intake, difficulty in eating or chewing, or an underlying disorder.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
An examination of the oral cavity requires adequate lighting for proper visualization. The nurse thoroughly inspects the oral cavity for any lesions, evidence of pain, or restriction of movement. Using a tongue blade, the nurse can visually examine all areas of the oral cavity. The nurse notes any alteration in speech attributable to tongue restriction. Following inspection, the advanced-practice nurse uses bimanual palpation of any visible nodules to determine size and fixation. The cervical lymph nodes should also be palpated (Figure 54-2).
RADIOGRAPHIC ASSESSMENT
The purpose of radiologic diagnostic tests for cancer of the oral cavity is to assess the extent and spread of the tumor. Computed tomography (CT) scans are helpful in determining the extent of the tumor and lymphatic or bone involvement.
OTHER DIAGNOSTIC ASSESSMENT
Biopsy is the definitive method for diagnosis of oral cancer; therefore the physician obtains a biopsy specimen of the oral tissue to assess for malignant or premalignant changes. Incisional biopsies allow for collection of normal and abnormal tissue. An intraoral biopsy can be done with the client under local anesthesia. In very small lesions, an excisional biopsy can permit complete tumor removal. Magnetic resonance imaging (MRI) is useful in detecting perineural involvement and in evaluating thickness in cancers of the tongue. Both CT and MRI can be used to determine metastatic spread to the liver or lungs if further staging of the disease is warranted.
An aqueous solution of toluidine blue 1% can be applied to oral lesions to determine if they are malignant. This preparation stains malignant lesions, leaving normal tissue unaffected. However, a lesion that is the result of an inflammatory process may also pick up the stain, leading to a false-positive result. Although a biopsy is still needed to confirm a cancer diagnosis, toluidine blue may be useful for screening high-risk individuals.
PSYCHOSOCIAL ASSESSMENT
The functioning and appearance of the oral cavity are strongly linked with body image and quality of life. Therefore the nurse assesses the impact of oral lesions on the client’s self-concept. In addition, the nurse assesses the client for any educational or cultural needs regarding instruction or therapy and evaluates the client’s support system and past mechanisms of coping.
CRITICAL THINKING CHALLENGE
You are a nurse in a busy family practice clinic. A 67-year-old woman comes in for her annual physical examination. In the course of providing her recent health history, she tells you that she has developed several white patches on her tongue “that won’t go away, no matter what I do.”
• What questions would be appropriate for the nurse to ask
this client in gathering more of her health history?
• What aspects of the oral cavity assessment should the
nurse pay particular attention to?
Analysis
COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are priority nursing diagnoses for clients with malignant tumors of the oral cavity:
1. Risk for Ineffective Airway Clearance related to obstruc
tion by the tumor, edema, or secretions
2. Impaired Oral Mucous Membrane related to effects of
the tumor
ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the commoursing diagnoses, clients with tumors of the oral cavity may have one or more of the following:
· Impaired Verbal Communication related to the tumor or surgery
· Disturbed Body Image related to impaired oral mucous membrane, surgery, chemotherapy, or radiation therapy Acute Pain related to impaired oral mucous membrane
· Risk for Infection related to impaired oral mucous membrane
· Impaired Swallowing related to presence of the oral tumor, surgery, or radiation
· Imbalanced Nutrition: Less Than Body Requirements related to pain and/or edema
Planning and Implementation
RISK FOR INEFFECTIVE AIRWAY CLEARANCE
PLANNING: EXPECTED OUTCOMES. The client with a malignant tumor of the oral cavity is expected to maintain a patent airway as evidenced by effective coughing, increased air exchange, and the absence of aspiration.
INTERVENTIONS. Extensive tumor involvement and tenacious secretions can impede airway patency. Nursing measures for maintaining airway patency center on assessment for dyspnea, inability to cough effectively, or inability to swallow.
NONSURGICAL MANAGEMENT. The nurse assesses for difficulty breathing and/or decreased air exchange and dysphagia. Measures to increase air exchange, remove secretions, and prevent aspiration are instituted (Chart 54-3). Clients at risk of aspiration should be fed in small amounts; thickened liquids can be used to prevent gagging.
SURGICAL MANAGEMENT. The client with an oral lesion may require a tracheostomy preoperatively. This may be due to the extent of surgical excision required to remove the tumor, or it may be due to excessive edema. A tracheostomy re-establishes a patent airway and can be performed by the physician with the client under local or general anesthesia. The tracheostomy tube is usually left in place until edema resolves and the airway is patent. If the tumor is the major cause of the oral airway blockage, however, the tracheostomy may be maintained through the periopera-tive period until oral healing begins, and in some cases it may be permanent. After postoperative edema resolves, the client is decannulated (the tracheostomy tube is removed). (Refer to Chapter 28 for nursing care of the client with a tracheostomy.)
AIRWAY MANAGEMENT. The nurse assesses for dyspnea resulting from the obstructive presence of the tumor or from excessive secretions. The nurse assesses the quality, rate, and depth of respirations and auscultates the lungs for decreased or absent ventilation, or for the presence of adventitious sounds. If oral secretions are excessive or thick, the nurse attempts to aid the client in expectorating secretions. To increase air exchange, the client is placed in a semi-Fowler’s or high Fowler’s position to maximize ventilation potential. Secretions can be mobilized by encouraging fluids to help liquefy secretions, by chest physiotherapy, and by measures to encourage effective coughing. If oral secretions remain problematic, oral suction equipment with a dental tip or a tonsil tip (Yankauer catheter) can be employed.
If edema is associated with oral cavity lesions, the client may receive steroids for reducing inflammation. Antibiotics may be ordered if infection is present, since infection can increase inflammation and edema in the lesion. A cool mist supplied by a face tent may assist with oxygen transport and control of edema.
COUGH ENHANCEMENT. Measures that promote deep inhalation generate high intrathoracic pressure, which assists the client in producing an effective cough to mobilize secretions. The nurse assists the client to a sitting position with the head slightly flexed and the knees flexed. The nurse then instructs him or her to take several deep breaths, hold the breath for 2 seconds, and then cough two to three times in succession. He or she is instructed to follow coughing with several maximal inhalation breaths. The client can also be instructed to enhance coughing by inhaling deeply several times and coughing at the end of exhalation.
ASPIRATION PRECAUTIONS. Aspiration precautions prevent or minimize the risk factors associated with aspiration. The nurse assesses the client’s level of consciousness, gag reflex, and ability to swallow. To prevent aspiration, the client is placed upright at 90 degrees (high Fowler’s position). As a precaution, suction equipment should be kept nearby.
IMPAIRED ORAL MUCOUS MEMBRANE
PLANNING: EXPECTED OUTCOMES. The client with a malignant tumor of the oral cavity is expected to maintain or re-establish oral mucosal integrity.
INTERVENTIONS. Both the presence of tumors of the oral cavity and the effects of treatment of oral tumors pose threats to the integrity of the oral mucosa. Oral cavity lesions can be treated by surgical excision, by nonsurgical treatments such as radiation or chemotherapy, or by a combination of treatments (referred to as multimodal therapy), which is the most expensive treatment option (see the Cost of Care box below). Nursing interventions focus primarily on the restoration and maintenance oral health.
NONSURGICAL MANAGEMENT. The purpose of non-surgical management is to promote tissue healing and to maintain and promote oral hygiene for the client with oral lesions.
ORAL CARE. The nurse works with the client to establish an oral hygiene routine. Ideally, oral hygiene is performed every 2 hours for ulcerated lesions or infection, or in the immediate postoperative period. Modifications might be needed because of oral discomfort, bleeding, or edema. Oral care with a soft-bristled toothbrush is preferred. In the event of a fall in the platelet count below 40,000/mm3, the client should be switched to an ultrasoft “chemobrush.” The use of tooth-ettes or a disposable foam brush is discouraged because these products may not adequately control bacteremia-promoting plaque (Toth et al., 1995)(see the Evidence-Based Practice for Nursing box at right). Lubricant can be applied to moisten the lips and oral mucosa as needed.
Clients with ulcerative or bleeding lesions should avoid using commercial mouthwashes and lemon-glycerin swabs. Commercial mouthwashes contain alcohol, and lemon-glycerin swabs are acidic. These substances can cause a burning sensation and contribute to drying of the oral mucous membranes. The nurse encourages frequent rinsing of the mouth with sodium bicarbonate solution, warm saline, or hydrogen peroxide solution (see also Chart 54-2).OST OF CARE
Implications for Nursing
The majority of the costs associated with oral cavity cancer care are incurred during treatment, especially if treatment involves a combination of surgery, chemotherapy, and radiation. Measures to permit early identification and treatment of the disease at a stage where single-modality treatment can be used more effectively would yield substantial decreases in management costs. Client education about the risk factors for oral cancer plus rigorous assessment of those with high-risk profiles (e.g., heavy alcohol and tobacco use) would be cost-effective in reducing the incidence and permitting early diagnosis and treatment of the disease.
RADIATION THERAPY. Radiation therapy has been used alone, as well as in conjunction with surgery and chemotherapy, in the treatment of cancer of the oral cavity. The goal of radiation therapy is tumor eradication while preserving function and appearance. There are several ways to apply radiotherapy. In collaboration with the client, the physician chooses the best mode on the basis of the tumor site and staging.
Radiation therapy for oral cancers can be given by external beam or interstitial implantation. External beam radiation passes through the skin or mucous membrane to the tumor site. Typically, treatments are given as five daily treatments per week over a 6- to 9-week period. Special precautions are taken to minimize the dose of radiation to the brain or spinal cord. Another option is the implantation of radioactive substances (interstitial radiation therapy) to either boost the dosage or deliver a radiation dose close to the tumor bed. This form of implant therapy can be curative in early-stage lesions in the floor of the mouth or anterior tongue, or to add an additional boost of radiation to a tumor that received external beam radiation.CE-BASED PRACTICE
FOR NURSING
Do foam swabs work as welt as toothbrushes to remove dental plaque?
Pearson, L. (1996). A comparison of the ability of foam swabs and toothbrushes to remove dental plaque: Implications for nursing practice. Journal of Advanced Nursing, 23,62-69.
The purpose of this study was to compare the effectiveness of a toothbrush and a foam swab in the removal of dental plaque over a 6-day period. Three experiments were conducted using the mouth of the author and a volunteer. A plaque scoring system was used to quantify the amount of plaque left on teeth adjacent to periodontal tissue. Plaque amounts were measured at the gum-tooth margin (gingival crevice plaque) and between teeth (approximal plaque).
At the end of 6 days, the ability of the toothbrush to remove plaque was noted to be superior to that of the foam swab; the toothbrush usually achieved complete removal of all visible plaque from the sites examined. The sites cleansed by the foam swabs revealed remaining plaque after using the “scrubbing” or “swabbing” technique outlined. When plaque was allowed to accumulate over a 6-day period, similar results were obtained. This study suggests that toothbrush use is more effective than foam swabs in removing plaque, but results could be impacted by user technique.
Critique. The very small sample size (2), as well as the use of the researcher as a study subject, may have permitted bias to be introduced into this study. It is also unclear who assigned the plaque scores to the study subjects. However, as nursing builds knowledge for evidence-based practice, the efficiency and utility of using these two mouth cleansing modalities need further examination.
Implications for Nursing. Nurses need to consider the aim of the intervention in selecting an instrument for mouth care. If the aim is to hydrate oral mucosa, a foam swab will deliver moisture to the tissues in an adequate fashion. Also, if damage to fragile oral mucosal tissue is a concern, a foam swab causes minimal damage. However, if removal of dental debris is the aim of mouth care, then the selection of a toothbrush appears to be more appropriate. This becomes important, since controlling plaque is a concern for those clients who may be immunocompromised (the overgrowth and invasion of organisms from plaque can be of concern).
Interstitial radiation is used for smaller lesions that do not infiltrate surrounding tissues. The following can be radioactive materials:
· Seeds, which are permanently implanted into the tissue (usually for tumors unable to be completely excised, or ieck nodes)
· Needles or wires, which are extracted at the end of therapy
· Radiation catheters or holders, which are loaded with radioactive materials
· A “mold” of radioactive material placed directly over the lesion for a specific time
The dose of interstitial therapy is often difficult to calculate. With the exception of radioactive seeds, which have a low level of activity, clients receiving interstitial radiation are usually hospitalized for the duration of treatment. Radiation isolation precautions must be instituted while the materials are active or in place. A tracheostomy may be required with interstitial implants because of edema and increased oral secretions. (See Chapter 25 for nursing care of clients undergoing radiation therapy.)
CRITICAL THINKING
The white patches on your client’s tongue have been diagnosed as leukoplakia. In addition, a biopsy performed on a nodule located on the floor of the mouth was determined to be squamous cell carcinoma. The client is preparing to undergo surgical excision and adjunctive treatment with radiation.
• What should the nurse include in the preoperative teaching
for this client?
• What complications from the treatment is this client at risk
for?
• What measures should the nurse include in the oral hygiene
care for this client?
CHEMOTHERAPY. The client may receive one or more chemotherapeutic agents (Table 54-3). The advantages of chemotherapy instead of, or as an adjunct to, surgery or radiation for cancer of the oral cavity continue to be evaluated.
Recent trials have been conducted on the use of two individual agents—mitomycin and cisplatin—to prevent local recurrence and improve survival. Response rates have varied from 0% to 30% (Vikram, 1998; Witt, 1998). The nurse instructs the client undergoing chemotherapy about the anticipated side effects of the medication, which vary with each agent. The nurse administers antiemetic medications as prescribed and provides other comfort measures as needed.
SURGICAL MANAGEMENT. The physician can often excise small, noninvasive lesions of the oral cavity in an ambulatory setting with local anesthesia. The surgical defect is usually small enough to be closed by sutures. These smaller lesions are also responsive to carbon dioxide laser therapy or cryotherapy (extreme cold application), which can be performed as an ambulatory care procedure in a surgical center (but may require general anesthesia).
Small oral cancers are equally responsive to radiation therapy and to surgery. More invasive lesions (stage III and IV) require more extensive surgical excision and result in a greater loss of function and disfigurement. Not all lesions can be excised by the peroral approach (through the mouth). The goal of surgical resection is the removal of the tumor with a surgical margin that is free of tumor involvement.
PREOPERATIVE CARE. Before excision of a lesion of the oral cavity, the nurse assesses and documents the client’s level of understanding of the disease process, the rationale for the surgery, and the planned intervention. Information is reinforced as needed. The nurse identifies family members or other caregivers and includes them in health teaching.
For small, local excisions, postoperative restrictions include a liquid diet for a day, then soft foods. There are no activity limitations, and postoperative analgesics are prescribed. The nurse instructs the client undergoing large surgical resections about the following:
· The placement of a temporary tracheostomy for approximately 10 days and the concomitant nursing care (oxygen therapy and suctioning)
· Temporary loss of speech due to the tracheostomy
· The need for vital signs to be taken frequently postoperatively
· The need to take nothing by mouth (remain on NPO status) for 10 to 14 days until intraoral suture lines are healed
· The need to have IV lines in place for medication delivery and hydration
· Postoperative medications and activity (out of bed on the first postoperative day)
· Any surgical drains
· The nurse also assesses the client’s ability to read and write. The client and nurse select the method of communication to use postoperatively with staff and family members (e.g., Magic Slate, picture board, or pad and pencil).
OPERATIVE PROCEDURES. Three factors influence the type of surgery performed for oral cancers: the size and location of the tumor, tumor invasion into the bone, and the presence of metastasis to neck lymph nodes (Olsen, 1999). Small tumors ( resection to decrease speech and swallowing problems post-operatively and improve appearance. For clients undergoing a complete glossectomy, a prosthesis will be necessary to aid in swallowing and speech.
Metastasis to cervical lymph nodes usually indicates a poor prognosis for clients with cancer of the oral cavity. In clients with cervical node metastasis, a neck dissection may also be performed. A radical neck dissection involves the removal of submental; submandibular; upper, mid, and lower jugular; and posterior triangular levels of the cervical lymph nodes, along with cranial nerve XI, the internal jugular vein, and the sternocleidomastoid muscle. Modified and selective neck dissections may be done in individuals with minimal lymph node involvement.
POSTOPERATIVE CARE. Postoperative care of the client with cancer of the oral cavity focuses on airway management as a priority. The client will have a temporary tracheostomy placed, requiring intensive nursing care to promote airway clearance. In addition, care must be taken to protect the surgical incision site from mechanical damage and infection. Nursing interventions to relieve pain or discomfort and promote nutrition are also important.
Maintaining Airway Patency. After extensive excision or resection, the most important nursing intervention is maintaining airway patency. The client may not recall on awakening from anesthesia that a tracheostomy tube is in place and may initially panic because of the inability to speak. The nurse reminds the client why he or she cannot speak and provides reassurance that the vocal cords are intact (unless a total laryngectomy has been performed, then the loss of voice is permanent). The nurse provides the client with the predetermined method of communication.
Nursing interventions are aimed at keeping the temporary tracheostomy patent. Frequent suctioning, using sterile technique, may be required for excessive secretions. Humidified oxygen may be ordered to help liquefy secretions in the early postoperative phase. After the immediate postoperative phase, the client may be able to cough effectively enough to decrease the need for suctioning. After oral edema has decreased and the tracheostomy tube has been changed to a noncuffed type, the client can speak by plugging the stoma with the fingertip. The nurse and physician determine the appropriateness of instructing the client in this technique. (See Chapter 28 for care of the client with a tracheostomy.)
When the client has been determined to have an adequate airway through the areodigestive tract and can effectively clear secretions by coughing, the tracheostomy tube is removed. An airtight dressing is placed over the tracheostomy site, and the incision heals without the need for sutures. The client is instructed to press fingers over the dressing to prevent the incision from separating during coughing (Reese, 1996). Clients who have undergone extensive resection may have slurred speech or difficulty in speaking. The nurse assesses the need for consultation with a speech/language pathologist.
Protecting the Operative Area. The surgical incision site requires careful attention to avoid infection. The nurse or assistive nursing personnel provides gentle mouth care for cleaning away thick secretions and stimulating the flow of saliva. The delivery of oral care depends on the nature and extent of the surgical procedure. Oral care should be provided every 4 hours in the early postoperative phase. The presence of unusual odors from the mouth can indicate infection. In the early postoperative phase, care must be taken to avoid disruption of the suture line during oral hygiene.
The nurse elevates the head of the bed to at least 30 degrees to assist in decreasing edema by gravity. If skin grafting was done, the nurse inspects the donor site (generally on the anterior thigh) during every nursing shift for bleeding or manifestations of infection. (See Chapter 29 for specific nursing care of the client with a radical neck dissection.)
Relieving Pain. To provide optimal pain relief in the postoperative period, the nurse relies on subjective and objective data to assess the need for analgesics and the effectiveness of the medications given. The goal of pain medication during this period is relief of pain while allowing the client to function at an optimal level. Clients who have undergone surgery for oral carcinomas describe their pain as throbbing or pounding. IV morphine is usually the initial postoperative pain medication given. Oral acetaminophen combined with codeine (Tylenol with Codeine) may be used for systemic relief of moderate pain.
Promoting Nutrition. Clients who have undergone extensive resections of the oral cavity remain on NPO status for 5 to 7 days or longer. This allows healing in the oral cavity before food contacts the incision. Nasogastric feeding or total parenteral nutrition is needed during this time (see Chapter 61). The tubes are usually inserted in the operating room.
When oral fluid intake is begun, the nurse assesses for and documents difficulty in swallowing, aspiration, or leakage of saliva or fluids from the suture line. Nursing care should also include the monitoring of weight and hydration. Nutritional supplementation may be used to improve the client’s quality of life (see the Legal/Ethical Issues in Health Care box below). Clients experiencing weight loss or having difficulty maintaining hydration may be candidates for gastrostomy tube placement.
A speech/language pathologist is often consulted to assist with swallowing techniques. A swallowing impairment may be temporary or permanent. The client is encouraged to perform swallowing exercises.
egal/Ethical
NUTRITIONAL SUPPLEMENTATION IN CLIENTS UNDERGOING RADIATION TREATMENTS
Maintaining optimal nutritional status for individuals with oral carcinoma is a difficult task, considering the many aspects of digestion impacted by the disease and treatment. Radiation therapy can pose additional challenges to nutrition because of the decreased saliva flow and alterations in taste that can result. Not only does increasing evidence point to nutritional status as a predictor of overall survival, but the ability to eat and enjoy food is an important component of quality of life.
The purpose of the study by McCarthy and Weihofen (1999) was to describe the effect of nutritional supplements on the food intake of clients undergoing radiotherapy. Forty clients beginning external beam radiation therapy were given weekly dietary counseling. The daily food intake was recorded 3 days per week for 4 weeks. One half of the subjects were assigned to ingest a nutritional supplement between meals and at bedtime. Findings suggested that those who ingested the nutritional supplements significantly increased their total caloric and protein intake while not reducing their food-derived caloric and protein intake. Based on this study, the addition of nutritional supplements to the normal food intake for clients undergoing radiotherapy for the treatment of oral cancer may be a viable option in helping to maintain adequate nutrition.
Community-Based Care
Continuing care for the client with an oral tumor depends on the severity of the tumor, the treatment for the tumor, and available support systems. Most clients are maintained at home during follow-up care. Ongoing nutritional management remains a vital part of the treatment plan. In addition, the short- and long-term effects of the treatment for cancers of the oral cavity must be monitored once the client is discharged home.
HOME CARE MANAGEMENT
If radiation therapy is part of the client’s treatment plan, home care considerations include preparatory information and management strategies. Complications due to radiation to the head or neck can be acute or delayed. Acute effects include treatment-related mucositis, stomatitis, and alterations in taste. Long-term effects such as xerostomia (excessive mouth dryness) and dental decay require ongoing oral care, the use of saliva substitutes, and follow-up dental visits. Although ongoing dental care is important, the possible adverse effects that radiation has on the cellular elements of the bone make elective oral surgical procedures, such as tooth extraction, impossible in the area of the radiation. Fatigue, which can be either short or long term, is a common side effect of radiation and chemotherapy.
The client whose tracheostomy has been removed is often taking a soft diet by mouth before discharge. Occasionally, however, clients are discharged from the hospital while still requiring tracheostomy suction, oral suction, and nasogastric feedings. Suction equipment, nutritional supplies, and nursing care can be provided by home care companies. (See Chapter 61 for home care preparation for the client receiving home parenteral nutrition and Chapter 28 for home care preparation for the client with a tracheostomy.)
K HEALTH TEACHING
The nurse instructs the client and family about medications, diet or feedings, any treatments (such as tracheostomy care, suture line care, and dressing changes), and early symptoms of infection.
Alterations in taste and dysphagia make maintaining adequate nutritional status a challenge. Alterations in taste occur when the taste buds are included in the radiation treatment field. Taste sensation begins to return several weeks after the completion of treatment. Changes in taste include aversions for meat, such as beef or pork, and metallic tastes in the mouth. Clients can be taught to add seasonings to foods, to use gravies or sauces to make foods more palatable, and to use high-protein foods such as cheeses, milk, eggs, puddings, and legumes in place of meat. Clients with dysphagia are instructed in swallowing exercises. Thickened liquids are recommended, since thin liquids, such as water, are difficult to control during swallowing. In collaboration with the dietitian, the nurse instructs the client and family on how to assess the nutritional intake of the client who is just beginning to eat. Liquid dietary supplements are usually recommended at this time. If bleeding is a problem, or if mucositis is present, a diet of soft foods that will not cause injury to the mucous membranes is preferred.
The nurse instructs the client and/or family members to inspect the oral cavity daily for areas of redness, indicating the onset of mucositis, or for lesions indicative of stomatitis. Meticulous oral hygiene should be continued in the postoperative phase, especially if adjuvant chemotherapy or radiation is planned or underway. The nurse reinforces the oral hygiene routine, putting particular emphasis on the need for frequent rinsing of the oral cavity to reduce the number of microorganisms and maintain hydration. The client should use a chemobrush, should rinse the chemobrush with hydrogen peroxide and water following each use, and should change chemobrushes weekly.
If the salivary glands were part of the radiation field, the client is instructed in the daily use of a fluoride gel to prevent dental caries. A 1% sodium fluoride gel is placed in a customized applicator that completely covers the tooth surface. This applicator is worn for 10 minutes daily. Saliva production is greatly reduced as a consequence of radiation. The resulting xerostomia results in the inability to eat dry foods. The nurse instructs the client in the use of saliva substitutes.
Skin reactions are also a common side effect of radiation. The nurse should instruct the client to avoid sun exposure, to avoid perfumed lotions or powders, and to cleanse the face or neck area with a gentle, nondeodorant soap.
To increase retention of the information, the client and the family demonstrate the skills they are taught. The nurse evaluates and documents their understanding of the treatments.
CONSIDERATIONS FOR OLDER ADULTS
For the older client with metastatic or invasive oral cancer, skilled home care or nursing home services are required for pain management, nutrition maintenance, and emotional support. Older adults often take subtherapeutic doses of analgesics for fear of becoming addicted. The home care nurse teaches the client about the need to promote comfort to improve nutrition and prevent depression. Chart 54-4 summarizes the focused nursing assessment for the older adult with oral cancer. (See Chapter 7 for further information on pain management in older adults.)
HEALTH CARE RESOURCES
Clients who have undergone composite resection often require community services, because they have both physical and psy-chosocial needs. Clients who have undergone surgical excision experience depression related to a change in body image. Excision of a portion of the mandible can leave a facial defect that may be difficult to hide. A social worker or other health care professional may be needed for client and family counseling. Clients who have undergone a total glossectomy may be able to speak with special training and the use of an intra-oral prosthesis fashioned by a maxillofacial prosthodontist. The prosthesis is similar to dentures, with augmentation to approximate the oral articulating surfaces.
FOCUSED ASSESSMENT of The Older Adult with Oral Cancer
· Assess the mouth and surrounding tissues for candiadiasis, mucositis, pain, and loss of appetite and taste.
· Monitor the client’s weight.
Monitor nutritional and fluid intake.
· Assess for difficulty in eating or speech.
· Assess pain status and measures used to control pain.
Monitor the client’s response to medications.
· Identify psychosocial problems, such as depression, anxiety, and fear.
The nurse consults the social worker or case manager for assistance in obtaining special equipment or nutritional resources required by the client at home. The case manager assesses the financial needs of the client and makes referrals to government, community, and religious organizations as needed.
Evaluation: Outcomes
The nurse evaluates the care of the client with a malignant tumor of the oral cavity on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes include that the client:
· Maintains a patent oral airway through removal of oral secretions
· Maintains nutritional status by eating foods that are well tolerated and nutritious
· Communicates thoughts and feelings to family members, friends, and health care personnel
· Maintains the integrity of the oral mucous membrane
DISORDERS OF THE SALIVARY GLANDS
Acute Sialadenitis
OVERVIEW
Acute sialadenitis, the inflammation of a salivary gland, can be caused by infectious agents, irradiation, or immunologic disorders. Salivary gland inflammation can have a bacterial or viral etiology. Acute sialadenitis can be caused by infection with cy-tomegalovirus (CMV). The most common bacterial organisms are Staphylococcus aureus, Staphylococcus pyogenes, Streptococcus pneumoniae, and Escherichia coli. This disorder most commonly affects the parotid or submandibular gland in adults.
A decrease in the production of saliva (as in dehydrated or debilitated clients or in those who are on NPO status postop-eratively for an extended time) usually precipitates acute sialadenitis. The bacteria or viruses enter the gland through the ductal opening in the oral cavity. Systemic medications, such as phenothiazines, chloramphenicol, and oxytetracy-cline, can also precipitate an episode of acute sialadenitis. Untreated infections of the salivary glands can evolve into abscesses, which can rupture and spread infection into the tissues of the neck and the mediastinum.
Clients who receive radiation for the treatment of cancers of the head and neck or thyroid may develop decreased salivary flow, predisposing them to acute or persistent sialadenitis. The effect of radiation on the salivary glands is rapid and dose related (Mandel & Mandel, 1999; McEwen & Sanchez, 1997). Immunologic disorders such as HIV infection can cause enlargement of the parotid gland that can be due to secondary infection. Sjdgren’s syndrome, an autoimmune disorder, is characterized by chronic salivary gland enlargement and inflammation (see Chapter 21).
COLLABORATIVE MANAGEMENT
Assessment
During the initial interview, the nurse assesses for any predisposing factors for sialadenitis, such as ionizing radiation to the head or neck area. The nurse asks about systemic illnesses such as HIV infection and collects a thorough medication history.
The presence of dehydration can be noted by assessing the oral cavity and the skin for turgor. Other assessment findings include pain and swelling of the face over the affected gland. Cranial nerve function is tested, since the branches of the facial nerve lie close to the salivary glands. Fever and general malaise also occur, and purulent drainage can often be massaged from the affected duct in the oral cavity (Chart 54-5).
Interventions
Collaborative management includes the administration of IV fluids and measures such as the following to treat the underlying cause and increase the flow of saliva:
• Hydration
• Application of warm compresses
• Massage of the gland
• Use of a saliva substitute
• Use of sialagogues (substances that stimulate the flow of saliva)
Sialagogues include lemon slices and fruit- or citrus-flavored candy. Massage is accomplished by milking the ede-matous gland with the fingertips toward the ductal opening. Elevation of the head of the bed promotes gravity drainage of the edematous gland.
Acute sialadenitis is best prevented by adherence to routine oral hygiene. This practice prohibits infections from ascending to the salivary glands from the oral cavity.
Postirradiation Sialadenitis
The salivary glands are sensitive to ionizing radiation, such as from radiation therapy or radioactive iodine treatment of thyroid cancers. Exposure of the glands to radiation produces xerostomia (very dry mouth caused by severe reduction in the flow of saliva) within 24 hours. Radiation to the salivary glands can also produce pain and edema, which generally abate after several days.
Xerostomia may be temporary or permanent, depending on the dose of radiation and the percentage of total salivary gland tissue irradiated. Little can be done to relieve the client’s dry mouth during the course of radiation therapy. Frequent sips of water and frequent mouth care, especially before meals, are the most effective interventions. After the course of radiation therapy has been completed, saliva substitutes may provide moisture for 2 to 4 hours at a time. Over-the-counter solutions are available, or solutions may be mixed with methylcellulose (Cologel), glycerin, and saline.
Salivary Gland Tumors
OVERVIEW
Tumors of the salivary glands are relatively rare; they constitute 5% of all oral tumors. Initially they present as slow-growing, painless masses (McEwen & Sanchez, 1997). Malignant tumors are characterized by more rapid growth than that of benign tumors and are generally associated with pain. Involvement of the facial nerve, more common with malignant tumors, results in facial weakness or paralysis (partial or total) on the affected side. Needle aspiration biopsy and open biopsy are useful procedures in establishing a diagnosis.
KEY FEATURES of Sialadenitis
· Swelling on the sides of the face or under the tongue, which increases when the client eats
· Alteration in the quantity or appearance of saliva
· Pain, especiatty during eating
· Purulent drainage from the affected duct
COLLABORATIVE MANAGEMENT
Assessment
The nurse collects information concerning prior radiation exposure, since radiation to the head and neck areas is associated with the occurrence of salivary gland tumors. Salivary gland malignancies present as localized, firm masses. In advanced stages of salivary gland tumors, the nurse may note a large preauricular mass accompanied by facial nerve paralysis. Submandibular and minor salivary gland tumors may be tender or painful. Tumor invasion of the hypoglossal nerve causes impaired movement of the tongue, and a loss of sensation can follow. The nurse pays particular attention to assessment of the facial nerve because of its close proximity to the salivary glands. The nurse assesses the client’s ability to:
• Wrinkle the brow
• Raise the eyebrows
• Squeeze the eyes shut
• Wrinkle the nose
• Pucker the lips
• Puff out the cheeks
• Grimace or smile
Interventions
The treatment of choice for both benign and malignant tumors of the salivary glands is surgical excision. However, radiation therapy is often used for salivary gland cancers that are large, have recurred, show evidence of residual disease after excision, or are highly malignant.
Clients who have undergone parotidectomy (surgical removal of the parotid glands) or submandibular gland surgery are at risk for weakness or loss of function of the facial nerve because the nerve courses directly through the gland. Facial nerve repair with autogenous nerve grafting can be done at the time of surgery. The majority of studies support combining surgery with postoperative radiation for advanced disease.
