NURSING PROCESS: THE PATIENT WITH A CONDITION OF THE ESOPHAGUS
Emergency conditions of the esophagus (perforation, chemical burns) usually occur in the home or away from medical help and require emergency medical care. The patient is treated for shock and respiratory distress and transported as quickly as possible to a medical facility. Foreign bodies in the esophagus do not pose an immediate threat to life unless pressure is exerted on the trachea, resulting in dyspnea or interfering with respiration, or unless there is leakage of caustic alkali from a battery. Educating the public to prevent inadvertent swallowing of foreign bodies or cor-rosive agents is a major health issue.
For nonemergency symptoms, a complete health history may reveal the nature of the esophageal disorder. The nurse asks about the patient’s appetite. Has it remained the same, increased, or de-creased? Is there any discomfort with swallowing? If so, does it occur only with certain foods? Is it associated with pain? Does a change in position affect the discomfort? The patient is asked to describe the pain. Does anything aggravate it? Are there any other symptoms that occur regularly, such as regurgitation, nocturnal regurgitation, eructation (belching), heartburn, substernal pres-sure, a sensation that food is sticking in the throat, a feeling of becoming full after eating a small amount of food, nausea, vomiting, or weight loss? Are the symptoms aggravated by emotional upset? If the patient reports any of these symptoms, the nurse asks about the time of their occurrence, their relationship to eating, and factors that relieve or aggravate them (eg, position change, belching, antacids, vomiting).
This history also includes questions about past or present causative factors, such as infections and chemical, mechanical, or physical irritants; the degree to which alcohol and tobacco are used; and the amount of daily food intake. The nurse determines whether the patient appears emaciated and auscultates the patient’s chest to determine whether pulmonary complications exist.
Based on the assessment data, the nursing diagnoses may include the following:
a) Imbalanced nutrition, less than body requirements, related to difficulty swallowing
b) Risk for aspiration related to difficulty swallowing or to tube feeding
c) Acute pain related to difficulty swallowing, ingestion of an abrasive agent, tumor, or frequent episodes of gastric reflux
d) Deficient knowledge about the esophageal disorder, diag-nostic studies, medical management, surgical intervention, and rehabilitation
The major goals for the patient may include attainment of ade-quate nutritional intake, avoidance of respiratory compromise from aspiration, relief of pain, and increased knowledge level.
The patient is encouraged to eat slowly and to chew all food thor-oughly so that it can pass easily into the stomach. Small, frequent feedings of nonirritating foods are recommended to promote di-gestion and to prevent tissue irritation. Sometimes liquid swal-lowed with food helps the food pass through the esophagus. Food should be prepared in an appealing manner to help stimulate the appetite. Irritants such as tobacco and alcohol should be avoided. A baseline weight is obtained, and daily weights are recorded. The patient’s intake of nutrients is assessed.
The patient who has difficulty swallowing or difficulty handling secretions should be kept in at least a semi-Fowler’s position to decrease the risk of aspiration. The patient can be instructed in the use of oral suction to decrease the risk of aspiration further.
Small, frequent feedings are recommended, because large quanti-ties of food overload the stomach and promote gastric reflux. The patient is advised to avoid any activities that increase pain, and to remain upright for 1 to 4 hours after each meal to prevent reflux. The head of the bed should be placed on 4- to 8-inch (10- to 20-cm) blocks. Eating before bedtime is discouraged.
The patient is advised that excessive use of over-the-counter antacids can cause rebound acidity. Antacid use should be directed by the primary care provider, who can recommend the daily, safe dose needed to neutralize gastric juices and prevent esophageal irritation. Histamine2 antagonists are administered as prescribed to decrease gastric acid irritation.
The patient is prepared physically and psychologically for diag-nostic tests, treatments, and possible surgical intervention. The principal nursing interventions include reassuring the patient and discussing the procedures and their purposes. Some disorders of the esophagus evolve over time, whereas others are the result of trauma (eg, chemical burns, perforation). In instances of trauma, the emotional and physical preparation for treatment is more dif-ficult because of the short time available and the circumstances of the injury. Treatment interventions must be evaluated continu-ally; the patient is given sufficient information to participate in care and diagnostic tests. If endoscopic diagnostic methods are used, the patient is instructed regarding the moderate sedation that will be used during the procedure. If procedures are being performed on an outpatient basis with the use of moderate seda-tion, the patient is instructed to have someone available to drive him or her home after the procedure. If surgery is required, im-mediate and long-term evaluation is similar to that for a patient undergoing thoracic surgery.
The self-care required of the patient depends on the nature of the disorder and on the surgery or treatment measures used (eg, diet, positioning, medications). If an ongoing condition exists, the nurse helps the patient plan for needed physical and psychologi-cal adjustments and for follow-up care (Chart 35-4).
Special equipment, such as suction or enteral or parenteral feeding devices, may be required. The patient may need assistance in planning meals, using medications as prescribed, and resum-ing activities. Education about nutritional requirements and how to measure the adequacy of nutrition is important. Elderly and debilitated patients in particular often need assistance and edu-cation in ways to adjust to their limitations and to resume activ-ities that are important to them.
Patients with chronic esophageal conditions require an individ-ualized approach to their management at home. Foods may need to be prepared in a special way (blenderized foods, soft foods), and the patient may need to eat more frequently (eg, four to six small servings per day). The medication schedule is adjusted to the patient’s daily activities as much as possible. Anal-gesic medications and antacids can usually be taken as needed every 3 to 4 hours.Postoperative home health care focuses on nutritional sup-port, management of pain, and respiratory function. Some pa-tients are discharged from the hospital with enteral feeding by means of a gastrostomy or jejunostomy tube or parenteral nutri-tion. The patient and care provider need specific instructions re-garding management of the equipment and treatments. Home care visits by a nurse may be necessary to assess the patient’s care and the care provider’s ability to provide the necessary care. For some pa-tients, a multidisciplinary team comprising a dietitian, a social worker, and family members is helpful. Hospice care is appro-priate for some patients.
Expected patient outcomes may include:
1) Achieves an adequate nutritional intake
a. Eats small, frequent meals
b. Drinks water with small servings of food
c. Avoids irritants (alcohol, tobacco, very hot beverages)
d. Maintains desired weight
2) Does not aspirate or develop pneumonia
a. Maintains upright position during feeding
b. Uses oral suction equipment effectively
3) Is free of pain or able to control pain within a tolerable level
a. Avoids large meals and irritating foods
b. Takes medications as prescribed and with adequate flu-ids (at least 4 ounces), and remains upright for at least 10 minutes after taking medications
c. Maintains an upright position after meals for 1 to 4 hours
d. Reports that there is less eructation and chest pain
4) Increases knowledge level of esophageal condition, treatment, and prognosis
a. States cause of condition
b. Discusses rationale for medical or surgical management and diet or medication regimen
c. Describes treatment program
Practices preventive measures so injuries are avoided
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