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CHAPTER 53 Care of Patients with Oral Cavity Problems
Terms in this set (42)
Risk Factors for Oral Cavity Disorders
Oral cavity disorders, then, can severely affect nutrition and gas exchange, as well as speech, body image, and self-esteem. These disorders commonly affect people who:
• Have developmental delays or mental health disorders
• Are homeless or have less (decreased) access to care
• Reside in institutions
• Use tobacco and/or alcohol
• Consume an unhealthy diet
• Have an oral cancer
Maintaining a Healthy Oral Cavity
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Stomatitis is a broad term that refers to inflammation within the oral cavity and may present in many different ways. Painful single or multiple ulcerations (called aphthous ulcers or "canker sores") that appear as inflammation and erosion of the protective lining of the mouth are one of the most common forms. Places the person at risk for bleeding and infection. May require treatment with opioid analgesics and/or antifungal medications. Primary stomatitis, the most common type, includes aphthous (noninfectious) stomatitis, herpes simplex stomatitis, and traumatic ulcers. Secondary stomatitis generally results from infection by opportunistic viruses, fungi, or bacteria in patients who are immunocompromised. It can also result from drugs, such as chemotherapy. A common type of secondary stomatitis is caused by Candida albicans(long-term antibiotic use). The result can be candidiasis, also called moniliasis, a fungal infection that is very painful. Candidiasis is also common in those undergoing immunosuppressive therapy, such as chemotherapy, radiation, and steroids. Stomatitis can result from infection, allergy, vitamin deficiency (complex B vitamins, folate, zinc, iron), systemic disease, and irritants such as tobacco and alcohol. Infectious agents, such as bacteria and viruses, may have a role in the development of recurrent stomatitis. Certain foods such as coffee, potatoes, cheese, nuts, citrus fruits, and gluten may trigger allergic responses.
Considerations for Older Adults: Candidiasis
Older adults are especially at high risk for candidiasis because aging causes a decrease in immune function. The risk increases for patients who are diabetic, malnourished, or under emotional stress. Many older adults take multiple medications that can contribute to oral dryness and decreased salivation, as well. Those who wear dentures may use soft denture liners that provide comfort but can also be colonized by C. albicans, contributing to denture stomatitis. In addition, older adults who have poor oral hygiene are at high risk for mouth infections and aspiration pneumonia. All health care professionals in any health care setting should be educated in and aware of best practices for oral care for older adults. Improved oral care could greatly improve patient outcomes, especially for older intubated adults in critical care settings.
Ask about a history of recent infections, nutrition changes, oral hygiene habits, oral trauma, and stress. Also collect a drug history, including over-the-counter (OTC) drugs and nutrition and herbal supplements. Ask the patient if the lesions interfere with swallowing, eating, or communicating. Symptoms of stomatitis range in severity from a dry, painful mouth to open ulcerations, placing the patient at risk for infection. These ulcerations can alter nutrition status and risk of airway obstruction. In oral candidiasis, white plaque-like lesions appear on the tongue, palate, pharynx (throat), and buccal mucosa (inside the cheeks). When these patches are wiped away, the underlying surface is red and sore. While examining the mouth, wear gloves, use a penlight to ensure adequate lighting, and use a tongue blade to aid examining the oral cavity. Assess the mouth for lesions, coating, and cracking. Document characteristics of the lesions including their location, size, shape, odor, color, and drainage. If lesions are seen along the pharynx and the patient reports dysphagia (pain on swallowing), the lesions might extend down the esophagus. The physical assessment also includes palpating the cervical and submandibular lymph nodes for swelling.
Action Alert: Stomatitis
When assessing the patient with stomatitis, be alert for signs and symptoms of dysphagia, such as coughing or choking when swallowing, a sensation of food "sticking" in the pharynx, or difficulty initiating the swallowing process. If dysphagia is suspected, document all findings and report these to the health care provider because dysphagia can cause numerous problems, including airway obstruction, aspiration pneumonia, and malnutrition.
When providing mouth care for the patient, you may delegate oral care to unlicensed assistive personnel (UAP). Remind UAP to use a soft-bristled toothbrush or disposable foam swabs to stimulate gums and clean the oral cavity and to use toothpaste that is free of sodium lauryl sulfate (SLS), if possible. Teach the patient to rinse the mouth every 2 to 3 hours with a sodium bicarbonate solution or warm saline solution (may be mixed with hydrogen peroxide). He or she should avoid most commercial mouthwashes because they have high alcohol content. Teach the patient to check the labels for alcohol content. Frequent, gentle mouth care promotes débridement of ulcerated lesions and can prevent superinfections. Drug therapy used for stomatitis includes antimicrobials, immune modulators, and symptomatic topical agents. Antimicrobials, including antibiotics, antivirals, and antifungals, may be necessary for control of infection. Tetracycline syrup may initially be prescribed, especially for recurrent aphthous ulcers (RAUs). The patient rinses for 2 minutes and swallows the syrup, thus obtaining both topical and systemic therapy. Minocycline swish/swallow and chlorhexidine mouthwashes may also be used. A regimen of IV acyclovir (Zovirax) is prescribed for immunocompromised patients who contract herpes simplex stomatitis. Patients with healthy immune systems may be given acyclovir in oral or topical. Fungal infections like yeast, nystatin (Mycostatin) oral suspension swish/swallow is most commonly prescribed. Ice pop troches (lozenges) of the antifungal preparation allow the drug to slowly dissolve, and the cold provides an analgesic effect. Topical triamcinolone in benzocaine (Kenalog in 1102Orabase) and oral dexamethasone elixir used as a swish/expectorate preparation are commonly used for stomatitis, especially RAU. May be prescribed as second-line therapy include:
• Topical amlexanox (Aphthasol)
• Topical granulocyte-macrophage colony-stimulating factor (GM-CSF)
Over-the-counter (OTC) benzocaine anesthetics (e.g., Orabase, Anbesol) and camphor phenol (Campho-Phenique) can also control pain. Viscous lidocaine may also be prescribed to use as a gargle or mouthwash. "Magic mouthwash," a mixture of lidocaine, Benadryl, Maalox, Carafate, glucocorticoids, and other ingredients, is also commonly prescribed for those with oral pain due to cancer treatments. Cool or cold liquids can be very soothing, whereas hard, spicy, salty, and acidic foods or fluids can further irritate the ulcers. Include foods high in protein and vitamin C to promote healing, including scrambled eggs, bananas, custards, puddings, and ice cream, unless the patient has lactose intolerance.
Care of the Patient with Problems of the Oral Cavity
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Teach patients to use viscous lidocaine with extreme caution because its anesthetizing effect may cause burns from hot liquids in the mouth and/or increase the risk for choking.
Oral cavity tumors can be benign, precancerous, or cancerous. Whether benign or malignant, tumors of the mouth affect many daily functions, including swallowing, chewing, and speaking. Pain accompanying the tumor can also limit daily activities and self-care. Oral tumors affect body image, especially if treatment involves removal of the tongue or part of the mandible (jaw) or requires a tracheostomy.
Leukoplakia presents as slowly developing changes in the oral mucous membranes causing thickened, white, firmly attached patches that cannot easily be scraped off. These patches appear slightly raised and sharply rounded. Most of these lesions are benign. Lesions on the lips or tongue are more likely to progress to cancer. 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 (OHL) can be found in patients with human immune deficiency virus (HIV) infection. The Joint Commission (TJC) Core Measures TOB-1 requires asking about tobacco use, because tobacco products (smoked, dipped, or chewed) have also been implicated in the development of leukoplakia, sometimes referred to as "smoker's patch." Leukoplakia cannot be removed by scraping. OHL is associated with Epstein-Barr virus (EBV) and can be an early manifestation of HIV infection. When associated with HIV infection, the appearance of OHL is highly correlated with progression from HIV infection to acquired immune deficiency syndrome (AIDS).
Erythroplakia appear as red, velvety mucosal lesions on the surface of the oral mucosa. There are more malignant changes in erythroplakia than in leukoplakia. 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.
People should visit a dentist at least twice a year for professional dental hygiene and oral cancer screening, which includes inspecting and palpating the mouth for lesions. Prevention strategies for oral cancer include minimizing sun and tanning bed exposure, tobacco cessation, and decreasing alcohol intake. Most dentists use digital technology instead of x-rays when performing the annual or biannual dental examination, because excessive, prolonged radiation.
Pathophysiology: Oral Cancer
90% of oral cancers are squamous cell carcinomas that begin on the surface of the epithelium. Alterations in the thickness of the lining of the epithelium develop, resulting in atrophy. These tumors usually grow slowly. Mucosal erythroplasia is the earliest sign of oral carcinoma. Oral lesions that appear as red, raised, eroded areas are suspicious for cancer. A lesion that does not heal within 2 weeks or a lump or thickening in the cheek is a symptom that warrants further assessment. The major risk factors in its development are increasing age(>40), tobacco use, and alcohol use. Occupations such as textile workers, plumbers, and coal and metal workers, mainly due to prolonged exposure to polycyclic aromatic hydrocarbons (PAHs). People with periodontal (gum) disease in which mandibular (jaw) bone loss has occurred are especially at risk for cancer of the mouth. Additional factors, such as sun exposure, poor nutrition habits, poor oral hygiene, and infection with the human papilloma virus (HPV16) may also contribute. Oral cancer associated with HPV appears in the tonsillar area or along the base of the tongue in younger people. Oral cavity inspection combined with neck palpation is recommended yearly to aid in early detection.
Basal cell carcinoma of the mouth occurs primarily on the lips. The lesion is asymptomatic and resembles a raised scab. With time, it evolves into a characteristic ulcer with a raised, pearly border. Basal cell carcinomas do not metastasize (spread) but can aggressively involve the skin of the face. The major risk factor for this type of cancer is excessive sunlight exposure.
Kaposi's sarcoma is a malignant lesion in blood vessels, appearing as a raised, purple nodule or plaque, which is usually painless. In the mouth, the hard palate is the most common site of Kaposi's sarcoma, but it can be found also on the gums, tongue, or tonsils. It is most often associated with AIDS.
Genetic/Genomic Considerations: Oral Cancer
Genetic changes in patients with oral cancer have been found, especially the mutation of the TP53 gene. The TP53 gene is nicknamed the "guardian of the genome" because tumor protein p53 is essential for cell division regulation and prevention of tumor formation. Because mutations in this gene are linked to various cancers, always ask about a personal and family history of any type of cancer when assessing the patient with oral cavity problems.
Assessment: Oral Cancer
Begin by assessing the patient's routine oral hygiene regimen and use of dentures or oral appliances, which might add to discomfort or mechanically irritate the mucosa. Ask about oral bleeding, which might indicate an ulcerative lesion or periodontal (gum) disease. Determine the patient's past and current appetite and nutrition 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. Requires adequate lighting. Thoroughly inspect the oral cavity for any lesions, evidence of pain, or restriction of movement. Gently using a tongue blade and penlight, examine all areas of the mouth. Carefully note any change in speech caused by tongue movement. Notice any change in voice or swallowing, and assess for thick or absent saliva. It is important to assess the impact of oral lesions on the patient's self-concept. OralCDx is a diagnostic procedure usually performed by a dentist during a routine dental examination. The procedure involves brushing of a lesion and is helpful in determining whether the lesion is precancerous. However, biopsy is the definitive method for diagnosis of oral cancer. Both CT and MRI can be used to determine spread to the liver or lungs if further staging of the disease is warranted.
Chart 53-3 Key Features
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Interventions: Oral Cancer
Both the presence of tumors of the oral cavity and the effects of their treatment threaten the integrity of the oral mucosa and the patient's airway. 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). Chemotherapy is currently not used independently in the treatment of oral cancers but is used in addition to other modes of treatment to sensitize malignant cells to radiation, to shrink a malignancy before surgery, or to decrease the potential for malignancy. Multimodal therapy is the most costly treatment option yet is more frequently used. If the patient has extensive tumor involvement and copious, tenacious (thick and "stringy") secretions, maintaining an open airway is your priority for care to promote gas exchange.
Nonsurgical Management: Oral Cancer
Implement interventions to manage the patient's airway by increasing air exchange, removing secretions, and preventing aspiration as needed. Assess for dyspnea. Assess the quality, rate, and depth of respirations. Auscultate the lungs for adventitious sounds, such as wheezes caused by aspiration. Listen for stridor caused by partial airway obstruction. Promote deep breathing to help produce an effective cough to mobilize the patient's secretions. To promote gas exchange, place the patient in a semi-Fowler's or high-Fowler's position. If the patient is able to swallow and gag reflexes are intact, it is beneficial to encourage fluids to liquefy secretions for easier removal. Chest physiotherapy also increases air exchange as well as promotes effective coughing. If available, collaborate with the respiratory therapist. se oral suction equipment with a dental tip or a tonsil tip (Yankauer catheter) to remove secretions that obstruct the airway. Teach the patient and family to use the catheters. The patient may receive steroids to reduce inflammation. Antibiotics may be prescribed if infection is present. A cool mist supplied by a face tent may assist with oxygen transport and control of edema. It is important to work with the patient to establish an oral hygiene routine. Perform oral hygiene every 2 hours for ulcerated lesions, infection, or in the immediate postoperative period. A soft-bristled toothbrush is preferred. If the platelet count falls below 40,000/mm3, switch the patient to an ultrasoft "chemobrush." The use of "Toothettes" or a disposable foam brush is discouraged because these products may not adequately control bacteremia-promoting plaque and may further dry the oral mucosa. Lubricant can be applied to moisten the lips and oral mucosa. Avoid using commercial mouthwashes and lemon-glycerin swabs. Commercial mouthwashes contain alcohol, and lemon-glycerin swabs are acidic. Encourage frequent rinsing of the mouth with sodium bicarbonate solution or warm saline. Radiation therapy for oral cancers can be given by external beam or interstitial implantation to reduce the size of the tumor before surgery. External-beam radiation passes through the skin or mucous membrane to the tumor site. Implantation of radioactive substances (interstitial radiation therapy or brachytherapy) either to boost the dosage or to deliver a radiation dose close to the tumor bed. This form of implant therapy can be curative in early-stage .
Place patients on radiation transmission precautions while the materials are active or in place. Patients need to be placed in a private room with lead-lined walls or moveable panels. When permitted, visitors may stay only 30 minutes or less each day and must sit or stand away from the patient. Pregnant women and children younger than 18 years should not be permitted to visit. Teach the patient undergoing chemotherapy and family members about the side effects of these agents. Give antiemetics as prescribed, and provide other comfort measures as needed.
One of these GFs is called epidermal growth factor (EGF), which has been associated with oral cancers. Newer drugs that can target and block EGF receptors (EGF-R) are being tested, and more than a dozen have been approved, including cetuximab (Erbitux), erlotinib (Tarceva), and panitumumab (Vectibix).
Action Alert: Aspiration
Aspiration Precautions prevent or reduce the risk factors for aspiration. Assess the patient's level of consciousness (LOC), gag reflex, and ability to swallow. To prevent aspiration, place the patient sitting upright at 90 degrees (high-Fowler's position). As a precaution, keep suction equipment nearby. For patients at high risk, assess the gag reflex before giving any fluids. Remind UAP to feed patients at risk for aspiration in small amounts. Teach visitors to speak with you before offering any type of food or drink to the patient. Provide thickened liquids as an aid to prevent aspiration. Referral to the speech/language pathologist can be beneficial for patients who are experiencing aspiration with swallowing. A swallow study may be needed to fully assess the risk for aspiration.
Patients who are undergoing radiation and/or chemotherapy treatment may experience a decreased ability to tolerate prescribed and over-the-counter medications due to being immunocompromised. Teach patients about expected side effects, and remind them to not take any medication (including over-the-counter medications, herbs, or vitamin supplements) without first discussing them with their health care provider.
Surgical Management: Oral Cancer
The physician can often remove small, noninvasive lesions of the oral cavity in an ambulatory surgical center with local anesthesia. These smaller lesions may also be responsive to carbon dioxide laser therapy or cryotherapy (extreme cold application), as well as photodynamic therapy. These procedures 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 or photodynamic therapy and to surgery. More invasive lesions (stages 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 removal of the tumor with a surgical margin that is free of cancer cells.
Preoperative Care: Oral Cancer
Assess and document the patient's level of understanding of the disease process, the rationale for the surgery, and the planned intervention. Reinforce information as needed. Include family members or other caregivers in the health teaching. For small, local excisions, postoperative restrictions include a liquid diet for a day and then advancing as tolerated. There are no activity limitations, and postoperative analgesics are prescribed. Instructions for the patient undergoing large surgical resections may include but are not limited to these expectations after surgery:
• Placement of a temporary tracheostomy, oxygen therapy, and suctioning
• Temporary loss of speech because of the tracheostomy
• Frequent monitoring of postoperative vital signs
• NPO status until intraoral suture lines are healed
• Need to have IV lines in place for drug delivery and hydration
• Postoperative drug therapy and activity (out of bed on the day or surgery or first postoperative day)
• Possibility of surgical drains
Because communication is interrupted, assess the patient's ability to read, write, and draw pictures to communicate. Select the method of communication to use after surgery with staff and family members (e.g., Magic Slate, handheld mobile device, computer, picture board, or pad and pencil). Preprinted flashcards may be used to communicate. Urge the patient to practice the chosen method before surgery
Operative Procedures: Oral Cancer
Three factors influence the extent of surgery performed for oral cancers: the size and location of the tumor, tumor invasion into the bone, and whether there has been metastasis (cancer spread) to neck lymph nodes. Small, noninvasive tumors can be removed perorally (through the mouth). The most extensive oral operations are composite resections, which combine partial or total glossectomy (tongue removal) and partial mandibulectomy (jaw removal). In the commando (co-mandible) procedure (COMbined neck dissection, MANDibulectomy, and Oropharyngeal resection), the surgeon removes a segment of the mandible with the oral lesion and performs a radical neck dissection. Metastasis to cervical lymph nodes usually indicates a poor prognosis for patients with cancer of the oral cavity. A radical neck dissection usually involves the removal of all cervical lymph nodes on the affected side, along with cranial nerve XI (the accessory nerve), the internal jugular vein, and the sternocleidomastoid (front neck) muscle.
Postoperative Care: Oral Cancer
The patient may have a temporary or permanent tracheostomy, 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. Ensure that the predetermined method of communication is available. When the patient has an adequate airway and can effectively clear secretions by coughing, the tracheostomy tube may be removed. When the tube is removed, an airtight dressing is placed over the site and the tracheostomy incision heals without the need for sutures. Collaborate with the speech-language pathologist if speech is altered. Protect the incision site to avoid infection. Provide gentle mouth care for cleaning away thick secretions and stimulating the flow of saliva. Give oral care at least every 4 hours in the early postoperative phase. The presence of unusual odors from the mouth can indicate infection. Take care to avoid disruption of the suture line during oral hygiene. Elevate the head of the bed to assist in decreasing edema by gravity. If skin grafting was done, inspect the donor site (generally on the anterior thigh) every 8 hours for bleeding or signs of infection. The desired outcome of drug therapy during this period is relief of pain while allowing the patient to function at an optimal level. IV morphine is usually the initial pain medication given with acetaminophen or ibuprofen to decrease inflammation. Tylox or Percocet (oxycodone plus acetaminophen) may be used for systemic relief of moderate pain after the IV morphine is discontinued.
Patients who have undergone extensive resections of the oral cavity remain on NPO status for several days. Nasogastric feeding or total parenteral nutrition may be needed until oral nutrition can begin. Encourage the patient to perform swallowing exercises. Collaborate with the speech-language pathologist to assist with swallowing techniques. Thickened fluids may be needed to prevent aspiration.
The Postoperative Older Adult with Oral Cancer
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Action Alert: Post-op
After extensive excision or resection for oral cancer, the most important nursing intervention is maintaining the patient's airway to promote gas exchange! Upon awakening from anesthesia, the patient may not recall, or realize, that a tracheostomy tube is in place and may initially panic because of the inability to speak. Remind the patient why he or she cannot speak, and provide reassurance that the vocal cords are intact (unless a total laryngectomy has been performed, in which case the loss of voice is permanent).
Action Alert: Post-op
When oral fluid intake is started, assess for and document signs of difficulty swallowing, aspiration, or leakage of saliva or fluids from the suture line. Monitor daily weights and hydration. Nutrition supplementation may be used to improve the patient's quality of life. Patients who have weight loss or who are having difficulty maintaining hydration may be candidates for the placement of a gastrostomy tube. Coordinate nutrition care with the dietitian.
Community-Based Care: Oral Cancer
Most patients are maintained at home during follow-up care. Ongoing nutrition management remains a vital part of the treatment plan. 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 bone make elective oral surgical procedures, such as tooth extraction, impossible in the area of the radiation. Fatigue is a common side effect of radiation and chemotherapy. Tracheostomy tube removed means placed on a soft diet by mouth before discharge. Occasionally, however, patients are discharged from the hospital while still requiring tracheostomy suction, oral suction, and nasogastric feedings. Suction equipment, nutrition supplies, and nursing care can be provided by home care companies.
Self-Management Education: Oral Cancer
Before hospital discharge, teach the patient and family about drug therapy, nutrition therapies, any treatments (e.g., tracheostomy care, suture line care, dressing changes), and early symptoms of infection. Alterations in taste and dysphagia make maintaining adequate nutrition a challenge for the oral cancer patient. Taste sensation may begin to return several weeks after the completion of treatment. Some types of chemotherapy can also affect the patient's taste. Sometimes the loss of taste is permanent. Changes in taste include dislike of meat, such as beef or pork, and metallic tastes in the mouth. Teach patients 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. Instruct patients with dysphagia in swallowing exercises. Recommend thickened liquids. Liquid dietary supplements are usually recommended at this time. If bleeding or stomatitis is present, recommend soft foods to prevent further injury to the mucous membranes. Teach the patient or family members to inspect the oral cavity daily for areas of redness, which can indicate the onset of stomatitis. Meticulous oral hygiene should be continued at home, especially with adjuvant chemotherapy or radiation. Reinforce the oral hygiene routine, emphasizing the need for frequent mouth rinsing to reduce the number of microorganisms and to maintain adequate hydration. The patient should use a chemobrush (an extra-soft type of toothbrush), rinse the chemobrush with hydrogen peroxide and water or with a diluted bleach solution after each use, and change chemobrushes weekly. The brush may also be cleaned in a dishwasher. The resulting xerostomia (dry mouth) causes the inability to eat dry foods and may be permanent. Teach the patient regarding the use of saliva substitutes.
Skin reactions are also a common side effect of radiation. Instruct the patient to avoid sun exposure, to avoid perfumed lotions and powders, and to cleanse the face and neck area with a gentle nondeodorant soap. Teach male patients to use an electric razor for shaving and to avoid alcohol-based aftershave lotions.
Care of the Patient with Oral Cancer at Home
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Health Care Resources.
Patients who have undergone composite resection often require community services because they have both physical and psychosocial needs. Depression related to a change in body image is common. Excision of a portion of the jaw can leave a facial defect that may be difficult to hide. Assess for depression and other behavioral responses. A social worker or other health care professional may be needed. Those who have undergone a total glossectomy may be able to speak with special training and the use of an intraoral prosthesis.
Collaborate with the case manager to provide assistance in obtaining special equipment or nutrition resources needed by the patient at home. The case manager assesses the patient's financial needs and makes referrals to government, community, and religious organizations.
Acute sialadenitis, the inflammation of a salivary gland, can be caused by infectious agents(Cytomegalovirus), irradiation, or immunologic disorders. The most common bacterial organisms are Staphylococcus aureus, Staphylococcus pyogenes, Streptococcus pneumoniae, and Escherichia coli. A decrease in the production of saliva (as in dehydrated or debilitated patients or in those who are on NPO status postoperatively for an extended time) can lead to acute sialadenitis. Systemic drugs, such as phenothiazines and the tetracyclines, can also trigger 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.
Patients 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. Immunologic disorders such as HIV infection can cause enlargement of the parotid gland that results from secondary infection. Sjögren's syndrome, an autoimmune disorder, is characterized by chronic salivary gland enlargement and inflammation that cause a very dry mouth.
Patient-Centered Collaborative Care: Acute Sialadenitis
Assess for any predisposing factors for sialadenitis, such as ionizing radiation to the head or neck area. Collect a thorough drug history, and ask about systemic illnesses, such as HIV infection.
Dehydration can be assessed by examining the oral membrane for dryness and the skin for turgor. Other assessment findings include pain and swelling of the face over the affected gland. Assess facial function because the branches of cranial nerve VII (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. Collaborative care includes the administration of IV fluids and measures such as these to treat the underlying cause and increase the flow of saliva:
• 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 citrus-flavored and other fruit-flavored candy. Massage is accomplished by milking the edematous 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.
The salivary glands are sensitive to ionizing radiation. Exposure of the glands to radiation produces a type of sialadenitis known as xerostomia (very dry mouth caused by a severe reduction in the flow of saliva) within 24 hours. Radiation to the salivary glands can also produce pain and edema. 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 patient'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 methylcellulose (Cologel), glycerin, and saline may be mixed to form a solution.
Salivary Gland Tumors
Relatively rare. Initially, malignant tumors present as slow-growing, painless masses. Involvement of the facial nerve results in facial weakness or paralysis (partial or total) on the affected side.
Collect information about any prior radiation exposure, because radiation to the head and neck areas is associated with the occurrence of salivary gland tumors. Salivary gland tumors present as localized, firm masses. 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. Pay particular attention to assessment of the facial nerve because of its proximity to the salivary glands. Assess the patient's ability to:
• Wrinkle the brow
• Raise the eyebrows
• Squeeze and hold the eyes shut while you gently pull upwards on the eyebrows and cheeks beneath the orbit to check for symmetry
• Wrinkle the nose
• Pucker the lips
• Puff out the cheeks
• Grimace or smile
Be aware of any asymmetry when the patient performs these motions. 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. Patients 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 grafting can be done at the time of surgery. A combination of surgery followed by radiation is common for advanced disease.
What might you NOTICE if the patient has inadequate digestion and gas exchange as a result of oral cavity problems?
• Dysphagia (difficulty swallowing)
• Stridor or wheezes
• Changes in speech or voice
• Copious, thickened oral secretions
• Excessive coughing during meals
Perform and interpret focused physical assessment findings, including:
• Breath sounds
• Oxygen saturation by pulse oximetry
• Ability to cough and clear the airway
• Ability to manage excessive oral secretions
• Ability to chew food and swallow
• Placing the patient with the head elevated to at least 30 degrees
• Applying oxygen as needed
• Suctioning the oral cavity as needed
• Encouraging deep breathing and coughing every 2 hours
• Increasing fluids to liquefy secretions, depending on swallowing ability
• Notifying the respiratory therapist or Rapid Response Team if interventions are not successful in restoring gas exchange (oxygenation).
Key Points: Safe and Effective Care Environment
• Be aware that airway management is the priority for care for patients having surgery for oral cancer. Safety image
• Place patients having oral cancer surgery in a high-Fowler's position to facilitate breathing and prevent aspiration.
• Be sure to assess for swallowing ability to prevent aspiration by checking the gag reflex before offering liquids or food to the patient who has had oral cancer surgery.
• Plan continuity of care to meet patients' needs when they are transferred from the hospital to community-based agencies.
Key Points: Health Promotion and Maintenance
• Teach patients to seek medical or dental attention for oral lesions that do not heal; these lesions could be oral carcinomas.
• Remind patients to visit their dentist regularly for dental hygiene and oral examination.
• Follow the best practice recommendations for maintaining oral health as listed in Chart 53-1.
• Instruct patients to avoid harsh commercial mouthwashes if they have oral lesions.
• In keeping with The Joint Commission (TJC) Core Measures TOB-2, teach patients to avoid tobacco, alcohol, and sun exposure to decrease their chance of having oral cancer.
• Instruct patients with acute sialadenitis to use sialagogues to stimulate saliva, such as citrus foods or candies.
Key Points: Psychosocial Integrity
• Identify the patient's and family's response to an oral cancer diagnosis.
• Assist the patient and family in identifying and using coping mechanisms to deal with possible changes in body image and altered self-esteem. Patient-Centered Care image
• Recognize that patients with stomatitis are often unable to eat or swallow without discomfort.
• Refer patients with oral cancer to support groups, such as those available through the American Cancer Society.
Key Points: Physiological Integrity
• Remember that stomatitis usually manifests as painful single or multiple ulcerations within the mouth.
• Recognize that stomatitis can be caused by a variety of organisms; Candida infections are very common in patients who receive antibiotic therapy and in those who are immunocompromised.
• Provide gentle oral care for patients with oral lesions, including using chemobrushes and warm saline or sodium bicarbonate solution.
• Be aware that patients with stomatitis receive antimicrobials, anti-inflammatory agents, immune modulators, and topical agents for relief of symptoms, including pain. Evidence-Based Practice image
• Differentiate leukoplakia and erythroplakia: leukoplakia presents as thin, white patches; and erythroplakia presents as red, velvety lesions.
• Be aware that patients with oral cancer may have chemotherapy, radiation, surgery, or a combination of these treatment methods.
• Be aware that sialadenitis can occur as a result of radiation therapy.
• For patients with salivary gland tumors, assess for facial nerve involvement.
• Remember that a parotidectomy involves the removal of the salivary glands; postoperative care is similar to that for patients who have oral cancer surgery.
THIS SET IS OFTEN IN FOLDERS WITH...
CHAPTER 54 Care of Patients with Esophag…
CHAPTER 55 Care of Patients with Stomach Disorders
CHAPTER 52 Assessment of the Gastrointestinal Syst…
CHAPTER 56 Care of Patients with Noninfl…
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