This interactive Florida Advanced Practice Nursing Ebook contains 29 hours of CE. To complete click the Complete Your CE button at the top right of the screen.
WHAT’S INSIDE
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Disorders of the Gastrointestinal System, 2nd Edition [8 contact hours]
Diseases and disorders of the gastrointestinal system affect millions of individuals each year. This course reviews many of the more common problems as well as presents patient assessment needs, current treatments, and best practices for nursing care. 82 Educating Patients: Creating Teaching Moments in Practice [4 contact hours] The purpose of this course is to provide HCPs with current evidence-based information to help them learn and apply skills and practice for effective patient and family teaching in a variety of settings. Effective education is essential to help patients and family gain knowledge. This is important to help them to manage health, improve adherence to healthcare plans, cope with health changes, participate actively in the decision-making process, and promote an overall healthy lifestyle. All healthcare professionals (HCPs) can identify teaching opportunities to assess and provide effective education. 124 Evidence Based Implicit Bias Implications for Physicians and Healthcare Professionals [1 contact hour] The purpose of this course is to provide a historical context of race and racism and its relationship to the development of racial implicit bias. The development of implicit bias will be discussed along with research demonstrating the impact of implicit bias on the clinical encounter. Recommendations for mitigating implicit bias are offered. 140 Mental Health Concerns and the Older Adult [6 contact hours] The healthcare worker meeting mental health needs will be able to view the older adult within the context of aging theories and identify interpersonal connection, biopsychosocial elements, and the assessment and treatment for common mental health problems in the older adult. The target audience is any healthcare worker who will assess, intervene, or treat mental health needs of an older adult client. Registered nurses, mental health technicians, mental health providers, case managers, and primary care healthcare workers can benefit from the perspective provided by this course. 200 Nursing Assessment, Management, and Treatment of Autoimmune Diseases [6 contact hours] Almost 4% of the world’s population is affected by one of more than 80 different autoimmune diseases. In the United States (US), as many as 50 million Americans are living with an autoimmune disease, at a cost of $86 billion a year (National Stem Cell Foundation [NSCF], 2021). This education program provides information on autoimmune diseases with the purpose of adding to the nurse’s ability to recognize, assess, and facilitate treatment of such diseases. 264 Nursing Care of the Postmenopausal Woman, 3rd Edition [5 contact hours] This course describes the changes that a postmenopausal woman experiences in various aspects of her life, including physiologic and psychologic changes. It provides the learner with information regarding alterations to a woman’s sexual self after menopause, periodic screenings needed to reduce the mortality and morbidity of aging women, and a review of how a woman’s health is affected as she ages.
Disorders of the Gastrointestinal System, 2nd Edition
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Disorders of the Gastrointestinal System, 2nd Edition 8 Contact Hours
Release Date: July 10, 2023 Expiration Date: July 10, 2025
AUTHOR
Stephani M. Hunt, MSN, RN, WCC, OMS, ONC, CFCN Wound care nurse, charge nurse, educator, instructor, manager, chief nursing officer
Stephani Hunt, MSN, RN, WCC, OMS, ONC, CFCN, received her master’s in nursing from Framingham State University and her baccalaureate in nursing degree from Northeastern University, Boston. She is wound care certified, an ostomy management specialist, a certified foot care nurse, and a certified orthopedic nurse. Ms. Hunt has worked as a medical-surgical clinical nurse educator and inpatient wound and ostomy specialist. She is currently working as a general and colorectal surgery nurse in Manchester, New Hampshire. In this role, she performs wound and ostomy care, patient and staff education, consultation, and triage. She is also assisting in creating a new wound and ostomy clinic and ostomy support group to serve the local population. Stephani Hunt has disclosed that she has no significant financial or other conflicts of interest pertaining to this course.
REVIEWER
Wendy Dusenbury, PhD, DNP, APRN, FNP-BC, AGACNP-BC, CNRN, ANVP-BC, FAHA Clinical instructor, assistant professor, CEO.
Wendy Dusenbury, PhD, DNP, APRN, FNP-BC, AGACNP-BC, CNRN, ANVP-BC, FAHA, graduated with a bachelor’s degree from Northwestern Oklahoma State University, a master of science in nursing (family nurse practitioner) from Wichita State University, a postmaster’s certificate as an acute care nurse practitioner from the University of Nebraska Medical Center, doctor of nursing practice from the University of Alabama at Birmingham, and doctor of philosophy from the University of Tennessee Health Science Center. In addition, Wendy completed a postgraduate neurovascular advanced practice fellowship program in 2013 from Arizona State University through the College of Nursing and Health Innovation. She has a wide range of clinical experience as a nurse practitioner, including primary care, pediatrics, neurosurgery, neuro intensive care unit (ICU), stroke program management, and acute stroke service in both inpatient and the mobile stroke unit. Wendy Dusenbury has disclosed that she has no significant financial or other conflicts of interest pertaining to this course. How to receive credit ● Read the entire course online or in print which requires a 8-hour commitment of time. ○ An affirmation that you have completed the educational activity. ○ A mandatory test (a passing score of 70 percent
● Complete the self-assessment quiz questions which are at the end of the course or integrated throughout the course. These questions are NOT GRADED. The correct answer is shown after you answer the question. If the incorrect answer is selected, the rationale for the correct answer is provided. These questions help to affirm what you have learned from the course. ● Depending on your state requirements you will be asked to complete either:
is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. ● Provide required personal information and payment information. ● Complete the MANDATORY Self-Assessment and Course Evaluation. ● Print your Certificate of Completion.
Disorders of the Gastrointestinal System, 2nd Edition
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COURSE OVERVIEW Diseases and disorders of the gastrointestinal system affect millions of individuals each year. This course reviews many of the more common problems as well as presents pa- tient assessment needs, current treatments, and best practices for nursing care.
LEARNING OUTCOMES ● Examine the anatomy of the gastrointestinal system. ● Compare selected diseases and disorders of the gastrointestinal tract. ● Examine the pathophysiology of diseases and disorders of the gastrointestinal tract. INTRODUCTION Diseases and disorders of the gastroin- testinal system affect millions of individ- uals each year. This course reviews many common problems and presents patient assessment needs, current treatments, and best practices for nursing care. ANATOMY OF THE GASTROINTESTINAL SYSTEM Figure 1. Gastrointestinal System
● Interpret signs and symptoms of gastrointestinal disease processes. ● Differentiate appropriate nursing interventions and treatments for selected gastrointestinal diseases.
The gastrointestinal (GI) system con- sists of the GI tract (also referred to as the alimentary canal) and accessory organs. The GI system is a long, hollow muscular tube that starts in the mouth, ends at the anus, and includes the following parts of the anatomy (Elsevier, 2022): ● Oral cavity. ● Pharynx. ● Esophagus. ● Stomach. The accessory glands and organs of the GI system are the salivary glands, liver, pancreas, and gallbladder. GI accesso- ry glands and organs secrete fluids, en - zymes, and emulsifying agents that lubri- cate and aid in the breakdown of food (Elsevier, 2022). The peritoneal cavity is the area within the abdomen that houses the gastrointestinal organs. ● Small intestine. ● Large intestine. ● Rectum. ● Anus.
Note . Haggstrom, M. (n.d.). Complete GI Tract. Wikimedia Commons. https://commons.wikimedia.org/wiki/ File:Complete_GI_tract_-_transparent_-_wider.png. In the public domain.
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Holding all of these structures and or- gans together and providing support is a special type of tissue called the peritone- um , which is made up of mesentery and connective tissue. The parietal peritone- um lines the peritoneal cavity to secure organs and vessels and maintain their position. The visceral peritoneum is the tissue that covers and protects the organs themselves (Elsevier, 2022). Diseases and disorders of the GI sys- tem can range from mild annoyances to life-threatening conditions. Therefore, nurses must recognize the numerous ab- normalities that can occur and how to most effectively intervene to help the pa- tient return to a state of maximum health and wellness. DISORDERS OF THE ORAL CAVITY The oral or buccal cavity contains the lips; the buccal mucosa (the inside lining of the mouth); the gingiva (gums); sub- lingual area (the floor of the mouth and under the tongue); the hard palate (roof of the mouth); the retromolar trigone (the area behind the wisdom teeth); and the front two- thirds of the tongue (American Cancer Society [ACS], 2021). The orophar- ynx, just behind the oral cavity, contains the soft palate (the area that connects the roof of the mouth to the pharynx); the back third of the tongue; the tonsils; and the walls of the throat (ACS, 2021). Many conditions can affect the oral cav - ity, and their impact can range from an- noying symptoms that can be fairly easily resolved to major problems that can have long-ranging effects. Stomatitis Stomatitis, generally classified as aph - thous stomatitis, is inflammation and ulceration of the oral mucosa that may spread to the lips, palates, and buccal
mucosa. It is a common condition and can be caused by (Mirowski, 2020): ● Infection with herpes simplex virus (HSV). ● HIV infection. ● Medication-related ulcerations. ● Environmental or food triggers (e.g., gluten, acidic foods, milk). ● GI diseases, including inflammatory bowel diseases. Acute herpetic stomatitis is common in young children and is caused by an infec- tion with the herpes simplex virus (HSV). Infection with HSV is usually self-limiting, but it can be severe or fatal, especially in neonates. Stomatitis symptoms have an abrupt onset and include malaise, an- orexia, irritability, mouth pain, swallowing problems, and fever (up to 104 °F [40 °C]), which may appear several days be- fore blisters and ulcers. Blisters that de- velop in the mouth and throat eventual- ly “pop” and acquire the appearance of “punched-out” lesions with red areolae. Children should be taught to avoid direct contact with other children, sharing toys or eating utensils, and kissing during an outbreak to avoid spreading HSV to oth- ers (Kaneshiro, 2021). | HEALTHCARE CONSIDERATION ● Blood disorders. ● Fungal infection. Although this condition typically re- solves with no long-term effects on the child, it is possible for it to spread to the eyes, which can cause blindness and is a medical emergency (Pendick, 2020).
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Aphthous stomatitis, commonly re- ferred to as canker sores, causes burning, tingling, pain, and minimal swelling of the mucous membranes. Single or mul- tiple superficial ulcers with white centers and red borders appear, heal, and form at other sites. Healing generally occurs spontaneously within one to two weeks. Causes may be idiopathic or may include stress, fatigue, anxiety, vitamin B deficien - cies, nutritional deficits, toothpaste con - taining sodium laurel sulfate (SLS), mouth injuries such as from ill-fitting dentures, and fever (Mirowski, 2020). Stomatitis treatment focuses on symp- tom relief and prevention of future out- breaks. Medications used in treating stomatitis are antivirals such as acyclovir, corticosteroids to reduce swelling or in- flammation, pain-relieving analgesic gels such as lidocaine gels, and nonsteroidal anti- inflammatory drugs (NSAIDs) or ac - etaminophen as an analgesic. Avoiding salty and spicy foods or a food that is a known cause may also be recommended to reduce discomfort and prevent exac- erbation. Intravenous therapy may be in- dicated in extreme cases when patients cannot ingest adequate amounts of food and liquids or when a secondary bacte- rial infection is present. Current research also shows that immunomodulatory med- ications (e.g., cyclosporine and retinoids) may help manage chronic and severe cas- es (Mirowski, 2020). Candidiasis (Thrush) Thrush is an infection caused by the yeast (fungus) Candida albicans or an- other fungus in the Candida family. The infection causes cream- colored or white patches or lesions on the tongue, mouth, or pharynx surrounded by erythema. Per- sons at high risk for candidiasis include premature neonates, older adults, immu-
nosuppressed persons, persons with dia- betes, persons taking antibiotics, persons taking steroids for a long time, and per- sons with conditions that cause hyposal- ivation, especially inhaled corticosteroids (Kauffman, 2022). For infants with thrush, the oral mucosa is swabbed with nystatin between feedings; however, feedings can wash away medication. Nursing mothers should also be treated to avoid reinfec- tion and coinfection (Pampers, 2019). Infants who are six months older or old- er may be prescribed oral fluconazole. Older children and adults may rinse with and swallow antifungal solutions for treat- ment. Oral or intravenous (IV) medica- tions, such as fluconazole or clotrimazole, may be necessary in more severe cases. Good oral hygiene is crucial for prevent- ing and treating candidiasis (Cleveland Clinic, 2019). Figure 2. Thrush
Note . Heilman, J. (n.d.). Human tongue infected with oral candidiasis. Wikimedia Commons. https://commons.wiki- media.org/wiki/File:Human_tongue_infected_with_oral_ candidiasis.jpg. CC BY-SA 3.0.
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Oral cavity cancer CASE STUDY 1
Cheri’s story is not uncommon. Near- ly 54,000 individuals in the U.S. receive a diagnosis of oral or pharyngeal cancer annually, and only 57% live longer than five years after diagnosis. Worldwide, this number is 657,000 new cases diagnosed yearly, which is likely an undercount, as many countries do not have standard re- porting systems. Oral cancer is not diffi - cult to diagnose, but it is often identified in later stages due to inconsistent screen- ing processes for early diagnosis. It has spread by the onset of symptoms (Oral Cancer Foundation [OCF], 2022). Risk factors associated with the de- velopment of oral cancer include (OCF, 2022): ● Use of tobacco products, including smokeless and chewing tobacco. ● Exposure to radiation and sunlight (x-rays, tanning beds, sunbathing) increases the risk for lip cancers. Frequent alcohol ingestion, especially if also using tobacco products. ● Infection with certain viral infections. Human papillomavirus (HPV) version 16. HPV-16 has been linked to an increasing number of oral cancer diagnoses. Epstein–Barr virus and cytomegalovirus are also associated with developing oral cancers. ● Race/ethnicity is a risk factor. Oral cancer affects twice as many African Americans as Whites. ● Historically, oral cancer occurred much more frequently in men, affecting six men for every woman; however, the ratio has now decreased to two men for every woman. It is believed that this is because of an increase in women who smoke and present with HPV infection (OCF, 2022).
Cheri is a 45-year-old manager of a busy upscale women’s boutique. She attends many social events related to business and drinks about two to three glasses of wine per day. Cheri smokes half a pack of cigarettes daily and loves to lay out in the sun and visit tanning beds in her spare time. About a month ago, she noticed a painless white patch about 1 cm in diam- eter on the inside of her left cheek. Be- cause it was not causing any discomfort, Cheri dismissed it as unimportant. Today, she visited her dentist for her regular six- month check-up. He expressed concern and recommended that she have her family doctor evaluate the white patch. A biopsy indicated that Cheri has oral can- cer. Question Cheri has all of the following risk factors for the development of oral cancer EXCEPT: a. Stressful work environment. b. Tobacco use. c. Regular alcohol consumption. d. Exposure to UV rays. Answer/Rationale: The correct answer is a. Stress levels are not linked to oral cancer. The use of alcohol, tobacco, and tanning beds is linked to oral cancer.
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Figure 3. Oral Cancer
| NURSING ALERT
Persons with an oral cancer diagno- sis may need to undergo oral health procedures with their dentist or or- thodontist to prevent complications after treatment, such as osteonecrosis and infection. This treatment includes cleaning and examination and may include tooth extraction if defects like caries or cracks are present (OCF, 2022). The confirmation of the diagnosis of oral cancer may be accomplished through a number of diagnostic tests; however, the first step is a thorough physical exam - ination. A biopsy of suspicious lesions is obtained to identify the presence of ma- lignant cells. Other diagnostic testing that may be helpful in diagnosis includes x-ray, pharyngoscopy or laryngoscopy, magnet- ic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) scan (OCF, 2022). The prognosis depends on the location and staging of cancer in the oral cavity or oropharyngeal area. The most common staging system for these types of cancers is the American Joint Committee on Can- cer (AJCC) TNM system, based on three key pieces of information (ACS, 2021): ● The extent of the tumor ( T ): Size of the primary tumor and if it has spread to surrounding tissues. ● The spread to nearby lymph nodes ( N ): If it has spread to lymph nodes, how many, what size, and how large they are. ● The spread (metastasis) to distant sites ( M ): If cancer has spread to distant organs.
Note . Pastore, L., Fiorella, M. L., Fiorella, R., Lo Mizio, L. (2008). Oral Cancer. https://commons.wikimedia.org/wiki/ File:PLoS_oral_cancer.png. CC BY-SA 2.5. Signs and symptoms of oral cancer in- clude (OCF, 2022): ● Sore(s) in the mouth or on the lip that does not heal within 14 days. ● White or red patch in the mouth. ● A lump or thickening in the mouth or on the lip. ● Problems chewing or swallowing. ● Trouble moving the jaw or tongue. ● Pain of the mouth or lip. ● Numbness in the mouth. ● Loose teeth or dentures that become uncomfortable or start to fit poorly (ACS, 2021). ● Change in the quality of the voice. ● Swelling of the jaw or lips, visible masses, or asymmetrical facial features. ● Weight loss, fatigue, or anorexia.
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Numbers or letters after T, N, and M provide more details about each factor. Higher numbers mean the cancer is more advanced. ● The T category can be assigned a letter or a number. ○ TX means there’s no information about the primary tumor, or it can’t be measured. ○ T0 means there is no evidence of a primary tumor. ○ Tis means that the cancer cells are only growing in the layer of cells where they started. It may be known as cancer in situ or precancer . ○ A number after the T (such as T1, T2, T3, or T4) might describe the tumor size and/or amount of spread into nearby structures. The higher the T number, the larger the tumor and/or the more it has grown into nearby tissues. ● The N category can be assigned a letter or a number. ○ NX means there’s no information about the nearby lymph nodes, or they can’t be assessed. ○ N0 means nearby lymph nodes do not contain cancer. ○ A number after the N (such as N1, N2, or N3) might describe the size, location, and/or the number of nearby lymph nodes affected by cancer. The higher the N number, the greater the cancer has spread to nearby lymph nodes. ● The M category is assigned a number. ○ M0 means that no distant cancer spread has been found. ○ M1 means that cancer has been found to have spread to distant organs or tissues.
The treatment course depends on the cancer stage and other factors, such as the patient’s age, overall physical strength, general health, and ability to tolerate the prescribed treatment. Treat- ment may include radiation therapy, sur- gery, chemotherapy, immunotherapy, or a combination of these initiatives (OCF, 2022). The five-year survival rate is based on cancer staging, patient age, the over- all level of health, how cancer responds to treatment, and other factors. DISORDERS OF THE ESOPHAGUS The esophagus is a long muscular tube composed of four layers and connects the hypopharynx to the stomach (National Cancer Institute [NCI], 2022). The layers of the esophagus are the mucosal layer, the submucosal layer, the muscular layer (a thick muscular band that rhythmical- ly contracts to propel food to the stom- ach), and the adventitial layer. The upper esophageal sphincter (UES) rests at the pharynx and upper esophagus. It blocks air from entering the stomach and food from regurgitating into the airway. The lower esophageal sphincter (LES), locat- ed at the bottom of the esophagus, pre- vents the reflux of stomach contents back into the esophagus (Bajwa et al., 2022). Esophageal cancers Esophageal cancers are aggressive malignancies with a high mortality rate. Esophageal cancer accounts for 1% of all cancers diagnosed in the U.S. and has a five-year survival rate of approximate - ly 20%. It is estimated that more than 20,000 new esophageal cancer cases are diagnosed annually, and it is three to four times more likely to be diagnosed in men than in women (ACS, 2022a). The most common esophageal cancers are squa- mous cell carcinoma and adenocarcino- ma (NCI, 2022).
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EVIDENCE-BASED PRACTICE Chronic gastroesophageal reflux dis - ease can lead to Barrett’s esophagus, where normal squamous cells of the esophagus are replaced with colum- nar cells. Research is being done at this time to identify which specific cells migrate to the site of the dam- age. Previously, it was thought that cells developed into the wrong type (instead of squamous cells, they would develop into columnar cells), but recent research has noted that the changes may result from stem cells coming from the gastric mucosa and developing into columnar cells. Bar- rett’s esophagus is highly associated with adenocarcinoma of the esopha- gus (Spechler, 2022a). Squamous cell carcinoma Squamous cell carcinoma occurs in the squamous cells that are located in the lining of the esophagus. The major risk factors for developing esophageal squa- mous cell carcinoma are cigarette smok- ing and chronic heavy alcohol consump- tion (ACS, 2022a).
CASE STUDY 2: PART 1 Lee is a 55-year-old man who arrived in the U.S. from Taiwan about 20 years ago. He is a heavy cigarette smoker, having smoked two packs per day for over 30 years. His wife tells him that his voice is different and hoarse. Lee also comments that he is having difficulty swallowing. These symptoms began several months ago and have become gradually, but steadily, worse. Lee decides to visit his doctor, who suspects an esophageal dis- order. A biopsy of esophageal tissue con- firms a malignancy. Question Lee has reported swallowing difficulty. Which recommendations would you consider discussing with Lee to address this issue? a. Eat larger meals less frequently throughout the day to prevent b. Gargle with salt water to help with the hoarseness and voice changes. c. Eat smaller meals more frequently to decrease the risk of aspiration. multiple pain episodes and decrease the risk of choking. d. Increase his intake of pickled vegetables to add fiber to his diet. Answer/Rationale: The correct answer is c. Those who report swallowing difficulties should eat smaller meals and take smaller bites to decrease the risk of aspiration.
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Esophageal adenocarcinoma Esophageal adenocarcinoma is cancer affecting the esophagus cells that make mucous and fluid known as glandular cells (NCI, 2022). Esophageal adenocarcinoma is strong- ly associated with obesity and gastro- esophageal reflux disease (GERD), while an even greater risk is the addition of to- bacco use. Work-related exposures, ge- netic predisposition, ingestion of a large amount of pickled foods (more common in some Asian countries), alcohol con- sumption, and HPV infection can also predispose a patient to develop esoph- ageal cancers (Gibson, 2022). Exposures to silica dust and airborne metal have also been associated with gastrointestinal cancers. Barrett’s esophagus increases the risk of developing adenocarcinoma (NCI, 2022). Signs and symptoms ● Often not initially distinctive. ● Dysphagia and weight loss are common early symptoms; the person reports taking increasingly smaller bites of food or eating foods that are easier to swallow, inadvertently causing weight loss or malnutrition. ● Chest pain. ● Hoarseness. ● Coughing. ● Feeling that something is caught in the throat or chest. ● Esophageal bleeding can be a potentially deadly symptom of esophageal cancer and is a medical emergency. ● Black tarry stools may indicate bleeding from high in the gastrointestinal tract (ACS, 2022b).
EVIDENCE-BASED PRACTICE ALERT Current research indicates that four genetically inherited syndromes may contribute to developing esophageal cancers. Future studies will focus on using this discovery to aid in screen- ing and treatment. In addition, target- ed therapies and immunotherapy are now being used to treat some esopha- geal cancers. However, more research is needed in these areas (ACS, 2020a). Screening for esophageal cancer Regular screening for low-risk patients without symptoms is not recommended, as there is no evidence that these screen- ings lower the mortality rate or decrease risk. In addition, screening using upper GI endoscopy or other invasive procedures may cause harm if tissue damage or reac- tions to the medications provided during the procedure occur. However, patients at significantly high risk, such as those with Barrett’s esophagus, should have period- ic examinations via upper GI endoscopy (NCI, 2022). Diagnosis is confirmed by undergoing an esophagogastroduodenoscopy (en- doscopic examination of the esophagus) with at least four biopsies of suspicious ar- eas. In addition, MRI of the chest and tho - racic region, PET scans, and CT scans are used to determine disease staging (NCI, 2022). Stage III and IV diagnoses involve tumors that invade the deepest layers of the esophagus and regional lymph nodes (ACS, 2022b). Treatment usually involves a combi- nation of surgery, chemotherapy, and radiation. Esophagectomy is the surgi- cal removal of the affected areas of the esophagus as well as local or affected lymph nodes and part of the stomach.
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This procedure can be indicated if a signif- icant amount of tissue is involved. Efforts are made to maintain a passageway for food by connecting the esophagus’s up- per part to the stomach’s remaining part. If this is not possible, it may be necessary for the patient to have a feeding gastros- tomy placed (Swanson, 2022). Postoper- atively, patients require a gastrostomy or jejunostomy tube, intravenous therapy, and supplemental oxygen. The feeding tube remains in place until a normal diet can be resumed and the anastomosis between the esophagus and stomach is healed (Swanson, 2022). Complications from esophagectomy can affect multiple body systems, with an overall mortality rate of up to 22%. Re- cent studies indicate that despite the high complication rate, approximately 86% of patients have an improvement in their symptoms. Frequent complications may include the following (Raymond, 2021): ● Respiratory complications (16%– 67%) : Atelectasis, pleural effusion, pulmonary embolism, acute respiratory distress syndrome, bronchospasm, and pneumonia. ● Cardiac complications : Cardiac arrhythmias (up to 20%) and myocardial infarctions (about 3.8%). ● Surgery-specific complications (up to 40%) : Wound infection, anastomotic leak (a breakdown of the new connection between the stomach and esophagus), stricture, conduit ischemia, laryngeal nerve injury, dysphagia, and gastric symptoms. Chemotherapy and immunotherapy may also be part of the treatment regi- men. Current research indicates that che- motherapy, in combination with radiation therapy, improves outcomes, especially if used before surgery, although chemo-
therapy may be used alone (ACS, 2020b). The most common chemotherapy-in- duced side effects are neutropenia, sto- matitis, mucositis, diarrhea, and emesis. Common side effects of immunotherapy can include fatigue, cough, nausea, skin rash, poor appetite, constipation, muscle or joint pain, itching, fever, and diarrhea. More serious complications of immuno - therapy may include infusion reactions and autoimmune reactions (ACS, 2022b). Radiation therapy, in conjunction with chemotherapy, may be used when sur- gery is not an option. This may be due to the patient’s refusal to undergo surgery or the inability to tolerate surgery due to poor overall health. Radiation may also be palliative in advanced esophageal cancer cases (ACS, 2020b). Potential complications associated with radiation to the esophagus may include (ACS, 2020b): ● Damage to the heart, lungs, or spinal cord. ● Fatigue. ● Skin issues such as radiation burns, compromised healing ability, and pain. ● Esophagitis, which can lead to difficulty with swallowing and result in nutritional deficits that require supplementation. ● Formation of esophageal strictures or shrinkage of the tissue, which leads to difficulty swallowing and may require esophageal dilation. The effects of surgery, radiation, and chemotherapy make patients susceptible to compromised nutritional status and swallowing complications.
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Esophageal fistula formation Tissue breakdown from radiation may cause an opening between the esopha- gus and adjacent areas, allowing GI con- tents to leak from the opening and poten- tially leading to infection or serious injury. For example, a fistula to the lung may allow GI contents to move into the lung and may be fatal (Majid & Kheir, 2021). CASE STUDY 2: PART 2 Lee underwent radiation and chemother- apy for his esophageal cancer. Howev- er, he reports that he has been having increasing difficulty swallowing since his treatments began. The nurse suspects he has developed esophageal strictures related to his radiation therapy. This will likely require multiple dilations. After the nurse confirmed this with Lee’s provider, she explained the process and provided emotional support for him. Question Lee was speaking with the nurse about the esophageal dilation after she explained the process to him. What statement about esophageal dilation indicates he needs more education? a. The healthcare provider may perform esophageal dilation with sedation and upper endoscopy. b. During the procedure, he might experience mild pressure in the back of the throat or chest. c. The dilator will cut off his airway during the procedure. d. He might experience a mild sore throat for the remainder of the day after the procedure. Answer/Rationale: The correct answer is c. The endoscope does not interfere with breathing.
| HEALTHCARE CONSIDERATION
Patients undergoing radiation ther- apy should ask their provider about appropriate lotions or salves for radi- ation irritation or burns. These areas are highly susceptible to infection and additional irritation from additives. Numerous salves, lotions, and dress- ings are available; however, there is no superior treatment from these cat- egories (Yang et al., 2020). As postoperative and radiation pa- tients begin to tolerate advances in diet, it is critical to observe for aspira- tion or sudden changes in pain level. Each step in changing the diet should be started with small amounts at inter- vals as tolerated and always with the head of the bed elevated (Raymond, 2021). Patients and families often need sig- nificant emotional support as well as assistance with the patients’ physical needs. The prognosis for esophageal cancers is generally not good, and as the disease progresses, information about home health assistance, pal- liative care, and/or hospice may be needed. Organizations that may help include The American Cancer Society (http://www.cancer.org; 1-800-227- 2345) and the Esophageal Cancer Awareness Association (http://www. ecaware.org; 1-800-601-0613).
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EVIDENCE-BASED PRACTICE ALERT Patients with asthma experience an in- creased incidence of GERD. Research also has shown that GERD exacer- bates existing asthma. Nerves in the lower part of the esophagus connect to nerves in the lungs, causing acid reflux to trigger asthma symptoms. People with both asthma and GERD may find that treating GERD can help reduce their asthma symptoms and use of asthma medication. (American Academy of Allergy, Asthma, and Im- munology [AAAAI], 2022). Data have shown that 25%–40% of in- dividuals in the U.S. report symptoms of GERD at some time, and 7%–10% report that they experience symptoms daily. The actual percentages may be even high- er because many people self-medicate with over-the-counter (OTC) preparations and never report symptoms (Patti, 2021). GERD tends to be chronic, with relapse common, and long-term medication main- tenance therapy may be required. GERD is often considered an adult problem with increased risk over 40 (Patti, 2021); how- ever, studies show that GERD is common in infants and children. Repeated vomit- ing, coughing, irritability or colic, and re- spiratory problems may indicate GERD in this young population. Most infants will have a resolution of their GERD by age six months without any treatment, as the infant is typically able to sit and eat some solid foods by this time, and the lower esophageal sphincter has matured. By the age of ten months, 90% of cases see full resolution (Schwartz, 2019).
CASE STUDY 3 Mrs. Dasher is a 75-year-old retired bi- ology teacher. She has taken verapamil (Calan, a calcium-channel blocker) and a low-dose aspirin daily since a mild heart attack five years ago. She is also being treated for asthma, which has worsened since she contracted COVID-19. During a routine doctor’s visit, Mrs. Dasher men- tions that she has been suffering from severe “heartburn” for the past several months, “especially after my fourth or fifth cup of coffee.” Mrs. Dasher needs to be evaluated for GERD. Question All of the following are risk factors for the development of GERD EXCEPT: a. Aspirin use. b. Excessive coffee consumption. c. Asthma. d. History of heart attack. Answer/Rationale: The correct answer is d. Aspirin use, excessive caffeine, and asthma contribute to GERD’s development. A history of heart attack does not contribute to the risk of GERD. Gastroesophageal reflux disease (GERD) Often referred to as heartburn, GERD is the backflow of gastric or duodenal con - tents into the esophagus past the low- er esophageal sphincter (LES; Kahrilas, 2022). GERD is often dismissed as a mi- nor annoyance. However, ongoing reflux may cause inflammation of the esoph - ageal mucosa and result in esophageal ulcers, strictures, or Barrett’s esophagus (Kahrilas, 2022). All reports of heartburn must be carefully evaluated.
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Under normal conditions, the LES sus- tains enough pressure around the lower end of the esophagus to close it, thus preventing reflux of gastric or duodenal contents. The sphincter relaxes after ev- ery swallow, allowing food to pass into the stomach. In GERD, the sphincter does not remain closed because inadequate LES pressure or the pressure in the stomach
propels gastric contents into the esoph- agus from hiatal hernia or obesity. Stom- ach contents are very acidic and cause pain and irritation when they move into the esophagus. The esophageal mucosa becomes inflamed, which can decrease LES pressure more and more until there is a recurrent cycle of reflux and heartburn (Patti, 2021).
Figure 4. GERD
Note . BruceBlaus. (2015). GERD. https://commons.wikimedia.org/w/index.php?curid=44923646. CC BY-SA 4.0.
● Conditions that increase abdominal pressure (pregnancy, obesity, and persistent vomiting or coughing). ● Medications, including anticholinergics, benzodiazepines, NSAIDs, aspirin, nitroglycerin, albuterol, calcium channel blockers, antidepressants, and glucagon. ● Acidic foods and drinks (coffee, soda, alcohol, tomatoes).
Risk factors associated with the devel- opment of GERD (International Founda- tion for Gastrointestinal Disorders [IFF- GD], 2022): ● Hiatal hernia. ● Conditions that cause delayed gastric emptying (inflammation, obstruction, vagal nerve injuries, neuropathy. ● Conditions that cause LES dysfunction (obesity, smoking, alcohol use, certain medications, and high-fat foods).
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The most common presenting symptom of GERD is burning pain in the epigastric area, which patients may report as experi- encing heartburn. Often, GERD presents in the same way as a myocardial infarc- tion. Until cardiac etiologies are ruled out, the symptoms should be treated as such (Patti, 2021). Pain often occurs after a meal or when lying down, and patients may complain of fluid accumulation in the throat or having food stuck behind their breastbone. A chronic cough or hoarse- ness upon awakening may develop as a result of the reflux of gastric contents into the throat (Patti, 2021). Diagnostic tests for GERD focus on identifying the underlying cause. In addi- tion to a careful history and physical, sev- eral specific tests are conducted (IFFGD, 2022): ● Ambulatory 24-hour pH monitoring (BRAVO): Assesses the competence of the LES and measures reflux activity over 24 hours. This helps to determine if reflux is the cause of the problem, distinguishes reflux from cardiac problems, and links episodes with symptoms. ● Esophagogastroduodenoscopy (EGD) : Used to evaluate the extent of the disease and identify pathologic changes. ● Barium swallow esophagram : Used to identify if hiatal hernia is a causative factor or if the esophageal stricture is a complication of GERD. ● Esophageal manometry : Measures the strength and function of the esophagus and the musculature of the throat and esophagus. Esophageal muscle pressure, movement, coordination, and strength are assessed. Esophageal sphincters are
evaluated, with a particular focus on the LES in patients with GERD. ● Esophageal impedance-pH study : Measures how liquid moves between the stomach and esophagus. This can be a helpful test to distinguish acid from bile reflux in patients who have had normal BRAVO results but still experience GERD-like symptoms. Treatment goals for GERD are to con- trol symptoms, promote healing of the esophagus, and prevent or manage com- plications. Symptom control focuses pri- marily on lifestyle modifications such as the following (Patti, 2021): ● Dietary habits : Avoid foods that trigger GERD symptoms, such as caffeine products, chocolate, spicy foods, carbonated beverages, orange juice, alcohol, onions, fatty foods, tomato juice, and tomato sauce. Encourage small, frequent meals and avoid eating large meals, which put pressure on the LES. ● Positioning : Patients should not lie down for three hours after eating and should sleep with the head of the bed raised about 8 inches. A flat position puts pressure on the LES. ● Weight : Obesity increases abdominal pressure, pushing gastric contents into the esophagus. Even moderate weight loss can help reduce symptoms. Lifestyle modifications can promote the healing of the esophagus and control symptoms. Many patients also take med - ications for the treatment of GERD (Patti, 2021): ● Antacids neutralize acidic gastric contents. ● Foaming agents, such as Gaviscon, prevent reflux.
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● H2 blockers reduce the amount of gastric acid production. ● Proton pump inhibitors (PPIs) block acid production. | NURSING ALERT Studies have shown that H2 receptor antagonists are effective for healing mild esophagitis but are less effective when the esophagus is eroded. More severe cases, or cases with esopha- geal erosion, may require using a PPI (Patti, 2021). A review of prescription and over-the-counter medications to identify possible drug interactions is important for patients who frequently use antacids. EVIDENCE-BASED PRACTICE Protein pump inhibitors (PPIs) limit gastric acid secretion and facilitate rapid resolution of symptoms and esophageal healing. Examples of ap- proved PPIs include Prilosec, Nexium, and Protonix. PPIs should be used only with a confirmed diagnosis of GERD. Chronic use has recently been shown to be associated with the fol- lowing conditions (Patti, 2021): ● Calcium homeostasis can be affected, increasing the risk for bone fracture, especially hip fractures in older adult women, and cardiac changes. ● Clostridium difficile infection. ● Iron, magnesium, and vitamin B12 malabsorption. ● Kidney disease (acute and chronic).
If treatment is unsuccessful, surgical op- tions for the treatment of GERD also exist. However, evidence is conflicting about whether surgery is an effective long-term solution. In a recent study reviewing the effectiveness of the surgical intervention fundoplication, 7.6% of those studied re- quired a revision of their original surgery, and 53.8% required anti-reflux medica - tions within six months of their surgery (Patti, 2021). Barrett’s esophagus In addition to helping patients adhere to their treatment regimen, nurses must be alert and teach their patients to be alert to the possibility of developing Barrett’s esophagus. Barrett’s esophagus is a dis- order characterized by normal tissue that lines the esophagus being replaced with tissue similar to the lining of the intestine, known as intestinal metaplasia (Spechler, 2022b). Barrett’s esophagus does not produce signs or symptoms. Its cause is unknown but often found in persons with GERD. The disorder affects up to 20% of adults age 50 and older in the U.S. It af- fects men about three times as often as women and White men more often than men of other ethnic backgrounds. Smok- ing also increases the risk of its develop- ment (Spechler, 2022b). According to one recent study by Kh- ieu and Mukherjee (2022), about 15% of those with GERD will develop Barrett’s esophagus. Because there are no specific signs and symptoms, physicians may rec- ommend that patients over age 50 with a lengthy history of GERD be screened for Barrett’s esophagus (Spechler, 2022b). A small percentage of patients with Barrett’s esophagus may develop esophageal ad- enocarcinoma. Because of the lack of symptoms, this cancer is often not detect- ed until it is advanced (Gibson, 2022).
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EVIDENCE-BASED PRACTICE ALERT Previously, it was thought that the bacteria Helicobacter pylori may in- crease the risk of developing Barrett’s esophagus when present in the stom- ach. However, recent research has shown the opposite may be true— H. pylori may have a protective effect on the mucosa. Although this finding is unclear, some researchers have posit- ed that the bacteria can prevent the stomach contents from damaging the esophageal mucosal tissue (Medical University of South Carolina [MUSC], 2022). Esophagitis Esophagitis is the term used to describe an inflammation of the esophagus lining, which can cause pain, bleeding, and dys- phagia. Esophagitis can be caused by a variety of factors (Devuni & Birk, 2020). GERD ● Certain medications, including NSAIDs, aspirin, osteoporosis medications, and iron supplements. candidiasis, herpes simplex virus (HSV), and cytomegalovirus (CMV). ● Certain allergies or inflammatory reactions, such as asthma (Antunes & Sharma, 2022). Diagnosis typically involves an esoph- ageal barium study or esophagography, especially in patients with dysphasia. An upper endoscopy can also assess the ex- tent of tissue damage and identify erosion areas. Most cases of esophagitis resolve within a few days of identification once treatment is started, but this depends on the underlying cause and whether that ● Cancer treatments such as chemotherapy and radiation. ● Certain infections, including
Barrett’s esophagus is diagnosed via an upper endoscopy and biopsy. After inser- tion of the endoscopic tube, the health- care provider can inspect the lining of the esophagus and note the presence of an abnormal lining. However, a biopsy of the lining of the esophagus is necessary to confirm the presence of a malignancy (Spechler, 2022b). Several treatment options for Barrett’s esophagus with severe dysplasia or ma- lignancy are available. The focus of these options is to destroy or remove the sec- tion of the lining that is dysplastic or can- cerous. Several endoscopic therapies may be used to treat Barrett’s esophagus under these conditions (Spechler, 2022b): ● Radiofrequency ablation (RFA) : This treatment uses radio waves to kill precancerous and cancerous cells by heating an electrode on an endoscope. ● Endoscopic cryotherapy : This approach uses liquid nitrogen or another cryogen to freeze the area of concern, disrupting the ability of the mutated cells to reproduce by damaging them and the vessels that supply them with blood. ● Endoscopic mucosal resection (EMR) : During an EMR, the affected mucosal lining is incised and removed through an endoscope. Complications can include bleeding or tearing of the esophagus. EMR may be performed in conjunction with PDT. Esophagectomy (surgical removal) may be recommended in severe dysplasia or malignancy cases.
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