DISORDERS

OF THE

ORAL CAVITY

CLEFT LIP
A facial malformation that involves the

failure of the fusion of the maxillary and

medial nasal processes in the embryo.
CLEFT PALATE
Failure of the palatal processes to close;

usually on the midline involving just the

anterior hard palate, the posterior soft
palate, or both.

DISORDE DIAGNOSTIC
FINDINGS
R
Ultrasonograp -can be detected while the
Cleft Lip
hy
infant is in
utero.
- as early as 14 to 16
weeks of gestation
Physical
-a typical picture clinical
Cleft
examination/ picture confirms
Palate
assessment
the diagnosis.
- determines the degree of
defect

CLEFT LIP

CLEFT PALATE

A facial malformation that

involves a failure in the
fusion of the maxillary and
medial nasal processes in
the embryo.
Defect ranges from a small
notch in the upper lip
(vermillion)
to
a
total
separation of the lip and
facial structure up into the
floor of the nose.

A
defect
that
is
characterized by the failure
of the palatal processes to
close.

Defect is readily seen upon

delivery
and
initial
assessment.

Is only revealed when the

examiners
finger
is
directly inserted to the
mouth in order to palpate
the palate.

Usually on the midline

involving just the anterior
hard palate, posterior soft
palate or both.

1. Cheiloplasty- it is the constructive operation

to correct cleft lip which must be done shortly

after birth.
Z-plasty is a plastic surgery technique that is used to
>Follows the RULE of 10
improve the functional and cosmetic appearance of
>Z-plastymosta common
scars.
It can elongate
contracted technique
scar or rotate the
tension line. The middle
linerepair
of the Z-shaped
2.scar
Palatorrhapysurgical
of cleft palate
incision
is made along
the line of greatest
or
>Multi-stage
operation:
not tootension
early and
contraction,
not too and triangular flaps are raised on opposite
sides of the two ends and then transposed. The length
late (6-18mos or 18-24mos)
and angle of each flap must be precisely the same to
3.avoid
Velopharyngeal
Flap
Operation
mismatched flaps that
may
be difficult to close.
Some possible complications of Z-plasty include flap
necrosis,

VELOPHARYNGEAL FLAP OPERATION

Preoperative
Breastfeeding may be possible.

a.HABERMAN FEEDER- with disc valve which controls

pressure and flow of feeding.
b. BRECK FEEDER- similar to a bulb syringe
Offer formula in amount and strength for age
Try several feeding methods to determine infants needs.

>When using a soft nipple, assist in sucking with a biting

type of movement.
>When dropper or a form of syringe is used, insert rubber
tip in the center of the mouth and side of the tongue
and
as far back in the mouth as practical.

NURSING DIAGNOSIS: Risk for

imbalanced nutrition: Less

than body requirements r/t
feeding problems caused by cleft
lip or palate
Outcome: Child will
demonstrate adequate nutritional
intake during preoperative
interval.

If unable to suck properly, prop on pillow,

gently hold lip together with one hand and

hold the bottle with soft nipple on the other.
Bubble frequently
Give water if cleft palate.
Gavage feeding if above measures are not
tolerated.
If surgery is delayed beyong 6 mos or the
time solid food is intoduced, teach parents
to be certain that any food offered is SOFT.

REMINDERS
employs the ESSR technique: (1) enlarge
the nipple, (2) stimulate the suck reflex,
(3) swallow fluid appropriately, (4) rest
when the infant signals
BREASTFEEDING: position the infants head

upright , either held in the caregivers hand or

cradled in the arm.
BOTTLEFEEDING: use of large, soft-nipples with
large holes improves delivery of milk formula
BOTTLEFEEDING: use of gravity flow nipple
attached to a squeezable plastic bottle
use of MEDICINE DROPPER
BOTTLEFEEDING: single small slit or crosscut
nipple

NURSING ALERT: techniques in feeding an

infant with defect

position the nipple so that it is compressed by the

tongue and the remaining palate (covering the

defect) facilitates proper feeding.
if a single slit nipple or cross cut nipple is used, it is
offered vertically
use gentle, steady pressure on the base of the
bottle
the person feeding should resist temptation of
removing the bottle when there is noisy feeding
BREATSFEEDING: the nipple is positioned and
stabilized well at the back in the oral cavity

Postoperative
Cleft Lip
NPO for the first 4 hours then liquids

(plain water) offered gradually to

prevent vomiting and aspiration.
Uses a specialized feeder
Avoid touching the suture line.
Breastfeeding is allowed 7-10 days after
surgery

Feed clear fluids gently with plastic

spoon or cup.
Do not include milk in the first fluids.
Soft diet after 3-4 days until healing
is complete
No straw.
Offer water after each feeding.

A. Risk for ineffective airway clearance r/t

oral surgery.
Nursing Interventions
Observe for respiratory distress due to

local edema formation after surgery.

Suction gently. Do not touch the suture
line with the catheter.
Do not lie infants on their abdomen after
CL surgery. Puts pressure on suture line
Position the patient on his side or as soon
as awake, in an infant chair.

B. NURSING DIAGNOSIS: Impaired

tissue integrity at incision line r/t
cleft lip/ cleft palate surgery
Nursing Interventions
Provide care r/t Cl and CP sutures
o Apply arm or elbow restraints one at a time for
o
o
o
o
o

short periods (jacket restraints for older in

Explain the purpose of restraints (arm/elbow)_
until suture is completely healed.
Position properly
Watch put for signs of swelling.
Observe for signs of respiratory distress.
Prevent crying

Cleft Lip

Cleft Palate

Do not remove or touch band-aid bar or DO not allow child to

LOGANs bar
put toys with sharp
edges in their mouth.
Assess the Logans bar after each
Do not use straw to
feeding or cleansing of the suture line. drink.

Minimize crying or facial movement to Do not allow child to

prevent tension on suture lines.
brush his own teeth.
- Anticipate infants needs.
-Have formula ready to feed on demand.
-Help parents use whatever measures
necessary to make infant feel secure and
comfortable.
-Bubble infant well after feeding

Cleft Lip
Report bleeding or
separation of suture
line.

Cleft Palate
Keep elbow restraints in
place as necessary
Provide diversional
activity.
May administer
Acetaminophen

NURSING DIAGNOSIS: Risk for

infection r/t inadequate primary
defenses
Nursing Interventions
Teach the correct method of brushing
Prevent infection of the cleft.
Clean suture line with sterile saline or

50% hydrogen peroxide every feeding.

Use smooth, gentle rolling motion to apply
the solution.
Dry suture line with dry sterile cottontipped applicator.

NURSING DIAGNOSIS: Risk for infection

(Ear) r/t altered slope of Eustachian tube with
cleft palate surgery
Nursing Interventions:
Review signs and symptoms of infection with
parents of children with cleft palate (take note
of any discharges, presence of fever and pain)
Report pharyngeal infection promptly (to treat
promptly and prevent spread to other area)
Myringotomy (to drain middle ear fluid and
protect hearing) tubes at the time of palate
repair.
Routine screening for healing loss (common
first-noticed sign of serious otitis media).

NURSING DIAGNOSIS: Impaired

communication r/t anatomic deficit (cleft
palate)
Nursing Interventions
Explain the relationship of chronic otitis

media with the development of typical

speech patterns.
Speech must be encouraged at ageappropriate times.
Encourage to voice vowel sounds.
Arrange for speech therapy, reinforce
training at home.
Provide speech exercises like blowing
games.

NURSING DIAGNOSIS: Risk for altered

parenting r/t infant with a highly visible
physical defect.
Nursing Interventions
Allow expression of feelings.
Convey attitude of acceptance of infant and family.
Focus on the positive aspects of the infants

appearance and behavior.

Support parents during the stage of grieving
process.
Explain the need of cosmetic surgery as the child
grows.
Arrange meeting with other parents who have
experienced as similar situation and coped
successfully.
To promote bonding, encourage parents to hold and
interact with their infant.

Caused by plaque formation and

bacterial colonization and may result

to gingivitis
Inflammation destroys the underlying

tissues and seperates the gingival

from the tooth.

DIAGNOTIC
PROCEDURES
Oral examination

FINDINGS

-may show dental caries before it is

otherwise visible,
particularly caries between the
teeth
Orthodontic (Dental) a dental radiograph that shows
tooth decay
X-ray

Drilling out cavities and filling the

tooth with material to restore the

tooth
Tooth extraction
Root canal therapy- to preserve the
tooth
Dental prosthesis
Full mouth extraction

Inflammation of the soft tissues

of the oral cavity

Classification: PRIMARY and

SECONDARY

DISORDER
Aphthous
Ulcers

DIAGNOSTIC

FINDINGS
>small, reddened,ulceration on
soft tissue of the tongue, lips,
Oral
and buccal mucosa.
examinatio >a circumscribed erythematous
n
macule creating a well-defined
pseudomembranous ulcer with
an eryhtematous border.

Herpes
Simplex

>presence of oral lesions

characterized byclear vesicular
at the mucocutaneous junction
of the lips

Vincents
Angina

>ulcers covered with a

pseudomembrane.
- usually with increase WBC
count

MANAGEMENT: Pharmacologic
Topical or systemic steroids
Aphthasol (Amlexanox)- shorten the healing

time

MANAGEMENT: Diet
Instruct to avoid tomatoes, chocolates, eggs

shellfish, milk products, nuts ,and citrus fruits.

Provide a soft bland diet.

MANAGEMENT: Pharmacologic
Symptomatic
Pain- analgesics, local or topical ointments and
anesthetic drugs
Immunocompromised Antiviral drug: IV Acyclovir
(Zovirax)
Competent immune system: acyclovir oral or
topical form or pencyclovir (Denavir) topical cream
If with secondary infection- antimicrobial
medications
ACTIVITY: rest and avoidance of stress.

Removal of devitalized tissue

Improve oral hygiene
Rest
Bland diet
Vitamins
Pain medications and saline mouth

rinses promote comfort.

Antibiotics

Impaired Oral Mucous Membrane r/t poor oral

hygiene, inflammation
Pain r/t to inflammation of oral mucous membrane
Knowledge deficit r/t lack of exposure/ recall
Imbalanced Nutrition: Less than body

requirements r/t oral pain and difficulty eating

and swallowing (mouth discomfort)

Alleviate the cause

Treat infection
Emphasize good oral hygiene
Use of soft, small tooth brushes
Gargle with water + hydrogen peroxide

solution
Soft, bland diet at room temperature
Avoid too hot foods and fluids;
spicy,salty, acidic, abrassive
Topical medications (hydrocotisone,
antibiotic ointments) as ordered.

Assist in the achievement of

therapeutic goals
Give antibiotics as ordered.
Crush tablets if with difficulty in

swallowing
If Nystatin (Mycostatin) is ordered for
oral thrush, instruct that patient to
hold suspension and swish it through
the mouth for as long as possible (for
at least 1minute and swallow)

Provide mouth care

Thorough and frequent mouth care (2-

3x/day)
Remove dentures if it is causing pain.
Use foam sponge toothbrush.
If toothbrush causes pain, gently wipe gum
and teeth with moistened gauze wrapped
around a tongue blade.
Dental floss at least once a day
Brush gums and tongue surface

Use the following solutions as

necessary:
Alkaline mouthwashes (NaHCO3)- tsp

in large glass of warm water.

Hydrogen peroxide diluted 1:4 with
normal saline (Mix just before using to
prevent decomposition).
Lidocaine rinses may be prescribed for
stomatitis resulting from chemotherapy.

Promote pain relief

Good oral hygiene
Avoid smoking
Give cold drinks or let patient suck

frozen popsicles
Give analgesics as prescribed
Provide topical anesthesia
Avoid commercial mouthwashes due to
high alcohol content.
Avoid hot and spicy foods
Soft and pureed diet

Facilitate eating and drinking

Administer analgesic as prescribed (30-

45 minutes before a meal)- decreases

the pain associated with eating
Encourage to have small frequent
feedings
Provide oral care before and after meals
to remove debris and minimize oral
odors.
Give soft foods including pureed
vegetables and fruits except citrus.
Cooked cereals, soups, flavoured gelatin,
and ice cream are best tolerated.

Avoid hot and spicy foods

High protein, high caloric diet
Weigh daily
Administer antiemetics to prevent

nausea and vomiting as prescribed.

Provide assistive device

Client teaching
Inform about the contributory factors

that causes the problem which can be

controlled maintain good nutrition, visit
the dentist regularly, avoid foods that
irritate the mouth, avoid smoking, and
use stress management
Techniques to decrease effects of stress.
Replace toothbrush every 2 months
Avoid alcohol and tobacco products

DISORDERS
OF THE
ESOPHAGUS

 A congenital defect involving the failure of the

esophagus to develop a continuous passage

from the throat to the stomach

DIAGNOSTIC PROCEDURES

FINDINGS

Maternal history

(+) polyhydramnios which

indicates atresia.Normally, fetus
swallows amniotic fluid during
intrauterine life.

Assess response for feeding

-coughing, become cyanotic,

DOB, appears to be blowing
bubbles (noted in
tracheoesophageal fistula)

X-ray of the abdomen

stomach distention

Barrium swallow, Bronchial

endoscopy

reveals blinded esophagus and

fistula

NURSING ALERT! It is important that the diagnosis of

esophageal atresia be made before the initial feeding.
Because of this, it is recommended that the first feeding
should only consist of plain water.

SIGNIFICANT
EXAMINATIONS:

maternal
polyhydramnios

DIAGNOSTIC
history

of

Broad spectrum antibiotics- to avoid and reduce

the risk for pneumonia.

MANAGEMENT: Surgical
Palliative
Gastrostomy/ PEG (Percutaneous Endoscopic

Gastrostomy)
Cervical Esophagostomy- involves opening in the cervical
section (distal end) of esophagus just over the sternum so that
mucus can drain and for placing of an indwelling feeding tube.

SURGICAL MANAGEMENT:

PALLIATIVE
SURGERY:
GASTROSTOMY (PEG)

PERCUTANEOUS

ENDOSCOPIC

SURGICAL MANAGEMENT:
CORRECTIVE SURGERY: END-TO-END ANASTOMOSIS

A. an opening is cut
into the chest
B The two parts of
the existing
esophagus are
identified
C. The lower
esophagus is
detached from the
trachea and
D. Connected to the
upper part of the
esophagus
The wound in the
trachea is closed,

Observe for signs of stricture at the

anastomosis site.
Maintain patent airway.
Maintain adequate nutrition.
Oral hygiene to prevent bacterial
growth.
Give pacifier
Encourage parental participation to
promote bonding.

NURSING
POSTOPERATIVELY

MANAGEMENT

the infant is returned to the incubator

gastrostomy tube is kept in place (pacifier)
if well tolerated, gastrostomy feeding may be
continued until the anastamosis is healed
oral feeding is withheld until the anastamosis is
healed, an esophagram is used to visualize it
WHEN ORAL FEEDING IS ALREADY INDICATED: begin
with
STERILE WATER (or GLUCOSE WATER) and is
followed by SMALL FREQUENT FEEDINGS of the MILK
FORMULA.
COMPLICATIONS:
pneumonia
pneumothorax
anastomotic leak
strictures

esophageal
disorders

CURRENT OVER-ALL
SURVIVAL RATE IS 85% 90%.
motility
MORTALITY IS ALWAYS
ASSOCIATED WITH THE
COMPLICATION.

NURSING DIAGNOSIS: Ineffective airway clearance

r/t tracheobronchial obstruction
Nursing Interventions
Report excessive secretions; unexplained 3 Cs
immediately if diagnosis has not been made.
Stop oral feedings- IV infusion or TPN is given.
Oxygen therapy prn.
Position properly to keep airway free of saliva or gastric
contents.
Suction prn as ordered.
Observe closely for; vital signs, respiratory behavior,
amount of secretions, abdominal distention, and skin color.

NURSING DIAGNOSIS: Risk for

aspiration r/t impaired swallowing
Nursing Interventions
IVF as ordered or TPN before and shortly
after the surgery
Oral feeding, TPN, Gastrostomy tube
feeding
Early introduction of fluids.

Formula is introduced into the tube slowly and allowed to

run by gravity, never put pressure.

After feeding, end of tube should be elevated , covered by
sterile gauze and kept in that position
Do not clamp the tube after feeding.
Position upright.
Clean the stoma with the use of gauze.
Keep tube left open.
Prevent Give pacifier while feeding.
Elevate HOB while feeding until one hour later.
NOTE: Glucose water is given in small amounts for first oral

feeding.

NURSING DIAGNOSIS: Risk for infection r/t

inadequate primary defenses
Nursing Interventions
Position upright or on the right side
Frequent oropharyngeal suctioning.
If with esophagostomy, use absorbent gauze around the
opening.
Apply protective ointment liberally.
Prevent patient from crying to limit and prevent air from
entering stomach.
Provide a high humidity oxygen source to liquefy
secretions.
Keep laryngoscope and ET tube at bedside.

It refers to a syndrome

resulting from esophageal

reflux
Backflow of gastric contents
in the esophagus.
INCOMPETENT LOWER
ESOPHAGEAL SPHNCTER

DIAGNOSTIC

FINDINGS

Barrium swallow

evaluates damage to the esophageal

mucosa
(+) inflammation and thickening of
esophageal foldS

Twenty four (24)-hour pH

probe monitoring test

measures and records reflux of acid in

the esophagus

Esophageal manometry

used to evaluate LES pressure and

esophageal motility.
-decrease motility of the esophagus.

Esophagoscopy

reveals esophagitis with edema and

erosion of the mucosa

Esophageal biopsy

-reveals hyperplasia of cells and

infiltration of
epithelium with eosinophils

Cytological examination
Bernstein test

Analysis for gastric

secretions

-a.k.a Acid Perfusion Test which reveals

reflux of gastric
secretion---- (+) Chest pain

Antacids: CaCarbonate/
MgCarbonate(Mylanta),MgOH/
AlOH( Maalox),AlOH/Mg Carbonate
( Gaviscon)
-to relieve pain for 10 to 30 minutes.
Action: To buffer and neutralize gastric
acid secretion and soothe the mucosal
lining.
Dosage: 30 ml, 1 hour before and 2 to 3
hours after meals.

H2 receptor antagonists: Ranitidine (Zantac), Famotidine

(Pepcid)
Action: Decrease gastric acid secretion by inhibiting H2
receptor in the parietal cells.
Given 1 hour before meals or after antacids (most
effective: BID).
Proton Pump Inhibitors: Lanzoprazole (Prevacid,
Esomeprazole (Nexium)
Action: Inhibit H and K ATPase enzyme in the parietal cells.
Initially given twice daily.
MOST EFFECTIVE for GERD: given 30 minutes before
meals.

Cholinergics: Bethanecol/ Urecholinelincrease LES pressure and prevent reflux

GI Stimulants: Metoclopramide (Reglan)
Action: increase LES pressure by
stimulating the smooth muscle of the GIT
and increases the rate of gastric emptying
-taken 30 to 60 minutes before meals.

Small frequent feedings (4-6x/day) to decrease the

amount of food in the stomach.

Adequate fluid intake/drink fluid with meals
Eat slowly and chew food thoroughly
Avoid irritants
Avoid eating and drinking for 3 hours before sleeping to
prevent nocturnal reflux.
Elevate HOB (6-8 inches) to prevent nocturnal reflux.
Lose weight prn to decrease gastroesophageal
gradient.
Avoid tobacco, salicylates or phenylbutazone which
may exacerbate esophagitis.

Endoluminal Gastroplication
-for symptomatic GERD
-an OP procedure which is done by creating

plications, or pleats, at the LES

(two sutures near the LES and then tied
together to create a pleat near the LES).
-mild sedation

It is characterized by herniation of a

part of the stomach into the thoracic

cavity through an enlarged
esophageal hiatus in the diaphragm.
Types: Sliding hernia, Rolling hernia

DIAGNOSTIC

Barium swallow with

fluoroscopy

CXR

FINDINGS

-reveals hiatal hernia by

showing the position of
the stomach in relation to
diaphragm.
shows the protrusion of the
stomach into the thorax

SAME with GERD

SURGICAL MANAGEMENT
Nissen Fundoplication
Hill Operation
Belsey (Mark IV) repair
Angelchik Prosthesis Insertion

NISSEN FUNDOPLICATION
the FUNDUS of the stomach is wrapped, or plicated, around

the lower end of the esophagus and stitched in place,

reinforcing the closing function of the LES Whenever the
stomach contracts, it also closes off the esophagus instead of
squeezing stomach acids into it.

SURGICAL MANAGEMENT
NISSEN FUNDOPLICATION

GASTROESOPHAGEAL

REFLUX

SURGICAL MANAGEMENT
NISSEN FUNDOPLICATION

GASTROESOPHAGEAL

REFLUX

SURGICAL MANAGEMENT
NISSEN FUNDOPLICATION

GASTROESOPHAGEAL

REFLUX

HILL OPERATION
Narrows the esophageal opening and

anchors the stomach and distal

esophagus to the median arcuate
ligament.
This reinforces the sphincter and
recreates the gastroesophageal
valve.
A partial wraparound (180deg) of
stomach around esophagus.

Belsey (Mark IV) Repair

Consists of plication of the anterior and

lateral aspects of the stomach onto the

distal esophagus.
Surgeon creates the esophageal angle
without opening the esophagus or the
diaphragm
A 280 deg esophageal wraparound is
created via a Thoracic Approach

Angelchik Prosthesis
Insertion
Synthetic C-shape silicone prosthesis

anchors the LES in the abdomen and

reinforces sphincter pressure.
For severe reflux.

Nursing Interventions
Client teaching to control GERD
Proper dietary management
Meet/Promote adequate nutritional needs
Small frequent meals
Chew food thoroughly
Drink fluid with meals
Provide a relaxing environment during meals

Avoid milk
Remain sitting for 20 minutes after each meal
Relieve pain/regurgitation
Give antacids/H2 receptor antagonist
Elevate HOB (6-8 hours)
Relaxing environment during meal time
Avoid constricting garters especially during

mealtime
Lose weight if overweight
Prevent pot-op complications

Postperative Assessment
Monitor for respiratory distress
Maintain patent NGT (to prevent stomach distention)
Monitor for possible presence of DVT
Prevent Respiratory Complications
Turning, coughing, deep-breathing exercises after
surgery
Explain chest tubes may be used in thoracic
approach
May use incentive spirometer.

Prevent Gas-Bloat Syndrome

Administer fluids after 24 hours
DAT once peristalsis returns
Small frequent feeding
Avoid gas forming food
Avoid carbonated beverages (gas-producing
foods)
Ambulation
Instruct patient to report dysphagia, feeling of
fullness, bloating, or excessive borborygmi

 Sac- like outpouching in one or more layers of

the esophagus
DIAGNOSTIC
Barrium swallow

FINDINGS/PURPOSE
-CONFIRMATORY TEST: reveals
outpouching of a part of esophagus

NOTE: Endoscopy is contraindicated because the scope

may be passed
into the diverticulum and can cause rupture and
perforation.
Esophagheal
-for epiphrenic diverticulum
Manometry
-high amplitude esophageal
motility
-elevated pressure in LES

Small frequent feeding of semi soft food to

facilitate passage of food.

Note food which ease/worsens the
manifestation.
Elevate HOB 2 hours after meals to avoid
reflux.
Avoid constrictive clothing
Avoid vigorous exercise

SURGICAL MANAGEMENT
Excision of diverticulum and

anastamosis
Cervical approach for Zenkers

diverticulum
Thoracic approach for
diverticulum in the lower
esophagus

Zenkers Diverticulum

NURSING DIAGNOSES
Pain
Risk for injury
Nursing Interventions
Decrease level/relieve from pain
Assess pain and administer analgesics
Elevate HOB (post-op; to reduce edema
the neck and upper chest)
Frequent Oral hygiene (for comfort).

Injury will be prevented by:

NPO after surgery
Maintain NGT until healing occurs
Dont move unless indicated to prevent
perforation
No irrigation
Low intermittent suctioning
To avoid trauma to the stomach lining and
for removal of secretions.
Check amount and color of drainage
Assess for esophageal perforation (chest pain,
fever, SQ emphysema).
IVF until tube feeding begins

It is characterized by progressively

increasing dysphagia
It is a motor disorder of the
esophageal smooth muscle in which
the lower esophageal sphincter does
not relax normally with swallowing,
and the esophageal body undergoes
non- peristaltic contractions.

DIAGNOSTIC
FINDINGS/PURPOSE
Barrium swallow To determine the presence of
achalasia
Reveals non- propulsive waves and
esophageal dilation.
Monitors the status of the LES, the
Endoscopy
amount of dilation, and presence of
food.
Examines the esophageal mucosa
and obtain biopsy specimen.
Manometry

CONFIRMATORY TEST revealing

elevated pressures in the LES at
rest, failure of the LES to relax,
slow, low-amplitude, or absent
peristalsis.

X-ray studies

- reveals abnormal changes in the

esophagus and absence of air in

 Calcium channel blockers, Nitrates,

Anticholinergic drugs- relax the lower

esophageal sphincter (LES) . lower
esophageal pressure
Non narcotic and narcotic analgesics
Antacids
H2 receptor Antagonist
Proton Pump Inhibitors
Botulism toxin- injected endoscopically into
the LES to paralyze the muscle.
*

Small frequent feeding- ease passage of food.

Offer semi-soft warm foods which are better

tolerated than cold, hard foods.

Avoid hot, spicy and iced foods.
Avoid alcohol and tobacco.
Chew food thoroughly.
*To add saliva to the mixture for lubrication
and to allow the bolus to pass more easily
from esophagus to stomach.

Try different positions to reduce pressure

while eating
Some patients may benefit from arching the
back while swallowing.
After eating, remain upright by standing or
sitting.
Avoid restrictive or tight clothing (increase
esophageal pressure).
Sleep with HOB (4-6 inches) elevated to
prevent nocturnal reflux of food.

Percutaneous Endoscopic Gastrostomy/

Percutaneous Endoscopic Jejunostomy
these involve tube insertion for patients who cannot
swallow for long periods.
Esophageal dilatation or Bougienage
forcefully dilates the LES by inflating a balloon in the
cardiac sphincter of esophagus
Esophagomyotomy (Hellers Procedure)
enlarges the vestibule by incising the circular fibers
down to the mucosa over the entire lenght of the LES.
Cardiomyotomy- enlargement of the cardiac sphincter.

Pain r/t irritation of the esophageal wall

secondary to regurgitation of esophageal

content
Risk for impaired skin integrity t/r
placement of gastrostomy, PEG, or PEJ tube
Risk for Injury r/t surgical procedure and
presence of tubes.
Risk for aspiration r/t regurgitation of
esophageal contents
Risk for fluid volume deficit r/t dysphagia

DISORDERS
OF THE
STOMACH

Inflammation of the gastric mucosa

Classified as Acute or Chronic
DIAGNOSTIC/
LABORATORY
PROCEDURES
History taking

FINDINGS

Food intake and medications taken

Disorders related to gastritis

Gastroscopy with
mucosal biopsy

acute: accumulation / infiltration of

polymorphonuclear cells
-chronic: mucosal atrophy or
metaplasia

Gastric analysis,
Hgb, Hct, RBC

-abnormal or decrease if bleeding

which may cause anemia

Interventions
involve removing
the cause
and treating the
manifestations.

Anti-emetic drugs: PHENOTHIOAZINE GROUP

(Compazine, Chlorperazine, Phenergan)

Antacids
H2 Antagonists
Prostaglandin E1 (PGE1) Analog- protects the
stomach mucosa and inhibit gastric acid
secretion
-usually given if ingestion of NSAIDs is a
problem
Antibiotics

Maintenance
Enteric-coated ASA
Misoprostol (Cytotec) decreased
secretions and stimulate production
of cytoprotective mucus
Cyclooxygenase 2 (COX-2) inhibitors
to decrease gastric acidity
H2 Antagonist
Proton pump inhibitors- to block
gastric acid secretion

It is characterized by progressive and

irreversible changes in the gastric

mucosa
DIAGNOSTIC PROCEDURES
Serum Vitamin B12 levels
Same with Acute Gastritis

Antacids
H2 Receptor Antagonist
Proton Pump Inhibitors
Antibiotics- to eliminate the bacteria

(Helicobacter Pylori)
Vitamin B12 Administration- for
pernicious anemia

NPO
Bland Diet
Small frequent feeding
Avoid food which causes the

onset of s/sx-

Subtotal Gastrectomy
Involves partial removal of the stomach.
Types

Billroth I (Gastroduodenostomy)
Billroth II (Gastrojejunostomy)
- for treatment of DUODENAL ULCER
- (+) Dumping Syndrome (a postprandial problem
occurs because ingested food rapidly enters the
jejunum without proper mixing and without the
normal digestive processing.

Pyloroplasty
A surgical procedure to widen
the opening in the lower part
of the stomach (pylorus) so
that the stomach contents
into the small intestine.
Prevents stasis and enhances
gastric emptying

Vagotomy
To eliminate the acid-secreting stimulus to gastric cells.
Types of VAGOTOMY
Truncal Vagotomy
- CNX (Vagus) is completely cut.
Selective Vagotomy
- partially cutting the nerves to preserve the hepatic and
celiac branches.
Proximal Vagotomy
-partial cutting of the nerve and only the parietal cell is
denervated
-with preservation of the innervation of antrum and pyloric
sphincter

Total Gastrectomy
Removal of the stomach, with
anastomosis of the esophagus to the
jejunum.
With chest tubes

It involves a disruption in the

continuity of the lower esophageal,

gastric or duodenal mucosa leading
to a local defect resulting from
inflammation.

DIAGNOSTIC

FINDINGS

History

Duodenal: Epigastric pain is

relieved with food
Gastric: Pain that worsens with
eating

Upper GI
series

Major diagnostic test (it comes with

series of x-ray test with contrast)
which reveals presence of
ulceration in the mucosal lining

Esophagogastr visualizes the site of bleeding/

ocduodenosco ulceration
py
Guaiac test

for occult blood if bleeding is

present.

CBC

Decrased Hct and Hgb if with

bleeding

gastric ulcer

gastric ulcer

gastric ulcer

duodenal ulcer

duodenal ulcer

duodenal ulcer

 PHARMACOLOGY
antacids (Maalox, Simethicone, KremilS)
Proton Pump Inhibitors
H2 blockers
Omeprazole

Cimetidine
(Prilosec)
(Tagamet)
Lansoprazole

Ranitidine
(Prevacid)
Hydrochloride

Rabeprazole
(Zantac)
Famotidine
(Peptid) (Aciphex)
Sucralfate
(Carafate)

Pantoprazole
Nizatidine (Axid)

ANTIBIOTIC
TRIPPLE
THERAPY:
(Protonix)
Clarithromycin
(Klaricid),
Metronidazole,

Esomeprazole
Lansoparazole
(Nexium)

Vitamin
B
12

supplementation
Hellvax
Prostaglandin Analogs (Misoprostol)

 DIETARY MANAGEMENT
avoid an empty stomach (eat on
TIME!)
bland diet
small, frequent feedings
avoid alcohol, caffeine, smoking,
protein rich foods and milk

COMPLICATIONS
intractability

hemorrhage
hematochezia, shock)
Perforation
Obstruction

(melena,

Assess bleeding
Prevent shock
Goals
Treat hypovolemic shovck
Prevent dehydration and electrolyte

imbalance
Stop the bleeding
IVF, NGT, Gastric cooling (cool saline lavage),
modified Trendelenburg
Replace fluid loss- report a decrease in urine
output
Administer Vasopressin- helps control bleeding.

Selective Arterial Embolization

It is done via angiography to promote clot

or injection of clot.
A fibrin glue or a clot may be made with a
mixture of the clients own blood,
aminocaproic acid, and platelets
Rest for several to decrease BP and decrease
gastric motility.
Maintain high gastric pH
maintain pH value from 5.5 to 7
administer H2 receptor antagonist and
antacids.

Stop bleeding surgically if bleeding

continues beyond 48 hours.

Multipolar electrocoagulation (MPEC)
or Heater-Probe Therapy
endoscopic procedure
MPEC- bipolar electrical current

cauterizes the bleeding lesion.

Heater- Probe-direct heat cauterizes
the lesion.

a surgical emergency which often results to

peritonitis and pancreatitis.

Management:
Assess pain
Peritonitis: tender, hard, rigid abdomen
Pancreatitis: constant, midepigastric or
periumbilical, radiating to the back or flank
area
Fluid replacement
Surgery
NGT remains in the stomach until peristalsis returns

Long standing ulcer disease

causes scarring because of

repeated ulcerations and healing
Management:
Surgery

Vagotomy
Vagotomy with Pyloroplasty
-involves cutting the right and left vagus
nerves and widening the existing exit of
the stomach t the pylorus.
Antrectomy
Subtotal Gastrectomy
Billroth I (Gastroduodenostomy)
Billroth II (Gastrojejunostomy)
Total Gastrectomy

gastroenterosto

antrectomy and vagotomy

bilroth I: gastroduodenostomy

bilroth II: gastroduojejunostomy

 COMPLICATIONS SURGICAL
PROCEDURES
marginal ulcers

hemorrhage

alkaline reflux gastritis

acute gastric dilation
nutritional problems
Vitamin B12 and Folic Acid Deficiency
Dumping

Syndrome

Gastrojejunocolic

Fistula

Pyloric
pyloroplasty)

Obstruction

(from

Marginal Ulcers
develops when gastric acids come in contact

with operative site

ulceration may cause scarring and
obstruction, hemorrhage, perforation
Hemorrhage
Alkaline Reflux Gastritis
caused by duodenal contents in patients
where bypass or removal of pylorus is
involved ( Pyloroplasty/ Vagotomy).
it is characterized by stomach inflammation
due to reflux of bile and alkaline pancreatic
secretions that disrupt mucosal barrier.

Acute Gastric Dilation

distention of the stomach produces

epigastric pain, tachycardia, hypotension.

patients complains of feeling of fullness,
hiccups, gagging
Nutritional problems secondary to
malabsorption
Fe/Vitamin B12 and Folic Acid Deficiency
Anemia
Calcium Malabsorption Disorder
Pyloric Obstruction
due to scarring, edema, inflammation of
pylorus. manifested by vomiting

 Gastrojejunocolic Fistula
this arise from perforation of a recurrent ulceration at the

gastrojejunal
anastomosis site ( forms a fistula between ulcer and adjacent
bowel).
S/SXS: fecal vomiting, diarrhea, wt loss, anorexia, belching.
Dumping Syndrome
It usually subsides in 6 to 12 months
Early manifestation (5 to 30 minutes after eating)
Vertigo, tachycardia, syncope, sweating, pallor,

palpitation, diarrhea, nausea, rise and fall of BP,

epigastric fullness, abdomina discomfort, and tenesmus.
Caused by rapid movement of ECF into the bowel to
convert the hypertonic bolus into an isotonic mixture.
Rapid fluid shift decrease circulating blood volume
Increase peristalsis and motility.

Late manifestations (2-3 months after eating)

Caused by rapid entry of high carbohydrate food into

jejunum, increase blood glucose level, and excessive

insulin levels.
MANAGEMENT:
Decrease the amount of food ingested at one time
High protein, fat, low-carbohydrate dry diet
Gastric emptying may be delayed by eating in a
recumbent or semi recumbent position, lying down after
meals, increasing the fat content in the diet, and avoiding
fluids one hour before, with, or 2 hours after meals.
May be given with sedatives, antispasmodic agents

PREOPERATIVE

Pain r/t gastric mucosal injury

Administer prescribed
medication
Promote rest and relaxation
to decrease gastric secretions and
peristalsis
>Decrease strenuous activities
>Adequate rest

Dietary Management
SFF at regular intervals
Discourage alcohol, cola, tobacco, caffeine,
milk, etc.
Bland, non-irritating, low-fiber diet
Administer comfort medications as ordered

Knowledge Deficit r/t cause of ulcer and

measures to treat and prevent recurrence
Nursing Interventions
Explain the need for NGT or gastrostomy
and suction post-op
Explain importance of TCDB (Turn, Cough,
Deep Breathing)
Warn patient that high abdominal incisions
make deep breathing very uncomfortable

End..
THANK YOU.