Question

Ringtoned Chapter 16: Management of Patients Quand le Disorden 1. George Smith, a 55-year-old patient is admitted to the intensive care unit after a thoracotomy approach was used for an esophagectomy to remove an early stage adenocarcinoma of the distal esophagus and gastroesophageal junction. The patient has a history of GERD and Barrett's esophagus. The patient sought medical treatment for dysphagia with solid foods, feeling that there was a lump in his throat and substernal pain with swallowing and subsequent regurgitation of undigested food and the development of hiccups. The patient has no other medical problems. (Learning Objectives 6 and 7) a. Describe the esophageal cancer that the patient has and how it relates to his history of GERD and Barrett's esophagus. b. Explain the rationale for the early symptoms and late symptoms of esophageal cancer. c. What course of cancer treatment should the nurse anticipate that the patient in this case study would have? d. What nursing care should be provided for the patient in the intensive care unit in the early postoperative period? e. Explain the care the nurse should provide when the patient begins to eat.

Answer 1

1. Mr. George Smith is diagnosed as having Adenocarcinoma of distal esophagus, at the gastroesophageal junction.

GERD

Back flow of gastric contents into esophagus

Breaking down esophageal mucosa

Resistance to body’s defense mechanisms to repair damaged mucosa due to prolonged and repeated exposure to acid reflux

Barret esophagus (damaged esophageal mucosa)

Metaplastic transformation of esophageal lining cells

Adenocarcinoma

2. Early symptoms:

• Heartburn
• Chronic cough
• Regurgitation
• Eructation

These are related to GERD and Barret esophagus.

Late symptoms:

• Dysphagia
• Indigestion
• Dyspepsia
• Substernal burning pain
• Weight loss

The above signs and symptoms are resulted from the metaplastic changes in mucosal lining suggestive of adenocarcinoma.

3. Patient had undergone partial esophagectomy in this scenario. The possible treatment methods include,

• Esophagogastrostomy – removal of part of esophagus and stomach is brought upto the remaining end of esophagus.
• Esophagectomy – removal of part or all of esophagus and replaced by colon.
• Gastrostomy – opening directly into stomach in which a feeding tube is usually inserted to bypass esophagus.
• Radiation and chemotherapy.

4. Early postoperative care in the ICU:

• Maintain airway and respiration.
• Pain assessment and management.
• Monitor vital signs and breath sounds
• Maintain patency of tubing to promote drainage, maintain decompression and to reduce pressure on suture line.
• Maintain I&O for signs of dehydration and electrolyte imbalance.

5. Nursing care or instructions when the patient begins to eat

• Encourage small and frequent feedings.
• Avoid spice, fat, caffeinated drinks and alcohol
• Avoid lying down immediately after food, sit upright for 2 hours after meal.
• Avoid overeating.
• Begin with soft diet and progress gradually to semisolid and solid in less quantity.