Primary Nursing Diagnosis

Altered nutrition: Less than body requirements related to dysphagia

OUTCOMES. Nutritional status: Food and fluid intake; Nutrient intake; Biochemical measures; Body mass; Energy; Endurance

INTERVENTIONS. Nutrition management; Nutrition therapy; Nutritional counseling and monitoring; Fluid/electrolyte management; Medication management

U PLANNING AND IMPLEMENTATION Collaborative

Because esophageal cancer is often terminal, treatment is usually for palliative purposes and to relieve the effects of the tumor. Surgery, radiotherapy, and chemotherapy are all options for treating cancer of the esophagus, and they may be used alone or in combination. Two surgical procedures are commonly performed: esophagectomy (removal of all or part of the esophagus with a Dacron graft replacing the part that was removed) and esophagogastrectomy (resection of the lower part of the esophagus together with a proximal portion of the stomach, followed by anastomosis of the remaining portion of the esophagus and stomach). Postoperatively, monitor the nasogastric (NG) tube for patency. Expect some bloody drainage initially; within 24 to 48 hours, the drainage should change to a yellowish-green. Do not irrigate or reposition the NG tube without a physician's order. Fluid and electrolyte balance should be monitored carefully, as well as intake and output. Monitor the patient who has had an anastomosis for signs and symptoms of leakage, which is most likely to occur 5 to 7 days postoperatively. These include low-grade fever, inflammation, accumulation of fluid, and early symptoms of shock (tachycardia, tachypnea).

Radiation reduces the size of the tumor and provides some relief to the patient. Usually, external beam radiation therapy is used. Normal esophageal tissue is also affected by the radiation, which is given over a 6- to 8-week period to minimize the side effects. Side effects include edema, epithelial desquamation, esophagitis, odynophagia, anorexia, nausea, and vomiting. Although radiation by itself does not cure esophageal cancer, it eases symptoms such as pain, bleeding, and dysphagia.

336 Esophageal Cancer

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Chemotherapy

Varies by drug

Types of chemotherapy: 5-fluorouracil, cisplatin, bleomycin, mitomycin, doxorubicin, methotrexate, paclitaxel, vinorelbine, topotecan, irinotecan, mitoguazone

Kills cancer cells. Primary chemotherapy will not cure esosphageal cancer unless surgery and/or radiation is also used. Preoperatively, chemotherapy may be given to reduce tumor size. Approximately 10%-40% of patients will have a significant shrinking of the tumor from these drugs.

Independent

Carefully monitor the patient's nutritional intake, and involve the patient in planning the diet. Maintain a daily record of caloric intake and weight. Monitor the skin turgor and mucous membranes to detect dehydration. Keep the head of the bed elevated at least 30 degrees to prevent reflux and pulmonary aspiration. If the patient is having problems swallowing saliva, keep a suction catheter with an oral suction at the bedside at all times. Teach the patient how to clear his or her mouth with the oral suction.

When appropriate, discuss expected preoperative and postoperative procedures, including information about x-rays, intravenous (IV) hydration, wound drains, NG tube and suctioning, and chest tubes. Immediately after surgery, implement strategies to prevent respiratory complications.

Provide emotional support. Focus on the patient's quality of life, and discuss realistic planning with the family. Involve the patient as much as possible in decisions concerning care. If the patient is terminally ill, encourage the significant others to involve the patient in discussions about funeral arrangements and terminal care such as hospice care. Provide a referral to the patient to the American Cancer Society, support groups, and hospice care as appropriate.

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