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Oesophageal Carcinoma (Oesophageal Neoplasm) (Diagnostic studies (chest x…

- - - - often originating in the upper half of oesophagus
      - higher incidence rate in china
    - - distal & middle third of the oesopghagus & at the gastroesphageal junction
- - - - patient distress: sensation of choking & cannot swallow -> allay fear by exploring clients concerns and feeling & reassure them the sensation will disappear soon
      - oversedationl: titration sedation鎮靜 to optimal dosage & with a specific antagonist if required
      - Hypoxia 缺氧 -> administer supplementary o2 & monitor vital signs, spo2...
      - Pharyngeal anaesthesia & risk of aspiration -> resume eating when gag reflux returns
      - Perforation -> most common area: pharynx & cervical oesophagus
      - Haemorrhage -> small risk monitor s/s of bleeding & shock
      - Cardiac dysrhythmias 心律不整: resuscitation equipment must be available
      - **Oesophageal Manometry
        
        assess the function of oesophageal body musculature & its sphincters
        
        indication: establish motility disorders (e.g. oesophageal spasm, GERD, dysphagia, achalasia)
- - - - 10% post-op mortality; 20% 5-yr survival
      - Middle & distal 1/3 -> transhiatal, transthroacic
      - Cervical: bilateral neck dissection; laryngectomy & thyroidectomy may be necessary
    - - dietary changes? weight loss? dysphagia? pain? cough & hoarseness
  - - - high-protein, high-calorie diet
      - TPN if unable to take food/ fluids orally
      - jejunostomy tube is clamped till feeding prescribed
      - meticulous 細緻 mouth care for patient
      - assess swallowing function by viedofluorographic swallowing study (VFSS) & to detect leak
      - assess bowel sound
      - assess any dysphagia when oral feeding resume
        
        S/S of disphagia
        
        difficulty in chewing/ in forming a food bolus
        
        drooling 流口水/ coughing during meals
        
        choking on medication/ food
        
        sob during / after eating
        
        observe tongue movement, note mouth closure during speech & at rest
      - but avoid overeating, chew food well, avoid bedtime meal (3 hours before sleep)
      - DUMPING SYNDROME: vagotomy during surgery resulted in unregulated gastric emptying -> rapid delivery of CHO/ partially digested food into small intestine
        
        frequent & small meals
        
        drink fluid, soap or water in between meals but not with meals
        
        report s/s of complications: e.g. nausea & vomiting, elevated temp., cough, dysphagia
    - - administer IV fluid as prescribed
      - TPN (total parenteral nutrition) may needed
      - NPO for 5-7 days
      - NG tube
        
        *attention to all: do not move, manipulate or irrigate; do not attempt to replace/ reinsert the tube if dislodged for any reason -> will damage the anastomosis
        
        monitor patency, note colour, amount & characteristic of drainage
        
        NG tube to bed side bed labelled clearly & drain by gravity
        
        All medication must be given NG, not orally
      - monitor vital signs, BP/P, RR, SPO2, Temp.
      - Monitoring for complications
        
        note drainage for bleeding/ purulence from chest tube, abdominal drains(round drain/ tubal drain) , cervical/ neck drain
        
        detect early warning signs: dysrrhythmias, hemorrhage, infection, aspiration, anastomosis leakage
        
        pulmonary function (CXR)
        
        mechanical ventilation during immediate post-op period
        
        pulse oximetry -> provide o2 as indicated after extubation
        
        deep breathing & coughing exercise; initiate the use of incentive spirometer
      - chest tube care
        
        avoid milking as it causes increase in intrapleural pressure
        
        only clamp tubing during changing bottle; always keep drain below chest level
      - Pain management
        
        initial stage: epidural PCA, IMI analgesia prn after PCA disconnected, oral analgesia: opioids/ NASIDs
        
        proper positioning, heat application, massage, distraction/ relaxation technique
    - - observe incision for bleeding
      - s/s of infection
      - asepsis during dressing
      - check chest drain exit & surrounding area
      - new onset of subcutaneous emphysema -> indicating oesphageal anastomosis leak
    - - early ambulation & encourage PCA use for pain control
      - low molecular weight Heparin
      - compression stocking
        
        below the knee/ high thigh, determine he correct size, remove hose 2-3 times/ day fro 30 min to assess skin integrity & neurovascular status