Carcinoma is the most common cause of obstruction of the esophagus. Approximately half of all esophageal cancers are squamous cell carcinomas, which usually occur in the middle and lower two-thirds of the esophagus and are often associated with alcohol and tobacco use. The remaining 50% are adenocarcinomas, which generally begin in glandular tissue of the esophagus. Adenocarcinomas are associated with Barrett’s esophagus, a condition that occurs because of continued reflux of fluid from the stomach into the lower esophagus. Over time, reflux changes the cells at the end of the esophagus. Adenocarcinomas may invade the upper portion of the stomach. Esophageal tumors begin as benign growths and grow rapidly because there is no serosal layer to inhibit growth. Because of the vast lymphatic network of the esophagus, esophageal cancers spread rapidly, both locally to regional lymph nodes and distantly to the lungs and liver. Complications include pulmonary problems that result from fistulae and aspiration; invasion of the tumor into major vessels, thus causing a massive hemorrhage; and obstruction and compression of the other structures in the head and neck. Although survival rates are improving, esophageal cancer is usually diagnosed at a late stage, and most patients die within 6 months of diagnosis. It is estimated that 14,520 new cases of esophageal cancer will be diagnosed in 2005, and 13,570 will die. While the survival rates have been improving over the last 50 years, only 15% of whites and 8% of African Americans will survive 5 years after diagnosis.
Although its etiology is unknown, esophageal cancer occurs predominantly in people with a history of alcohol and tobacco use. Individuals who have achalasia, strictures, or hiatal hernias are also at increased risk. In parts of the world where it is most common (Japan, Russia, China, the Middle East, and South Africa), the disease has been linked to nitrosamines and other contaminants in the soil. It has also been found to have a higher incidence in individuals whose diets are chronically deficient in fresh fruits, vegetables, vitamins, and proteins. Other risk factors include: obesity, gastroesophageal reflux disease (GERD), lye ingestion, occupational exposure (perchloroethylene), and esophageal webs.
Nursing care plan assessment and physical examination
Obtain an accurate history of risk factors, including race, cultural background, use of cigarettes and alcohol, or any esophageal problems. Dysphagia, which is often the most common symptom, is usually experienced when at least 60% of the esophagus is occluded. Initially, it is mild and intermittent, and it occurs only with solid foods. Patients may report a sensation that “food is sticking in their throat.” Symptoms of the disease soon progress to the inability to swallow semisoft or liquid food, and the patient experiences a severe weight loss, as much as 40 to 50 pounds over 2 to 3 months. Eventually, the patient is unable to swallow her or his own saliva. Also inquire about regurgitation, vomiting, chronic hiccups, odynophagia (painful swallowing), and dietary patterns. Patients may report pain radiating to the neck, jaw, ears, and shoulders.
Observe the patient’s ability to swallow food. Note any chronic coughing and increased oral secretions. Listen to the patient’s voice: Tumors in the upper esophagus can involve the larynx and cause hoarseness. Place the patient in the recumbent position; pain, hoarseness, coughing, and potential aspiration often occur in this position. Weigh the patient, and determine the patient’s strength and motion of the extremities. Severe weight loss and weakness are common symptoms.
The patient needs to make a psychological adjustment to the diagnosis of a chronic illness that is usually terminal. Evaluate the patient for evidence of altered mood (such as depression or anxiety), and assess the coping mechanisms and support systems.
Nursing care plan primary nursing diagnosis: Altered nutrition: Less than body requirements related to dysphagia.
Nursing care plan intervention and treatment
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.
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.
Nursing care plan discharge and home health care guidelines
The patient should be able to state the name, purpose, dosage, schedule, common side effects, and importance of taking her or his medications. Teach the patient to report any dysphagia or odynophagia, which may indicate a regrowth of the tumor. Teach the patient to inspect the wound daily for redness, swelling, discharge, or odor, which indicates the presence of infection. Teach family members to assist the patient with ambulation, splinting the incision, and chest physiotherapy. Educate caregivers on nutritional guidelines, food preparation, tube feedings, and parenteral nutrition, as appropriate. Inform the patient and family about the
availability of high-caloric, high-protein, liquid supplements to maintain his or her weight. Provide patients with a list of resources for support after discharge: visiting nurses, American Cancer Society, hospice, support groups.