Nursing Care Plan for Gastroesophageal Reflux Disease (GERD)

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Pathophysiology

GERD is the return (reflux) of stomach acid and contents into the esophagus, past the Lower Esophageal Sphincter (LES) causing irritation and thinning of the lower esophagus.  Regurgitation often occurs without effort, such as when lying down or bending over. Frequent recurrences without treatment may lead to erosion of the mucus membranes of the lower esophagus.

Etiology

Weakness or incompetence of the LES may be related to excessive pressure being placed on the abdomen such as in the case of obesity or pregnancy. Certain medications such as calcium channel blockers, sedatives, antidepressants and antihistamines relax the smooth muscle of the LES, which weakens the ability of the sphincter to fully close, thus allowing food and digestive acids to enter the esophagus. Patients who smoke or have a hiatal hernia are at increased risk of developing GERD.

Desired Outcome

Eliminate pain of the esophagus and regurgitation while  maintaining normal function of lower esophageal sphincter and preservation of the esophageal tissue.

Gastroesophageal Reflux Disease (GERD) Nursing Care Plan

Subjective Data:

  • Burning sensation behind breastbone (heartburn)
  • Chest pain
  • Nausea, often with  vomiting
  • Dysphagia (difficulty swallowing)

Objective Data:

  • Vomiting
  • Coughing
  • Wheezing
  • Weight loss
  • Erosion of tooth enamel

Nursing Interventions and Rationales

  • Perform a detailed pain assessment (PQRST or OLDCARTS)

 

Pain may be associated with eating or lying flat. It is also typically burning. Getting details about the pain can help rule out possible cardiac etiology of chest pain

 

  • Obtain 12-lead EKG

 

To rule out possible cardiac etiology of chest pain.

 

  • Prepare for and assist with upper endoscopy

 

Endoscopy is a procedure that is done by a doctor using a scope that is placed orally to visualize the upper GI tract including the esophagus, stomach, and upper portion of the small intestine. Tissue samples may be taken during this procedure if necessary.

  • Patients must be fasting, no food or drink for 4-8 hours prior to the procedure
  • Administer conscious sedation
  • Monitor vitals while patient is sedated per facility policy
  • Assist with ambulation immediately following procedure until sedation is fully worn off
  • NPO until gag reflex returns

 

  • Education of Lifestyle changes

 

  • Encourage patients to stop smoking – nicotine relaxes the LES
  • Maintain a healthy weight – obesity and belly fat create stress and pressure on the abdomen and stomach
  • Avoid tight fitting clothes – clothes that are tight around the waist put extra pressure on the stomach and esophageal sphincter
  • Elevate the head of the bed by 6-9 inches with risers, boards or blocks to allow gravity to help reduce reflux. Using pillows is not effective because it only raises the head and can become disarranged throughout the night

 

  • Diet and nutrition education

 

  • Avoid highly acidic foods such as citrus, tomatoes and spicy foods
  • Avoid carbonated beverages and alcohol that cause the stomach to expand and increase pressure on the LES
  • Eat meals at least 2 hours prior to bedtime or lying down to allow the stomach to fully empty
  • Avoid foods that trigger reflux such as fried foods, fatty foods, caffeine, garlic, onions and chocolate
  • Encourage adequate hydration (drink water)

 

  • Encourage good oral hygiene

 

Tooth enamel erosion often occurs in patients with severe vomiting due to GERD. Encourage patients to maintain good oral health to reduce the risk of infection and protect teeth

 

  • Administer medications as ordered

 

  • Proton pump inhibitors– reduce the amount of acid produced in the stomach
  • Antacids– are alkaline substances that counteract the acid in the stomach
  • Antibiotic– Erythromycin can help empty the stomach

 


References

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Video Transcript

All right. Let’s work through an example Nursing care plan for a patient with GERD or gastroesophageal reflux disease. So let’s collect all information. What kinds of information are we going to see on a patient who has GERD? Well, first they’re going to have this chest pain, right? They’re going to have this burning midsternal or midepigastric chest pain. It depends on the patient as to where they feel it and what they describe it, but typically it’s burning and they might be nauseated. They might actually have vomiting, just depends on how severe their reflux is. They might actually have trouble swallowing because they’ve had so much irritation to their esophagus. Maybe they have weight loss because they’re not eating very well or they’re vomiting up a lot. They might have some tooth decay. I mean, you see these patients that vomit a lot. The teeth get all rotted out because of all the acid and vomiting and things like that. 

So you have a lot of this gastrointestinal upset, nausea, vomiting, burning chest pain, weight loss. They’re not eating well. If they’re not eating well and they have this weight loss, they’re definitely at risk for some malnutrition, right? So you might see some signs of that. Their skin might be pale. Their lab values, and vitamin levels might be low. With GERD, one of the biggest things that we see is trigger foods, right? Where somebody will tell you every time I eat a Taco, I just get such bad reflux. So they might actually report that to you and tell you they have some trigger foods. All right. So this is our issue with our reflux patients. 

Now in this stage of care planning, when you’re gathering all data, you’re probably going to have a ton of other information too.  You know, you’re going to see information about their urine output and their bowel sounds and the strength, right? So just gather all the information you’ve got and know that in step two, analyze, you’re actually going to say, Hey, this is not relevant to the problems I’m actually identifying. So when you say, okay, what now that I’ve seen this for this patient, what is actually a problem? Well, I would argue that this patient is going to be in a lot of pain or at least if at the very least they’re going to be uncomfortable, right? They’re not going to have a lot of comfort. They’re probably going to be nauseated and vomiting. That’s gonna contribute to the comfort issues. Right? Um, we also know that their nutrition status probably needs to be improved. They’re probably not eating very well. They might have signs of nutrient malabsorption and they’re going to be vomiting.

So definitely an issue to kind of think about improving their nutrition. They might need even a special diet potentially. Right? And so there might be some education that we need to kind of teach them about best special diets. So big priority here, honestly I would say is probably the pain and comfort. That’s the most immediate thing that we can do something about right? Nutrition long term, making sure they have adequate nutrition, that they’re not getting malnourished. But I would say at this point, the, the, the actual problems and the immediate concern would probably be pain. So we start to ask our how questions, how do we know it was a problem? And this is the point at which we start to just data link. We start to take the data that we had and we link it with the problem and we ignore all of the irrelevant information.

So I don’t really need to know anything about their urine output. Don’t really need to know anything about their skin unless it’s a nutrient absorption thing. And I’m saying their skin is pale and dry, right? So I’m going to data link, I’m going to figure out how everything fits together and then I’m gonna figure out what I’m going to do about it. How would I address their problems? Well, the first thing I would say is I need to assess their pain because if this person comes in complaining of chest pain, I need to make sure that that’s not cardiac, right? I need to make sure it’s not cardiac in nature. So definitely assess their pain. And you might even get a 12 lead. Just again, just to make sure that it’s not cardiac in nature. 

And you’re going to give meds. What kind of meds do we give to a patient in GERD?  We’re going to give PPIs. We might give antacids and we also might even just give pain meds just depending on how severe and how uncomfortable this patient is. And let’s see, we talked about nutrition and dietary changes. So there might be some education I can do. I can educate them on avoiding trigger foods. I can educate them on diet choices that will actually help them and be beneficial for them. So definitely some patient education we can do. And even some lifestyle changes. One big thing that really, really causes problems with GERD and reflux is smoking. So especially if your patient’s a smoker, we definitely want to make sure they stopped smoking. You might have a patient who’s going to get an EGD or an upper endoscopy and so we’ll want to make sure we prepare them well for that. 

And again, we talked about nutrition.  So maybe monitor, we’re going to monitor those vitamin levels and as electrolyte levels just to make sure we’re not seeing any symptoms. So again, we’re just kind of data linking. We’re saying, Hey, what, how did I know this was a problem and what am I going to do about it? And then of course, how did I, how do I know if it’s better? Well, the pain one’s easy, right? The patient reports decreased pain easy, right? That tells me they’re doing better. Remember, anytime we educate, we want the patient to either verbalize or demonstrate something. So maybe they can verbalize trigger foods that they should avoid or dietary choices that would help. We would maybe want them to report less nausea and have less vomiting, right? And then maybe we could just say things like, no signs of malnutrition. So all of the things that we said were a problem.

We figured out something we were going to do about it. And then we said, how would I know if it gets better? Most of the time your how do I know if it gets better is going to be the opposite of what you’re actually experiencing. So my patient has pain, I’m going to assess their pain and give them pain meds. How do I know if it’s better? Their pain decreases. So you can typically kind of go opposite there, right? So next step, step four, translate, be concise, concisely communicate what the problem is. Again, here at NRSNG we prefer to use nursing concepts over things like nursing diagnoses because we really feel like it gives you big picture priorities instead of forcing you to drill down to really specific things. So let’s see, what do we think are top priorities, top concepts are for this patient?

Well, again, we said the first one was probably their comfort, or pain, both related to the pain as well as being really nauseous. Like we just need to make sure this patient is really comfortable. The second thing I think we can go ahead and put nutrition up there. We know if they’re vomiting a lot, if they’re not keeping food down, if they have a lot of reflux, they have a lot of acid production, they’re probably not absorbing, nutrients like they should. So I think focusing on nutrition is a really important thing. And then we did talk about them having some maybe diet and lifestyle changes, some things they could avoid. So I think patient education is probably a great idea. 

Again, when you’re doing a care plan on an actual patient, you’re not isolating one disease process and choosing three priorities.  Typically you’re gonna look at their whole big picture. So it might be that they have a perfusion and an airway issue. Well all of that’s going to come before nutrition and patient education, right? So make sure that whatever you’re doing with your patient, you’re looking at the big picture, you’re looking at everything that they’ve got going on. But in this case, let’s just transcribe, get it on paper for a patient with an isolated problem of GERD. So we said our big things were comfort, pain control, nutrition and patient education. So let’s connect the dots here. Remember the purpose of getting this stuff on paper is to link all your data together so that you can see what’s the problem, how do I know, what am I going to do about it and why and what do I expect to see? 

So big things, subjective data and objective data for your comfort.  Well, they have burning chest pain and they probably have nausea and vomiting. They’re definitely uncomfortable. So what am I going to do? I’m going to assess those pain details. I’m going to give them meds and possibly analgesics. So both meds to decrease the reflux but also meds for pain. And that’s because we want to make sure this pain is not cardiac and we want to make sure we improve their symptoms. The less pain and discomfort that they have, the less nausea and vomiting they have, that actually is going to help start to improve all their other problems as well. Right? So again, our expected outcome tends to be kind of the opposite of what we found, right? So expected outcome, patient reports decreased pain, patient reports, decreased nausea and vomiting. Fair enough, right? 

So nutrition, what was our data that told us there might be a nutrition issue? Well if they have dysphasia, if they have trouble swallowing cause they have damage to their esophagus, if they’ve been vomiting, and maybe they actually have some active weight loss. If they have active weight loss, that’s definitely a problem, right? And then we said they also might have some electrolyte or vitamin levels that are way off and out of whack because of this malnutrition issue. So what are we going to do? Well I want to monitor those levels, right? I want to make sure they’re not showing any signs of malnutrition. I’m going to monitor their weight and I’ll probably do some diet education because I want to see if this is becoming an actual problem or if it’s still just a risk, right? So again, they’re at risk for malnutrition and we want to try to increase their effective nutrient intake. So that’s where this diet education is going to come in is making sure they’re getting good things into their system. So expected outcome while we really said this was a risk, right? There are risk for malnutrition. So accepted outcome for risks is they don’t develop it, right? No signs and symptoms of malnutrition, no weight loss. And you could even, if you want to, you could talk about the patient gaining weight, just make sure your timelines are realistic. 

Okay. So education, the big thing we talked about was this patient might come to you and say, you know, this happened to me last time I had pizza up to they had pizza again and there they are, right? So if they’re telling you they’ve got these trigger foods or maybe that they’re a smoker, we definitely have some education we can do, right? So educate them on diet changes, smoking cessation. And the big thing here is understanding that avoiding those trigger foods can decrease your reflux symptoms.

And of course, smoking increases reflux. Smoking causes lots and lots and lots of problems. So always do smoking cessation if you have a patient who is a smoker. So again, what are expected outcomes? Well, when we do patient education, we always want to verbalize or demonstrate, right? So verbalize lifestyle or diet changes to make. You can even give an actual number here. You can say the patient will verbalize 2 diet changes. They will make or they will verbalize three trigger foods that they’re going to avoid. Or you can actually talk about them quitting smoking and give them a little timeline. So this is our best way to just put this on paper and see a big picture of what we need to do for this patient. Again, an isolated GERD patient were pretending like they have absolutely no other issues besides GERD, but it helps you to get a picture, big picture of the different things you need to be looking for in this patient.

So just a quick reminder of your five step process for creating a nursing care plan. You’re going to collect all information, all information, you’re going to analyze it, pick out the important things that tell you there’s a problem and I figure out what your priorities are. Ask Your how questions, how did I know it was a problem? How would I make it better and how would I know that it worked? And then you’re going to translate it, put it into whatever terms you need to use, whether that’s nursing concepts, NANDA nursing diagnoses, NIC and NOC, whatever you need to use. Just translate that into terms that can be simplified and then use a form or a template that you prefer or one that you have to use, but either way, get it on paper. All right, guys, I hope that was helpful to help you see how to create a quick nursing care plan for a patient with GERD. Make sure you check out the rest of the examples in this course as well as our nursing care plan library. All right, we love you guys. Go out and be your best selves today, and as always, happy nursing.

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  • Question 1 of 1

A nurse is planning medication administration for a client who has all of the following oral medications due at 0900: Calcium carbonate, Codeine, Levetiracetam, Metoclopramide. What is the most appropriate action by the nurse?

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