Case study - Gastroesophageal reflux disease: Nursing

Nurse Max works in a primary care office and is caring for Anuja, a 54-year-old with a history of gastroesophageal reflux disease, or GERD, who's being seen for a three-month follow-up appointment. In collaboration with registered nurse, RN Steve, Nurse Max goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Anuja’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Max recognizes important cues including vital signs which are temperature 98.2 F or 36.9 C, heart rate 76 beats per minute, respirations 14 breaths per minute and regular, blood pressure 128/84 mmHg, and oxygen saturation 98 percent on room air. Nurse Max asks Anuja if she’s having any pain, and she reports burning in her mid-upper abdomen after eating, despite taking her prescribed medication.  

Next, Nurse Max analyzes these cues. Nurse Max understands that a band of smooth muscle located between the esophagus and the stomach, called the lower esophageal sphincter, or LES, opens during swallowing to allow food to move from the esophagus into the stomach, and then closes, to keep food from backing up into esophagus. Nurse Max also knows that in patients with GERD, the LES may not close properly, or it may relax when it shouldn’t, so the acidic gastric contents can flow back, or reflux, into the esophagus. They recognize that when the esophageal lining is exposed to gastric contents, it causes symptoms like heartburn and pain in the chest and upper abdomen.

Nurse Max then reviews the electronic health record, or EHR, and notes that Anuja has been on proton pump inhibitor, or PPI, therapy for three months to treat her GERD and should be experiencing symptom relief by now; so, they talk with Anuja about what she knows about GERD and her prescribed medication.

Nurse Max: Anuja, I’m glad you’ve been taking your PPI every day and I’m sorry it hasn’t been working for you. We want to figure out what might be happening. What time do you take your medication?

Anuja: I take it every night after dinner. I set an alarm, so I don’t forget.

Nurse Max: Setting an alarm is a great idea! What do you typically eat at home?

Anuja: I’ve been making a noodle dish lately with lots of fresh jalapenos drizzled with sriracha. My family loves it!

Now, using the information they’ve gathered, along with Anuja’s medical history, Nurse Max reports his findings to Nurse Steve, and they choose a priority hypothesis of knowledge deficit.

Then, they generate solutions to address this problem that will include pharmacologic and nonpharmacologic interventions, and they establish the outcome that after intervening, Anuja will verbalize an understanding of GERD management.