Gastroesophageal reflux disease (GERD): Nursing process (ADPIE)

Frank Green is a 52-year-old male client who presents to the clinic for his annual physical.

During his visit, he reports having heartburn pain during the day and being awakened from it at night.

He says for the past several months he has occasionally taken cimetidine, a Histamine H2 Receptor Antagonist, or H2RA, to treat his heartburn.

But over the past month he needed to take it every evening, and it no longer relieves his discomfort.

Gastroesophageal reflux disease, or GERD, occurs when there is an abnormal backflow of gastric contents into the esophagus, which then irritates the esophageal lining.

Normally, food travels from the mouth, down the esophagus, and into the stomach where a band of smooth muscles called the lower esophageal sphincter, or LES, keeps the food from moving back up the esophagus.

In GERD, however, the gastric contents will flow back, or reflux, into the esophagus.

GERD is a common gastrointestinal disorder with an estimated prevalence of 17 to 28% in the US population.

The risk for GERD increases with factors that decrease the LES tone so it is not as effective in protecting the esophagus from gastric contents.

For example, certain medications like nitrites and calcium channel blockers decrease LES tone and increase the risk of reflux.

A hiatal hernia, where part of the stomach bulges through the diaphragm, allows gastric contents to pool below the esophagus where it can reflux more easily.

On the other hand, gastric contents can be forced past the LES with conditions that put pressure on the stomach, like obesity and pregnancy, and actions like coughing, vomiting, and heavy lifting, which increase intra-abdominal pressure.

Reflux is also more likely to happen within an hour of eating or when lying down after a meal.

Lastly, alcohol, tobacco, caffeine and spicy foods tend to trigger reflux.

Now, when the esophageal lining is exposed to the acidic gastric contents it produces symptoms like heartburn and pain in the chest and upper abdomen.

If reflux travels further up the esophagus, tiny droplets of gastric contents can enter the larynx and bronchial tree, stimulating a cough.

This can become a vicious cycle as coughing contributes to reflux and reflux stimulates the cough.

And if aspiration occurs, it can lead to further complications like pneumonia or asthma-like symptoms such as bronchospasm.

If the reflux regurgitates all the way into the mouth, it produces a bitter taste and halitosis, otherwise known as bad breath.

Over time, exposure to acid can lead to erosion of tooth enamel, oral ulcers, and esophageal inflammation, or esophagitis.

Chronic reflux eventually erodes the lining of the esophagus causing ulcers which can bleed, potentially leading to anemia.

Fibrosis or scarring can occur in response to repeated tissue injury, leading to esophageal strictures, which makes swallowing difficult.

Ultimately the esophagus adapts to the chronic reflux by transforming the squamous epithelial cells that normally line the lower esophagus into columnar epithelial cells that are more resistant to injury.

This metaplastic change results in a condition called Barrett’s esophagus, which is a risk factor for adenocarcinoma.

A diagnosis of GERD is initially based on clinical findings and if symptoms resolve with conservative treatment.

Conservative treatment usually involves acid-reducing medications and lifestyle modifications such as avoiding foods that trigger reflux, eating small, frequent meals to avoid gastric distension, avoiding laying down 2-3 hours after eating, sleeping with the head of the bed elevated, avoiding activities that increase intra-abdominal pressure, and weight reduction.

If symptoms persist, are severe, or if complications are suspected, additional testing is required.

Monitoring esophageal pH for 24 hours will determine the degree of acidity in the esophagus.

An upper gastrointestinal endoscopy will visualize the degree of inflammation, fibrosis, and other pathological changes.

Depending on the diagnostic findings, treatment consists of an individualized approach focused on lifestyle modifications and acid-reducing medications such as antacids like calcium carbonate; H2RAs like famotidine; and proton-pump inhibitors, or PPIs, like omeprazole.

An anti-reflux surgical procedure called a Nissen fundoplication is indicated for those who have persistent severe symptoms or complications such as esophagitis, strictures, or Barrett’s esophagus.

Okay, so now it is time to start your nursing assessment and gather information about Mr. Green’s health status.

After reviewing his chart, you enter the exam room, perform hand hygiene, confirm his identity, and introduce yourself to Mr. Green as his nurse.

You note Mr. Green is sitting comfortably in a chair with no visible signs of distress.

You begin by asking about his symptoms.

He explains his heartburn normally starts about an hour after eating.