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.

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's 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. GERRD 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't 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 distention, avoiding laying down 2 to 3 hours after eating, sleeping with the head of the bed elevated, avoiding activities that increase intraabdominal 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.

OK, 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 that Mister 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.

It is painful and leaves a bitter taste in his mouth. He says his main problem is at night because the pain from his heartburn wakes him up.

He denies coughing, difficulty swallowing, or bleeding. You inquire if anything helps with his symptoms, and he tells you he started taking an over the counter drug, which doesn't help much.

Next, you pull out your pen light and ask if you can look inside his mouth. His mucous membranes are pink and moist, and he has malodorous breath.

You do not see ulcers in his oral mucosa or erosions in the enamel of his teeth. Other assessment findings include a height of 5 ft 11 inches and a weight of 200 lbs, or 90.7 kg.

His vital signs are temperature of 98.1 °F or 36.7 °C, heart rate of 62 BPM, respiratory rate of 16 per minute, BP 118/84 millimeters of mercury, pain, 0 out of 10, and oxygen saturation, 94% on room air.

A quick look at his lab work shows a hemoglobin of 17.5 g per deciliter and a hematocrit of 52%. You document your assessment findings before leaving the room.

So based on your assessment findings, you developed the following nursing diagnoses, acute pain related to esophageal irritation from acid reflux, disturbed sleep pattern related to a report of being awakened during the night by acid reflux, risk for impaired tissue integrity related to esophageal exposure to gastric acid, and imbalanced nutrition, more than body requirements related to increased BMI.

Next, you collaborate with Mr. Green and the members of the healthcare team to start planning the goals for his care.

By his follow-up visit in 8 weeks, Mr. Green will report a decrease in reflux and heartburn pain and the resolution of sleep disturbance.

He will make an appointment with the registered dietitian to formulate a plan for weight reduction. Finally, before he leaves the office today, he will verbalize understanding of the importance of contacting his primary care physician, or PCP right away if he experiences any worsening acid reflux, or if he notices signs or symptoms of complications, such as difficulty swallowing, increased pain, or bleeding.

OK, so now you're ready to take action and implement your interventions. His PCP has diagnosed Mr.

Green with GERD and has prescribed the PPI pantoprazole. So you teach him to discontinue the H2RA he was taking previously, and to take his new medication once each day for 8 weeks.

Next, you provide a list of foods to avoid that can trigger reflux symptoms. And advise him to organize his day so he can eat smaller, more frequent meals throughout the day, and to time his last meal of the day at least 3 hours before bedtime.

Because his elevated BMI is contributing to acid reflux, you schedule an appointment for him to meet with a registered dietitian.

Finally, you encourage Mr. Green to use extra pillows to elevate the head of his bed 4 to 6 inches, or 10 to 15 centimeters during sleep.

All of these interventions will help eliminate pain, promote sleep, and decrease the risk for further damage to his esophagus.

Eight weeks later, he returns for his follow-up visit, and you're excited to hear he's been sleeping much better at night and has had only an occasional pain from heartburn.

With the help of the dietitian, he discovered new and healthy food choices that don't trigger reflux, and he already lost 4 lbs, or 1.8 kg.

He denies new complaints or concerns that signaled the development of complications. You document your evaluation in the medical record and share these findings with his PCP.

You continue to reassess, reevaluate, and document Mr. Green's response to interventions to determine if his plan of care should be revised.

All right, so let's recap. You've been caring for Mr.

Green, who came in for an annual physical, complaining of heartburn. He was diagnosed with GERRD, which is a common gastrointestinal disorder where an impaired LES allows a reflux of gastric contents into the esophagus, leading to heartburn and esophageal irritation.

Left untreated, GERD can lead to complications like esophagitis, fibrosis, strictures, or Barrett's esophagus, which increases the risk for adenocarcinoma.

The risk for GERD increases with conditions such as obesity, pregnancy, or hiatal hernia, with certain medications like calcium channel blockers, with changes in position like bending or lying flat when the stomach is full, or it can be triggered by smoking, consuming alcohol, or spicy foods.

Your nursing assessment reveals Mr. Green is experiencing pain during the day and having difficulty sleeping at night.

You develop nursing diagnoses to address pain, sleep disturbance, contributing factors like obesity, and the risk of complications.

Along with the interdisciplinary team, you develop a plan aimed at restoring Mr. Green's optimal well-being and implement interventions to help him reach these goals.

During your interactions with Mr. Green, you continually evaluate his response to your interventions and adapt his care plan as needed to achieve positive outcomes.