Video Case Study - Caring for Patients With Gastroesophageal Reflux Disease

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.

Nurse Max then takes action to implement these solutions. They can tell from the conversation that Anuja has misunderstood RN Steve’s initial instructions about medication self-administration and lifestyle modifications for GERD from her previous appointment.

They know she needs reinforcement of initial education to manage her condition at home. Nurse Max: Anuja, I want to review some information that RN Steve went over with you during your last appointment.

Anuja: Okay. Nurse Max: You’re right to take your PPI every day, but it'll be more effective if you take it before the first meal of the day.

Anuja: Oh yes, I do remember that from Nurse Steve, now that you mention it. Okay, I can do that.

I’ll change the time of the alarm I’ve set. Nurse Max: Great!

It’ll also improve your symptoms if you adjust your diet. It seems like you really like spicy foods, but unfortunately this can make your GERD worse.

Anuja: I do love spicy foods, but I can make those changes if it’ll help. Remind me, is there anything else I should do?

Nurse Max: Yes. You also should avoid eating three hours before you go to bed and avoid lying down after meals.

There are some other lifestyle modifications you can make, but first, let me get a pamphlet to explain everything and then we can review it together.

Then, Nurse Max evaluates the outcome of their interventions. After reviewing the pamphlet together, Anuja verbalizes an understanding of the treatment plan and states she’ll bring home the pamphlet to reference when needed.

They also ensure Anuja has an active prescription for her PPI and remind her to monitor her symptoms to check back in three weeks to determine if the lifestyle changes have helped.

Alright, as a quick recap…. Nurse Max recognized and analyzed cues related to Anuja’s knowledge deficit and in collaboration with RN Steve, prioritized hypotheses, and generated solutions to address this problem.

Nurse Max and RN Steve then implemented pharmacologic and nonpharmacologic measures and evaluated Anuja’s outcomes and compared them to the expected outcome.

Since Anuja was able to verbalize an understanding of GERD management after reinforcement of education, they determined the plan of