Gerd 6d333g

CARE PLAN STUDENT NAME: Steve Randolph MEDICAL DX: GERD DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage. SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus. NURSING ASSESSMENT

NURSING DIAGNOSIS

Objective: Facial grimacing, guarding chest and stomach area, difficulty swallowing, dyspnea, anorexia, Pain 7 on scale 1-10 Subjective: Patient states,” My heartburn never goes away! Why does it always hurt so badly?”

Physiological: Chest pain Related to inflammation of esophageal tissues caused by gastric reflux

NURSING INTERVENTIONS

RATIONALE

1. Assess level of pain using appropriate pain scale 2. Identify factors that cause pain or increase it. 3. Provide medications to relive acidity of gastric contents as ordered. 4. Position patient in a Fowler’s position. 5. Provide small frequent meals and avoid foods that trigger heartburn.

1. Provides information of severity of pain 2. Enhances management of condition and helps to formulate teaching plan. 3. Helps decrease gastric acidity to promote comfort. 4. Helps prevent reflux of gastric contents into esophagus. 5. Prevents pain caused by heartburn and gastric contents from reaching esophagus.

PATIENT TEACHING

PATIENT OUTCOME

1. Provide information on proper positioning to prevent gastric reflux. 2. Provide information on medication and proper dosage. 3. Foods and activity that may trigger pain caused by gastric reflux. 4. Cease smoking and use of alcohol as they exacerbate symptoms. 5. Avoid strenuous activity and bending at the waist after meals.

Patient will have relief from pain as evidenced by verbalization of a lower level of pain on a scale of 1-10.

CARE PLAN STUDENT NAME: Steve Randolph MEDICAL DX: GERD DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage. SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus. NURSING ASSESSMENT

NURSING DIAGNOSIS

Objective: Nausea, vomiting, pallor, diaphoresis, dypnea, guarding of stomach and throat areas. Subjective: Patient states,” I’m so tired of vomiting all the time after I eat, but it’s always worse before I go to sleep.”

Physiological: Nausea and vomiting related to gastric reflux.

NURSING INTERVENTIONS

RATIONALE

1. Assess vital signs. 2. Assess causes of nausea and vomiting. 3. Maintain upright position 30 to 45 minutes a.c. 4.Provide small frequent meals 5. Avoid giving food that is high in acidity or caffeine.

1. Provides baseline information for later comparison. 2. Finding the causes of N/V may help to prevent episodes of N/V. 3. Maintaining an upright position will help after meals helps prevent gastric reflux. 4. Small frequent meals prevent stomach contents from overflowing into the esophagus. 5. High acid foods may exacerbate nausea and vomiting.

PATIENT TEACHING

PATIENT OUTCOME

1. Avoid eating large meals, eat smaller more frequent meals. 2. Do not eat meals before hours slept 3. Maintain an upright position 30-45 minutes after meals. 4. Avoid situations that may cause episodes of N/V. 5. Identify and avoid foods that cause nausea and vomiting

Patient will experience less nausea and vomiting episodes as evidenced by avoiding situations that exacerbate nausea and vomiting.

CARE PLAN STUDENT NAME: Steve Randolph MEDICAL DX: GERD DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage. SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus. NURSING ASSESSMENT

NURSING DIAGNOSIS

Objective: Subjective:

NURSING INTERVENTIONS

RATIONALE

PATIENT TEACHING

PATIENT OUTCOME

CARE PLAN

STUDENT NAME: Steve Randolph MEDICAL DX: GERD DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage. SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus. NURSING ASSESSMENT

NURSING DIAGNOSIS

Objective: Withdrawn, tearful, anxiety, tachpnea, anorexia, tachycardia, marked nervousness, self destructive behaviour. Subjective: Patient states,” I’m scared out of my head; I have never had surgery before! What if I don’t make it?”

Psychological: Fear related to possible fundoplication surgery to alleviate symptoms of GERD

NURSING INTERVENTIONS

RATIONALE

1. Provide opportunities to express concerns, fears, feelings, and expectations through therapeutic communication. 2. Assess available or useful past and present coping mechanisms. 3. Encourage patient to identify own strengths and abilities. 4. Provide information the patient wants and needs, not provide more than patient can handle. 5. Reduce stimuli in environment that could be misinterpreted as threatening.

1. Providing an environment of openness and therapeutic communication my help calm the patient. 2. Assesses level of coping ability and past successful coping methods. 3. During crises, patients may not be able to recognize their strengths. Fostering awareness can expedite use of these strengths. 4. Patients who are coping ineffectively have reduced ability to assimilate information. 5. Patients are exposed to new equipment and environments that may be perceived as threatening.

PATIENT TEACHING

PATIENT OUTCOME

1. Use of groups may help patient and family understand they are not alone. 2. Teach use of relaxation, exercise, and diversion activities as methods to cope with stress. 3. It is ok to let people know how you feel. 4. Include family in decision making process concerning care being received.

Patient will experience a lowered level of fear through therapeutic communication as evidenced lower level of anxiety and tearfulness.

CARE PLAN STUDENT NAME: Steve Randolph

MEDICAL DX: GERD DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage. SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus. NURSING ASSESSMENT

NURSING DIAGNOSIS

Objective: Heatburn, chest pain, nausea vomiting, guarded position, facial grimacing, Subjective: Patient states,” The doctor said I have GERD, What is GERD? Is this why I always have heartburn?” And ,” It seems it gets worse when I get back from the bar everynight.”

Psychological: Knowledge deficit related to repeated heartburn as evidenced by not taking medications insufficient knowledge of disease and proper lifestyle changes.

NURSING INTERVENTIONS

RATIONALE

1. Assess patient’s knowledge of the disease. 2. Identify any existing misconceptions regarding material to be taught. 3. Determine cultural influences on health teaching. 4. Explore attitudes and feelings about changes. 5. Provide a quiet atmosphere without interruption

1 Helps assess what the patient knows to help formulate a teaching plan. 2. This provides an important starting point in education. 3. Providing a climate of acceptance allows patients to be themselves and to hold their own beliefs as appropriate. 4. Assists in understanding how learner may respond to information and possibly how successful the patient may be with the expected changes. 5. This allows patient to concentrate more completely.

PATIENT TEACHING

PATIENT OUTCOME

1. Teach patient the causes of GERD to his level of understanding. 2. Information on medication and proper dosage of medication. 3. Foods to avoid that may cause symptoms to get worse. 4. Proper positioning during hours slept. 5. Proper diet and nutrition: low fat, low acidic or spicy foods. high fiber, lean protein and small frequent meals. 6. Lifestyle changes such as cessation of smoking and refraining from alcohol.

Patient will be more sufficient in self care as evidenced by less heartburn and making positive lifestyle changes through education.