languha Ngati

Med surge  

chapter 51 care plan for GERD.

1-18-20

Correction
Case Study, Chapter 46, Management of Patients With Oral and Esophageal Disorders 

1. George Smith, a 55-year-old patient is admitted to the intensive care unit after a thoracotomy

approach was used for an esophagectomy to remove an early stage adenocarcinoma of the distal

esophagus and gastroesophageal junction. The patient has a history of GERD and Barrett’s

esophagus. The patient sought medical treatment for dysphagia with solid foods, feeling that

there was a lump in his throat and substernal pain with swallowing and subsequent regurgitation

of undigested food and the development of hiccups. The patient has no other medical problems.

(Learning Objectives 6 and 7) 

a. Describe the esophageal cancer that the patient has and how it relates to his history of

GERD and Barrett’s esophagus.

b. Explain the rationale for the early symptoms and late symptoms of esophageal cancer.

c. What course of cancer treatment should the nurse anticipate that the patient in this case

study would have?

d. What nursing care should be provided for the patient in the intensive care unit in the early

postoperative period?

e. Explain the care the nurse should provide when the patient begins to eat.
Gastroesophageal reflux disease or simply GERD is the excessive backflow of gastric or

duodenal contents, or both into the esophagus and past the lower esophageal sphincter (LES) for

a sustained length of time without associated belching or vomiting.

Signs and symptoms .

- A burning sensation in your chest (heartburn), usually after eating, which might

be worse at night

- Chest pain

- Difficulty swallowing

- Regurgitation of food or sour liquid

- Sensation of a lump in your throat

   Head to toe assessment.

General appearance

- Patient is alert and oriented to person, place, time, and situation.

- Patient is clean and well groomed

- Patient standing upright erect and relaxed.

- No congenital or acquired physical deformities noted.

 - Independent and mobile, no use of assistive device. Full range of motion present in

bilateral upper and lower extremities.

- Patient can speak without any difficulties.

- Vital signs: B/P 113/68 pulse 64, 02 98, Temp 97.3, R 18.

Skin, hair, and nails:

- Patient skin is free of lesion, rashes and bruising.

- Patient skin is warm and moist to touch.

- No pressure area noted.

- No edema noted

- No lice on hair.

- Patient Nails capillary refill less than 3 seconds bilateral and is consistent.

Head and Face

1. Scalp, hair, cranium

Head round, symmetric skull, and appropriate proposition to body size and shape.

2. Face, stroke check

Face symmetrical, no facial skin pigmentation or abnormalities noted. Client had

calm and relaxed facial expression.

3. Temporomandibular joint
 No pain full range of motion temporomandibular joint. No grunting sound heard or

felt during jaw opening and closing.

4. Maxillary sinuses, frontal sinuses palpation

No visible or palpable maxillary and frontal sinus swelling noted.

7 Facial expression, mood, and affect

Calm, cooperative, pleasant and maintain eye contact during conversation.

8 Speech

Clear, fluent and meaningful conversation.

Eyes

1. Vision is good with or without glasses.

2. EOM’s: Corneal light reflexes were bilaterally symmetrical at 12-o’ clock position.

EOM’s: 6 positions of gaze are smooth tracking, no nystagmus noted bilaterally.

3. Conjunctivae: Covers inside of eyelids. Bilateral conjunctiva translucent, flat, clear,

and transparent on visualization.

5. Sclera: Bilateral Sclera appears white in color. No redness or discharges noted.

6. Cornea: Bilateral cornea clear bright smooth surface,

7. Pupils: bilateral pupils equal, round, 2 mm, reactive, accommodation to light

Ears
 1. External ear: Bilateral external ears symmetrical, no swelling or tenderness noted.

2. bilateral tympanic membrane intact, shiny, and translucent, with pearly-gray color.

3. Hearing: Able to hear two syllable words clearly.

Nose

1. External nose

External nose appears round symmetrical, appropriately proportioned to other facial

features. No visible nasal skin abnormality noted.

2. Patency of nostrils

Bilateral nostril patent, client can blow her nose as well as sniff without difficulty.

no septal deviation. Bilateral nasal mucosa is red, smooth, and moist. No visible

trauma, swelling, or discharge present.

Mouth and Throat

1. Lips and buccal mucosal

Lips and buccal mucosa are pink, moist, and free from lesion and cracks.

2. Teeth and gums

 Teeth are white, evenly spaced, clean and free from decay. Upper and lower jaw

aligned evenly, normal occlusion upon bite.

Gums are pink moist and smooth. No gingival margins noted.

3. Hard/soft palate

Hard palate: pink irregular rugae present. No visible lesion present.

Soft Palate: Pink smooth and upwardly movable.

4. Tonsils

Bilateral tonsils appears pink , same as oral mucus membrane. Bilateral tonsils are 1+

size at the scale of 4+.

5. Uvula

Pink consistent with buccal mucus membrane. Uvula Rises with phonation.

6. Tongue

Pink and even slightly rough at dorsal surface. No lesion or induration.

Neck

1. Symmetry, lumps, pulsations

 Neck muscles symmetrical , present at midline. Full range of motion while turning

left, right, extending head backward and forward. No lumps or skin abnormalities

found.

2. Cervical lymph nodes

Lymph nodes are bilaterally smooth, movable, discrete, soft, and nontender.

3. Carotid pulse (palpation and auscultation)

Brisk upstroke slower downstroke, moderate and equal bilaterally. No bruit or

swishing noted.

4. Trachea

No tracheal swelling or rigidity noted. Present at midline of shoulder and neck.

5. ROM and muscle strength

Full range of motion.NO muscles spasm, no neck rigidity noted, able to move neck

left, right, upward, and downward without any difficulty.

Chest and Lungs: Anterior, Posterior, and Lateral:

 Anterior and posterior chest: symmetrical bilaterally. Elliptical shape with downward

sloping ribs. Patient is sitting in a relaxed posture.

Thoracic cage configuration : skeletal framework of the chest has 12 pairs of

ribs and sternum. Anterior/posterior transverse diameter is 1:2.

1. Symmetric expansion: symmetrical chest expansion bilaterally upon inhalation.

No Lumps or mass, no tenderness upon palpation, smooth and soft skin.

Breath sounds: Respiration is regular, breathing at a rate of 18 breaths per minute.

2. Spinous processes: costal rib angle 90 degree and downward sloping ribs.

3. CVA tenderness: no costal vertebral angle tenderness noted bilaterally upon

percussion.

Upper Extremities

1. ROM and muscle strength: full range of motion bilaterally and are equal strength.

Able to circumduction, flex and extend bilateral shoulders, abduct and adduct

bilateral elbows, able to perform pronation and supination of bilateral wrists.

Fingers: full range of motion in all 10 digits.

2. Capillary refill less than 3 seconds bilaterally.

3. Handgrips: bilateral hand grips strong and equal.

Heart
 1. Precordium: no pulsations, heaves visualized any palpable thrills present at this time.

2. Heart sounds x 5 cardiac landmarks:, no murmurs, no friction rub, no arterial gallops

or S4 gallops noted. S1 sound heard very prominent at apex. S2 sound was greater at

base.

3. Denies chest pain.

Abdomen

1. Contour, symmetry : Abdomen flat symmetrical, with no apparent masses

Skin characteristics: abdominal skin smooth with no striae, scar, or lesion.

Umbilicus and pulsations: Umbilicus located at the center of abdomen. Umbilicus

is inverted, clean, and free from dirt and discharges. No pulsation noted.

2. Bowel sounds bowel sound present, no bruit.

3. Vascular sounds (aortic, ileac, renal) : Vascular is osculated via bell of stethoscope no

bruit or friction rub noted.

4. Light and deep palpation: Abdomen soft and palpable, non-tender, no organomegaly,

or mass noted.

Lower Extremities

1. Symmetry: Bilateral lower extremities equal and symmetrical

Skin characteristics: Skin appears to be smooth and warm, no swelling or lesions on

bilateral lower extremities.

Hair distribution: bilateral lower extremities have uniformed fine hair distribution.

2. Posterior tibial: 2+ pulse present bilaterally at the scale of 3+pulse. No edema noted.
 3. Dorsalis pedis: 2+ pulse present bilaterally at the scale of 3+pulse. No edema noted.

4. Temperature: warm to touch bilateral lower extremities.

5. Pretibial edema: no edema present at this time.

6. Toes-capillary refill: less than 3 seconds bilateral toes.

7. ROM/Muscle Strength:

Hips: bilateral hip symmetrical at the level of iliac crest, bilateral hip joints are

stable .bilateral hip flexion at 90 degree.

Knees: full range of motion present on bilaterally. Able to flex and extend smoothly.

Ankles: full range of motion present at bilateral ankle bilaterally. Able to flex and

extend smoothly

Feet: full range of motion present at bilateral feet Able to flex and extend smoothly.

Skin (may assess with corresponding region)

1. Hands and nails

Bilateral upper extremities warm to touch. Skin appears smooth, firm, and evenly

surfaced.

Nails surface are slightly curved, angled close to 160 degree. Bilateral index figure

shows diamond shape upon touching each other. Edges are smooth, rounded, and

clean.

2. Color and pigmentation

Skin pale and scattered senile lentiginous noted at bilateral upper arms.

3. Temperature, moisture, texture

 Skin warm to touch, appears smooth, firm, and evenly surfaced.

4. Turgor

Elastic upon checking on skin from chest. Pulled chest skin and released it returned

to its previous state.

5. Any lesions

No visible lesions present.

Neurological/Musculoskeletal

1. Sensation

Face: Able to sense touch on her face at forehead, left cheek and her chin. .

Arms and hands: able to feel and identify sharp and dull sensation on bilateral

arms. Able to feel and identify known objects with bilateral hands.

Legs and feet: able to feel and identify sharp and dull sensation bilaterally.

2. Position sense: Able to perceive direction of passive movement of index finger

bilaterally
 3. Stereognosis : able to feel and identify 3 known object via bilateral hands.

4. Cerebellar function: able to perform finger to nose repetitions.

5. Cerebellar function: able to perform heel to shin repetitions.

6. Deep tendon reflexes: no deep tendon reflexes present bilaterally.

7. Patellar : no patellar reflexes present bilaterally.

8. Babinski reflex: negative Babinski reflex.

1. Walk across room: able to walk with steady gait and stay balanced.

Able to touch heal to toe without any difficulty bilaterally.

2. Romberg sign : negative

3. Touch toes: able to bend and touch her bilateral toes without any difficulty.

ROM of spine: full range of motion against gravity present. full resistance and normal spin

curvature. No kyphosis lordosis or scoliosis noted

Lab Values  

- Upper endoscopy.

- Ambulatory acid (pH) probe test.

- Esophageal manometry

- X-ray of your upper digestive system

Expected lab value changes 

Endoscopy will detect inflammation of the esophagus (esophagitis)

All Nanda diagnosis 

- Imbalanced Nutrition: Less Than Body Requirements

- Acute Pain

- imbalanced Nutrition: More Than Body Requirements

- Risk for Aspiration

- Deficient Knowledge

3 NANDA priority nursing diagnoses

- Deficient Knowledge

- Imbalanced Nutrition: Less Than Body Requirements

- Risk for Aspiration

Goals for Deficient Knowledge

- Client will have increased knowledge of actions that reduce reflux

Intervention and rationale

- Assess patient for information needed and ability to perform actions independently

Rationale: Provides a basis for teaching

- Assist with the reduction in caloric intake

Rationale: Overweight increases intraabdominal pressure.

 - Provide patient with information regarding disease process, health practices that can be

changed, and medications to be utilized.

Rationale: Provides knowledge and facilitates compliance.

- Instruct patient regarding eating small amounts of bland food followed by a small amount

of water. Instruct to remain in upright position at least 1–2 hours after meals, and to avoid

eating within 2–4 hours of bedtime.

Rationale: Gravity helps control reflux and causes less irritation from reflux

action into the esophagus.

- Instruct patients to eat slowly, chew foods well and maintain a high-protein, low-fat diet.

Rationale: Helps prevent reflux.

- Instruct patient to avoid temperature extremes of food, spicy foods, and

citrus, and gas forming foods.

Rationale: These food items increase acid production that precipitates heartburn

and increased reflux.

- Instruct patient regarding avoidance of alcohol, smoking, and caffeinated beverages.

- Rationale: Increases acid production and may cause esophageal spasms.

Goals for Imbalanced Nutrition: Less Than Body Requirements

- Patient will ingest daily nutritional requirements in accordance to his activity level and

metabolic needs.

Intervention and Rationale

 - Accurately measure the patient’s weight and height.

Rationale: For baseline data

- Obtain a nutritional history

Rationale: Determining the feeding habits of the client can provide a basis for

establishing a nutritional plan.

- Encourage small frequent meals of high calories and high protein foods.

Rationale: Small and frequent meals are easier to digest.

- Instruct to remain in upright position at least 2 hours after meals; avoiding eating 3 hours

before bedtime.

- Rationale: Helps control reflux and causes less irritation from reflux action into esophagus.

- Instruct patient to eat slowly and masticate foods well.

Rationale: Helps prevent reflux

Goals for Risk for Aspiration

- Client will maintain patent airway

Intervention and rationale

- Assess for pulmonary symptoms resulting from reflux of gastric content.

- Rationale: These include subsequent aspiration, chronic pulmonary disease, or nocturnal

wheezing, bronchitis, asthma, morning hoarseness, and cough.

- Assess for nocturnal regurgitation.

 Rationale: This is a rare condition wherein the patient awakens with coughing, choking,

and a mouthful of saliva

- Assess patient’s ability to swallow and the presence of gag reflex. Have

the patient swallow a sip of water.

Rationale: Loss of the gag reflex increases the risk of aspiration.

- Avoid placing patient in supine position, have the patient sit upright after meals

Rationale: Supine position after meals can increase regurgitation of acid.

- Instruct patient to avoid highly seasoned food, acidic juices, alcoholic drinks, bedtime

snacks, and foods high in fat.

Rationale: These can reduce the lower esophageal sphincter pressure.

Medications 

- Famotidine is a histamine-2 blocker that works by decreasing the amount of acid the

stomach produces.

- Omeprazole is a proton pump inhibitor that decreases the amount of acid produced in

the stomach.

- Ranitidine also treats gastroesophageal reflux disease (GERD) and other conditions in

which acid backs up from the stomach into the esophagus, causing heartburn.

Teaching
- Before taking famotidine, tell your doctor if you have kidney or liver disease, a history of

Long QT syndrome, stomach cancer or other problems, or asthma, COPD, or other

breathing problems.

- With omeprazole teach patient that Omeprazole can cause kidney problems. Tell your

doctor if you are urinating less than usual, or if you have blood in your urine.

- Teach patient that with ranitidine is not expected to be harmful to an unborn baby. Tell

your doctor if you are pregnant or plan to become pregnant during treatment.