TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

PATIENT EDUCATION FORM

Name Krisianne Mae L. Francisco Area

Inclusive
Year Level BSN III B RLE Group B3 dates of
Rotation
Name of
John Pascual Age 33 years old Gender
Patient Male
Date
April 10, 2021 Diagnosis Gastroesophageal Reflux Disease
Admitted

MAIN CONCEPT / TOPIC: Proper food intake

Details of Patient Education Content:

 Advised the client to avoid food or drink 2 hours before bedtime or lying down after
eating which may helps control reflux and causes less irritation from reflux action into
esophagus.
 Discussed the proper medication intake.

Instructed the patient to:

 Eat slowly and chew food thoroughly for proper digestion of food.
 Take small, frequent feedings in order for the food to pass easily into the stomach.
 Avoid irritants such as tobacco and alcohol.
 Avoid very hot or cold foods, spices, fats, coffee, chocolates, and citrus juices.

Patient’s Signature / Significant Other’s Signature

Date Signed
Date Submitted