Name and Age: John Pacual, 33 yrs old

Date and Time Admitted: April 10, 2021, 8:00 am

Gastroesophageal Reflux Disease

SOAPIE CHARTING
SUBJECTIVE

“nagigising po ako sa sobrang sakit po ng tiyan ko at mainit na pakiramdam sa dibdib

ko.”

OBJECTIVE
 sore throat
 cough
 dysphagia
 abdominal pain with pain scale of 7/10
 facial grimace with arms against the stomach
 Heart burn
 Regurgitation
 Mid-thoracic, bilateral back pain

Vital signs
 BP: 132/78mmHg
 PR: 80 bpm
 RR: 18 bpm
 BT: 37.3 ⁰C

ASSESSMENT

 Acute Pain related to irritated esophageal mucosa as evidenced by verbalization of pain,

cough, heartburn, dysphagia, and abdominal pain.

PLANNING

After 4 hours of nursing intervention, the client will report relieved of pain.

INTERVENTION

 Placed the head of the bed on 4 to 8 inches blocks to relieve heartburn sensation.
 Advised the client to avoid food or drink 2 hours before bedtime or lying down after
eating which helps to control reflux and causes less irritation from reflux action into
esophagus.
 Encouraged the patient to avoid activity and remain upright for 1 to 4 hours after each
meal to prevent reflux.
 Advised the patient to avoid tight fitting clothes to enhance breathing pattern this may
contribute in relieving pain.
 Instructed the patient to eat slowly and chew food thoroughly to promote proper digestion
of food.
 Administered medication as prescribed by the physician.
- Omeprazole20 mg/tab OD 
 Discussed with family members to provide patient small, frequent feedings, effect of
irritants such as tobacco and alcohol and avoid very hot or cold foods, spices, fats, coffee,
chocolates, and citrus juices.
 Discussed the importance of quitting from alcohol intake in the condition of the client
and advised him to quit from drinking alcohol.

EVALUATION

After 4 hours of nursing intervention, the client reported decreased of pain as evidenced
by the pain scale from 7/10 into 3/10. Goal met.
SUBJECTIVE

“pakiramdam ko po nangangayayat na po ako kasi hindi po ako nakakakain ng maayos

ng isang buwan.”

OBJECTIVE
 sore throat
 dysphagia
 Heart burn
 Abdominal pain
 Regurgitation
 increasing postprandial fullness
 early satiety
 Weight loss from 190 lbs to 102 lbs.

Vital signs
 BP: 132/78mmHg
 PR: 80 bpm
 RR: 18 bpm
 BT: 37.3 ⁰C
 Height: 65 inches
 Weight: 102 lbs
 BMI: 16 (underweight)

ASSESSMENT

Imbalanced Nutrition: Less Than Body Requirements related to lack food intake due to reflux as
evidenced by dysphagia, abdominal pain, regurgitation, weight loss, postprandial fullness and
early satiety.

PLANNING

After 4 hours of nursing intervention, the client will verbalize change in eating habits to meet his
nutritional needs.

INTERVENTION

 Obtained a nutritional history to determine the feeding habits of the client thatcan provide
a basis for establishing a nutritional plan.
 Weighed the patient to monitor patient’s nutritional status.
 Advised the client to avoid food or drink 2 hours before bedtime or lying down after
eating
  Encouraged the patient to avoid activity and remain upright for 1 to 4 hours after each
meal.
 Advised the patient to avoid tight fitting clothes.
 Instructed the patient to eat slowly and chew food thoroughly.
 Administered medication as prescribed by the physician and monitor the patient
regularly.
- Hydrochlorothiazide 25 mg/tab BID 
- Omeprazole20 mg/tab OD 
 Discussed with family members to provide patient small, frequent feedings.
 Discussed with the family members the effect of irritants such as tobacco and alcohol.
 Discussed with the family members to avoid very hot or cold foods, spices, fats, coffee,
chocolates, and citrus juices.

EVALUATION

After 6 hours of nursing intervention, the client verbalized change in eating habits as evidenced
by eating small, frequent meal; eating slowly and chewing food thoroughly; and avoiding
irritants. Goal met.