Name and Age: Mrs S, 78 y/o

Date and Time Admitted: November 15, 2021, 8:00 am

Gastroesophageal Reflux Disease

SOAPIE and FDAR CHARTING

S

Chief complaint of indigestion pain and reflux burning sensation

O
 Shortness of breath
 Non-productive cough
 Nausea
 indigestion pain with pain scale of 8/10
 Reflux burning sensation

Vital signs
 BP: 80/60 mmHg
 PR: 106 bpm
 RR: 24 bpm
 BT: 37.2 ⁰C
 Weight: 150 lbs
 Height: 5ft 4inches

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

cough, dysphagia, and indigestion pain.

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

ü Placed the head of the bed on 4 to 8 inches blocks to relieve heartburn sensation.
ü 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.
ü Encouraged the patient to avoid activity and remain upright for 1 to 4 hours after each meal
to prevent reflux.
 ü Advised the patient to avoid tight fitting clothes to enhance breathing pattern this may
contribute to relieving pain.
ü Instructed the patient to eat slowly and chew food thoroughly to promote proper digestion
of food.
ü Administered medication as prescribed by the physician.
ü 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.
ü Discussed the importance of quitting from alcohol intake in the condition of the client and
advised him to quit from drinking alcohol.

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.
 DATE AND TIME F DAR

D – patient experiences shortness of

breath, Non-productive cough, Nausea,
11/15/2021 Gastroesophageal Reflux Disease indigestion pain with pain scale of 8/10,
and Reflux burning sensation. The
0800H patient’s blood pressure is 80/60 mmHg,
pulse rate of 106 bpm, respiratory rate of
24 bpm, body temperature of 37.2 ⁰C,
weight is 150 lbs, and height is 5ft
4inches.

A - Placed the head of the bed on 4 to 8

inches blocks to relieve heartburn
sensation.

ü 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.
ü Encouraged the patient to avoid
activity and remain upright for 1 to 4
hours after each meal to prevent
reflux.
ü Advised the patient to avoid tight
fitting clothes to enhance breathing
pattern this may contribute to
relieving pain.
ü Instructed the patient to eat slowly
 and chew food thoroughly to
promote proper digestion of food.
ü Administered medication as
prescribed by the physician.
ü 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.
ü Discussed the importance of quitting
from alcohol intake in the condition
of the client and advised him to quit
from drinking alcohol.

R - 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.