A Nursing Case Study on

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

In Partial Fulfillment of the

Requirements on NCM 218-RLE

PRIMARY NURSING ROTATION

Submitted to:

Edric Joy A. Ebero, RN, RM, MAN

Clinical Instructor

Farisa Jane G. Bango, StN

Angel Shane P. Bangonon, StN
Practicing Clinical Instructors

Submitted by:
Kharyl Roisse C. Castillano, StN
Doreen Mae P. Cavalida, StN
Charisse S. Caydan, StN
Jonji Dominic C. Coronel, StN
Dale Jade M. Cuta, StN
Aira Mae D. Espanola, StN
Alyssa Beatrice Caryl F. Espineli, StN
BSN-4L, Group 1, Subgroup 2

September 28, 2022

 TABLE OF CONTENTS

I. INTRODUCTION………………………………………………………………… 1
II. GOALS AND OBJECTIVES…………………………………………………… 2
III. DATABASE……………………………………………………………………… 4
a. Biographical Data…………………………………………………………….4
b. Clinical Data………………………….……………………………………….4
c. Family Health History………….……………………………………….…….4
d. Past Health History…………………………………………………………..5
e. History of Present Illness……………………………………………………5
f. Developmental Tasks……………………………………………………….5
IV. PHYSICAL/NEUROLOGICAL ASSESSMENT……………………………… 6
V. DEFINITION OF DIAGNOSIS…………………………………………………. 18
VI. ANATOMY AND PHYSIOLOGY………………………………………………. 19
VII. PATHOPHYSIOLOGY……………………………………………………………21
a. Etiology…………………………………………………………………………21
i. Causative Factor………………………………………………………21
ii. Mode of Transmission………………………………………………..22
iii. Predisposing Factors…………………………………………………22
iv. Precipitating Factors………………………………………………….23
b. Symptomatology………………………………………………………………25
c. Schematic Tracing…………………………………………………………….32
d. Narrative……………………………………………………………………….35
VIII. MEDICAL MANAGEMENT………………………………………………………37
a. Actual Laboratory Examinations…………………………………………….37
b. Diagnostic Exams…………………………………………………………….51
c. Therapeutics…………………………………………………………………..61
i. Drug Studies
IX. SURGICAL MANAGEMENT…………………………………………………….83
a. Possible Surgical Interventions
X. NURSING MANAGEMENT………………………………………………………88
 a. Nursing Theory………………………………………………………………88
b. Nursing Care Plans…………………………………………………………91
c. Review of Related Literature……………………………………………...107
d. Discharge Planning…………………………………………………………111
XI. PROGNOSIS……………………………………………………………………114
XII. REFERENCES………………………………………………………………….116
 I. INTRODUCTION

Primary nursing, also known as relationship-based nursing, developed in the late

1960s and used some of the concepts of total patient care and brought the registered
nurses back to the bedside to provide clinical care. According to Manthey (2009), "the
foundational principles of primary nursing were revolutionary." In primary nursing, the
primary nurse assumes 24-hour responsibility for planning the care of one or more
patients from admission or the start of treatment to discharge or the treatment's end.
During work hours, the primary nurse provides total direct care for that patient. Associate
nurses will follow the care plan established by the primary nurses, especially if the primary
nurse is not on duty. In this rotation, primary nursing, the student nurses will be able to
understand better the flow of authority and organizational flow of the hospital and give
high-quality care to the patients.
Both adults and kids typically experience gastroesophageal reflux, the back-flow of
gastric or duodenal contents into the esophagus. The prevalence of Gastroesophageal
Reflux Disease (GERD) is rising globally. It is characterized as a condition brought on by
a continuous retrograde movement of stomach contents into the esophagus, oral cavity,
or lungs. Dysfunction of the lower esophageal sphincter, pyloric stenosis, or a motility
issue can contribute to excessive reflux. With age, reflux seems to occur more frequently.
The esophagus, lower esophageal sphincter (LES), and stomach can be considered a
straightforward plumbing circuit. The stomach serves as a reservoir, the LES as a valve,
and the esophagus as an antegrade pump. Any system component may be to blame for
the anomalies that cause GERD. Acidic material is cleared less effectively when there is
poor esophageal motility. Gastric juice can reflux in excessive amounts due to a faulty
LES. Delay in gastric emptying can raise the reservoir's contents and pressure until the
valve mechanism is broken, resulting in GERD. From a medical or surgical perspective,
it is critical to determine which parts are damaged so that a successful treatment plan
may be implemented. GERD frequently results in bothersome symptoms or side effects
such as acid regurgitation, heartburn, and a persistent cough. Even though GERD is
considered a non-life-threatening condition, its symptoms can negatively affect a person's
quality of life in terms of their health.

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 One of the most widespread gastrointestinal conditions is GERD, affecting 20% of
adults in western societies. According to El-Serag et al.'s review, GERD prevalence in
the US ranges from 18.1% to 27.8%. Nevertheless, the actual prevalence may be higher
due to access to over-the-counter acid-reducing drugs. According to estimates, GERD
affects a significant portion of the general population—up to 20% of people worldwide.
GERD is now the most often diagnosed condition in gastrointestinal practices. According
to a 2014 study, GERD is more common (10–20%) in Europe and the US but less
common in Asia. According to epidemiological data, the prevalence of symptomatic
GERD has been increasing throughout the Asia Pacific Region. In Eastern Asia, the
frequency of GERD was between 2.5–4.8% in 2005 and rose to 5.2–8.5% by 2010.
According to published time trend research, erosive esophagitis (EE), a common
consequence of GERD, has increased more than twofold in the Philippines during the
past 20 years. Similar findings have been reported from the Philippines, where
esophagitis prevalence increased noticeably over six years, rising from 2.9% to 6.3%.
This case study is advantageous for nursing education because it can assist nurse
educators in promoting active learning and enhancing critical thinking skills, which are
essential for nurses and other healthcare professionals. Better preparing future medical
professionals for cases involving gastroesophageal reflux disease will also help them
acquire more knowledge. In nursing practice, this case study allows nurses to practice
nursing by educating them on GERD and the proper interventions. It offers a perspective
to help patients get better care and shines a light on the holistic component of the nursing
job. Lastly, this study can further improve the pathophysiology of gastroesophageal reflux
disease for nursing research, adding to its value. Researchers can use this work to
incorporate more GERD prevention strategies and possibly a more all-encompassing
treatment plan.

II. OBJECTIVES

General Objectives
Within the four (4) weeks of Primary Nursing Rotation, the Group 1 Subgroup 2 of
BSN 4L student nurses will develop a comprehensive Nursing Case Study regarding

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Gastroesophageal Reflux Disease (GERD) with reliable sources that will improve their
understanding and sharpen their skills about the case, for them to apply the principles
and concepts of Primary Nursing Rotation in the hospital setting.

Specific Objectives
The student nurses specifically aim to:
a. define Primary Nursing Rotation;
b. provide an overview of Gastroesophageal Reflux Disease;
c. discuss available data on the global and national situation of
Gastroesophageal Reflux Disease;
d. describe its implication to nursing education, nursing practice, and
nursing research;
e. formulate objectives that are specific, measurable, attainable, realistic,
and time-bounded;
f. discuss who is at risk and its risk factors;
g. distinguish the signs and symptoms of Gastroesophageal Reflux
Disease;
h. elaborate Gastroesophageal Reflux Disease's disease process;
i. determine the complications brought by Gastroesophageal Reflux
Disease;
j. discuss the medical, surgical, and nursing management of
Gastroesophageal Reflux Disease;
k. create three nursing care plans for patients with Gastroesophageal
Reflux Disease;
l. discuss the prognosis of Gastroesophageal Reflux Disease;
m. relate the case to two nursing theories;
n. compare recent related studies on Gastroesophageal Reflux Disease;
and
o. cite the sources in formulating the manuscript following the APA format.

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III. DATA BASE
a. Biographical Data
Client XYZ is a 47-year-old male of Filipino descent born on
December 25, 1965. He has been working as a medical representative head
supervisor for a big pharmaceutical company for 10 years. Currently, he is
married and resides in Davao City.

b. Clinical Data
Patient stated that the pain worsens after eating and when he is lying
flat. He wakes up from the pain and is having a feeling of an acid moving
back into the esophagus and reports concurrent retrosternal chest pain that
occurs during the episodes, heartburn, regurgitation, and painful
swallowing.
Upon Assessment, abdomen was observed to be distended and
bloated with stomach gurgling noises heard upon auscultation performed.
He has a vital signs of: BP: 140/90 mmHg, Temp: 37.5, RR: 23 cpm, PR:
105 bpm, Wgt: 86 kgs and a pain scale of 8/10.

c. Family History
Client XYZ is the eldest child of three siblings. The middle child, ABC
was born on November 10, 1970, male. ABC suffered from hypertension
and died at 45 years old in his sleep. The youngest child, DEF, was born on
August 26, 1977, is alive and is diagnosed with hypertension.
For the paternal side, XYZ’s father, 72 years old, XY suffered from
coronary artery disease and died due to cardiac arrest. His grandmother,
BH, suffered from coronary artery disease and died in her sleep at 77 years
old. His grandfather, PO, died from gastric cancer. Aunt 1 named LV, 66
years oid, suffers from diabetes mellitus type 1, while Aunt 2, named CC,
69 years old, suffers from hypertension
For maternal side, his mother, XX, is 70 years old and is diagnosed
with type 1 diabetes mellitus. His grandmother named HK, suffered from

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 hypertension, and died due to stroke at 69 years old. His grandfather, OA,
suffered from pneumonia and died in his sleep at the age of 72. Uncle 1,
YT, is 80 years old and suffers from lung cancer, while uncle 2 NM, is 66
years old and suffers from hypertension
The client’s wife named, GH, is 43 years old and suffers from
Hypertension. Their children IJ, 20 years old, female, and KL, 18 years old,
male, both have no medical conditions.

d. Past Health History

The client does not have any significant medical history, such as past
admissions and surgeries. He does not smoke and is a social drinker. He
does not use any medication other than the occasional over the counter
(OTC) medications such as Mylanta and Zantac.

e. History of Present Illness

The client sought medical attention due to episodes of mid-epigastric
pain or a “burning” sensation in his chest on September 8, 2022, at 8 am
and was placed under the care of Dr. Sabido. He mentioned that he has
been experiencing the pain for a month now. He also stated that he wakes
up from the pain and has a feeling of an acid moving back into the
esophagus with acidic taste in the mouth, sore throat, and hoarseness of
the voice. To relieve the pain, he takes Zantac and adjust from lying to sitting
position. The patient is experiencing a pain rate of 8/10 and Zantac doesn’t
give some relief with his condition. Upon admission, he appears with facial
grimacing and guarding behavior.

f. Developmental Task
Considering the symptom of “burning” sensation in his chest, reflux,
nausea and vomiting, the patient is diagnosed with Gastroesophageal
Reflux Disease (GERD). Treatment should be initiated as soon as the
diagnosis is made to prevent further damage to the esophagus. Primary

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 treatment for GERD is Histamine receptor antagonists since it relieves
heartburn and their effects last longer. Another drug such as Alginate also
has prolonged effect as it floats to the top of the gastric content and keeps
newly secreted acid away from the esophageal inlet.
If symptoms still occurs, patient may able to receive surgical
treatment such as the Nissen Fundoplication involves wrapping the upper
part of the stomach around the lower end of the esophagus

IV. PHYSICAL / NEUROLOGICAL ASSESSMENT

General Survey
Upon assessment, the patient is well-dressed and well-groomed. Even though
the patient had an overall tired or fatigued look, the patient displayed that she is awake
responsive to minimum stimulation. He also displayed an appropriate deportment and
mood throughout the interview because he was cooperative, expressive about his
concerns and raised clarifications, and had good eye contact. He is an endomorph
due to the fat deposition surrounding mostly her torso. His weight is 86 kg. The
patient’s weight was evenly distributed as he is able to stand on her heels and toes
straight ahead and equal on both sides. Her arm movements are coordinated and
rhythmic, where it strides in opposition appropriately. Hence, the patient is ambulatory.
There were no anomalies noted in his posture and gait. There is no sign that the
patient is in cardiac or respiratory distress. Upon admission, his vital signs are as
follows: Blood pressure is at 140/90 mmHg, his temperature is at 37.5 °C, pulse rate
is at 105 beats per minute, and respiratory rate is at 23 breaths per minute.

Skin
The general color of the client’s skin was uniform and its texture was smooth.
The skin turgor was good, his skin’s temperature was warm and the skin's moisture
was dry. There is hyperpigmentation present mainly on his forehead and the buccal
area. It is noted that the patient has several hyperpigmentations. These
hyperpigmentation are macules as they are small, flat, nonpalpable and the size is up

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to 1 cm. Despite the several lesions, nothing grossly wrong was noted. There were no
edema and ulceration noted. His nails were also well-trimmed.

Head
The client’s head and skull were normocephalic and symmetrical. Her
fontanelles were also closed. Her hair is smooth and distributed normally throughout
her scalp. Her scalp has dandruff. There are no lacerations, swelling, tenderness, or
lice noted during the assessment. Yet, two lesions were found on her hairline at the
back of her neck area. The lesions assessed are palpable with fluid within its cavities
and filled with pus. The lesions are at 1 cm at most. The size of the cranium is normal
as both are symmetrical and smooth. The patient’s face is symmetrical, and no
involuntary movements are noted as the patient is capable of performing facial
expressions freely without any swelling and tenderness. His muscle jaw is normal as
well.

Eyes
The eyebrows of the patient are symmetrical in alignment, yet the distribution
is sparse, especially on the left eyebrow. Both the upper eyelid symmetrically covers
only the top region of the iris. Hence, no ptosis and retraction were noted. His lashes
are curled outward. The lacrimal duct openings are evident at nasal ends and no
edema and tenderness are noted as well as discharges. The eyeballs sit to their
socket normally as there is no bulging noted. The delicate periorbital area appears
discolored because there are shadows underneath. The conjunctivae appeared pale,
yet there is no sign of edema, lesions, or discharges noted. Furthermore, the sclera
of the patient appeared anicteric and surrounds the iris and the pupil. When assessed,
the pupils are isocoric as both briskly constrict with light bilaterally. The eyes also
converge as the patient is focused on the pen thus, the patient’s eyes can
accommodate. In assessing the eyes’ extraocular muscles, the eyes were able to
complete the 6 cardinal gaze test without any restrictions, and the movement of the
eyes is conjugated except when converging on an object moving closer. The client
has also been assessed for eyes with pupils equally round and reactive to light. Visual

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acuity and visual fields are grossly normal, and were able to complete her functional
vision without any anomalies noted.

Ears
The pinna of the client is normoset. His external canal was patented and his
ears were also checked with clear tympanic membranes, and the canals are clear
bilaterally. Furthermore, the patient was able to repeat the words using a normal tone
and was able to hear the ticking of the watch. During the whisper test, the patient
misheard 2 words out of 10 words given.

Nose
The patient’s nasolabial fold has a uniform color and is symmetrical because
the nasal septum is intact and straight and not perforated or deviated. The nose is
also patent as the air moves freely as the client breathes. The patient is also able to
smell the aroma of the coffee. Abnormal secretions aren’t found as the mucosa is pink.
There are also no signs of growth of tenderness, lesions, and blood points as well.
The paranasal sinuses, such as the maxillary and frontal sinuses, don’t have any
tenderness as there is no pain within touch.

Mouth

During the assessment, the patient had chapped, dry, and pallor lips. His lips
appeared to have pigmentation as it is darker on the edges as if to outline the lips.
There are no fissures, lesions, or ulcers noted on the lips. The tongue of the patient is
fitted comfortably in the midline of the mouth, tip against lower incisors. No anomalies
were noted. The patient has 24 permanent teeth in total and four missing teeth. His
missing teeth are his right and left 1st premolars on his upper jaw, right 1st molar of
the lower jaw, and left 2nd molar of his lower jaw. The right and left canine on the
lower jaw has dental carries on them. Lesions and lingual erosion of teeth were noted
as his incisors and canines had these symptoms. All of the teeth appeared to be
yellowish, and some were slanted. The patient has an overbite as well. his gums were
pinkish; thus, normal. The buccal mucosa of the patient has an entire pinkish oral

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cavity however, the presence of some erythema was observed. His palate is pinkish;
thus, normal.

Pharynx
The uvula is on the center and mobile as well. The pharyngeal wall has smooth
and pink homogenous surface prominences. No swelling and ulceration was noted.
The tonsils are inflamed and enlarged. Also, the patient had a gag reflex.

Neck
The neck fits symmetrically in the center however, the neck is slightly leaning
forward. Upon palpation, the lymph nodes are palpable thus, swelling and enlarged.
The thyroid is in normal size. The movement of the patient is coordinated and smooth.
Jugular vein distention is not observed. The muscle strengths of the patient are of
equal strength and power.

Thorax
The thorax’s shape of the patient is symmetrical and his spinal alignment is
also normal. There were no anomalies noted. Her breathing pattern was effortless and
his chest turgor was also normal. Her respiratory excursion is also normal, thorax’s
tactile fremitus was symmetrical, and resonance upon percussion. The patient had
vesicular breath sounds in all areas of auscultation thus no adventitious sounds noted.
Lungs are clear to bilateral auscultation, with no rales, no ronchi and no wheezing.

Heart
The precordium of the patient’s heart is normodynamic. There were no extra
sounds recorded upon auscultation. Upon palpation, all of the eight pulse sites had
strong pulsation. There was no calf tenderness recorded for both of the extremities.
There was no irregular rhythm, no murmurs, or even no gallops noted.

Breast
The patient’s breasts were equal and flat and there were no masses, dimpling,
redness, or edema noted. The breast was not tender as there's pain upon touch. The

9
color of his nipples and areola is brownish black, and there were no anomalies
recorded.

Abdomen
The patient’s lower abdomen has striae present and his abdomen was
observed to be distended and bloated with stomach gurgling noises heard upon
auscultation performed. No abnormalities were noted. His bowel movement was
normoactive and there was no bruit heard during auscultation. There’s an absence of
friction rub and upon percussion, it is tympanic. His bladder was nonpalpable and
there were no ascites and muscle guarding.

Breast
The patient’s breasts were equal and flat and there were no masses, dimpling,
redness, or edema noted. The breast was not tender as there's pain upon touch. The
color of his nipples and areola is brownish black, and there were no anomalies
recorded.

Abdomen
The patient’s lower abdomen has striae present and his abdomen was
observed to be distended and bloated with stomach gurgling noises heard upon
auscultation performed. No abnormalities were noted. His bowel movement was
normoactive and there was no bruit heard during auscultation. There’s an absence of
friction rub and upon percussion, it is tympanic. His bladder was nonpalpable and
there were no ascites and muscle guarding.

Genito-Urinary
The patient’s penis was normal. There were no lesions or tenderness noted.
No discharges were recorded and the meatus is in the midline. His scrotum is
symmetrical and there were no hernia or hydrocele noted.

Musculoskeletal
On both sides of his body, the patient has muscles of comparable size
supporting his interphalangeal joints, metacarpophalangeal joints, wrists, elbows,
shoulders, metatarsophalangeal joints, ankles, knees, and hip joints. No evidence of

10
 contractures, atrophy, hypertrophy, tremors, or spasticity was found when the muscle
and tendons were examined. A rating of five (5) indicates that the patient's
sternocleidomastoid, trapezius, biceps, triceps, and fingers/wrist can move actively
against full resistance. However, when flexed or extended, the patient's hamstrings,
quadriceps, and ankles/feet have a limited range of motion. Rating of five (5) indicates
that the patient's sternocleidomastoid, trapezius, biceps, triceps, and fingers/wrist can
move actively against full resistance. The patient's bones are symmetrical and free of
abnormalities and painful spots. The patient has equal-sized joints with no lumps and
no visible edema. The patient's sternocleidomastoid, trapezius, biceps, triceps, and
fingers/wrist are given a rating of five (5), which is regarded as an active movement
against full resistance for muscle strength. There were no visible indications of skeletal
deformities, anomalies, redness, crepitation, warmth, swelling, or soreness.

Neurological Assessment
Upon interview, the patient was able to enunciate words freely and he was able
to express himself. There were no abnormalities in his speech and language. He was
also able to tell the time, date, and place thus, oriented. He was able to answer the
questions and his statements during the interview are concise and coherent, thus
oriented in orderly and appropriate words. Even though he was aware and responsive
throughout the interview, he seldom forgets minimal details throughout his day, when
asked. However, he answered questions from his childhood with ease. Also, he was
able to concentrate and focus entirely during the interview.

Cranial Nerve Test

CRANIAL NERVE METHODS OF RESULTS

ASSESSMENT

I. Olfactory Odor identification was used to The patient could identify all
assess the olfactory cranial the odors he presented
nerve. The patient was asked bilaterally, such as coffee and
to close their eyes and identify alcohol.

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 the odor presented in front of
each nostril while the other
nostril was covered.

II. Optic Visual acuity was tested Upon assessment, the patient
through the Snellen chart in had trouble seeing from both
assessing the optic nerve. eyes as he could read the
Using the Snellen chart, the letters until 20/30.
patient will be 10 feet away
from the chart. Since the
patient is not wearing
corrective lenses, he would
not be wearing any during the
assessment. He will close one
eye at a time and read the
most familiar, and readable
letters. He will continue to
voice out the letters until he
cannot distinguish them. Then,
this would be repeated in the
other eye.

As for the patient's visual Upon assessment, the patient

fields, this would be assessed correctly identifies all of the
through a confrontation visual numbers of fingers held up in
field test. Firstly, the patient all of the visual quadrant of
will remove their hat or both eyes.
anything that could interfere
with their peripheral vision. Sit
approximately three to four
feet away and directly in front

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 of the patient. If possible,
adjust the seat height to the
patient's eye level. Then, ask
the patient to gently cover their
left eye with their left hand and
instruct the patient to fix their
gaze directly on their left eye
throughout the test. While the
patient focuses on the nurse’s
eye, close the nurse’s right
eye and maintain fixation on
the patient's open eye. The
nurse will raise their hand to
the inferior temporal edge of
your peripheral vision halfway
between the nurse and the
patient while holding up 1, 2, or
5 fingers. Using only 1, 2, and
5 fingers helps to make the
number more easily
distinguished by the patient.
Ask the patient how many
fingers are seen. This will be
repeated to all four visual
quadrants and to the other
eye.

III. Oculomotor Using a penlight, the nurse In all four visual quadrants,
IV. Trochlear
should hold it at least 12 including the midline, the
VI. Abducens
inches away from the patient's patient could follow the
nose when evaluating penlight.

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 nystagmus. Instruct the patient
to follow the penlight in all four
visual quadrants as it
advances across the midline
and toward the tip of the nose
using only their eyes and not
their heads.

Allowing the patient to look at

a faraway item that can Both of the patient's pupils
enlarge their pupils will help were able to contract rapidly
you evaluate the patient's pupil in response to light.
structure in a dimly illuminated
space. Cast a light with a
penlight to close the pupils at
the outer corners of each eye.

In assessing the
accommodation, instruct the When the index finger was
patient to focus their eyes and brought closer to the patient’s
allow them to follow the tip of nose, the patient’s pupils
the index finger as it gently constricted as his eyes closed
slide it towards the tip of the
patient’s nose. As your index
finger approaches the
patient’s nose and eyes are
crossed, the patient’s pupils
should constrict

V. Trigeminal In order to assess the patient's The patient was able to clamp
trigeminal motor function, the his teeth and was able to

14
 masseter muscles are felt open his mouth against
while the patient clenches their resistance
teeth, and the patient is asked
to open their mouth against
resistance. When the mouth is
opened, the jaw shifts to one
side if a pterygoid muscle is
weak.

VII. Facial Ask the patient to tightly close The patient could close both
both eyes and open them eyes tightly, grin, and blow
when signaled to test the facial out his cheeks. No facial
nerve. After that, request from spasms, weakness, or
the patient a smile, a frown, drooping were noted.
and a cheek blow.

VIII. Vestibulocochlear Using the whisper test, cranial The pateint can hear from
nerve 8 was evaluated. With both ears.
your hand, cover one of the
patient's ears while speaking
into the other. The patient
ought to be able to understand
the murmured words. On the
opposite side of the ear,
repeat the procedure.

IX. Glossopharyngeal To evaluate the uvula, ask the The uvula of the patient was
patient to open their mouth able to move upward when he
and say “Ahh.” It is normal to opened his mouth.
anticipate the uvula moving
upward.
The gag reflex is present

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 In assessing the gag reflex,
ask the patient to open their
mouth and use a tongue
depressor to press on the
throat gently.

X. Vagus To check for voice No hoarseness of voice was

hoarseness, ask the patient to noted.
talk

To check the patien’s ability to The patient was able to

swallow, ask the patient to swallow without any
swallow discomfort or pain.

XI. Accessory In assessing the head’s range The patient was able to move
of motion, the patient should his head and shrug against
be instructed to move their resistance
head side-to-side, up-and-
down, and shrug against
resistance

XII. Hypoglossal Instruct the patient to stick out The patient was able to stick
their tongue and move it from out his tongue and move it
side-to-side to assess for from side to side without
tongue movement. discomfort.

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Reflexes

REFLEX RESULT

Biceps reflex Contraction upon tapping is present, and flexion of

the forearm is noted with a brisk response. Graded as
2+ (normal).

Triceps reflex Extension upon tapping the tendon with the reflex
hammer is present with brisk reaction. Graded as 2+
(normal).

Brachioradialis reflex Brisk flexion and supination of the forearm were noted
upon tapping with a reflex hammer. Graded 2+
(normal).

Patellar reflex There is a a quick, although mild, contraction of the

quadriceps muscles, resulting in a small kicking
motion. Knee reflex jerks graded as 2+ (normal).

Achilles reflex There is normal reflex response as there is flexion of

the great toe. Graded 2+ (normal).

Sensory Exam

SENSATION RESULT

Position Sense The patient was able to identify all of the

position sense and there was no observed
abnormality noted.

Vibration The patient was able to feel vibrations on

both ankles when tunic fork was placed on
his ankles.

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 V. DEFINITION OF THE DIAGNOSIS

Gastroesophageal reflux disease (GERD) is a widespread digestive disorder

worldwide. It is characterized by troubling symptoms and consequences caused by the
reflux of stomach contents into the esophagus. It occurs when a muscle at the end of the
esophagus fails to close properly, allowing stomach contents to flow back into the
esophagus and irritate it. A doctor may diagnose GERD if a person has persistent acid
reflux more than twice a week. Furthermore, GERD is a significant public health concern
linked to lower quality of life and considerable morbidity. A person suffering from GERD
may have symptoms such as heartburn, which has been described as a flaming feeling
in the chest, and regurgitation of sour or bitter liquid into the throat or mouth. On the other
hand, there may be no burning chest pain but may have difficulties swallowing, and
unusual reflux symptoms such as sore throat, coughing, increased salivation, and even
shortness of breath.
The severity of reflux into the esophagus determines the illness stage. There are
four (4) phases of GERD, each with its own set of symptoms ranging from minor heartburn
to severe chest pain mimicking a heart attack, and treatment options differ in each stage.
Stage one (1), Mild GERD, an individual may have infrequent heartburn and regurgitation
(less than once a week) or a lump in the back of the throat, although this stage is normally
addressed with lifestyle changes and OTC acid suppression drugs only if needed. Stage
two (2), Moderate GERD, is characterized by more typical symptoms such as heartburn
and regurgitation that occur a few times per week and necessitate daily prescription acid
suppression drugs. In stage three (3), Severe GERD, an individual's symptoms are poorly
controlled on prescription drugs, and they are likely to develop erosive esophageal
inflammation. It is usually treated with antisecretory treatment daily to twice daily and
should be monitored by a GERD expert. Furthermore, at this time, a person is a candidate
for antireflux operations that may help restore the integrity of their lower esophageal
sphincter. Finally, stage four (4), reflux-induced precancerous lesions or esophageal
cancer, is caused by years of untreated severe reflux. Individuals may experience all
symptoms of the three stages, including hoarse voice, persistent cough, and dysphagia,
and usually develop a precancerous condition known as Barrett's esophagus, which can

18
progress to cancer if not treated. Furthermore, all treatments and diagnostic tests for
suspected GERD are performed at this time.
GERD is often diagnosed based on classic symptoms and an empiric trial's
response to acid suppression. If GERD is clinically suspected and endoscopy is not
indicated, empiric therapy ranging from lifestyle changes to a short trial with PPIs should
be undertaken. As a result, GERD is anticipated in individuals who react to this therapy
regimen. On the other hand, treatment of GERD symptoms has been linked to
considerable improvements in quality of life, including lower physical pain, greater vigor,
physical and social function, and mental well-being.

VI. ANATOMY AND PHYSIOLOGY

A muscular tube known as the esophagus connects the pharynx to the stomach.
The mucosa, a pink, wet tissue, lines the esophagus that measures approximately 8
inches long. The esophagus is located in front of the spine, behind the trachea and heart.
The esophagus travels through the diaphragm before entering the stomach. At the top of
the esophagus, there is a group of muscles known as the upper esophageal sphincter.
The upper esophageal sphincter muscles are utilized for breathing, eating, belching, and
vomiting, which are controlled by the nervous system. They prevent fluids and food from
entering the trachea. A group of muscles known as the lower esophageal sphincter is
located where the esophagus enters the stomach at the lower end. Acid and stomach
contents cannot pass backward from the stomach when the lower esophageal sphincter
is closed. The lower esophageal sphincter muscles are not controlled voluntarily.

19
 In the top region of the abdomen is the muscular, J-shaped stomach. It stores and
digests food as part of the digestive system. The size of each person's stomach is
different depending on the number of meals they eat and the structure. The esophagus
and the top of the stomach are connected and the gastroesophageal junction is the region
where the esophagus and stomach converge. The bottom of the stomach connects to the
duodenum. There are 5 sections in the stomach. The first section of the stomach that
connects to the esophagus is called the cardia. It has the cardiac sphincter, a little
muscular ring that aids in preventing reflux of stomach contents into the esophagus. The
upper, rounded region to the left of the cardia is known as the fundus. The stomach's
largest and most important component is its body. Here, food is combined and begins to
break down. The stomach's lowest third is known as the antrum. Until the meal is
prepared to enter the small intestine, it stores the broken-down food. The portion of the
stomach that joins the small intestine is known as the pylorus. It contains the pyloric
sphincter, a muscular ring that serves as a valve to regulate the emptying of the contents
of the stomach into the duodenum. The pyloric sphincter also stops the duodenum's
contents from returning to the stomach.
The mucosa, which is the stomach's inner lining, is one of the several layers of
tissue that make up the stomach. Its glands and specialized cells produce enzymes,
hydrochloric acid, and mucus. When the stomach is empty, the mucosa is ridged. As the
stomach is full from eating, the ridges flatten out. A layer of connective tissue called the
submucosa encircles the mucosa. It has bigger nerve cells, lymphatic and blood arteries,
and fibers. The submucosa is covered by the muscularis propria, which is the following

20
layer. It has two layers of muscle and is the primary muscle of the stomach. The fibrous
membrane that covers the exterior of the stomach is known as the serosa. The visceral
peritoneum is another name for the stomach's serosa. Your stomach receives instructions
from the central nervous system (CNS) to produce gastric juice, which is a mixture of
acids, enzymes, and mucus used for digestion. The hormone gastrin is released into the
blood by endocrine cells in the stomach to help regulate stomach activity. Food and liquids
pass through the esophagus and into the stomach after being swallowed. As the muscles
in the stomach wall contract and relax, food is combined with enzymes and acids. The
stomach lining is shielded from acids by mucus. Food and liquids are digested into chyme,
a viscous, acidic soup-like substance. The pyloric sphincter relaxes as chyme forms. In
order to transfer the chyme into the duodenum, where digestion occurs and many
nutrients are absorbed, the stomach muscles contract and then relax. The stomach
doesn't play a significant part in food absorption. Only water, alcohol, and some narcotics
are absorbed by it.

VII. PATHOPHYSIOLOGY
a. ETIOLOGY
i. Causative Factor
Gastroesophageal reflux disease, also known as chronic acid
reflux, is a disorder in which the esophagus, the tube that connects
your neck to your stomach, frequently becomes infected with acid-
containing stomach contents. The lower esophageal sphincter
(LES), at the end of the food pipe, can become relaxed, thus allowing
food back into the esophagus. In most cases, this occurs
postprandially. GERD occurs when LES fails to close such that the
stomach content or acid flows back into the esophagus. The reflux
disturbs the lining of your esophagus and as a result causing GERD.
Generally, damage to the esophagus is likely to arise when reflux is
very acidic, frequent, or if the esophagus cannot clear acid as quickly
as it should. In such instances, a person would feel heartburn.

21
 ii. Mode of Transmission
Gastroesophageal reflux disease (GERD) is not contagious.
This disease is caused by internal factors in the body. Even though
a majority of people assume that GERD is caused by certain food,
lifestyle habits, or stressful situations, scientist suspect that it is
caused by both genetic and environmental factors. With this in mind,
one's genes can play a role in causing structural problems in the
esophagus which in turn causes GERD. Another causative agent is
H. pylori strains that may colonize the esophageal mucosa,
aggravate the inflammation of the lower esophagus, and induce
intestinal metaplasia or even adenocarcinoma.

iii. Predisposing Factors

FACTOR PRESENT/ABSENT MECHANISM/RATIONALE
Gender (Female) ABSENT GERD is more prevalent in
females and their
frequency increased by
increase in age. Such
findings may be due to
female hormones and
hiatal hernia (Yaseri,
2017).
Age PRESENT Anyone can develop
GERD at any age but a
person is more likely to
develop it as it gets older
due to lifestyle (Ratini,
2021).

22
iv. Precipitating Factors
FACTOR PRESENT MECHANISM/RATIONALE
Obesity Absent Obesity is a risk factor for
GERD, although the
specific
mechanism remains to be
determined. In an obese
person the
intraabdominal pressure is
increased, which can
exacerbate
GERD. (Harding, 2020).
Diet PRESENT Foods may stimulate the
production of stomach
acid, making GERD
symptoms more severe.
Others may relax the
muscle that separates the
esophagus and stomach,
allowing acidic stomach
contents to flow back up
into the esophagus. This
flow can cause symptoms
such as lower chest
burning and pain. (Walker,
2018).
Hiatal Hernia Absent A hernia of this nature is
characterized by the
stomach being pulled into
the chest, which is higher
than where it normally sits.

23
 As the stomach gets
trapped into a higher
position than where it
normally sits, it becomes
easier for stomach acid to
flow back up into the
esophagus and cause acid
reflux. (The Surgical Clinic,
n.d.)
Continuous intake of Nonsteroidal anti-
NSAIDS inflammatory drugs
(NSAIDs), such as aspirin
and ibuprofen, break down
the protective barrier in
your stomach. This allows
acid to irritate the lining of
your stomach and worsen
symptoms of GERD.
(Walker, 2018).
Pregnancy Pregnancy hormones can
make the valve at the
entrance to the stomach
relax so that it doesn't
close as it should. This lets
acidic stomach contents
move up into the
esophagus. (Joseph, n.d.)
Smoking One of the effects of
nicotine on the body is that
it acts as a relaxant to
smooth muscle. Since the

24
 lower esophageal
sphincter is composed of
smooth muscle, the intake
of nicotine during smoking
can cause the muscle to
relax and function
improperly. In these
circumstances (especially
if combined with any other
gastroesophageal
problems), stomach acid
can leak through and
cause heartburn
(CaryGastro, 2021).

b. Symptomatology
SIGN/SYMPTOM PRESENT/ MECHANISM/RATIONALE NURSING
ABSENT REPONSIBILITIES
Heartburn PRESENT It occurs when the 1. Avoid certain
sphincter muscle at the foods that can
lower end of your cause
esophagus relaxes at the heartburn
wrong time, allowing such as mint,
stomach acid to back up fatty foods,
into your esophagus spicy foods,
(MayoClinic, 2022). tomatoes,
onions, garlic,
Chest Pain PRESENT It's a painful burning coffee, tea,
sensation in the middle chocolate,
of your chest caused by and alcohol.

25
irritation to the lining of 2. Do not drink
the esophagus caused carbonated
by stomach acid. This beverages
burning can come on R: They make
anytime but is often you burp,
worse after eating. For which sends
many people heartburn acid into the
worsens when they esophagus.
recline or lie in bed, 3. Stay up after
which makes it hard to eating
get a good night's sleep. R: When
Chest pain due to GERD you're
is relieved by antacids standing, or
(Cleveland Clinic, 2019). even sitting,
gravity alone
helps keeps
acid in the
stomach,
where it
belongs.
Finish eating
three hours
before you go
to bed. This
means no
naps after
lunch, and no
late suppers
or midnight
snacks.

26
 Dyspepsia PRESENT Patients may also 1. Encourage
complain of dyspepsia. small frequent
Dyspepsia is pain or meals of high
discomfort centered in calories and
the upper abdomen high protein
(mainly in or around the foods.
midline as opposed to R: Small and
the right or left frequent
hypochondrium). meals are
Stomach ulcers or acid easier to
reflux can cause digest.
dyspepsia. If there is 2. Instruct to
reflux, stomach acid remain in
backs up into the upright
esophagus (Lewis, position at
2020). least 2 hours
after meals;
avoiding
eating 3 hours
before
bedtime.
3. Instruct
patient to eat
slowly and
masticate
foods well.
R: Helps
prevent reflux.
Regurgitation PRESENT Regurgitation is usually 1. Instruct to
described as a sour taste remain in
in the mouth or a sense upright

27
 of fluid moving up and position at
down in the chest. It least 2 hours
happens when a mixture after meals;
of gastric juices, and avoiding
sometimes undigested eating 3 hours
food, rises back up the before
esophagus and into the bedtime.
mouth (Sethi, S., 2019). 2. Stay up after
eating
R: When
When you have GERD, you're
Coughing acid from your stomach standing, or
backs up into your even sitting,
esophagus. If the acid is gravity alone
brought back in, it can helps keeps
make a person cough acid in the
(Gillson, 2022). stomach,
where it
belongs.
Finish eating
three hours
before you go
to bed. This
means no
naps after
lunch, and no
late suppers
or midnight
snacks.
Water Brash ABSENT People with 1. Avoid certain
gastroesophageal reflux foods that can

28
 disease may experience trigger water
a symptom called water brash such as
brash. Water brash chocolate,
occurs when a person alcohol, and
produces an excessive fatty foods
amount of saliva that 2. Instruct client
mixes with stomach to increase
acids that have risen to daily activity
the throat (Brennan, and lose
2021). weight.
3. Administer
antacids and
or proton
pump
inhibitors as
ordered.
Wheezing ABSENT The refluxed gastric acid 1. Assess the
irritates the nerve patient’s VS
endings in the and
esophagus generating characteristics
signals to the brain. of respirations
Subsequently, the brain at least every
responds with impulses 4 hours.
to the lungs that R: To obtain
stimulate the muscle and baseline data
mucus production in the 2. Encourage
airways (Gillson, 2022). coughing.
Suction
secretions as
needed.

29
 R: To help
clear
remnants that
the patient
may not be
able to
expectorate
3. Administer
supplemental
oxygen as
prescribed
R: To increase
oxygen level.
Globus ABSENT According to Selleslagh 1. Instruct client to
Sensation et.al. (2013), globus may Drinking plenty of
be attributed to reflux fluids. Avoid
going past esophagus throat clearing as
into hypopharynx this tends to
causing irritation and exacerbate the
inflammation to globus
laryngeal tissue symptoms.
(laryngopharyngeal 2. Teach client to
reflux) have gentle
throat massage
and rolling neck
to release tight
muscles or any
tight sensations.
Odynophagia ABSENT The acidity of the 1. Check for
stomach's contents can coughing or
cause irritation in the choking

30
esophagus, which cause during eating
pain when swallowing and drinking.
(Biggers, 2021). 2. Check for
residual food
in mouth after
eating.
3. Check for food
or fluid
regurgitation
through the
nares.

31
c. Schematic Tracing of Gastroesophageal Reflux Disease

32
33
34
Narrative
The predisposing factors of G.E.R.D. are (1) Age and (2) Gender. The precipitating
factors are (1) Obesity, (2) Diet, (3) Hiatal Hernia History, (4) Continuous taking of
NSAIDs, (5) Pregnancy, and (6) Smoking/Exposure to Smoking.

The Esophageal Tissue is exposed to stomach acid, causing pro-inflammatory

cells and cytokines to proceed to the are where there is a stomach acid exposure. And
this mechanism can be divided into two- primary and secondary. If the case is primary, it
can be caused by Diet, NSAIDs, Obesity, and Pregnancy. Diet and NSAIDs are due to
incompetent Lower Esophageal Sphincter. And in obesity and pregnancy, there is Hiatal
Hernia, which is also considered as a complication of GERD. If the case is otherwise, it
can be caused by scleroderma (an autoimmune disease), large amounts of meal, and
delayed gastric emptying. Scleroderma makes GERD worse because the stomach
remains filled with noxious materials for a longer time after eating, thus decreasing
peristalsis. As per delayed gastric emptying and large consumption of meal, the CN XI
stimulates the Lower Esophageal Sphincter. Now, there is an excessive of prolonged
transient lower esophageal sphincter relaxation and due to that relaxation, HCl Acid is
pushed up due to increased intra-abdominal pressure. And because of that, the refluxate
contain proteolytic enzymes and bile. Continuously exposed to that, it can lead to (a)
Pharyngeal Lining and Airway Damage and (b) Squamous Esophageal Epithelium
Damage.

If there is damage in pharyngeal lining, the cough sensory nerve endings are
stimulated, airway becomes irritated, and fibroblasts proliferate and deposit granulation
tissue in airway. If Cough Sensory Nerve Endings are stimulated, the vagal reflex is
activated, causing activation of cough center. If the airway, on the other hand, is irritated,
it causes increased bronchial reactivity, thus causing increased vagal tone. There would
be bronchoconstriction that can be manifested by wheezing, globus sensation, and or
odynophagia that eventually ends in asthma or chronic cough. If the granulation tissue in
airway is deposit causing fibroblasts to proliferate, it can lead to a certain complication

35
called Chronic Laryngitis in which it is the narrowing of laryngeal space that can further
ascend to Laryngeal or Tracheal Stenosis.

For Squamous Esophageal Epithelium Damage, increased inflammation of cells is

present causing esophagitis. And that esophagitis forms ulcers in esophagus and
collagen is deposited where ulcers heal. As the time goes by, the collage fibers will
contract, leading to Esophageal Stricture Disease. Another damage that may cause is
that it would undergo metaplasia to become columnar epithelium, causing Barrett’s
Esophagus, thus having premalignant changes, that would eventually end in esophageal
adenocarcinoma if not diagnosed early.

If the client has no bleeding, and adheres to treatment regiment (antacids,

antibiotic therapy if H. pylori is the causative agent, taking prescribed drugs, and lifestyle
modification), it would lead to good prognosis. Non-compliance to treatments and
manifestations of different complications such as esophagitis, Barrett’s Esophagus,
Ulcerations and Narrowing of Esophagus, then, it could be under fair or poor prognosis.

VIII. SFS
a. SFSFSF

36
DATE COMPO DEFINITION RATION RESULT INTERPRE NURSING
NENT AND NORMAL RANGE ALE TATION & RESPONSIBILITIES
SIGNIFICA
NCE

9/8/ Complet One of the most routinely CBCs September 8, The Before
22 e Blood requested blood tests is the are 2022 @9:00AM results
● Encourage to avoid
Count complete blood count used to WBC: 5.7/uL indicate
stress if possible
(CBC). It measures the rule out RBC: 5.27/uL that the because altered
quantity of all the different other Hbg: 15.4g /dL patients physiologic status
influences and
types of cells in the blood. It illnesse Hct: 44.1% have
changes normal
also includes some s and to MCV: 84 fL normal hematologic values
valuable information on better MCH: 29.2 pg values of
● Explain that fasting is
other properties associated assess MCHC: 34.9 g/dL CBC.
not necessary.
with each type of blood cell. function RDW: 13.7% However, fatty meals
al status Platelet: 268 u/L may alter some test
and results as a result of
Compone Normal lipidemia.

37
 prognos
nt Values
is. ● Explain test
WBC 4.0-10.5 procedure. Explain
x10E3/uL that slight discomfort
may be felt when the
RBC 4.10-5.60 skin is punctured.
x10E3/uL

Hbg 12.5-17.0 During

g/dL
● Apply manual
Hct 36.0- pressure and
50.0% dressings over the
puncture site on
Mean 80-98 fL removal of needle.
corpuscula
r volume After
Mean 27.0-34.0
● Monitor the puncture
corpuscula pg
site for oozing or
r
hematoma formation
hemoglobi
● Instruct to resume
n
normal activities and
Mean 32.0-36.0 diet.
corpuscula g/dL
r
hemoglobi
n
concentrati

38
 on

Red cell 11.7-

distribution 15.0%
width
(RDW) size
and shape

Platelet 140-415
count x10E3/uL

Urinalys A urinalysis (also known as This September 8, The Before

is a urine test) is a test that usually 2022 @8AM patient’s ● Instruct the patient to
examines the visual, detects urine color void directly into a
Comp Resul
chemical and microscopic and onent t was clean, dry container.
aspects of the urine (pee). manage Color Yellow normal Sterile, disposable
It includes a variety of tests s a wide however, containers are
Appea Cloud
that detects and measures range of the recommended.
rance y
various compounds that disorder appearanc Women should
pass through the urine s, such Gluco 3+ e was always have a clean-
using a single sample of as se cloudy, catch specimen if a
urine. urinary Occult TRAC and microscopic
tract Blood indicates examination is
E
infectio that the ordered. Feces,
Componen Normal

39
 ns, patient discharges, vaginal
t Result Protei 3+
kidney n may be secretions and
Color Yellow
disease Leuko 1+ dehydrate menstrual blood will
Appearanc Clear
and cyte d or contaminate the
e
diabete Estera having a urine specimen.
Glucose Negative
s. se symptom During
Occult Negative of chronic ● Collect specimens
Blood WBC >60
disease. form infants and
Protein Negative
Bacter MANY The young children into a
Leukocyte Negative ia Glucose disposable collection
Esterase Crysta FEW componen apparatus consisting
ls t also of a plastic bag with
WBC <=5
WBC/HP shows that an adhesive backing
F
the patient around the opening
Bacteria None have that can be fastened
seen HPF glycosuria to the perineal area
. or around the penis
Crystals None
to permit voiding
seen HPF
directly to the bag.
Depending on
hospital policy, the
collected urine can

40
 be transferred to an
appropriate
specimen container.
● Cover all specimens
tightly, label properly
and send
immediately to the
laboratory.

After

● Observe standard
precautions when
handling urine
specimens.
● If the specimen
cannot be delivered
to the laboratory or
tested within an hour,
it should be
refrigerated or have
an appropriate

41
 preservative added.

9/9/2 FBS & Fasting Blood Sugar Test FBS is September 9, The result Before
2 Lipid measures the blood sugar often 2022 @9AM shows that ● Tell the patient to fast
Profile after an overnight fast. the first the before undergoing a
Whereas, Lipid profile test patient’s lipid profile test. The
Comp Resul
measures the amount of done to onent t Glucose- samples are taken
cholesterol and check Gluco 7.72 FBS is after 12-14 hours of
triglycerides in the blood. for se- mmol/ above overnight fasting so
prediab FBS L normal. that the results will
Component Normal
Result etes This be more accurate.
Lipid Profile
Glucose- 4.1-6.6 and indicates
FBS mmol/L diabete Triglyc 1.23 that the ● Tell the patient they
s. erides mmol/ body was can drink clear fluids
Lipid Profile
L not able to such as water, but

Triglycerides <1.7 lower should avoid drinking

Chole 4.25 blood beverages such as
mmol/L
sterol mmol/ sugar coffee and tea.
Cholesterol <5.20m L levels.
mol/L The lipid During
HDL- 0.64
results ● Patient’s blood
HDL-C 0.13- C mmol/

42
 were all in sample is taken by
3.5- L
normal inserting a needle
mmol/L
LDL 3.05 range into the vein.
LDL <2.50 mmol/ except for
mmol/L L the LDL, After
which was
VLDL 0.51- VLDL 0.56
above ● The blood is
1.50 mmol/
normal collected in a vial.
mmol/L L
and this Upon collection of
Another supporting
indicates patient’s blood
reference of the normal
that the sample, it will be
values:
patient analysed in the
https://healthy-
have more laboratory, where the
ojas.com/cholesterol/lipopr
than level of triglycerides,
otein-profile-test.html
enough HDL cholesterol and
cholestero LDL cholesterol are
l in the measured.
blood
● Tell the patient that
the procedure lasts
only for a few
minutes.

43
Basic Metabolic panel test is a Metabol September 8, The Before
Metaboli blood test that assesses ic panel 2022 @10AM results ● Explain test
c Panel your blood sugar, fluid and tests shows procedure and that
BMP Resul
electrolyte balance, kidney are t normal when skin is
function, and liver function. commo Sodiu 130 values punctured, there may
nly m mmol/ except for be some slight
BMP Normal L
Values request the discomfort.
Potassi 3.3
Sodium 135-147 ed to sodium ● Encourage patient to
um mmol/
mmol/L rule out L where it minimize stress as
Potassium 3.5-5.2 other Chlorid 100 was below much as possible
mmol/L e mmol/
disease normal, because their
L
Chloride 95-107 s and this physiologic status
mmol/L CO2 24
assess indicates influences and
mmol/
CO2 22-30 function that has changes their
L
mmol/L
al status Urea 20 hyponatre hematologic values.
Urea 7-20 mg/dL
Nitrogen and Nitroge mg/dL mia. ● Clarify that fasting
n
(BUN) prognos isn't necessary.
(BUN)
Creatinine 0.5-1.2 is. However, because of
Creatin 1.2
mg/dL lipidemia, fatty meals
ine mg/dL
Glucose 60-110 may affect some test
Glucos 100
mg/dL
e mg/dL results.
During

44
 September 8, ● Over the puncture
2022 @3PM site, apply manual
pressure and
BMP Resul
t dressings.
Sodiu 136 After
m mmol/ ● Keep an eye out for
L
bleeding or
Potas 3.5
hematoma formation
sium mmol/
L at the puncture site.

Chlori 100 ● Instruct the patient to

de mmol/ resume normal
L
activity and a healthy
CO2 24 diet.
mmol/
L

Urea 20
Nitrog mg/dL
en
(BUN)

Creati 1.1
nine mg/dL

Gluco 106
se mg/dL

45
H. pylori An H. pylori breath test, Determi September 8, The UREA BREATH TEST
test also called a urea breath nes 2022 @10AM normal
test, helps in diagnosing whether result is Before
infections caused by this an (+) Positive negative,
type of bacteria. infectio however,
Normal Result: n with the patient ● Collect a sample of
(-) Negative H. pylori is positive. your breath before
bacteria This the test starts.
may be indicates
causing that the During
an ulcer patient
or has an H. ● Give the patient a
irritation pylori capsule or some
of the infection. water to swallow that
stomac contains tagged or
h lining. radioactive material.

After

● Collect more
samples of your
breath. The samples

46
 will be tested to see if
they contain material
formed when H.
pylori comes into
contact with the
tagged or radioactive
material.

STOOL ANTIGEN TEST

Before

● Pass stool into a dry

container. Either
solid or liquid stools
can be collected. Be
careful not to get
urine or toilet tissue
in with the stool
sample.
● Replace the
container cap. Label

47
 the container with the
patient’s name,
doctor's name, and
the date the sample
was collected.

During

● Take the sealed

container to your
doctor's office or to
the lab as soon as
you can.

After

● Tell the patient to

wait for the results of
the stool antigen test.

STOMACH BIOPSY

48
Before

● Instruct the patient to

follow instructions on
how to prepare for
the procedure. The
patient will likely be
asked not to eat or
drink anything for 6
to 12 hours before
the procedure.

During

● The tissue sample is

removed during a
procedure called
upper endoscopy (or
EGD). It is done with
a flexible tube with a
small camera
(flexible endoscope)

49
 at the end. The
scope is inserted
down the throat into
the stomach.

● The health care

provider sends the
tissue sample to a
laboratory where it is
examined for signs of
cancer, certain
infections, or other
problems.

After

● Tell the patient that a

gastric tissue biopsy
is normal if it does
not show cancer,
other damage to the

50
 lining of the stomach,
or signs of organisms
that cause infection

b. DIAGNOSTIC EXAMINATION

DATE COMPO DEFINITION AND NORMAL RATION RESULT INTERPRET NURSING RESPONSIBILITIES
NENT RANGE ALE ATION &
SIGNIFICA
NCE

Abdomi Abdominal ultrasound is a This Actual results: The Before

nal type of imaging test. It is helps in Degenerative results of ● For an A.M.
Ultraso used to look at organs in the evaluati changes in the the appointment, Instruct
und abdomen, including the ng the spine patient’s patient for a fat free
liver, gallbladder, spleen, cause abdominal dinner the evening
pancreas, and kidneys. The of Gastric ulcer ultrasound before. Nothing to
blood vessels that lead to stomac Hepatic Cyst at shows eat or drink from
some of these organs, such h pain left lobe degenerati midnight until after
as the inferior vena cava or ve the examination. For
and aorta, can also be distenti Atherosclerotic changes in a P.M. appointment,

51
examined. on aorta the spine clear liquid breakfast
Normal findings: (enlarg which (no milk) before 9
- No focal liver lesions ement). Coronary artery indicates A.M. Nothing to eat
- No gallstones in disease the patient or drink after
gallbladder has breakfast.
- No intra or arthritis.
extrahepatic duct The During
dilatation patient ● An abdominal
- CBD diameter also ultrasound may be
(1.8mm to 5.9 mm) indicates done as an
to have outpatient or as part
peptic of your stay in a
ulcer hospital.
disease as
Gastric After
ulcer was ● There is no special
found in care required after
the an abdominal
results. ultrasound.
Hepatic
Cyst at left ● Tell the patient
lobe

52
indicates he/she may resume
that there to usual diet and
are fluid- activities unless the
filled doctor advises
cavities in differently.
the liver.
Atheroscle
rotic aorta
indicates
that there
is a build
up plaque
in the
aorta.

and
coronary
artery
disease
indicates
that there
is a

53
 blockage
in the
patient’s
coronary
artery.

Esoph Esophageal manometry is a This Abnormal results Before

ageal test that examines the identifie may indicate
mano coordinated muscle s or - A problem ● Instruct patient to
metry movement (motility) of the rules with the avoid eating and
esophagus. This uses a out a esophagus drinking for a time
narrow, flexible, pressure- narrowi that affects before esophageal
sensitive tube called a ng, its ability to manometry. The
catheter. The catheter complet move food doctor will give a
measures pressure created e toward the specific instructions.
by the muscles in the blockag stomach
esophagus and the valves e or an (achalasia) During
in the top and bottom area of - A weak
portions of the esophagus. inflamm LES, which ● While your patient is
Normal Results ation in causes sitting up, a member
The LES pressure and the heartburn of the health care
muscle contractions are esopha (GERD) team sprays the

54
normal when you swallow. gus. - Abnormal patient’s throat with a
contraction numbing medication
s of the or puts numbing gel
esophagus in your nose or both.

muscles ● A catheter is guided

through the patient’s
that do not
nose into his
effectively
esophagus. The
move food
catheter may be
to the
covered by a water-
stomach
filled sleeve.
(esophage ● After the catheter is
al spasm) in place, patient be
asked to lie on their
back on an exam
table or to remain
seated.
● Then let them
swallow small sips of
water. And a
computer connected
to the catheter
records the

55
 pressure, speed and
pattern of their
esophageal muscle
contractions.
● During the test,
Patient will be asked
to breathe slowly
and smoothly
● A member of the
health care team
might move the
catheter up or down
into their stomach
while the catheter
continues its
measurements.
● The catheter then is
slowly withdrawn.
● The test usually lasts
about 30 minutes.

56
 After

● Tell the patient When

their esophageal
manometry is
complete, they can
return to their normal
activities.

Upper Allows direct visualization Proced Abnormal Before

gastroi and therapeutic treatment ure of Results
ntestin of abnormal conditions of choice ● Patient assessment
al (GI) esophagus, stomach, and for - Larger than and preparation for
endosc duodenum that uses an evaluati normal the procedure
opy endoscope, a flexible tube on of veins in the ● Explain what to
with camera, to see the upper esophagus ● expect from the
lining of the upper GI tract. GI - Bleeding, procedure
structur growths, ● Prepare the
Normal endoscopy es and ulcers, and endoscopy room
results function inflammatio with the right

57
- The esophagus, and ns instruments and
stomach, and allows device
duodenum should be for the
smooth and of possibili During
normal color (). ty of a
- No bleeding, therape ● Assist endoscopist
growths, ulcers, or utic during the procedure
inflammation. interven ● Assist anaesthetist
tion during the procedure
(stomac ● Preventing infection
h and quality
biopsy, assurance
hemost ● Keep the patient
atic comfortable
therapy ● Vital signs
for monitoring
bleedin
g ulcers After
and
esopha ● Reprocessing of
geal endoscopic
varices)

58
 . instruments and
devices
● Transfer patient to
recovery room
● Handover to
recovery nurse

Esoph Esophageal pH monitoring It is Abnormal Before

ageal is a test that measures how done to - Sudden ● Instruct Patient to not
pH often stomach acid enters quantify decrease eat or drink after
monito the tube that leads from the the from 7 to 4 midnight before the
ring mouth to the stomach. The problem within 30 test. You should also
test also measures how and seconds avoid smoking.
long the acid stays there. also
used to During
Normal esophageal pH determi ● Inform the patient
- 7 ne that it will briefly feel
effectiv like gagging as the
eness tube is passed
of through your throat.
treatme ● The Bravo pH

59
nt. On monitor causes no
the discomfort.
other
hand, it After

is
commo ● Tell the patient that

nly used he will return to the

to hospital the next day

diagnos and the tube will be

e removed. The

GERD. information from the

monitor will be
compared with his
diary notes.

60
 c. THERAPEUTICS (DRUG STUDIES)

1. Ranitidine

GENERIC NAME Ranitidine

BRAND NAME Zantac

CLASSIFICATION Histamine H2 Antagonists
MODE OF ACTION Ranitidine reduces the secretion of
gastric acid by reversible binding to
histamine (H2) receptors, which are
found on gastric parietal cells. This
process leads to the inhibition of
histamine binding to this receptor,
causing the reduction of gastric acid
secretion.
ORDERED DOSE 50mg/2ml 1 amp IVTT BID
DOSE AND ROUTE Gastroesophageal Reflux Disease
● 150 mg orally every 12 hours or
50 mg
intramuscular/intravenously every
6-8 hours
Gastric Ulcer, Benign
● Treatment: 150 mg orally every 6
hours or 50 mg
intermuscular/intravenously every
6-8 hours intermittent bolus or
infusion; alternatively, 6.25

61
 mg/hours intravenously by
continuous infusion
● Maintenance of healing: 150 mg
orally every 12 hours
Hypersecretory Conditions
● 150 mg orally every 12 hours, up
to 6 g/day used

Parenteral: 50 mg (2 mL) intramuscularly

or intermittent intravenous bolus or
infusion every 6-8 hours, not to exceed
400 mg/day; alternatively, 6.25 mg/hour
continuous infusion
INDICATION It is used alone or with concomitant
antacids for the following conditions:
short-term treatment of active duodenal
ulcer, treating gastric acid
hypersecretion due to Zollinger-Ellison
syndrome, systemic mastocytosis, and
other conditions that may pathologically
raise gastric acid levels

It also used in the short term treatment of

active benign gastric ulcers and
maintenance therapy of gastric ulcers at
a reduced dose.

Ranitidine can be used for the treatment

of GERD symptoms, treatment of
erosive esophagitis (endoscopically
diagnosed) and the maintenance of
gastric or duodenal ulcer healing
CONTRAINDICATION ● Hypersensitivity to Ranitidine
● History of acute porphyria

62
SIDE EFFECTS ● Diarrhea
● Constipation
● Headache (may be severe)
ADVERSE EFFECTS ● Reversible hepatitis
● blood dyscrasias occur rarely
● malaise
● dizziness
● insomnia
● tachycardia
● bradycardia
● leukopenia
● gynecomastia
● increased serum creatinine
DRUG INTERACTIONS ● Magnesium or Aluminum
antacids may decrease
absorption
● May decrease absorption of
atazanavir, itraconazole,
ketoconazole
● May decrease concentration
effects acalabrutinib, bosutinib,
cefuroxime, neratinib, pazopanib
● May increase concentration/effect
of risedronate, warfarin

NURSING RESPONSIBILITIES 1. Inform client to stop smoking

2. Monitor other CNS symptoms
such as confusion, hallucinations,
and headache
3. Potential toxicity results from
decreased clearance and
therefore prolonged action
4. Long-term therapy may lead to
vitamin B12 deficiency
5. Assess heart rate, ECG, and
heart sounds
6. Monitor signs of hypersensitivity
reactions
7. Assess for dizziness and
drowsiness that might affect gait,
balance, and other functional
activities
8. Advise patient to avoid alcohol
9. Monitor IM injection site for pain,
swelling, and irritation

63
 10. Adhere to scheduled periodic
laboratory checkups during
ranitidine treatment

2. Omeprazole
Generic Name Omeprazole

Brand Name Omeprazole (Inj: Na), Omeprazole cap,

Prilosec, Omeclamox-Pak, Losec
Classification Antacids, Antireflux Agents &
Antiulcerants
Ordered Dose 40mg IVTT STAT then
40mg/cap 1 cap BID PO
Dosage and Route Intravenous
Adult: 40 mg once daily given via
infusion over 20-30 minutes until oral
administration is possible.
Oral
Adult: 20 mg once daily for 4-8 weeks.
For severe cases: 40 mg once daily for
8 weeks.

64
 Maintenance: 10 mg once daily, may
increase to 20-40 mg once daily if
necessary.
Child: ≥1 year weighing 10-20 kg: 10
mg once daily, increased to 20 mg once
daily if necessary. ≥2 years weighing
>20 kg: 20 mg once daily, increased to
40 mg once daily if necessary.
Treatment duration: 4-8 weeks.
Mode of Action Omeprazole is a substituted
benzimidazole gastric antisecretory
agent and is also known as proton pump
inhibitor (PPI). It blocks the final step in
gastric acid secretion by specific
inhibition of the adenosine
triphosphatase (ATPase) enzyme
system present on the secretory surface
of the gastric parietal cell. Both basal and
stimulated acid are inhibited.
Indication Intravenous:
Treatment of duodenal ulcers,
prevention of relapse of duodenal ulcers,
treatment of gastric ulcers, prevention of
relapse of gastric ulcers, Helicobacter
pylori (H. pylori) eradication in peptic
ulcer disease, treatment of NSAID-
associated gastric and duodenal ulcers,
prevention of NSAID-associated gastric
and duodenal ulcers in patients at risk,
treatment of reflux oesophagitis, Long-
term management of patients with
healed reflux oesophagitis, treatment of
symptomatic gastro-oesophageal
reflux disease and treatment of
Zollinger-Ellison syndrome.

65
 Cap:
Short-term treatment of active duodenal
& gastric ulcer, GERD & pathological
hypersecretory conditions.
Contraindication Hypersensitivity to omeprazole, other
proton pump inhibitors. Concomitant use
with products containing rilpivirine.
Cautions: May increase risk of fractures,
gastrointestinal infections. Hepatic
impairment, pts of Asian descent.
Side Effects Frequent (7%): Headache.
Occasional (3%–2%): Diarrhea,
abdominal pain, nausea.
Rare (2%): Dizziness, asthenia,
vomiting, constipation, upper respiratory
tract infection, back pain, rash, cough.
Adverse Effects Significant: Hypomagnesaemia,
cutaneous lupus erythematosus, SLE,
osteoporosis-related fractures, fundic
gland polyp, carcinoma, Clostridium
difficile-associated diarrhoea, interstitial
nephritis, Vitamin B12 deficiency (long-
term therapy), gastrointestinal infection
(e.g. salmonella, Campylobacter).
Gastrointestinal disorders: Nausea,
vomiting, diarrhoea, constipation,
flatulence, abdominal pain.
General disorders and administration
site conditions: Weakness, malaise.
Hepatobiliary disorders: Increased
liver enzymes. Immune system
disorders: Urticaria.
Metabolism and nutrition disorders:
Peripheral oedema.
Musculoskeletal and connective
tissue disorders: Back pain.

66
 Nervous system disorders: Headache,
dizziness, somnolence, paraesthesia,
vertigo.
Psychiatric disorders: Insomnia.
Respiratory, thoracic and mediastinal
disorders: Cough. Skin and
subcutaneous tissue disorders: Rash,
dermatitis, pruritus.
Drug Interaction DRUG:
- May decrease
concentration/effects of
atazanavir, clopidogrel.
- May increase
concentration/effects of
diazePAM, oral anticoagulants
(e.g., warfarin), phenytoin.
HERBAL:
- St. John’s wort may decrease
concentration/effects.
FOOD: None known.
LAB VALUES:
May increase serum alkaline
phosphatase, ALT, AST.
Nursing Responsibilities 1. Assess sensitivity to the drug
and or history of allergies.
R: To prevent unwanted allergic
reactions.
2. Inform the patient about the
reason for treatment and the
expected results.
R: The more knowledge the patient has
about their medication, the better
decisions they will make in improving
their current status.
3. Observe 10 rights of drug

67
 administration.
R: To prevent medical errors.
4. Assess dizziness that might
affect gait, and other functional
activities.
R: If one is taking omeprazole for more
than 3 months, the levels of magnesium
in the blood may fall. Low magnesium
can make the individual feel tired,
confused, dizzy, and cause muscle
twitches, shakiness and an irregular
heartbeat.
5. Advise patient to report severe
diarrhea; black tarry stool,
abdominal cramps or pain,
changes in urinary elimination,
or continuing headache.
R: Urinating less than usual, or if you
have blood in your urine and diarrhea
may be a sign of a new infection and
medication may have to be discontinued.
6. Advise patient to avoid alcohol
and foods that may cause an
increase in GI irritation.
R: A person’s diet can affect the
underlying condition PPIs treat. This
means PPIs may have a harder time
providing relief.
7. Instruct patient to report
bothersome or prolonged side
effects, including skin

68
 problems (itching, rash) or GI
effects.
R: Reporting side effects is a key
element in building an improved system
of pharmacovigilance.
8. Advise patient to not take other
medicines unless prescribed
by the physician.
R: Taking other medications that are not
prescribed by the physician may lead to
the disease getting worse,
hospitalization and even death.
9. Do not breastfeed while taking
this drug.
R: Use only if benefits outweigh fetal risk;
cautious use in breastfeeding since this
may pass into the breast milk in tiny
amounts.
10. Provide patient support.
R: Offering support and encouragement
helps the patient cope with the disease
and the drug regimen.

3. Atorvastatin
GENERIC NAME Atorvastatin

69
BRAND NAME Caduet, Lipitor
CLASSIFICATION Pharmacologic class: HMG-CoA
reductase inhibitor
Therapeutic class: Antihyperlipidemic
MODE OF ACTION Reduces plasma cholesterol and
lipoprotein levels by inhibiting HMG-CoA
reductase and cholesterol synthesis in
the liver and by increasing the number of
LDL receptors on liver cells to enhance
LDL uptake and breakdown.
ORDERED DOSE 40mg/cap 1 cap OD @ HS
SUGGESTED DOSE/ROUTE Dyslipidemias

PO: ADULTS, ELDERLY: Initially, 10–

20 mg/day (40 mg in pts requiring
greater than 45% reduction in LDL-C).
Range: 10–80 mg/day.

Heterozygous Hypercholesterolemia
PO: CHILDREN 10–17 YRS: Initially,
10 mg/day. Maximum: 20 mg/day.

Dosage in Renal Impairment

No dose adjustment.

70
INDICATION Atorvastatin is indicated for the
treatment of several types of
dyslipidemias, including primary
hyperlipidemia and mixed dyslipidemia
in adults, hypertriglyceridemia, primary
dysbetalipoproteinemia, homozygous
familial hypercholesterolemia, and
heterozygous familial
hypercholesterolemia in adolescent
patients with failed dietary modifications

Atorvastatin is indicated, in combination

with dietary modifications, to prevent
cardiovascular events in patients with
cardiac risk factors and/or abnormal
lipid profiles.

Atorvastatin can be used as a

preventive agent for myocardial
infarction, stroke, revascularization, and
angina, in patients without coronary
heart disease but with multiple risk
factors and in patients with type 2
diabetes without coronary heart disease
but multiple risk factors.

Atorvastatin may be used as a

preventive agent for non-fatal
myocardial infarction, fatal and non-fatal
stroke, revascularization procedures,
hospitalization for congestive heart
failure and angina in patients with
coronary heart disease
CONTRAINDICATIONS Contraindications: Hypersensitivity to
avelumab.

Cautions: Acute infection, conditions

predisposing to infection (e.g., diabetes,

71
immunocompromised pts, renal failure,
open wounds); corticosteroid in-
tolerance, hematologic cytopenias,
hepatic impairment, interstitial lung
disease, renal insufficiency; history of
autoimmune dis- orders (Crohn’s
disease, demyelinating polyneuropathy,
Guillain-Barré syndrome, Hashimoto’s
thyroiditis, hyperthyroidism, myasthenia
gravis, rheumatoid arthritis, Type I
diabetes, vasculitis); CVA, diabetes,
intestinal obstruction, pancreatitis.

• Contraindicated in patients
hypersensitive to drug and in those with
active liver disease or unexplained
persistent elevations of transaminase
levels.
• Some dosage forms contain
polysorbate 80, which can cause
delayed hypersensitivity reactions.
• Use cautiously in patients with hepatic
impairment or heavy alcohol use, in
patients with inadequately treated
hypothyroidism, with other drugs
associated with myopathy, and in elderly
patients. • Withhold or stop drug in
patients at risk for renal failure caused by
rhabdomyolysis resulting from trauma; in
serious, acute conditions that suggest
myopathy; and in major surgery, severe
acute infection, hypotension,
uncontrolled seizures, or severe
metabolic, endocrine, or electrolyte
disorders.

72
SIDE EFFECTS Common: Atorvastatin is
generally well tolerated. Side
effects are usually mild and
transient.
Frequent (16%): Headache.
Occasional (5%–2%): Myalgia,
rash, pruritus, allergy.
Rare (less than 2%–1%):
Flatulence, dyspepsia,
depression.

ADVERSE EFFECTS Contraindications: Hypersensitivity to

atorvastatin. Active hepatic disease,
breast- feeding, pregnancy or women
who may be- come pregnant,
unexplained elevated LFT results.
Cautions: Anticoagulant therapy;
history of hepatic disease; substantial
alcohol consumption; pts with prior
stroke/TIA; concomitant use of potent
CYP3A4 inhibitors; elderly (predisposed
to myopathy).
CNS: insomnia
CV: Stroke

EENT: nasopharyngitis,
pharyngolaryngeal pain,
GI: UTI.
Metabolic: Diabetes mellitus
Musculoskeletal: rhabdomyolysis,
arthralgia, myalgia, extremity pain,
muscle spasms, musculoskeletal pain.
Skin: Rash
DRUG INTERACTIONS Drug: Strong CYP3A4 inhibitors (e.g.,
clarithromycin, protease inhibitors,
itraconazole) may in- crease
concentration, risk of rhabdomyolysis.
Cyclosporine may increase
concentration.

73
 Gemfibrozil, fibrates, niacin,
colchicine may increase risk of
myopathy, rhabdomyolysis.
Strong CYP3A4 inducers (e.g.,
rifampin, efavirenz) may decrease
concentration.
HERBAL: St. John’s wort may
decrease level.
FOOD: Grapefruit products may
increase serum concentrations.
Red yeast rice may increase serum
levels (2.4 mg lovastatin per 600 mg
rice).
LAB VALUES: May increase serum
transaminase, creatinine kinase
concentrations.

NURSING RESPONSIBILITIES ● Check the patient’s blood test

results, particularly the LDL
and HDL levels. Assess the
patient for signs and symptoms
of hypercholesterolemia.

R: To conform the indication for

administering atorvastatin.

● Check the patient’s allergy

status.

R: Previous allergic reaction to

atorvastatin or any its contents may
render the patient unable to take
them.

● Assess if the patient is

pregnant or lactating.

74
R: Contraindication: atorvastatin
should not be prescribed to a
pregnant woman or lactating mother
as these drugs can potentially harm
the fetus or newborn.

● If administering oral
atorvastatin, assess the
patient’s mucous membranes
and his/her ability to swallow.

R: To check for any potential

problems with administration,
hydration, and absorption.

● To ensure that the right form of

atorvastatin is given through the
right route.

Assess for signs of renal

impairment.

R: atorvastatin can increase liver

enzyme levels. They must be used
with caution in people with impaired
renal function.

● Check for history of

hypothyroidism. Collect bloods
for thyroid function tests as
indicated.

R: Hypoactive thyroid can cause high

cholesterol levels. Treating this
condition may correct the problem
without the need for taking
atorvastatin.

75
 ● Check the patient’s list of
current medications
fordigoxin, warfarin, or oral
contraceptives.

R: Digoxin and warfarin – these

drugs increase the serum levels of
atorvastatin, causing drug toxicity. •
Oral contraceptives – when
taking both atorvastatin and oral
contraceptives, it is important to note
that serum estrogen levels may
increase.

● Atorvastatin can increase liver

enzyme levels. They must be
used with caution in people
with impaired renal function.

R: atorvastatin may cause myopathy,

liver or renal impairment, and high
blood glucose levels, and therefore
should be prescribed with caution in
patients included in the listed risk
groups.

4. Metoclopramide Hydrochloride
Generic Name Metoclopramide hydrochloride

76
Brand Name Plazimide
Classification Antiemetic Agents; Prokinetic Agents
Mode of Action Metoclopramide hydrochloride
stimulates motility of the upper
gastrointestinal tract without stimulating
gastric, biliary, or pancreatic secretions.
Thus, it increases the tone and
amplitude of gastric contractions,
relaxes the pyloric sphincter and the
duodenal bulb, and increases the
peristalsis of the duodenum and
jejunum, resulting in accelerated gastric
emptying and intestinal transit. It also
increases the lower esophageal
sphincter tone and blocks dopamine
receptors at the chemoreceptors trigger
zone, stimulating nausea and vomiting.
Ordered Dose and Route Adult: 10 mg/ amp 1 amp IVTT STAT
then, 1 amp IVTT PRN for active
vomiting
Suggested Dose and Route Chemotherapy-Induced Nausea &
Vomiting
Adults: 1-2 mg/kg IV (infused over at
least 15 minutes) 30 minutes before
chemotherapy, then repeat every 2
hours for two doses (after initial dose)

Diabetic Gastroparesis
Adults: 10 mg IV/IM/PO q6hr 30
minutes before meals and at bedtime;
use injectable dosing only if severe
symptoms are present

Small Bowel Intubation/Radiologic

77
 Examination of Upper GI Tract
Adults and children older than age 14:
10 mg IV over 1-2 minutes
Children ages 6 to 14: 2.5-5 mg IV as a
single dose slowly over 1 to 2 minutes
Children younger than 6: 0.1 mg/kg IV
as a single dose slowly over 1 to 2
minutes

Gastroesophageal Reflux Disease

Adults:10-15 mg PO q6hr 30 minutes
before meals and at bedtime; not to
exceed 80 mg/day

Indication Metoclopramide is used as a short-term

treatment for ongoing heartburn when
the usual medicines do not work well
enough. It is used primarily for heartburn
that occurs after a meal or during the
daytime. Treating ongoing heartburn can
decrease the damage done by stomach
acid to the swallowing tube and help it
heal.

Metoclopramide is also used by diabetic

patients who have poor emptying of their
stomachs (gastroparesis). Treating
gastroparesis can decrease symptoms
of nausea, vomiting, and
stomach/abdominal fullness. Also, it
facilitated small-bowel intubations

Metoclopramide works by blocking a

natural substance (dopamine). It speeds
up stomach emptying and movement of
the upper intestines. It prevents or
reduces nausea and vomiting from
emetogenic cancer chemotherapy

78
Contraindication Contraindicated in patients
hypersensitive to drugs and in those with
pheochromocytoma or other
catecholamine-releasing
paragangliomas, tardive dyskinesia, or
seizure disorders

Contraindicated in patients for whom

stimulation of GI motility might be
dangerous especially patients with
hemorrhage, obstruction or perforation
Side Effects Central Nervous System: Sedation,
fatigue, restlessness, headache,
sleeplessness, dystonia, dizziness,
Cardiovascular: Hypotension,
Gastrointestinal: Dry mouth,
constipation, nausea, anorexia,
vomiting, diarrhea
Genitourinary: Decreased libido,
prolactin secretion, amenorrhea,
galactorrhea
Integumentary: Urticaria, rash
Adverse Effects Central Nervous System: Suicidal
ideation, seizures, neuroleptic
malignant syndrome, tardive dyskinesia
Cardiovascular: supraventricular
tachycardia
Hematology: Neutropenia, leukopenia,
agranulocytosis
Drug Interaction Individual drugs
Alcohol: increased sedation
Haloperidol: increased extrapyramidal
reaction

Drug classifications
Anticholinergics, opiates: decreased
action of metoclopramide

79
 CNS depressants: increased sedation
MAOIs: avoid use Phenothiazines:
increased extrapyramidal reaction
Nursing Responsibilities 1. Monitor BP carefully during IV
administration. Prepare
phentolamine.
Rationale: blood pressure might get too
high while you are using this medicine.
This may cause headaches, dizziness,
or blurred vision. Have phentolamine
readily available in case of hypertensive
crisis; most likely to occur with
undiagnosed pheochromocytoma.

2. Monitor diabetic patients, and

arrange for alteration in insulin dose
or timing if diabetic control is
compromised by alterations in the
timing of food absorption.
Rationale: Medication can cause
hyperglycemia if taken excessively.

3. Monitor patient for involuntary

movements of the face, tongue, and
extremities
Rationale: Drug may cause tardive
dyskinesia, parkinsonian symptoms for
motor restlessness. These could be
symptoms of a serious condition called
neuroleptic malignant syndrome (NMS).

4. Do not use alcohol, sleep remedies,

and sedatives.
Rationale: Serious sedation could
occur.

5. Monitor for possible hypernatremia

and hypokalemia, especially if the
patient has CHF or cirrhosis.

80
Rationale: Under normal conditions,
dopamine causes tonic inhibition of
aldosterone. Metoclopramide is a D2
dopamine receptor antagonist hence, its
administration leads to increased
aldosterone levels.

6. Guard against falls and trauma,

especially if gait and balance are
affected by drowsiness, dizziness, or
ataxia
Rationale: Medication causes CNS
depression.

7. Avoid driving and other potentially

hazardous activities for a few hours
after drug administration
Rationale: Medication can cause
dizziness and CNS Depression

8. Check for breast swelling or

soreness, unusual breast milk
production, absent, missed, or
irregular menstrual periods, stopping
of menstrual bleeding, loss in sexual
ability, desire, drive, or performance,
decreased interest in sexual
intercourse, or an inability to have or
keep an erection.
Rationale: This medicine may increase
prolactin blood levels if used for a long
time. Both men and women with high
prolactin levels may have infertility, low
sex drive, and bone loss.

9. Do not breastfeed while taking this

drug without consulting a physician.
Rationale: Metoclopramide, a drug
frequently used for nausea and vomiting
in pregnancy, is thought to be safe, but

81
information on the risk of specific
malformations and fetal death is
lacking.

10. Eat bland foods; stay away from

spicy, fatty, or salty foods.
Rationale: Eating over-spicy foods can
aggravate ulcers in the sensitive
mucosal lining or in the small intestine,
called the duodenum, or sometimes
even in the esophagus making it worse.
These ulcers are excruciatingly painful,
further causing stomach pain, nausea,
vomiting, and weight loss.

82
 IX. SURGICAL MANAGEMENT

PROCEDURE DATE ORDER RATIONALE NURSING RESPONSIBILITIES

Laparoscopic N/A N/A Laparoscopic fundoplication is a keyhole PRE-OP:

fundoplication
procedure performed for patients with
severe acid reflux, Barrett's esophagus ● Secure the informed consent.
and symptomatic hiatus hernias that no R: To ensure that the patients are
longer respond to medication. It is done to aware of the consequences of the
prevent acid from the stomach travelling treatment, and for the institution’s legal
the wrong way into the esophagus. protection.
Laparoscopic fundoplication is indicated
for the treatment of objectively Bowel Preparation
documented, relatively severed
gastroesophageal reflux disease (GERD). R: Bowel prep is an essential prerequisite of
The 2008 American Gastroenterological any surgical procedure. Doctors usually
Association medical position statement on suggest liquid diets for bowel evacuation.
gastroesophageal reflux disease notes However, in case there are some special
ani reflux surgery is a consideration in instructions, patients must pay heed and
chronic (long-term) management of follow them steadfastly.
GERD.
Laparoscopic fundoplication is the Prepare the patient for the following

83
standard surgical treatment for GERD. It
is highly effective in curing GERD with a
80% success rate at 20-year follow-up
(Frazzoni et al., 2018)
diagnostic procedures:
Complete blood count
- To identify the presence of anemia
that must be ruled out
Cardiac enzymes
- To rule out myocardial pain related
to the atypical pain felt with GERD.
Serum Ion
- To identify presence of iron-
deficiency anemia
Gastrin levels
- To identify toxicity of proton pump
inhibitors.
Gastric acid secretory analysis
- o determine if failure with
pharmacologic agents is caused by
inadequate suppression of gastric
acid secretion, which may signify
bile reflux or pill-induced disease
Esophageal pH monitoring
- Used to document pathologic acid
84
 reflux, especially for patients who
have atypical symptoms.

POST-OP:

Encourage small frequent meals of high

calories and high protein foods.
- 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.
- Helps control reflux and causes
less irritation from reflux action into
esophagus.

Instruct patient to eat slowly and

masticate foods well.
- Helps prevent reflux

85
 Managing Shoulder Pain

R: Shoulder pain is a common occurrence

post laparoscopy. The pain is due to the CO2
introduced in the abdomen during the
procedure. But there is no reason to panic as
the pain subsides with time. In the meantime,
one can use heat therapy for lessening the
pain.

Nissen N/A N/A Nissen fundoplication, also referred to as a PRE-OP

Fundoplication Lap Nissen, is a laparoscopic procedure
performed for patients with Secure the Informed consent and waiver.
gastroesophageal reflux disease (GERD). R: to ensure that the patient is aware of the
In this procedure, the surgeon wraps the
possible consequences of the treatment.
top of the stomach around the lower
esophagus. This reinforces the lower Prepare the patient for the diagnostic tests
esophageal sphincter, making it less likely
needed:
that acid will back up in the esophagus.
Nissen Fundoplication isindicated to treat Esophageal Manometry
gastroesophageal reflux disease (GERD) · It shows the strength of the lower

86
and hiatal hernias. esophageal sphinter and how well the
esophagus pushes food and liquid in to the
stomach.

24 hour pH Probe
· A test that measure the amount of
time stomach acis is splashing into the
esophagus and how high the acid goes up
into the esophagus

Barium Swallow or Upper GI x-ray

· A good way to detect strictures or other
abnormalities that may need to be repaired
during the surgery

POST-OP

87
 X. NURSING MANAGEMENT
a. Nursing Theory

“Self-Care Theory”
By: Dorothea Orem

Dorothea Elizabeth Orem (July 15, 1914 – June 22, 2007) was one of America’s
foremost nursing theorists who developed the Self-Care Deficit Nursing Theory, also
known as the Orem Model of Nursing.
Her theory defined Nursing as “The act of assisting others in the provision and
management of self-care to maintain or improve human functioning at the home level of
effectiveness.” It focuses on each individual’s ability to perform self-care, defined as “the
practice of activities that individuals initiate and perform on their own behalf in maintaining
life, health, and well-being.
The self-care deficit theory was formulated by Dorothea Orem in 2001 and has
become of the most popular nursing theories in contemporary practice and education.
The main principle offered in the theory is that all humans are capable of self-care and
the goal of nurses is to help patients to achieve a maximum level of independence with
their condition (Jarošová, 2014). The key focus of the theory is thus on the person and
his or her capacity for self-care. The environment is viewed as a factor that might impair
this capacity by impacting the person’s state. Health is perceived to be the outcome of

88
environmental influences on the person’s capacity for self-care. Ideal health can be
maintained only when the person is able and willing to fulfill all of the self-care requisites
appropriate to age, gender, and developmental stage. Lastly, the nursing profession helps
the person to fulfill the self-care deficit by providing treatment, education, or physical aid
(Jarošová, 2014).
In relation to this case, Orem’s Self Care theory is essential to guide the nurse in
giving care to patients with Gastroesophageal Reflux Disease which occurs when acidic
stomach juices, or food and fluids back up from the stomach into the esophagus because
in reducing the frequency of acid reflux, the person must know how to provide a self-care,
and one can achieve that by maintaining a healthy diet, doing smoke cessation, eating
food slowly and chew thoroughly, avoiding drinks that could trigger reflux, and following
a healthy life style. Orem’s theory aims to have a healthy lives for the patients.

“Care, Cure, Core Theory”

By: Lydia Hall

Lydia Eloise Hall (September 21, 1906 – February 27, 1969) was a nursing theorist who
developed the Care, Cure, Core model of nursing. Her theory defined Nursing as “a participation
in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas
the CORE and CURE are shared with other members of the health team. She was an innovator,
motivator, mentor to nurses in all phases of their careers, and an advocate for chronically ill
patients.

89
 Lydia Hall used her knowledge of psychiatry and nursing experiences to formulate this
theory known as “the Three Cs of Lydia Hall.” It contains three independent but interconnected
circles: the core, the care, and the cure. Her theory was defined as the “participation in care, core
and cure aspects of patient care, where care is the sole function of nurses, whereas the core and
cure are shared with other members of the health team.” Moreover, the major purpose of care is
to achieve an interpersonal relationship with the individual to facilitate the development of the
core. The care circle is focused on performing the noble task of nurturing patients which on the
other hand solely represents the role of nurses. The core circle is the patient receiving the care.
And lastly, the cure circle is the involvement of administration of medications and treatments.
In relation to Cushing’s Disease, the Care, Cure, Core Theory would stand in aiding clients
with this condition to help them cope with the symptoms. This model is highly focused on meeting
the needs of patients while reflecting on the three essential subconcepts of the theory. Hall’s
theory is particularly helpful because clients with GERD are immunocompromised due to
esophagitis. The nurse is given the opportunity to establish closeness by reflecting on the Care
circle, to help clients explore their own feelings about their current health status.
The student nurses chose this theory for the case analysis since it would definitely help
widen the perspective of the student nurses. In the context of the care circle, It will help in
understanding the roles of student nurses and redirect their emphasis not just on completing
duties but also on actions or interventions that could benefit and improve the health status of the
patients in the context of the care circle. For the core, It will serve as a guide in re-evaluating the
patient's feelings and values, allowing the student nurses to deliver a more appropriate treatment
for the patient's benefit. And lastly, Understanding the cure circle will enable the student nurses
to re-evaluate their relationships with other healthcare teams, as well as find methods to improve
patient care.

90
 b. NURSING CARE PLANS
NCP #1- ACUTE PAIN

DA CUES N NURSING PATIENT OUTCOME PLANNING OF IMPLE EVALUATION

TE/ E DIAGNOSIS INTERVENTION MENT
TIM E ATION
E D
S Subjective Cues: C Acute Pain After 8 hours of • Rapport should 1 September 22, 2022 @
E • “Matagal- related to initiation of be established 3pm
P tagal na din O damage of intervention, the to the client
T sumasakit esophageal patient will be relieved
E G mucosa as from pain as R: A tight and “Goal completely met”
ang tiyan ko
M evidenced by evidenced by: harmonious
B like a month N verbalization of • Pain scale of relationship with
E already,but, chest pain 8/10 2/10 to 4/10, patients is created via
R I usually I and abdominal mild to good rapport. It
After 8 hours of
ignore it. guarding moderate pain, enables the nurse to initiation of intervention,
2 Sometimes, T and grasp the patient's the patient was able to
2 I feel Rationale: • Stable vital emotions, relieve the pain as
, I Due to the signs. communicate
nauseated evidenced by a
excessive effectively, and obtain
2 and may V transient lower their cooperation. verbalization of
0 parang esophageal • “Hindi na siya
2 heartburn E sphincter, the masyado maskit
2 lalo na HCl in the • Administer 2
- stomach can be compared
pagsumasa prescribed
@ pushed up by medications that kanina. Mga
kit na tiyan
P increase of intra- alleviate the nasa 3 na siya,”
7 ko. Tulad abdominal symptoms of absent
: ngayon, E pressure, such heart burn and
0 nasa 8/10 as exercise, chest pain, as
abdominal
0 ang sakit na R obesity and per doctors’ guarding and
A nararamda pregnancy, or order. stable vital signs
M man ko. I C positional with a blood
changes R: The stomach
usually feel pressure of
E especially lying acidity can be

91
 na may down. This neutralized with the 120/80, pulse
reflux ako P repeated help of an antacid. rate of 98 and
every after I regurgitation will Acid in the stomach
T cause repeated can be mitigated by temperature of
eat then 37.2 C.
damage to the taking medication that
hihiga agad. U esophagus. blocks H2 receptors.
Pagsumasa Thus, epigastric Proton-pump
kit na A or retrosternal inhibitors are effective
KRCC
talaga, burning because they lower Kharyl Roisse C.
meron L sensation is felt. gastric acid Castillano, StN
akong Continuous production. Those
esophageal who suffer with
Zantac DJMC
P damage will GERD may find relief
always with cause scarring with baclofen, which Dale Jade M. Cuta, StN
me to A and bleeding. works by relaxing the
somehow muscles in the lower
relieve the T Rationale: esophageal AMDE
pain, but, Hinkle, J.L. & sphincter. Aira Mae D. Espanola,
right now, it T Cheever, K.H. StN
(2017). Brunner • Give Tepid 3
doesn’t give
E & Suddarth's Sponge Bath
some relief Textbook of and administer
with my R Medical-Surgical acetaminophen
condition,” Nursing (14 ed.).
by the N Philadelphia: R: To relieve fever by
patient. Elsevier reducing high
temperature and also
• “May mga
helpful in alleviating
times din po pain or discomfort.
na
nagigising • Assess the 4
ako sa patients vital
sobrang signs and
sakit ng characterestics
of pain at least
dibdib ko
30-40 mins after
parang may

92
burning administration
tapos may of medication.
asim na
R: To monitor
galing sa
effectiveness of
tiyan ko medical treatment for
parang the relief of heartburn.
ganon yong
lasa. • Elevated the bed
Maybe, sa
sobrang R: To reduce the
backwash of acid from 5
stress sa
the stomach to the
trabaho din. esophagus.
Kaya
kaninang • Encourage the
umaga, patient to follow
hindi ko na appropriate 6
natiis kasi meals at times
and meal
sobrang
portions.
sakit na ng
tiyan ko R: To ensure that the
kaya sabi patient does not eat
ko, huge meal,or that he
papahospita does not eat late at
l na ako, night before bedtime
as both of these
hindi na rin
contribute to GERD.
ako
nakakatulog
ng maayos • Advise the client
at hindi ko to avoid tight 7
na talaga fitting clothes
kaya ang
sakit,” as

93
 verbalized R: To enhance
by the breathing pattern as
patient this may contribute to
alleviating the pain.
• Pain scale
of 8/10 • Encourage
patient to avoid
Objective Cues: alcoholic 8
• Facial beverages,
grimacing cigarettes and
noted coffee.
• Guarding
R: It can irritate the
behavior at stomach by
his increasing the HCL.
abdomen
• Clammy • Provide calm,
skin restful
surroundings, 9
• Hoarseness
and minimize
of voice environmental
• Inflamed activity and
tonsils noise. Limit the
• Enlarged number of
lymph visitors and
length of stay.
nodes in the
neck R: : It helps lessen
• Vital signs: sympathetic
• BP: 140/90 stimulation; promotes
• Temp: 37.5 relaxation.
• PR: 105
• Schedule
bpm 10
adequate rest
• RR: 23 cpm periods.

94
 R: Prevents fatigue
and conserves energy
for healing.

• Provide time for

the patient to
ask questions
and express 11
feelings; be
reassuring and
supportive. Be
certain to
address the
patient’s main
concerns.
R: Expressing
feelings and having
questions answered
are essential
ways of reducing
confusion while
learning new
information.

• Emphasize
importance of 12
adhering to
treatment
regimen

R: To promote
comfort and wellness
(and that leads to fair
prognosis)

95
 NCP #2- DEFICIENT FLUID VOLUME

DA CUES N NURSING PATIENT OUTCOME PLANNING OF IMPLE EVALUATION

TE/ E DIAGNOSIS INTERVENTION MENT
TIM E ATION
E D
S Subjective Cues: N Deficient fluid Within 8 hours of • Rapport should 1 September 22, 2022
E • Now ng U volume related be established
nursing intervention, @3PM
P dahil sa T to insufficient to the client
T paulit-ulit R fluid intake as the patient will Goal Partially Met
E I evidenced by R: A tight and
na display improved Within 8 hours of
M T rapid weight harmonious
B sumasakit I loss, limited hydration as relationship with nursing intervention, the
E tiyan at O self water patients is created
evidenced by: patient displayed
R sumusuka N intake and via good rapport. It
ako, wala A cloudy urine enables the nurse to improved hydration as
2 na talaga L output. grasp the patient's
• Moist mucous evidenced by:
2 akong emotions,
, - R: Elderly and membranes communicate a. Moist mucous
gana
adults effectively, and
2 kumain like M frequently drink • Intake within membranes
obtain their
0 for two E tea or coffee. the body cooperation. b. Intake of fluid of
2 weeks na T These both
requirements about 2.3L
2 limited na A have a diuretic
yong kain B effect that • Vital signs • Monitor vital c. Normal vital
@ O increases urine signs and 2
ko, hindi within the signs
L production compare with
8 na I while also Vital signs:
normal range the client's
: umaabot C depleting normal and
0 ng three electrolytes. • previous
BP: 120/80
0 times a P Accompanied readings RR: 20
A day. A by limited
PR: 85
M Pumayat T intake of water

96
 talaga ako T and water- R: Changes in BP
from 92 E containing food and pulse may be
R these factors used for rough CC
kgs to 86
N can easily lead estimates of fluid Charisse Caydan, St. N
kgs na
to dehydration imbalances.
yata. Then, JDC
and weight
less water loss. • Monitor Intake Jonji Dominic Coronel,
intake, and and output. 3 St. N
sobrang Reference: Weigh daily
sakit and Reber, Gomes,
dry ng Dähn, R: Provides the
Vasiloglou, & best assessment of
throat ko.
Stanga. (2019). current fluid status
Natatakot Management of and adequacy of
kasi ako Dehydration in fluid replacement.
pag-iinom Patients
na naman Suffering • Promote a
ako ng Swallowing comfortable 4
madaming Difficulties. environment.
Journal of Cover the
tubig,
Clinical client with light
isusuka ko Medicine, sheets.
din naman. 8(11), 1923.
Konti lang https://doi.org/1 R: Avoids
talaga 0.3390/jcm811 overheating, which
water 1923 could promote
intake” as further fluid loss
verbalized
• Reinforce the
by the pt. importance of
proper 5
Objective Cues: hydration.

97
• BP: 140/90 R: To encourage
mmHg adherence to
(120/80 - interventions and to
allow the patient to
110/70)
recognize the
• RR: 23 importance of
(12-20) adequate hydration
• PR: 105
(60-100) • Encourage the
patient to 6
• Limiting
increase fluid
self fluid
intake within
intake the body
• Cracked requirement
lips 1.5-2L / day.
• Dry skin May start with
ice chips and
• Nausea
small frequent
and sips of water
vomiting until a large
amount of
water intake is
tolerated.

R: To relieve fluid
loss and maintain
adequate levels of
fluid in the body

• Gradually
increase intake 7

98
R: To make the
patient comfortable
with the increase in
intake.

• Administer
fluids, as 8
indicated such
as IV.

R: Intravenous
solutions replace
extravascular and
intravascular fluids
and replenish
electrolyte losses.
They also dilute
both the levels of
glucose and
circulating
counterregulatory
hormones

• Keep the head

elevated when 9
lying down

R: : The gravity
prevents the reflux
of acid.

99
• Advise not to
wear tight 10
clothes.
R: TIght clothes
increase the
pressure in the
abdomen which
promotes reflux of
acid.

• Maintain
adequate 11
nutrition and
follow the
prescribed diet.
Avoid dairy,
coffee and
other highly
acidic food.
R: These foods are
highly acidic which
may promote
discomfort in the
patient. Additionally,
Increased acid
intake may
precipitate acid
reflux

• Increase fiber
diet while
avoiding highly 12
acidic food.

100
R: To promote
comfort and wellness
(and that leads to fair
prognosis)

• Administer
prescribed 13
medication
including
antiemetics,
and
antihypertensiv
e medication.
R: This can help
prevent and reduce
incidence of
vomiting and
increased blood
pressure in the
patient.

101
 NCP #3- DEFICIENT KNOWLEDGE

DA CUES N NURSING PATIENT OUTCOME PLANNING OF IMPLE EVALUATION

TE/ E DIAGNOSIS INTERVENTION MENT
TIM E ATION
E D
S Subjective Cues: C Deficient Within 8 hours of • Assess patient 1 September 22, 2022
E • “matagal- O knowledge nursing intervention for information
@3PM
P tagal na G related to the patient will be needed and
T din N inadequate ability to Goal Met
able to:
E I knowledge of perform
M
sumasakit
T resources as ● Verbalize Within 8 hours of
actions
B ang tiyan I evidenced by understanding independently nursing intervention, the
E ko like a V presence of of the cause of R: provides a basis
patient understood the
R month E preventable acid reflux for teaching
already complications. ● Discuss own health teachings by
2 but, I - role in means of:
2 usually preventing • Provide patient 2
, P with • Verbalizing what
ignore it” recurrence.
E information
as ● Identify and he understood of
2 R regarding
0 verbalized C implement disease the cause of acid
2 by the E necessary process, health
reflux
2 patient P lifestyle practices that
• “Sometime T changes can be • Discussed own
@ U changes, and
s, I feel role in preventing
A medications to
8 nauseated L be utilized recurrence
: and may R: provides
0 parang P • Identify and
knowledge and
0 heartburn A facilitates implement
A lalo na T compliance
M T necessary
pagsumas

102
 akit na E • Instruct patient lifestyle changes.
tiyan ko” R to avoid
• “Minsan, N bending over, 3
coughing, DMPC
nakakalimu
straining at Doreen Mae P.
tan ko like defecations,
di na pala and other Cavalida, St. N
ako activities that ABCFE
nakakapag increase reflux.
Alyssa Beatrice Caryl F.
lunch R: promotes
basta may comfort by the Espineli, St. N
decrease in
kape okay
intraabdominal
na araw pressure, which
ko.” reduces the reflux
of gastric contents

Objective Cues: • Instruct patient

• Facial to eat slowly, 4
grimacing chew foods
well and
• Guarding maintain a
behavior high-protein,
• low-fat diet
R: this helps
prevent reflux

• Instruct patient
regarding 5
eating small
amounts of
bland food
followed by a

103
 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.
R: gravity
helps control
reflux and
causes less
irritation from
reflux action into
the esophagus

• Advise the
patient to avoid 6
smoking
R: Nicotine from
smoking relaxes the
esophageal
sphincter and
increases acid
production in the
stomach.

104
• Instruct patient 7
to raise both
arms, fully
extended
towards the
ceiling prior to
eating.
R: relieves spasms
and allows for more
comfort when
eating.

• Assist patient
with the 8
reduction of
caloric intake.
R: Being
overweight
increases intra
abdominal pressure

• Instruct patient
to avoid 9
temperature
extreme food,
spicy foods,
and citrus and
gas forming
foods
R: : These food
items increase acid
production that
precipitates

105
heartburn and
increased reflux.

• Instruct patient
in medications, 10
effects, side
effects, and to
report to
physician if
symptoms
persist despite
medication
treatment
R: Promotes
knowledge,
facilitates
compliance with
treatment, and
allows for promt
identification of
potential need for
changes in
medication regimen
to prevent
complications

106
 c. REVIEW OF RELATED LITERATURE

SALIVARY PEPSIN AS AN INTRINSIC MARKER FOR DIAGNOSIS OF SUB-TYPES

OF GASTROESOPHAGEAL REFLUX DISEASE AND GASTROESOPHAGEAL
REFLUX DISEASE-RELATED DISORDERS

The prevalence of GERD has increased recently, having a substantial influence

on the quality of life. Gastroesophageal reflux disease (GERD) is "a condition that occurs
when the reflux of stomach contents into the esophagus causes symptoms and
consequences." One of the key constituents in the reflux fluid and one of the leading
damage causes in GERD patients is pepsin, released by the chief cells and activated in
acidic gastric secretions. Pepsin can enter the oral cavity with the reflux fluid and be mixed
with saliva when reflux occurs. Pepsin is deactivated at pH 7.0 and reactivated following
re-acidification. Saliva pepsin may therefore be crucial in diagnosing GERD as it can be
used to predict the development of the condition. The study aims to test whether salivary
pepsin is a definitive diagnostic value for GERD-related disorders.

The study demonstrated salivary pepsin's critical role in diagnosing GERD and
GERD-related diseases. Salivary Pepsin Collection was significantly higher in the groups
with extra-esophageal symptoms, Barrett's esophagus, non-erosive reflux disease,
erosive esophagitis, and EES + T-GERD than in the healthy control group. Thus, salivary
pepsin level is an intrinsic biomarker for diagnosing GERD and GERD-related disorders.
The positive rates of salivary pepsin in this study ranged from 65.0 to 76.3% for the
diagnosis of non-erosive reflux disease, erosive esophagitis, extra-esophageal
symptoms, and Barrett's esophagus. A previous study reported a positive rate of 78.6%
using salivary pepsin to diagnose reflux-related diseases.

Salivary pepsin levels are crucial for evaluating GERD patients with primarily
respiratory symptoms because they can immediately discriminate between real reflux and
non-reflux disorders. This study demonstrated that the salivary pepsin test positive rate
for NERD patients was significantly higher than the pathologic reflux as determined by
24-hour pH monitoring, indicating that the salivary pepsin test can complement or
combine with the 24-hour pH monitoring and improve the efficiency in the diagnosis of
GERD. The study also revealed that SPC and positive rates dramatically decreased after
PPI treatment in the NERD and EES groups, indicating that PPI medication may lessen
the SPC by preventing gastric acid secretion.

A previous study by Li et al. revealed that the intercellular space measurements

were higher in the EE and NERD groups. Pepsin is one of the main ingredients in the
reflux fluid and one of the main injury factors in GERD. Previous studies have shown that

107
esophageal and throat tissues were sensitive to pepsin and that a small amount of
activated pepsin could cause inflammation in the mucosa of the esophagus and throat.
This would then cause Salivary pepsin levels to be higher in NERD patients than in FH
patients. In the NERD group, SPCs were linked with the degree of mucosal integrity
deterioration. Diagnostics can therefore use low amounts of salivary pepsin to identify FH
patients.

Therefore, salivary pepsin is crucial for diagnosing GERD and GERD-related

illnesses. Comparing the salivary pepsin test to conventional GERD diagnostic
techniques reveals some advantages. It is anticipated that the salivary pepsin test will
play a significant role in diagnosing GERD patients. Salivary pepsin and 24-hour pH
monitoring may work in conjunction to increase the effectiveness of the diagnostic
process.

INVERSE CORRELATION BETWEEN GASTROESOPHAGEAL REFLUX DISEASE

AND ATROPHIC GASTRITIS ASSESSED BY ENDOSCOPY AND SEROLOGY

The condition known as gastroesophageal reflux disease (GERD) is characterized

by recurring reflux of gastric contents into the esophagus as a result of momentary
relaxation or low pressure of the lower esophageal sphincter. Erosive reflux disease is a
condition with bothersome symptoms and structural changes in the esophagus, such as
mucosal breaks, erosion, or ulcers. However, only one-third to one-half of GERD patients
have endoscopic findings that are positive.
While this is going on, non-ERD is defined as the presence of normal esophageal
symptoms without endoscopic alterations. The rise in GERD prevalence may be
influenced by a number of variables, including an extended life expectancy, a westernized
lifestyle, and an increased incidence of obesity. As a result of hospital visits, high medical
costs for diagnosis and treatment, and numerous issues with quality of life, GERD and its
consequences, including reflux esophagitis and Barrett's esophagus, place a heavy
socioeconomic burden on society. Numerous epidemiological studies have assessed the
GERD risk factors. There are several established risk factors for GERD, including male
sex, caffeine intake, smoking, alcohol consumption, dietary variables, a low level of
education, and obesity.
Numerous research studies have shown an inverse relationship between GERD
and Helicobacter pylori (H. pylori) infection. In a case-control study conducted in Japan,
the majority of instances of reflux esophagitis occurred in patients with atrophic gastritis
without H. pylori infection or in less severe cases of gastritis with the infection. According
to multiple epidemiological research and systematic reviews, H. pylori infection lowers the
likelihood and severity of GERD. Furthermore, following H. pylori eradication therapy, the
severity of reflux esophagitis and GERD symptoms worsen. These results point to a

108
potential protective role for H. pylori infection in the prevention of GERD due to the
reduction in acid secretory capability brought on by gastric mucosal atrophy. Numerous
research have examined the connection between atrophic gastritis and GERD because
gastric mucosal atrophy is thought to be a crucial mechanism by which H. pylori infection
avoids the occurrence or aggravation of GERD.
H. pylori infection may not be the only factor influencing the development of reflux
esophagitis, according to a few studies that used endoscopic biopsies to grade the
severity of atrophic gastritis using a modified updated Sydney classification. In the
meantime, the gastric corpus's involvement and degree of atrophy are separate protective
factors against GERD. However, because to its invasive character, endoscopic forcep
biopsy-based histological diagnosis of atrophic gastritis is not always practical in routine
clinical settings. A recognized serologic marker, pepsinogen, reflects the stomach gland's
capacity to secrete acid. As a result, it might be used to forecast if stomach atrophy will
occur. It's interesting to note that GERD was adversely linked with H. pylori IgG
seropositivity. The prevalence of H. pylori infection is noticeably lower in GERD patients,
according to several earlier research. It is believed that H. pylori-caused chronic
inflammation causes gastric atrophy, which further reduces the gastric mucosa's ability to
secrete acid. As a result, the kind and spread of gastritis caused by H. pylori are more
significant than the infection itself. Patients with antral gastritis have a higher chance of
developing GERD because antral gastritis causes hypergastrinemia and increased
acidity. Contrarily, it is believed that decreased stomach acid production in situations of
severe corpus gastritis is the primary mechanism through which H. pylori infection
protects against GERD. Using this information, we calculated the risk of GERD based on
the degree of EAG. Interestingly, as the degree of EAG increased, the risk of GERD
gradually decreased. It was highest in connection with C1. This demonstrates that the
main risk factor for GERD is atrophic gastritis rather than H. pylori infection itself.

EFFICACY AND SAFETY OF DOMPERIDONE IN COMBINATION WITH PROTON

PUMP INHIBITORS IN GASTROESOPHAGEAL REFLUX DISEASE: A SYSTEMATIC
REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Gastroesophageal reflux disease (GERD) is defined as a condition that develops

when the reflux of stomach content causes irritating symptoms and/or complications.
GERD is a major public health issue that is becoming increasingly common. It is
associated with a significant economic burden and a lower quality of life.

Despite being predominantly a disease of the lower esophageal sphincter (LES),

gastroesophageal reflux can be brought on by a number of physiological or pathologic

109
reasons. Transient relaxation of the lower esophageal sphincter, or the momentary
suppression of lower esophageal sphincter tone that happens without swallowing, is the
most frequent cause of this condition. However, GERD patients have acid reflux as a
result of their increased frequency postprandially. Low LES pressure, hiatal hernia,
esophageal obstruction, and delayed gastric emptying are further causes.

The aims of gastroesophageal reflux disease (GERD) treatment are symptom

relief and healing of esophagitis. Besides proton pump inhibitors (PPIs), prokinetic agents
are also commonly prescribed to treat GERD. Domperidone, a well-known antiemetic, is
an example of a prokinetic agent. It is a dopaminergic blocker that increases lower
esophagus sphincter pressure and activates gastric motility.

This meta-analysis incorporated 11 studies with a total of 841 participants (419 in

the PPI plus domperidone group and 422 in the PPI monotherapy group). The
combination of a PPI and domperidone resulted in a significant reduction in global GERD
symptoms. Adverse events associated with PPI plus domperidone treatment were similar
to those associated with PPI monotherapy.

The hydrogen-potassium adenosine triphosphatase is inhibited by PPI during the

latter stage of stomach acid production (i.e., the gastric proton pump). Omeprazole and
esomeprazole, which have been authorized for use in patients older than one year and
less than twelve months, respectively, are two PPIs that can be used to treat GERD in
children. Pantoprazole was shown to be well tolerated in babies and kids from one month
to six years old, but not in those older than six. PPIs merely change the pH of the reflux
from acidic to neutral or mildly acidic; they do not, however, lessen the frequency of reflux
episodes in either adults or children. Agents other than PPIs are commonly utilized to
treat people with GERD because of this inconsistent effectiveness. These include
prokinetics, alginate, baclofen, and H2R antagonists. When treating GERD, PPI
medication has been found to be more successful than H2R agonists and prokinetics,
and some meta-analyses have demonstrated that prokinetics combined with PPI is
preferable to PPI alone. Prokinetics were shown to be helpful in lowering GERD
symptoms, according to a number of prior meta-analyses on PPI plus prokinetics in
general, including mosapride, cisapride, acotiamide, revexepride, and domperidone
therapy.

In conclusion, the combination of domperidone and a PPI is generally safe and

effective in treating GERD as compared with that of PPI alone.

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 d. DISCHARGE PLANNING

Method Health Teaching Rationale

Medication Instruct the patient to follow In order to effectively treat

all prescription instructions
precisely. Stress the
importance of not skipping
doses or taking less than
the prescribed dosage.
the illness and enhance the
patient's general health and
wellbeing, it is necessary to
take all prescription
medications exactly as
prescribed.

Exercise Maintain adequate rest Being well rested will assist

in decreasing stress and in
the recovery process.

Certain exercises can

Do mild to moderate decrease blood flow to your
exercise making sure not to gastrointestinal area. This
overwork the body and can cause gastric fluids to
avoiding exercises that pool, leading to
would taunt the lower inflammation and irritation.
esophageal sphincter’s Restrictive body positions
barrier function can also put pressure on
your stomach and chest,
which may trigger
symptoms.

Treatment Avoid having tight clothing Tight clothing around the

especially around the
abdominal area, after
eating a meal.
abdomen can increase the
pressure on the stomach
and promote reflux of acid
from the stomach, up into
the esophagus.

These activities can

Avoid bending over or increase the pressure on
reaching below your waist the stomach and cause
for 2 hours after having a reflux of acid from the
meal for any activity, such stomach, up into the

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 as tying shoe lace or
picking up items from the
ground.
Always elevate the level of
head when lying down.
Hygiene Practice hand washing
before and after eating,
preparing foods, and in
contact with something
dirty.
Secure clean and safe food
preparation and water
source
Avoid sharing eating
utensils.
Practice proper oral
hygiene
Outpatient Instruct the patient or
caretaker to visit the doctor
for medical follow-up and if
specific symptoms persist.
esophagus.
Sleeping or lying down with
the head elevated lets the
gravity prevent the reflux.
Good hand hygiene will
reduce the risk of
contagious diseases, food
poisoning, and spreading
bacteria.
To ensure that food and
water is safe for human
consumption
To reduce transmission of
communicable diseases
and microorganism
To prevent dental plaque
formation. Since in the oral
cavity H. pylori is mostly
found in dental plaque, it
can be a source of gastric
infection.
A physician-ordered follow-
up guarantees appropriate
drug adherence,
therapeutic response, and
illness progression. This
may avoid the development
of problems and/or
infections.
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Diet Instruct the patient to avoid
food that is high in fats,
sodium, caffeine, dairy and
sugar content. Avoid acidic
foods such as alcohol,
acidic liquids, etc.
Instruct the patient to avoid
eating big meals. Eat small,
frequent meals instead of a
big meal.
Avoid eating closer to
bedtime.
These foods take more
time to empty and stay in
the stomach longer and
increase the risk to
promote GERD symptoms.
Additionally, these foods
are highly acidic in the
stomach which can cause
acid reflux.
Big meals increase the
pressure in the stomach
and can contribute to the
return of acid contents into
the esophagus, resulting in
GERD symptoms.
Gravity acting in downward
direction, prevents acid
from traveling up into the
esophagus and helps with
preventing GERD
symptoms. Eating closer to
bedtime and laying down
can eliminate the effect of
gravity, contribute to the
return of acid contents into
the esophagus, and make
GERD symptoms.
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 XI. PROGNOSIS

The prognosis of GERD is extremely good with 80-90% of the affected individuals
recovering with the help of antacids. There is a possibility that some patients will require
additional medication, but it is difficult to predict how long it will take for them to become
better. In other cases, it's possible that the recovery will only be temporary or in part
(Tharu, 2018).

If gastroesophageal reflux disease (GERD) is not treated, it can lead to a number of

significant consequences, such as esophagitis and Barrett's esophagus. The severity of
esophagitis can range greatly, with the most severe cases leading to widespread erosions
and ulcerations in the esophagus as well as a narrowing of its diameter. Additionally,
esophagitis can result in bleeding in the gastrointestinal (GI) tract. However, many people
experience a recurrence after therapy is stopped, underscoring the significance of
continuing medicine for the long term. Medication is helpful for the majority of patients
who have GERD. However, many people experience a relapse after treatment is stopped.
It is critical to rapidly treat patients who fall into the group of people who are at the highest
risk of developing the most serious consequences of GERD. This subset can be
determined by determining the individuals who are at the highest risk. When it comes to
these patients, performing surgery at a more preliminary stage is more likely to be
beneficial. Moreover, the majority of people are responsive, both to alterations in lifestyle
and to drugs that are prescribed for them. Nevertheless, it is necessary for many patients
to continue taking their prescribed drugs in order to keep their symptoms under control.

The prognosis of the patient in the case study is also considered to be a good prognosis
because there is no history of bleeding and the causative factor for his ulcers has already
been identified as H. Pylori, which is typically responsive to antibiotic treatment. As a
result, the prognosis for the patient is considered to be a good prognosis.Treatment of
symptoms of gastroesophageal reflux disease (GERD) that is successful has been
associated with a considerable increase in quality of life. This improvement involves a
decrease in the amount of physical pain that is experienced, as well as increases in
vitality, physical and social function, and mental well-being. In addition, this improvement

114
includes a decrease in the amount of time spent in pain. If treated effectively,
gastroesophageal reflux disease (GERD) has a favorable prognosis.

115
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