Ics Reflux Esophagitis

Saint Mary’s University
School of Health and Natural Sciences

Nursing Department
REFLUX ESOPHAGITIS SECONDARY TO ACHALASIA
Presented to
the Faculty of the School of
Health and Natural Sciences

Bayombong, Nueva Vizcaya
In Partial Fulfillment of the Requirements for Nursing Care of Clients with

Problems in Nutrition and Gastrointestinal, Metabolism and
Endocrine (NCM 116 RLE)
Submitted by:
Ragual, Mica T.
BSN 3B
Submitted to:
Ms. Nathalie Nicole Sumabat
Clinical Instructor
Nursing Department
CHAPTER I
3Ps
Personal Profile
Name: Mr. V
Age: 43
Birthdate: December 09, 1978
Birthplace: Solano, Nueva Vizcaya
Sex: Male
Blood Type: A+
Address: Brgy. Quezon, Solano, Nueva Vizcaya
Religion: Roman Catholic
Height: 5’6”
Weight: 57kg
Marital Status: Married
Occupation: Businessman
Educational Attainment: College Graduate
Nationality: Filipino
Ethnicity: Ilokano
Dialect: Ilokano and Tagalog
Significant others:
Name of Husband: Mrs. J
Age: 40
Occupation: Accountant
Educational Attainment: College Graduate
Name of Child: Child G

Age: 20
Admitting Diagnosis: Achalasia

Nursing Department
Final Diagnosis: Reflux Esophagitis Secondary to Achalasia

Admitting Physician: Dr. M
Date of Admission: April 10, 2022 around 10 AM
Date of Discharge: April 13, 2022 around 12 PM
HEALTH HISTORY
Present Health History

A patient had a history of achalasia starting two years before his admission.
Endoscopy performed at the onset of his reflux symptoms revealed esophagitis. The
patient was put on PPI therapy, and consequently, his reflux symptoms stopped.
However, he coughed and vomited on the evening before the admission. On April 10,
2022, Mr. V went to the OPD in the R2TMC together with his wife at 10 o’clock in the
morning due to difficulty swallowing food, heartburn, regurgitation of food intake/fluid
intake, and abdominal pain. During the admission, the doctor performed a physical
exam to assess the chief complaints of Mr. V. The physical exam resulted in a
weight loss of 5 kg. The abdominal pain was rate 7/10 according to the pain rating
scale. The following vital signs were recorded: BP 110/70 mmHg, PR 80 bpm, RR 20
breaths per minute, and temperature of 37℃. Laboratory tests were performed to
rule out other health problems. Tests such as endoscopy, esophageal manometry,
and barium swallow were performed. All of the diagnostic test results were examined,
and patient V was diagnosed with reflux esophagitis secondary to achalasia.
Esophageal manometry showed an LES pressure of 31 mmHg with incomplete
relaxation (46%) and dysmotility in the tubular esophagus with “mirror wave images,”
which is characteristic of achalasia.
Past Health History

When Mr. V was younger, he did not have any major health issues. He had no
history of surgery and any history of smoking, or using any other drugs. He has an
allergy to perfume and dust. In the previous year, he suffered from cough and colds
for three days. Also, according to the patient, he was hospitalized when he was 20
years old because of a motorcycle accident.
Family History
Mrs. V was the third child among five siblings. According to Mr. V, both sides of the
family have a history of GERD and achalasia. His first cousin from his father side was
diagnosed with GERD since she was a 25 years old and her sibling was diagnosed
with achalasia five years ago.
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Social Health History

Ms. V is 43 years old who lives at at Brgy. Quezon, Solano, Nueva Vizcaya.
Their household consists of three member and considered a nuclear family. Mr. V
mentioned that they also have a good relationship with their neighbors as well as
other people. During this time of pandemic, the family uses face-mask, face-shield
and social distance when they go out in public.
Lifestyle and Health Practices

Mr. V stated that he was consuming green, leafy vegetables on a daily basis. The
family sometimes eat fast food after the mass. He sometimes drinks alcohol and
loves fruit juices. He goes to sleep around 10 p.m. and gets up at 5 a.m. every day.
He also stated that during weekends, he likes to go for a morning stroll together with
his dog. He eliminates about once a day and urinate about 4-5 times. Two days
before the admission, he only drinks 1L of water everyday and eat his meal thrice a
day but he has a difficulty swallowing food. He also vomits and has a regurgitation of
food and fluid intake.
Nursing Department
CHAPTER II
BRIEF DESCRIPTION
Definition
Reflux esophagitis is an esophageal mucosal injury that occurs secondary to
retrograde flux of gastric contents into the esophagus. Typically, the reflux disease
involves the distal 8-10 cm of the esophagus and the gastroesophageal junction.
Reflux esophagitis is one of the complications that can come from having chronic
heartburn and acid reflux, also known as gastroesophageal reflux disease (GERD).
Esophagitis is inflammation that damages the lining of the esophagus and often
causes painful or difficult swallowing and chest pain. The type of esophagitis caused
by heartburn and acid reflux/GERD is known as reflux esophagitis.
Achalasia is a rare esophageal motility disorder that makes it difficult for food and
liquid to pass into your stomach. Achalasia occurs when the nerve cells in the
esophagus cause the muscles in the esophagus and in the lower esophageal
sphincter (LES) to not work properly. The muscles in the esophagus do not contract
normally, so food that is swallowed does not move through the esophagus and into
the stomach the way it should. Normally the LES relaxes when we swallow to allow
food into the stomach. With achalasia, the LES muscle continues to squeeze,
creating a barrier that prevents food and liquids from passing into the stomach.
Because the LES contracts abnormally, the esophagus dilates and large volumes of
food and saliva can accumulate over time. People with this disorder have an
increased risk of esophageal cancer.
Epidemiology
There are geographical variations in the distribution of reflux esophagitis. In Western
countries, the prevalence of the disease is approximately 10% to 20%, and severe
disease is observed in 6% of the population, while in Asian countries, the prevalence
is approximately 5%.[5][12] Reflux esophagitis is equally prevalent among men and
women. However, the predominance of esophagitis and Barrett esophagitis in men
compared to women is 3:1 and 10:1, respectively. The incidence of reflux esophagitis
is greatest at the age of 60 to 70 years old and decreased slightly thereafter. Genetic
variations, environmental factors, and lifestyle play a role in the development and
prevalence of esophageal reflux.
Approximately half of the pregnant women complain of reflux during pregnancy: 20%
to 30% in the first trimester, 40% to 45% in the second trimester, and 60% in the third
trimester.[13] Usually, these patients do not have symptoms such as heartburn
before their pregnancy. Only 14% may have infrequent mild heartburn.
Etiology
Reflux esophagitis is usually due to a condition known as gastroesophageal reflux
disease (GERD).
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The exact cause of achalasia is not known. Some clinical researchers suspect that
the condition may be caused by the degeneration of a group of nerves located in the
chest (Auerbach’s plexus). It is believed that there may be a rare, inherited form of
achalasia, but this is not yet well understood at this time.
Predisposing Factor
 White males, over the age of 50, and a family history of reflux esophagitis
 Central obesity: This is associated with ERD, and complications, including
Barrett esophagus and adenocarcinoma
 Tobacco smoking is considered an etiological factor of reflux esophagitis, while
alcohol consumption is considered a triggering factor of reflux
 Delayed gastric emptying
 Esophageal dysmotility
 Increased abdominal pressure
 Hiatus hernia
 Non-alcoholic fatty liver disease
 Decreased thoracic pressure, such as in chronic chest problems
 Psychosocial stress and the severity of reflux esophagitis correlate with the
degree of stress
Complication
Reflux Esophagitis
If left untreated, reflux esophagitis may change the structure and function of the
esophagus and lead to more serious complications such as Barrett’s esophagus,
strictures and esophageal cancer.
Achalasia
Aspiration pneumonia. This is caused when food or liquids in your esophagus back
up into your throat and you breathe them into your lungs.
Esophageal perforation. This is a hole in the esophagus. It may happen if the walls of
your esophagus become weak and bulge. It may also happen during treatment.
Esophageal perforation may cause a life-threatening infection.
Esophageal cancer. People with achalasia are at higher risk for this type of cancer.
Clinical Manifestation
Reflux esophagitis
Nursing Department
 Difficulty swallowing (dysphagia)

 Painful swallowing (odynophagia)
 Chest pain
 Swallowed food becoming stuck in the esophagus
 Nausea
 Vomiting
 Abdominal pain
 Decreased appetite
Achalasia
 Weight loss
 Chest pain
 Difficulty swallowing (dysphagia)
 Coughing, especially when lying down
 Aspiration- food, liquid and saliva which is retained in the esophagus can be
inhaled into the lungs
Diagnostic Procedure
Reflux Esophagitis
Barium Swallow
For this test, you drink a solution containing a compound called barium or take a pill
coated with barium. Barium coats the lining of the esophagus and stomach and
makes the organs visible. These images can help identify narrowing of the
esophagus, other structural changes, a hiatal hernia, tumors or other abnormalities
that could be causing symptoms.
Upper Endoscopy
Doctors guide a long, thin tube equipped with a tiny camera (endoscope) down your
throat and into the esophagus. Using this instrument, your doctor can look for any
unusual appearance of the esophagus and remove small tissue samples for testing.
The esophagus may look different depending on the cause of the inflammation, such
as drug-induced or reflux esophagitis. You'll be lightly sedated during this test.
Biopsy. During this test, a small sample of the esophageal tissue is removed and
then sent to a laboratory to be examined under a microscope.
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Achalasia
Endoscopy. A flexible lighted tube is passed through your mouth to look at your
esophagus and the lower esophageal sphincter (LES).
Esophogram. This is a type of X-ray that takes pictures of your esophagus while you
swallow a thick contrast material called barium. You may swallow a barium tablet as
well. The radiologist looks for signs of achalasia. These include widening of the
esophagus, incomplete emptying, and tightness of your LES.
Manometry. A thin tube that measures pressure is passed through your nose down
into your esophagus. Pressure measurements are taken as you swallow sips of
water. This test can show if the muscles in your esophagus are weak and don’t work
well. The test can also show pressure buildup at your LES. This test confirms a
diagnosis of achalasia.
Laboratory Procedure
Complete Blood Count (CBC)- is a blood test used to evaluate your overall health
and detect a wide range of disorders, including anemia, infection and leukemia. A
complete blood count test measures several components and features of your blood,
including: Red blood cells, which carry oxygen.
Pharmacologic Management
Reflux Esophagitis
Over-the-counter treatments. These include antacids (Maalox, Mylanta, others);
medications that reduce acid production, called H-2-receptor blockers, such as
cimetidine (Tagamet HB); and medications that block acid production and heal the
esophagus, called proton pump inhibitors, such as lansoprazole (Prevacid) and
omeprazole (Prilosec).
Prescription-strength medications. These include H-2-receptor blockers as well as
proton pump inhibitors, such as esomeprazole (Nexium), lansoprazole (Prevacid),
omeprazole (Prilosec) and pantoprazole (Protonix). You also may be prescribed
prokinetics such as bethanechol and metoclopramide (Reglan), which help your
stomach empty more quickly.
Achalasia
Medications such as calcium channel blockers and nitrates that can help dilate the
narrowed part of the esophagus so that food can pass through properly
Botulinum toxin (BT) injection is the most common and effective pharmacological
therapy used in the treatment of achalasia.This muscle relaxant can be injected into
the LES with an endoscope. It can be injected into the muscles that control your LES.
This helps to relax the valve opening. This procedure is done during endoscopy. You
may be asleep or partly asleep with sedation through an IV (intravenous line). The
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benefits often go away in 3 to 12 months. So the procedure needs to be repeated.

This option is mainly used for older patients who are not good candidates for surgery.
Lifestyle and Home Remedies

 Avoid foods that may increase reflux. Avoid eating excessive amounts of foods
that you know worsen your symptoms of gastroesophageal reflux. These may
include alcohol, caffeine, chocolate and mint-flavored foods.
 Use good pill-taking habits. Always take a pill with plenty of water. Don't lie down
for at least 30 minutes after taking a pill.
 Lose weight. Talk to your doctor about an appropriate diet and exercise routine
to help you lose weight and maintain a healthy weight.
 If you smoke, quit. Talk to your doctor if you need help ending a smoking habit.
 Avoid certain medications. Avoid some pain relievers and antibiotics, as well as
some other medications, if you have an enlarged left upper heart chamber
(atrium) or after heart surgery.
 Avoid stooping or bending, especially soon after eating.
 Avoid lying down after eating. Wait at least three hours after eating to lie down or
go to bed.
 Raise the head of your bed. Place wooden blocks under your bed to elevate your
head. Aim for an elevation of 6 to 8 inches (15 to 20 centimeters). Raising your
head by using only pillows isn't effective.
Nursing Diagnosis
 Imbalanced Nutrition: Less Than Body Requirements.
 Acute Pain.
 Imbalanced Nutrition: More Than Body Requirements.
 Risk for Aspiration.
 Deficient Knowledge.
Nursing Department
CHAPTER III
ANATOMY AND PHYSIOLOGY
Esophagus
The esophagus is a muscular tube connecting the throat (pharynx) with the stomach.
The esophagus is about 8 inches long, and is lined by moist pink tissue called
mucosa. The esophagus runs behind the windpipe (trachea) and heart, and in front
of the spine. Just before entering the stomach, the esophagus passes through the
diaphragm.
The upper esophageal sphincter (UES) is a bundle of muscles at the top of the
esophagus. The muscles of the UES are under conscious control, used when
breathing, eating, belching, and vomiting. They keep food and secretions from going
down the windpipe.
The lower esophageal sphincter (LES) is a bundle of muscles at the low end of the
esophagus, where it meets the stomach. When the LES is closed, it prevents acid
and stomach contents from traveling backwards from the stomach. The LES muscles
are not under voluntary control.
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Stomach
The stomach is a muscular organ located on the left side of the upper abdomen. The
stomach receives food from the esophagus. As food reaches the end of the
esophagus, it enters the stomach through a muscular valve called the lower
esophageal sphincter.
The stomach secretes acid and enzymes that digest food. Ridges of muscle tissue
called rugae line the stomach. The stomach muscles contract periodically, churning
food to enhance digestion. The pyloric sphincter is a muscular valve that opens to
allow food to pass from the stomach to the small intestine.
Mouth
Mouth, also called oral cavity or buccal cavity, in human anatomy, orifice through
which food and air enter the body. The chief structures of the mouth are the teeth,
which tear and grind ingested food into small pieces that are suitable for digestion;
the tongue, which positions and mixes food and also carries sensory receptors for
taste; and the palate, which separates the mouth from the nasal cavity, allowing
separate passages for air and for food. All these structures, along with the lips, are
involved in the formation of speech sounds by modifying the passage of air through
the mouth. Food enters the digestive system through the mouth. Food is broken
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down into smaller pieces by chewing. The teeth cut and crush the food, while it's
mixed with saliva. This process helps to make it soft and easier to swallow.
Nursing Department
CHAPTER IV
PATHOPHYSIOLOGY
Nursing Department
CHAPTER V
LABORATORY TEST AND DIAGNOSTIC PROCEDURE
Name: Mr. V Admitting Physician: Dr. M Sex: Male
Address: Brgy. Quezon, Admitting Hospital: Age: 43 y.o.

Solano, Nueva Vizcaya R2TMC
Date: April 10, 2022
I. Endoscopy
Laboratory Report at Region II Medical Trauma Center (RIITMC)
Result Implication
A thin, flexible tube equipped with a light

and camera (endoscope) down the
patient’s throat, to examine the inside of
your esophagus and stomach. Test
results can often be normal when reflux is
present, but an endoscopy may detect
inflammation of the esophagus
(esophagitis) or other complications.
II. Barium Swallow

Result Implication
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A person swallows a barium solution,

then X-ray films are taken of the
esophagus and stomach. Most often, a
barium swallow is used to seek the cause
of difficulty swallowing. Barium coats the
lining of the esophagus and stomach and
makes the organs visible. These images
can help identify narrowing of the
esophagus, other structural changes, a
hiatal hernia, tumors or other
abnormalities that could be causing
symptoms.
III. Esophageal Manometry Test

Result Implication
A thin tube that measures pressure is

passed through your nose down into your
esophagus. Pressure measurements are
taken as you swallow sips of water. This
test can show if the muscles in your
esophagus are weak and don’t work well.
The test can also show pressure buildup
at your LES. This test confirms a
diagnosis of achalasia.
Nursing Department
COMPLETE BLOOD COUNT

TEST NORMAL RESULT PHYSIOLOGICAL
COMPONENTS VALUES BASIS
Red Blood Cells 4.10 -5.20 x 3.95 x 10(12)/L A low RBC count
10(12)/L may signify internal
kidney disease.
White Blood Cells 3.8 – 10.4 13 x 10(9)/L WBC count in urine
x10(9)/L is high, it may
indicate that there is
inflammation in the
kidneys.
Hemoglobin 11.8-14.7 g/dL 10.9 g/dL Hemoglobin gives
color to red blood
cells and allows for
the transport of
oxygen throughout
the body. Low levels
lead to anemia,
which causes
symptoms like
fatigue and trouble
breathing.
Platelets 177-381 x 10(9)/L 176 x 10(9)/L Low platelet count
can cause the
inability to properly
form clots to stop
bleeding.
Hematocrit 34% A low hematocrit
35-43% level means they are
too few red blood
cells in the body. In
these cases, a
person may
experience
symptoms that signal
anemia.
Mean Corpuscular 76.9fL Mean corpuscular
Volume 77.8-91.1fL volume (MCV) is a
number that
describes the
average size of red
blood cells circulating
in the bloodstream.
Thus, a low MCV
would mean they are
smaller than
average, this is seen
with microcytic
anemias such as iron
deficiency anemia.
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Scientific explanation: A complete blood count (CBC) is a blood test used to

evaluate your overall health and detect a wide range of disorders, including anemia,
infection and leukemia.
CHAPTER VI
PHYSICAL ASSESSMENT AND ITS PATHOPHYSIOLOGICAL BASIS
Demographic and Biological Data
Patient initials Mr. V
Age 43 years old
Date of birth December 9, 1978
Place of birth Solano, Nueva Vizcaya
Sex Male
Address Brgy. Quezon, Solano, Nueva Vizcaya
Civil Status Married
Chief complaints Mr. V has a chief complaints of difficulty

swallowing food, heartburn, regurgitation of food
intake/fluid intake, and abdominal pain.
Admitting diagnosis Achalasia
Final diagnosis Reflux Esophagitis Secondary to Achalasia
Admitting Physician Dr. M
Date of Admission April 10, 2022
Date of Discharge April 13, 2022
HEALTH HISTORY
Current Health Problems  On April 10, 2022, at 10 o’clock in the

morning, his wife, Mrs. JR, accompanied her
husband to Region 2 Trauma Medical Center
for a consultation.
 According to him, he went to the OPD in the
R2TMC due to difficulty swallowing food,
heartburn, regurgitation of food intake/fluid
intake, and abdominal pain.
Past Health Problems  Mr. V had a history of achalasia starting 3

years before his admission.
 In the previous year, he suffered from cough
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and colds for three days.
Surgical History  Mr. V did not undergo any surgical

procedures.
Accidents  According to the patient, he was

hospitalized when he was 20 years old
because of a motorcycle accident.
Family Risk Factors GERD and Achalasia
Medications Omeprazole (Prilosec)

Cimetidine (Tagamet HB)
Maalox
PSYCHOSOCIAL
Significant Others The wife, Mrs. K,

accompanied her
Wife Mrs. J
husband to Region 2
Trauma Medical Center
for a consultation.
Structure of Family Nuclear Mr. V has a traditional

family structure which
composed of husband,
wife, and children.
Coping Mechanism He received support from his wife and Coping strategies is
children. used to overcome
He is expressing how he feels to his wife stressful events that
and spending time with his children. people face in every day
because it helps to
relieve stress and regain
control over that
stressful events.
Religion Roman Catholic

Primary language Ilocano and Tagalog
Primary source of Region II Trauma Medical Center (R2TMC)
healthcare
Nursing Department
Financial PhilHealth & SSS

Resources Related to
Health Care
Occupation Businessman
Educational Attainment College graduate
PRE-ASSESSMENT POST- PATHOPHYSIOLOGICAL

April 10, 2022 ASSESSMENT
April 13, 2022 BASIS
General Client is dressed with Client present good Altered level of

Appearance shirt and pants with hygiene and consciousness can be
slippers. grooming wearing caused by a head injury,
clean loose blue medicines, alcohol or drugs,
His hair is black and shorts and white shirt dehydration, or some
nails are cut short. and a pair of slides. diseases.
His nails are cut
Upon assessment, his short and his hair is
level of consciousness black.
was altered.
Client is alert and
awake upon
assessment and
ready for discharge
Affect The patient has a The patient has a It is natural for the patient to
restricted affect.The broad affect. exhibit restrictive emotion as
patient shows worry a result of worry and fatigue
about his current associated with his current
condition. condition, as evidenced by
his facial expression and
body language/movement.
Orientation The patient has difficulty Mr. V is aware of Checking orientation of the
concentrating and the date and time client help the nurses to
delayed response on the and also where evaluate mental status and
questions asked by the and who’s with help to diagnose other
nurse him. condition caused by the
incident.
Questions
Time:
Question: anong petsa
Nursing Department
po ngayon?
Answer: April 10, 2022
(delayed response)
Person:
Question: sino pong
kasama nyong pumunta
dito?
Answer: yung
asawa ko po
(delayed response)
Place:
Question: Alam niyo po
ba kung saan kayo
ngayon ?
Answer: Oo nasa
hospital ako ngayon
Memory The client’s memory is The client’s

intact but delayed memory is intact
response
Immediate memory is
good because he can
follow our instructions to
repeat the numbers
“1,3,5,8,15”
Recent memory is good

because he remembers
what he ate in the
morning.
Answer: “pandesal at
kape po”
Remote memory is good

because he remembers
the date of their
anniversary.
Answer: Ang aming
anibersaryo ay noong
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December 30, 1992.
Speech Patient’s voice is weak He responds well

but still audible and his voice is
clear.
Nonverbal behavior The patient was looking He is smiling and he

down and cannot keeps eye
maintain eye contact. contact.Patient was
nodding when he
agrees to the
questions.
ELIMINATION
PRE- POST- PATHOPHYSIOLOGICAL BASIS

ASSESSMENT ASSESSMENT
April 10, 2021 April 13, 2021
STOOL
Frequency Once a day Once a day
Pattern N/A Early in the morning
Consistency and N/A Soft and well

shape formed
Presence of N/A None

unusual odor
Color N/A Yellow to brown
URINE
Amount 800mL per day 1.5L per day The normal range for 24-hour urine
volume is 800 to 2,000 milliliters per
day (with a normal fluid intake of about 2
liters per day)
Frequency He urinates This morning, the More urine production and increased
approximately every patient urinated urinary frequency and urgency, called
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four hours twice. At 7 a.m., he polyuria. Some patient may notice they
last emptied his have to get up every couple of hours
bladder. during the night to urinate.
Presence of None None

unusual odor
Color Yellow urine Pale yellow urine
Abdomen He experiences Abdomen is soft, Acid reflux causes abdominal

bloating symmetric, non symptoms, such as bloating or cramps.
tender and without
distention.
With difficulty or N/A N/A

with pain upon
urination
Toileting Ability Urinates and Urinates and Due to weakness and dizziness, he
defecates in the defecates in the needs assistance.
toilet with toilet by himself
assistance
REST AND ACTIVITY

April 10, 2022 April 13, 2022
Current Activity Mr. V is able to walk The patient can
Level and rise from his walk, and get on
bed with minimal and off the bed and
assistance. perform personal
care without
assistance.
ADL’s
The patient can The patient does not
The client is able
groom himself require assistance
to:
independently, with ADLs.
• Groom Himself including combing
his hair and
• Feed Herself dressing himself
with minimal
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• Move assistance. He is
self-sufficient in
• Communicate
feeding. With the
assistance of his
wife, he can walk or
go to a comfort
room. He is capable
of communicating
effectively but not
instantly.
Sleep Pattern Duration: 6-7 hours Duration: 6-7 hours

from 11 pm to 5 am
Quality and
No sleep during the Characteristics: no
day disturbance
Pattern: no
Quality and
disturbance
Characteristics:
easily awaken
because of frequent
urination
Pattern: woke 3-4
times
Body Frame Ectomorph Ectomorph This body type is thin, usually tall, and
lanky. Individuals with a sturdy, rounder
bone structure have wider hips, stocky
limbs and barrel-shaped rib cages.
Posture N/A N/A
Gait N/A The patient has an

asymmetrical gait
pattern.
Coordination Coordinated using Coordinated using

nose to finger test. nose to finger test.
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Balance Mr. V is able to Can walk without

remain upright but assistance
need assistance
when walking.
Motor Function Gross: He can flex

upper extremities and
lower extremities.
Can bend his head at
all sides.
Fine: He can hold
light material like a
ball pen and can
write
Muscle Strength He scored 4 which 5- full strength
means his movement
is against at least
some resistance
supplied the
examiner.
Mobility/ use of Patient does not use Patient does not use .
assistive devices assistive device for assistive device for
mobility mobility
SAFE ENVIRONMENT

April 10, 2022 April 13, 2022
Allergies/Reaction Medication: N/A Medication: N/A
Food: N/A Food: N/A
Environment: N/A Environment: N/A
Eyes/Vision Pupils Pupils
are equal, round, are equal, round,
and reactive to light and reactive to light
and accommodation. and
He is using accommodation.
eyeglasses (100 He is using
grades in both eyes) eyeglasses (100
grades in both eyes)
Hearing/Hearing Patient is not Patient is not
Aid wearing hearing aid. wearing hearing aid.
No discharge and No discharge and

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no swelling no swelling
Skin
Upon No lesions, no
observation,there is scars, and no tattoo.
no lesions, no scars, No presence of
and no tattoo. But bruises and
patient foot is abrasion on his left
swelling foot
Lips Pale Pinkish

Nail beds Patient’s nail is pale. Patient’s nail is
Patient has rounded pinkish. Patient has
and smooth nails. rounded and smooth
nails.
Mucous Upon observation, The patient has Dry mucous membranes are a sign of
Membrane the patient has dry moist and intact dehydration and can cause various
mucous membranes mucous health problems. Dry mouth can be due
which indicates membranes. to certain health conditions, such
dehydration. as diabetes, stroke, yeast infection
(thrush) in your mouth or Alzheimer's
disease, or due to autoimmune diseases,
such as Sjogren's syndrome or
HIV/AIDS.
Temperature 36.8°C 37°C

April 10, 2022 April 13, 2022
Activity Tolerance Mr. V can walk and Able to walk and

move with move without any
assistance. assistance
ADLs The patient needs The patient can

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assistance in perform ADLs by

performing ADLs. himself.
Airway clearance Mr. V reported Mr. V nose and

coughing. mouth has no
obstruction and
secretion.
Respiration Rate: 18 cpm Rate: 16 cpm
Rhythm: regular Rhythm: regular
Depth: regular Depth: regular
Blood Pressure 110/70 mmHg 120/80 mmHg For the majority of adults, normal blood
pressure is defined as a systolic
pressure less than 120 and a diastolic
pressure less than 80.
Apical Pulse 80 bpm 85 bpm An apical pulse rate is typically
considered abnormal in an adult if it’s
above 100 beats per minute (bpm) or
below 60 bpm.
Oxygen 96%Sp02 98% Sp02

Saturation
Lung Sounds No adventitious No adventitious
sounds were heard sounds were heard
on the lungs such on the lungs such
as crackles or as crackles or
wheezes when wheezes when
auscultated auscultated
Skin Integrity Color: pale Color: pinkish
Capillary Refill The blanched The blanched Any noticeable delay in refill indicates a
toenail regains its toenail regains its reduction in tissue perfusion, which may
pink tone for 3 pink tone also produce moderate cyanosis (bluish
seconds after the immediately after tinge) of the mucous membranes.
pressure was the pressure was
released released
Edema Patient has no No edema
edema
Nursing Department
NUTRITION

April 10, 2022 April 13, 2022
Hospital Diet Avoid thin liquids Avoid thin liquids This diet contains foods that are soft,easy
which may cause which may cause to swallow and are not irritating to the
choking or choking or esophagus.
gagging. Use high gagging. Use high It(is(important(that(foods(consumed(be(s
protein, thick liquids protein, thick liquids mooth(in(texture(to(facilitate(the(moveme
and higher calorie and higher calorie nt(of(food( through(the(swollen(areas(of(t
items, such as items, such as he(esophagus(or(stomach.
milkshakes, custard, milkshakes, custard,
pudding, macaroni pudding, macaroni
and cheese, etc. and cheese, etc.
Some other soft or Some other soft or
liquid-‐type foods liquid-‐type foods
are applesauce, are applesauce,
cooked cereals, cooked cereals,
strained cream soup, strained cream
mashed potatoes, soup, mashed
Jello, rice pudding, potatoes, Jello, rice
etc. pudding, etc.
Fluid Intake He drinks water (1 He drinks 2L of Lack of water, calcium, and magnesium
L) per day water can cause ulcers, gastritis, and acid
reflux because the stomach doesn't have
enough water to produce digestive acid.
Studies have shown that drinking water
can help limit the serious symptoms of
acid reflux by temporarily raising stomach
pH.
IVF’s N/A
D5LRS 1L with 40
drop factor run for 12
hours
Height 5’6’’ 5’6’’
Weight 57kg 58 kg As chronic GERD continues untreated,

the stomach acid can scar the lining of
the esophagus. As the scar tissue
increases, it makes the esophagus more
narrow in certain spots. It becomes
difficult to eat and drink and may lead to
dehydration and weight loss.
Nursing Department
Skin Turgor His skin goes back His skin goes back Skin with normal turgor snaps rapidly
after 3 seconds immediately when back to its normal position. Skin with poor
when pinched pinched turgor takes time to return to its normal
position.
Food The patient has a The patient can Difficulty swallowing, also known as
Tolerance/Ability difficulty chewing, chew, swallow, and dysphagia, is the feeling of food “sticking”
swallowing, and tolerate food. He in your throat or chest and is one of the
tolerating food by can feed himself complications of acid reflux/GERD. When
himself. with a soft diet. acid reflux occurs, acid flows back into
your esophagus causing irritation and
discomfort.
Nursing Department
CHAPTER VII
DRUG STUDY
DRUG STUDY
Name of Classification Doctor’s Order Mechanism of Side Effects Adverse Effects Nursing
Medication Action Consideration
Nursing Department
Generic Name: Proton pump D.O: Omeprazole is a -Headache -joint pain along a) History taking.
inhibitors type of medicine with a red skin rash
Omeprazole Omeprazole 40 -stomach pain
called a proton -Back, leg, or
mg IV up to -nausea
pump inhibitor stomach pain b) Take note of
q24hr
(PPI). Proton pumps Note: This is patient’s current
-bleeding or
are enzymes in the not a complete crusting sores on medications and
lining of your list of side the lips. ask if the patient
stomach that help it effects and
is allergic to the
others may -blisters.
make acid to digest occur. medication or has
food. Omeprazole -bloody or cloudy any other allergies
prevents proton urine.
pumps working -continuing ulcers
properly which or sores in the c) Before giving
reduces the amount mouth. this medication,
of acid the stomach -difficult, burning, first check the
makes. or painful urination. MAR (medication,
administration, &
record)
Note: This is not a
complete list of
side effects and
others may occur.
d) Observe 10R
e) Obtain
specimen for
Nursing Department
culture and
sensitivity test
before giving first
dose.
f) Provide health
education or
information about
the drugs.
g) Caution patient
about the side
effect and adverse
effects they may
experience and if
any of this persist
and worsen
immediately
report it.
Nursing Department
Nursing Department
Brand Name: Time:

Prilosec Q24h
Date Given: Route:

April 10, 2022 IV
Date Frequency:
Discontinued:
Once a day
April 10, 2022
Indication
Nursing Department
- For the treatment

of certain conditions
where there is too
much acid in the
stomach and to
inhibit gastric
production
Contraindication
Omeprazole is contr
aindicated in
patients with a
history of
hypersensitivity to
the drug or any
excipients from the
dosage form.
Nursing Department
DRUG STUDY
Nursing Department
Generic Name: H2 blockers D.O: -The H2-receptor -Headache -pain when a) History taking.
antagonist swallowing,
Cimetidine 200 mg PO up cimetidine competiti -Diarrhea
to q12hr -bloody or tarry
vely blocks
stools, b) Take note of
histamine from
stimulating the H2- Note: This is -cough with bloody patient’s current
receptors located not medications and
a mucus,
on the gastric ask if the patient
complete list -vomit that looks
parietal cells (these is allergic to the
cells are of side like coffee grounds
medication or has
responsible for effects and -mood changes
any other
hydrochloric acid others may
-hallucination allergies
secretion and occur.
secretion of the
intrinsic factor)
Note: This is not a c) Before giving
complete list of this medication,
side effects and first check the
others may occur. MAR (medication,
administration, &
record)
d) Observe 10R
e) Obtain
Nursing Department
specimen for
culture and
sensitivity test
before giving first
dose.
f) Provide health
education or
information
about the drugs.
g) Caution patient
about the side
effect and
adverse effects
they may
experience and if
any of this persist
and worsen
immediately
report it.
Nursing Department
Brand Name: Time:

Tagamet HB Q12h
Date Given: Route:

April 10, 2022 Oral
Date Frequency:
Discontinued:
twice a day with
April 10, 2022 breakfast and
at bedtime.
Indication
Nursing Department
- For the treatment

of occasional
heartburn caused
by too much acid in
the stomach (also
called acid
indigestion or sour
stomach). It is also
used to prevent
heartburn and acid
indigestion caused
by certain foods
and beverages.
Contraindication
Nursing Department
-stomach cancer.
-chronic kidney
disease stage 3A
(moderate)
-chronic kidney
disease stage 3B
(moderate)
DRUG STUDY
Nursing Department
Generic Name: Antacids D.O: -Cefuroxime -Headache high doses of a) History taking.
inhibits bacterial antacids may
Aluminum 10 mL PO up to -Diarrhea cause diarrhea or
Hydroxide and q6hr cell wall synthesis
constipation
Magnesium following Note: This is b) Take note of
Hydroxide attachment to not a patient’s current
Suspension penicillin binding complete list medications and
proteins (PBPs). of side ask if the patient
This results in the effects and is allergic to the
interruption of cell others may medication or has
wall occur. any other
(peptidoglycan) allergies
biosynthesis, which
leads to bacterial
cell lysis and death. c) Before giving
this medication,
first check the
MAR
(medication,
administration, &
record)
d) Observe 10R
Nursing Department
e) Obtain
specimen for
culture and
sensitivity test
before giving first
dose.
f) Provide health
education or
information
about the drugs.
g) Caution patient
about the side
effect and
adverse effects
they may
experience and if
any of this persist
and worsen
immediately
report it.
Nursing Department
Nursing Department
Brand Name: Time:

Maalox Q6h
Date Given: Route:

April 10, 2022 Oral
Nursing Department
Date Frequency:
Discontinued: Two to four
April 10, 2022 teaspoonfuls
(10-20 mL) four
times a day
taken 20
minute to 1
hour after
meals and at
bedtime or as
directed by the
physician. May
be followed
with milk or
water.
Indication
Nursing Department
-As an antacid for

the symptomatic
relief of
hyperacidity in
general.
Contraindication
Nursing Department
Contraindicated in
the patients who
are severely
debilitated or
suffering from renal
insufficiency, or if
there is severe
abdominal pain
and/or the
possibility of bowel
obstruction.
Nursing Department
CHAPTER VIII
COURSE IN THE WARD
Day 1: 10 AM, April 10, 2022, Region II Trauma and Medical Center
April 10, 2022
Time Doctors Progress Notes Nurse’s Notes
Order
10AM Admit patient Vital signs Focus: Admission
at general  Temperatu
ward under re 37C Data: Mr. V is a 43-year-old man
the care of Dr. went to the OPD in the R2TMC at 8
M  Pulse Rate o’clock in the morning due to
80bpm difficulty swallowing food,
 Respiration heartburn, severe weight loss and
20cpm vomiting after meals.
Secure
consent for  Blood Action: Consent for admission and
admission. Pressure management was secured.
110/70mm
Hg Vital signs taken and recorded.
 O2sat 96%
May have full IV line started with D5LRS x 8hr at
diet as 40 gtts/min in the right dorsal arch
tolerated vein of the hand.
I and O q shift Diagnostic procedures facilitated

such as Covid Antigen test,
Refer to Endoscopy and CBC
laboratory for
CBC Instructed to for a complete bed
rest, DAT
Refer for an
endoscopy,
esophageal
manometry Response: Patient complied
and barium
swallow
Administer
D5LRS 1L
with 40 drop
factor run for
12 hours
Put patient in
complete bed
Nursing Department
rest.
11AM Pain scale of 7/10 Focus: Pain

Data: grimace, irritability, and
guarding behavior on affected part.
With complaints of 7/10 pain scale.
Action: Deep breathing exercise
initiated.
Administer Omeprazole 40 mg IV up
to 24 hr
Instructed to use the call bell to call for
help when needed.
Remind SO about the patient’s safety.
Raised the side rails and safety
ensured.
Monitored for any signs of distress
Position to bed of comfort.
Response: Patient pain reduced to
5/10 as claimed.
Patient performed purse lip breathing.
Nursing Department
1PM Administer Vital signs Focus: Medications

Cimetidine  Temperatu
200mg PO up re 36.8C Data: For administration of
to 12 hr Cimetidine 200mg PO up to 12 hr
 Pulse Rate and Aluminum Hydroxide and
Administer 105bpm Magnesium Hydroxide Suspension
Aluminum  Respiration 10Ml PO up to q6hr
Hydroxide and 27cpm
Magnesium Action: Positioned to bed of
Hydroxide  Blood comfort
Suspension Pressure
10Ml PO up to 130/80mm Monitored and assessed patency of
q6hr Hg IVF.
Dr. M  O2sat 98%

Interviewed the patient about his
current health condition, past health
history, surgical history, accidents
history.
Vital signs were monitored every 4

hours.
Assessed General Appearance
Medications administered
aseptically
Monitor for adverse reaction
Medicine and management is

continued.
Response: Patient response and

complies to the nurse
Nursing Department
7:00PM Vital signs Focus: Vital signs

 Temperatu
re 36.8C Data: Check vital signs for
comparison for the progression of
 Pulse Rate the initial vital signs.
88bpm
 Respiration Action: Encourage small frequent
18cpm meals of high calories and high
protein foods.
 Blood
Pressure
120/80mm Instruct to remain in upright position at
Hg least 2 hours after meals; avoiding
 O2sat 97% eating 3 hours before bedtime.
Instruct patient to eat slowly and
masticate foods well.
Response: Patient sitting on bed

eating dinner while watching TV
Patient understood the teaching

7PM Pain scale of 2/10 Focus: Pain
Data: Reporting of decreased pain
Action: Deep breathing exercise
initiated..
Instructed to use the call bell to call
for help when needed.
Remind SO about the patient’s safety.
Raised the side rails and safety
ensured.
Response: Patient pain reduced to
2/10 as claimed.
Nursing Department
10PM Vital signs Focus: Health teaching about

 Temperatu surgery
re 36.6C
Data: Check vital signs for
 Pulse Rate comparison for the progression of
95bpm the vital signs.
 Respiration Action: Bowel needs to be emptied
20cpm before the surgery
 Blood NPO
Pressure
120/70mm Monitored for any signs of distress
Hg
Response: Patient getting ready for
 O2sat 97% sleeping
Patient understood the teaching
Day 2: 7:00AM, April 11, 2022, Region II Trauma and Medical Center
April 11, 2022
Order
7:00AM Vital signs Focus: Morning care
 Temperatu
re 36.8 C Data: Awake on bed. Conscious
and conversant. With patent IVF
 Pulse Rate and infusing well.
85bpm
 Respiration
19 bpm Action: Instruct patient to do not eat
or drink anything before the surgery.
 Blood The stomach and bowel need to be
Pressure totally empty during your surgery.
110/70mm
Hg NPO
 O2sat 97% Patient needs an additional enema,

using warm water, the morning of
your his surgery
Response: Patient cooperated.
Nursing Department
10:00AM Plan for Focus: Surgery

Nissen
Fundoplicatio Data: Patient getting ready for
n on April 11, surgery
2022
Action: Instructed patient and SO
to prepare for the surgery
Secured a Assisted patient’s needs

consent form
Instruct the patient to do not wear

tight-fitting clothes
Response: SO and patient

understood.
Patient was stable at the ward.

1PM Vital signs Focus: Post operative care
 Temperatu
re 36.7C
Data: Patient awake with patent IVF
 Pulse Rate and infusing well
86 bpm
Action: Taken to a recovery room
 Respiration
until he is fully awake.
16 bpm
ET tube was removed after the
 Blood
patient is awake and can breathe
Pressure
120/80mm well on his own.
Hg Urine catheter and tube going into
 O2sat 97% the stomach may also be removed.
Watch closely for any problems
Advise the patient to do not get out
of bed until the healthcare provider
says it is okay
Keep the area clean and dry to
prevent infection.
Response: Patient understood the

nurse and kept rested
6PM May have a Focus: Change in diet

clear liquid diet
Data: Patient’s on a clear liquid diet
Monitor intake
Action: Explained to the patient and
Nursing Department
and output SO the diet that need to be followed.

Observe or Position to bed of comfort, elevate
monitor for HOB while in bed.
bowel sounds,
Safety ensured.
passing of flatus
or bowel Assess patient’s ability to swallow
movements, and
gag reflex Response: Patient able to eat
dinner, shows understanding and
cooperative. Eating without
assistance.
7PM Inspect the Focus: Wound inspection

dressing and
watch for Data: The dressing is dry and intact.
signs of Action: Checking the surgical
infections incision site for possible beginning
infection.
Response: The patient is

cooperative, shows understanding
and resting.
April 12, 2022

Order
7:00AM May have clear The patient can feed Focus: Morning care
liquid diet himself without
assistance Data: Awake on bed. Conscious
and conversant. With patent IVF
Monitor intake
and infusing well.
and output
Action: The nurse explained to the
patient and SO the diet that need to
Perform wound be followed.
care bid
Medicine and management where
continued.
Oral hygiene initiated.
Dressing inspected and signs of
infections is monitored for possible
infection.
Nursing Department
Position to bed of comfort

Safety ensured.
Response: The patient was

cooperative and shows
understanding. Demonstrated
optimal performance of activities of
daily living.
9:00AM Vital signs Focus: Vital signs
 Temperature Data: Monitoring vital signs

36C
 Pulse Rate Action: Vital signs taken and
75bpm recorded.
 Respiration
16 bpm
Monitor any signs of distress
 Blood
Pressure
110/80mmHg Response: patient was
cooperative.
 O2sat 97%
Patient was stable at the ward.
6PM May have a Focus: Evening care
clear liquid diet
Data: The dressing is dry and intact.
Monitor intake Action: The surgical incision site

and output was checked for possible beginning
infection.
Perform wound Dressing inspected as ordered.
care bid Safety is ensured by raising the side
rails and safety ensured.
Remind SO about the patient’s
safety.
Monitored for any signs of distress.
Response: The patient is

cooperative and resting
Nursing Department
April 13, 2022

Time Doctors Order Progress Notes Nurse’s Notes
8:00 AM Final assessment of Vital signs were Focus: Monitoring

the patient taken and
Data: Awake on bed. Conscious and
recorded as
conversant.
follows:
Terminate IV Action: Vital signs obtained and
 Temperat
ure 37C recorded. The patient bath himself
 Pulse assisted by his SO. Oral hygiene
Rate 85 initiated.
bpm Dressing inspected and signs of
 Respirati infections is monitored for possible
on 16bpm
infection.
 Blood
Pressure Position to bed of comfort
120/80m
mHg Safety ensured.
 O2sat
Medicine and management where
97%
continued.
Response: Vital signs within normal

limits. Patient cooperated.
Breakfast:
The patient and SO shown
Intake: watery cooperative and shows
porridge and understanding. Demonstrated optimal
yogurt. performance of activities of daily
living.
11:00 AM Patient is for Patient general

discharge condition was
improved; he
was well adapted
to his state.
Patient reports
no pain, and
Nursing Department
irritation felt, and

dependent on his
ADLs, except for
eating and
drinking
11:20 AM Secure Billings Notify the SO

11:45 AM Health Teaching Focus: Discharge plan and continues
regarding home care home care nursing management
management
Data:Start health teaching
Action: The nurse implemented a
plan for the patient and continued
home care nursing management. The
patient was advised to follow some
general advice from the nutritionist as
they’re experts in the use of food and
nutrition to promote health and to
start a meal plan. The patient was
educated about some activities that
may worsen his condition. Health
teaches the patient about the time of
drinking the medications especially
the prescribe medication, its side and
adverse effects that are needed to be
contact to the nearest hospital.
Health teaching was given to patient
about proper wound care and proper
food intake.
Response: The patient shows
understanding of his current condition
that he will have limitation in activities
and gradually go back in his normal
routine as he reaches the fully
recovered
Client shows appropriate facial
expressions (broad affect) in relation
to emotions as he knows that he
has progress in his condition.
12 PM Advice for follow-up Encourage patient for a follow-up

check-up appointment about 1 to 2 weeks.
Nursing Department
12:30 DISCHARGE
Nursing Department
Chapter IX
Nursing Care Plan
Assessment Diagnosis Scientific Goals Interventions Rationale Evaluation
explanation
Acute pain Factors that After 8 hours Independent After 8 hours
SUBJECTIVE: related to cause chronic of nursing •The HOB should be placed -to relieve heartburn of nursing
irritated irritation and intervention, on 4 to 8 inches blocks sensations intervention
“Nahihirapan po esophageal esophageal the patient -Advise the client to avoid -to minimize the goal was
akong lumunok, mucosa as mucosa will verbalize food or drink 2 hours before occurrence of met as
sinusuka ko rin evidenced by inflammation may relief from bedtime or lying down after indigestion evidenced by:
po ang kinakain verbalization of pain eating -to prevent reflux
increase the risk
ko at masakit pain, cough, -Advise patient to avoid tight- -to enhance the patient
for esophageal
siya sa heartburn, and fitting clothes breathing pattern will reported
sikmura“ as dysphagia squamous cell -Advise the patient to chew -to promote proper decreased of
verbalized by the carcinoma. These slowly digestion of food pain as
patient factors evidenced by
include moderate- Dependent the pain scale
OBJECTIVE: to-heavy alcohol Administer medication as For medical from 7/10
drinking, prescribed by the physician management of acid becomes
-patient is smoking, and monitor patient reflux disease to 2/10.
conscious and achalasia, regularly relieve pain
coherent diverticuli, and
-dysphagia consumption of Collaborative
-abdominal pain extremely hot -Discuss with the family to In order for the food
with pain scale of provide small, frequent to pass easily into
beverages,
7/10 feedings the stomach
-heart burn coarse grains or
- seeds, lye, and
caustic spices.
•V/S taken as
Nursing Department
follows
T: 37°C
PR: 80bpm
RR: 20bpm
BP:
110/70mmHg
Assessment Diagnosis Scientific Goals Interventions Rationale Evaluation

explanation
Risk for A ring of muscle After 24 Independent These include After 24
SUBJECTIVE: aspiration fibers in the hours of •Assess for pulmonary subsequent hours of
related to lower esophagus nursing symptoms resulting from aspiration, chronic nursing
“Umuubo at esophageal prevents intervention, reflux of gastric content pulmonary disease intervention
nagsusuka po disease swallowed food the patient -Assess for nocturnal or nocturnal the goal was
ako nung isang affecting the from moving will maintain regurgitation wheezing, met as
gabi“ as stomach valve patent airway -Assess patient’s ability to bronchitis, asthma evidenced by:
back up. These
verbalized by the function swallow and the presence of and cough
muscle fibers are
patient gag reflex. Have client the patient
called the lower swallow a sip of water This is a rare maintained a
OBJECTIVE: esophageal -Instruct patient to avoid condition wherein patent airway
sphincter (LES). highly seasoned food, acidic the patient’s and shows no
•difficulty in When this ring of juices, alcoholic drinks, awakens with sign of
swallowing muscle does not bedtime snacks and food coughing, choking aspiration
close all the way, high in fats and mouthful of
stomach saliva
contents can leak -loss of gag reflex
back into the increases the risk for
esophagus. This aspiration
is called reflux -these can reduce
the LES pressure
Nursing Department
Assessment Diagnosis Scientific explanation Goals Interventions Rationale Evaluation

Impaired Esophageal After 24 hours of Independent -to determine After 24
SUBJECTIVE: swallowing dysphagia is difficulty nursing intervention, -review the client’s the level of the hours of
related to passing food down the patient will ability to swallow client’s ability to nursing
“Nahihirapan esophageal the esophagus. It results demonstrate effective swallow intervention
akong spasm as from either a motility swallowing after -increase efforts to be the goal
lumunok” as evidenced by disorder or a mechanical chewing soft food diet able to conduct -to increase was met as
verbalized by coughing and and fluid intake effective ingestion, efforts the client evidenced
obstruction.
the patient regurgitation such as helping the in the process of by:
client to enforce the swallowing
OBJECTIVE: head the patient
-to facilitate the demonstrat
-coughing -put the client in a client in ed effective
-regurgitation siting position/upright consuming food swallowing
of food intake during and after the after
meal -soft foods chewing
facilitate food soft food
-start to give oral goes unscathed diet and
semi-liquid foods, soft in the fluid intake
foods when client are esophagus
able to swallow the 1e
water -for ease of
swallowing and
-help the client to the client still
choose food that are gets nutrients
easy to swallow
-to speed
-suggest to participate healing at the
in an exercise swallowing
Nursing Department
program disorder
Nursing Department
REFERENCES
Dhingra, S. (2020). Reflux Esophagitis. Retrieved from

https://emedicine.medscape.com/article/1610393-
overview#:~:text=Reflux%20esophagitis%20is%20an%20esophageal,esophagus%20an
d%20the%20gastroesophageal%20junction.
Azer, S., Kumar, A. & Reddivari, R. (2021). Reflux esophagitis. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK554462/
https://www.dovepress.com/achalasia-following-reflux-disease-coincidence-
consequence-or-accommod-peer-reviewed-fulltext-article-TCRM
Reflux esophagitis. Ocean and surgery. Retrieved from

https://oceanendosurgery.com/condition/reflux-esophagitis
Esophangitis. Mayo clinic. Retrieved from https://www.mayoclinic.org/diseases-

conditions/esophagitis/diagnosis-treatment/drc-20361264#:~:text=Endoscopy-
,Endoscopy,the%20small%20intestine%20(duodenum).
Achalasia. Cedars sinai. Retreived from https://www.cedars-sinai.org/health-

library/diseases-and-conditions/a/achalasia.html
Pathak, N. (2020). Esophangitis. Retreived from https://www.webmd.com/digestive-

disorders/esophagitis#:~:text=Esophagitis%20is%20caused%20by%20an,Candida.
Park W, Vaezi MF. Etiology and pathogenesis of achalasia: the current understanding.
Am J Gastroenterol. 2005 Jun;100(6):1404-14. doi: 10.1111/j.1572-0241.2005.41775.x.
PMID: 15929777.
Felson, S. (2020). Picture of the stomach. Retrieved from

https://www.webmd.com/digestive-disorders/picture-of-the-
stomach#:~:text=The%20stomach%20is%20a%20muscular,and%20enzymes%20that%
20digest%20food.
Felson, S. (2020). Picture of the esophagus. Retrieved from

https://www.webmd.com/digestive-disorders/picture-of-the-
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Ics Reflux Esophagitis

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Ics Reflux Esophagitis

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Saint Mary’s University

School of Health and Natural Sciences

REFLUX ESOPHAGITIS SECONDARY TO ACHALASIA

Saint Mary’s University

In Partial Fulfillment of the Requirements for Nursing Care of Clients with

Name of Child: Child G

Admitting Diagnosis: Achalasia

Final Diagnosis: Reflux Esophagitis Secondary to Achalasia

Present Health History

Past Health History

Social Health History

Lifestyle and Health Practices

 Difficulty swallowing (dysphagia)

benefits often go away in 3 to 12 months. So the procedure needs to be repeated.

Lifestyle and Home Remedies

Name: Mr. V Admitting Physician: Dr. M Sex: Male

Address: Brgy. Quezon, Admitting Hospital: Age: 43 y.o.

A thin, flexible tube equipped with a light

II. Barium Swallow

A person swallows a barium solution,

III. Esophageal Manometry Test

A thin tube that measures pressure is

COMPLETE BLOOD COUNT

Scientific explanation: A complete blood count (CBC) is a blood test used to

Demographic and Biological Data

Patient initials Mr. V

Age 43 years old

Date of birth December 9, 1978

Place of birth Solano, Nueva Vizcaya

Address Brgy. Quezon, Solano, Nueva Vizcaya

Civil Status Married

Chief complaints Mr. V has a chief complaints of difficulty

Admitting diagnosis Achalasia

Final diagnosis Reflux Esophagitis Secondary to Achalasia

Admitting Physician Dr. M

Date of Admission April 10, 2022

Date of Discharge April 13, 2022

Current Health Problems  On April 10, 2022, at 10 o’clock in the

Past Health Problems  Mr. V had a history of achalasia starting 3

and colds for three days.

Surgical History  Mr. V did not undergo any surgical

Accidents  According to the patient, he was

Family Risk Factors GERD and Achalasia

Medications Omeprazole (Prilosec)

Significant Others The wife, Mrs. K,

Structure of Family Nuclear Mr. V has a traditional

Religion Roman Catholic

Financial PhilHealth & SSS

PRE-ASSESSMENT POST- PATHOPHYSIOLOGICAL

General Client is dressed with Client present good Altered level of

Memory The client’s memory is The client’s

Recent memory is good

Remote memory is good

December 30, 1992.

Speech Patient’s voice is weak He responds well

Nonverbal behavior The patient was looking He is smiling and he

PRE- POST- PATHOPHYSIOLOGICAL BASIS

Frequency Once a day Once a day

Pattern N/A Early in the morning

Consistency and N/A Soft and well

Presence of N/A None

Color N/A Yellow to brown

Presence of None None