Care Plan

GORD: Gastro-oesophageal reflux disease

Explain and reassure mum:

1. Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat (acid
reflux), if this keep presenting then it is likely to be gastro-oesophageal reflux disease (GORD).
2. Is very common (affects at least 40% of infants) and is usually becomes less frequent with time (it resolves in
90% of affected infants before they are 1 year of age).
3. Plan of action as of now: Obs, doctor will assess child, run tests if situations get worst?
4. Ask mum if she has any questions or concerns
5. Offer her tea
A - G Nursing Note:
A - Airway is clear, due to baby vomiting

B - RR 40, SATS 98%, no resp distress

C - Mottled? Flushed cheeks? Warm to touch? Colour? HR 135

D - GCS? Disability?

E - Afebrile, rashes? Cyanosis? Abdomen? Wet/Dry nappies? History of vomiting last 24 hours?

F - With mum

G -2hrly Obs, r/v by doctor/gastroenterologist, referral to social worker/community nurse, NG? IV fluids?
Fluid Requirement for formula fed:
Mom is feeding 5oz every feed 6 times (142mls 6 times a day)

150mls/kg per day

150ml x 6kg = 900ml

900mls/6 feeds a day=150mls

900mls/ 8 feeds a day = 112.5mls per feed

12 midday begins NG feeds

3 hourly feeds

Document pH and colour of aspirate

Fluid Balance
Fluid balance charts The aim of a fluid balance chart is to keep an accurate record of a patient's fluid input and
output and to identify any deficits. It is important to identify which patients require a fluid balance chart and to
hand this over to staff between shifts.
Activity of living:
Eating and Drinking: NG feeds

Elimination: How many wet nappies? Open bowels? Frequent change of nappies

Maintaining a safe environment: NG feeds clean spigots before every feed to reduce risk
of infection

Sleeping: Needs to be sleeping on back, No co-sleeping