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​Case Study – GERD

Mr GERD is a 56 y/o with diagnosis of mild GERD during his annual physical exam. His health history include: -wt 250 lbs -smokes ½ pack/day -drinks 3 cups coffee daily -hiatal hernia -HTN

1. Mr GERD is asking you the causes of GERD – what would you tell him? What is “mild” GERD? Gastroesophageneal Reflux disease is when acidic gastric contents are regurgitated into the esdphagus and cause irritation to the lining. It may be caused by a defect in the lower esophageal sphincter (LES) which inhibits it from closing completely when food is consumed. predisposing conditions include hiatal hernia, incompetent LES, decreased esophageal clearance resulting from impaired esophageal motility and decreased gastric emptying.the acidic gastric secretions that reflux up into the lower esophagus can result in esophageal irritation and inflammation.

Mr GERD is stating he has friends who have been diagnosed with GERD, but he has only had occasional pain in the upper abdomen. He states that one of his friends went to the hospital to be evaluated for an MI and was told her had GERD.

2. What are other s/s of GERD? dyspepsia, regurgitation without nausea-bitter or sour taste in the mouth, pain after eating, increase salivation, flatulence, hx of stress, frequent belching.

Mr GERD states that when he has the pains in his abdomen they are sometimes relieved with milk or a Tums.

3. Why would this occur? antacids produce quick but short-lived relief of heartburn by neutralizing HCL acid.

2 years later Mr GERD presents to the ER with c/o dysphagia, coughing and wheezing. He thinks he is having a stroke. After evaluation it is determined Mr GERD has an sever GERD. The ER provider admits him for further observation.

You are the nurse working on the med/surg unit and assigned to MR GERD. Upon report you learn he is scheduled for an endoscopy this AM.

4. What is the reason for the endoscopy? endoscopy is a procedure that enables the examiner (usually a gastroenterologist) to examine the esophagus (swallowing tube), stomach, and duodenum (first portion of small bowel) using a thin, flexible tube through which the lining of the esophagus, stomach, and duodenum can be viewed using a TV monitor. The purpose  of an  endoscopy  is to allow the physician to observe what is happening within the body. The procedure can help the physician to identify signs that an organ is not functioning as it should, is enlarged, or in some other manner is not as it should be. At the same time, an endoscopy  can be used to visually evaluate any type of abnormal growths present in or around an organ, such as a tumor. The results of the endoscopy reveal columnar epithelium.

5. What does this mean to you? Why does this occur? What can happen with these changes? this means the client has Barrett's esophagus. this is a precancerous lesion that increases the pt's risk for esophageal cancer. 10 -15% with chronic reflux have Barrett's esophagus. the esophagus is made up of normal squamous epithelium and when they change there is a chance you can develop adenocarcinoma so you need to be monitored on a regular basis.

Mr GERD is diagnosed with bronchitis related to GERD.

6. Mr GERD is asking you why GERD would cause bronchitis – what would you tell him. What other resp. complications can occur with GERD. ​ ​ Gerd can cause bronchitis as a result of aspiration of cotents into the respiratory system. The other respiratory complications that can occur are cough, bronchospasms, laryngospasms, and cricophayngeal spasms as a result of irritation of the upper airway by gastric secretions. They can also get asthema and pneumonia.

You are helping Mr GERD with AM cares. When he is brushing his teeth he states that he has noticed changes to his teeth and has had an increased in cavities in his posterior teeth. He seeks advice from you.

7. What would you tell him? Denatal erosion may could be the reult of acid reflux coming up into the mouth this will wear away the enamal of your teeth and make them more sensitive to foods and beverages. Tell him to be sure that he brushes his teeth more often and makes a dental appointment.

Mr GERD is scheduled for a barium swallow. He is asking you what this test consist of to include prep, procedure and post-procedure. He is asking you why the provider ordered this test.

8. What would you tell him? Barium Sulfate is a metalic compoundm that will show up on an xray. It is a chalky liquid similar in consistancy of milk. Mr. Gerd will be strapped onto a table that can be moved around durring the testing. baseline xrays are taken, then he will be asked to take a few sips, slides will be taken, pt will be asked to take a few more sips, and again xrays are taken. This repeats with the table being tilted in all diff erent directions to get films on the pathway the barium takes. (I couldn't log in- C.Merritt)

It is noted from the barium swallow result he has a small esophageal stricture.

The provider orders Protonix 40mg IV daily.

9. What is the purpose of Proton pump inhibitors? What are other proton inhibitors? []

Proton pump inhibitors act to produce a long lasting and pronounced reduction of gastric acid. In addition to protonix, some other examples are Prilosec, Prevacid, Aciphex, Nexium and Zegarid, a rapid release form of prilosec. The provider asks you to educate Mr GERD on lifestyle changes to decrease the symptoms of GERD.

10. You will educate him on the following: nutrition, wt, smoking It would be best for the pt to quit smoking, smoking affects the lower sphinter's ability to function properly. The pt would want to avoid acidic food and drink, like coffee, fatty foods, chocolate. Anything that triggors heartburn. The pt would also be informed NOT to lay down flat for at least an hour or two after eating (Carrie). Upon discharge you are filling out the medication reconciliation sheet. Dr Provider orders Nexium 40mg Po daily and Pepcid 20mg PO twice a day. He also want Carafate 1 gram before meals and Reglan 10mg QID (AC and HS). []

11. What nursing education would you perform related to these drug? What is the different mechanism of these drugs? Which one helps the esophageal stricture? Which one is used for cytoprotective properties? Which one is used to help increase gastric emptying and reduce gastric reflux?

Carafate- GI protectant, anti-ulcer agent. Med combines with gastric acids to form protective coating. Teach pt not to take within 30 minutes of taking an antacid; Watch for constipation- keep BM diary; the importance of finishing prescription, even if S/S are gone(Carrie)

Inform that smoking interferes with actions, inform pt to take entire dose even when feeling better.

Mr GERD is asking you about the use of antacids such as Tums or Mylanta.

12. What would you tell him? Antacids produce quick but short lived relief of heartburn they neutralize HLC acid. They should be taking 1-3 hours after meals and at bedtime these may be useful in patients with mild intermitten heartburn. However in patients with moderate to severe heartburn these regiments are not efective in relieving symptoms.

Mr GERD is asking concerned that the medication and lifestyle changes may not help decrease his symptoms. He states he has heard that surgery is needed at times.

13. What would surgical interventions can occur to treat GERD? He would have antireflux surgery this would decrease reflux of gastric contents by enhancing the integrity of the LES. They types of surgery are Nissen and Toupet fundopications. This involves taking the fundas of the stomach and wrapping it around the lower portion of the essphagus to reinforce and repair the defective barrier. These are laparoscopic surgeries and they greatly reduce the complications, overall morbidity, and he cost of hospitalizations.

One year later, Mr GERD is admitted for a **Nissen fundoplication.**

14. How does this surgical intervention help treat GERD? This surgery helps to reinforce the esophageal sphincter ( the fundus of the stomach is wrapped around the lower portion of the esophagus) to help prevent reflux. What are your post-op nursing interventions when caring for a patient with this procedure (position, resp, pain, labs, hydration concerns, introduction of diet and type of foods, education on what patient may experience during the first month of the procedure, warning signs that the patient should report). Post op care focuses on prevention of respiratory complications (deep breathing, coughing, incentive spirometer, fowler's position), Respiratory rate, rhythm and pulse must be closely monitored, high abdominal incisions can lead to respiratory complications. Careful monitoring and maintenance of fluids and electrolytes is necessary as these are common complications of this type of surgery. Patients should be on strict I&O. During the post op phase patients will need medications to control post operative nausea and vomiting and also pain. Once peristalsis returns, only fluids are given initially. Solids are added back in gradually so that the stomach is not overdistended. Gradually, a normal diet is resumed. The patient should avoid foods that are gas forming, should try to prevent gastric distention (eating slowly, not over eating, avoid carbonated beverages), and be sure to chew food thoroughly. During the first month post op, the patient should be aware that they may experience dysphagia caused by edema around the surgical site, but this should resolve on it's own. The patient must report persistent symptoms such as heartburn and regurgitation.

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