CARE PLAN

STUDENT NAME: Steve Randolph

MEDICAL DX: GERD
DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage.
SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus.

NURSING ASSESSMENT NURSING DIAGNOSIS

Objective: Facial grimacing, guarding chest and Physiological: Chest pain Related to inflammation
stomach area, difficulty swallowing, dyspnea, of esophageal tissues caused by gastric reflux
anorexia, Pain 7 on scale 1-10
Subjective: Patient states,” My heartburn never
goes away! Why does it always hurt so badly?”

NURSING INTERVENTIONS RATIONALE

1. Assess level of pain using appropriate pain scale 1. Provides information of severity of pain
2. Identify factors that cause pain or increase it. 2. Enhances management of condition and helps to
3. Provide medications to relive acidity of gastric formulate teaching plan.
contents as ordered. 3. Helps decrease gastric acidity to promote
4. Position patient in a Fowler’s position. comfort.
5. Provide small frequent meals and avoid foods 4. Helps prevent reflux of gastric contents into
that trigger heartburn. esophagus.
5. Prevents pain caused by heartburn and gastric
contents from reaching esophagus.

PATIENT TEACHING PATIENT OUTCOME

1. Provide information on proper positioning to Patient will have relief from pain as evidenced by
prevent gastric reflux. verbalization of a lower level of pain on a scale of
2. Provide information on medication and proper 1-10.
dosage.
3. Foods and activity that may trigger pain caused
by gastric reflux.
4. Cease smoking and use of alcohol as they
exacerbate symptoms.
5. Avoid strenuous activity and bending at the waist
after meals.
CARE PLAN
STUDENT NAME: Steve Randolph
MEDICAL DX: GERD
DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage.
SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus.

NURSING ASSESSMENT NURSING DIAGNOSIS

Objective: Nausea, vomiting, pallor, diaphoresis, Physiological: Nausea and vomiting related to
dypnea, guarding of stomach and throat areas. gastric reflux.
Subjective: Patient states,” I’m so tired of vomiting
all the time after I eat, but it’s always worse before
I go to sleep.”

NURSING INTERVENTIONS RATIONALE

1. Assess vital signs. 1. Provides baseline information for later
2. Assess causes of nausea and vomiting. comparison.
3. Maintain upright position 30 to 45 minutes a.c. 2. Finding the causes of N/V may help to prevent
4.Provide small frequent meals episodes of N/V.
5. Avoid giving food that is high in acidity or 3. Maintaining an upright position will help after
caffeine. meals helps prevent gastric reflux.
4. Small frequent meals prevent stomach contents
from overflowing into the esophagus.
5. High acid foods may exacerbate nausea and
vomiting.

PATIENT TEACHING PATIENT OUTCOME

1. Avoid eating large meals, eat smaller more Patient will experience less nausea and vomiting
frequent meals. episodes as evidenced by avoiding situations that
2. Do not eat meals before hours slept exacerbate nausea and vomiting.
3. Maintain an upright position 30-45 minutes after
meals.
4. Avoid situations that may cause episodes of N/V.
5. Identify and avoid foods that cause nausea and
vomiting
CARE PLAN
STUDENT NAME: Steve Randolph
MEDICAL DX: GERD
DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage.
SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus.

NURSING ASSESSMENT NURSING DIAGNOSIS

Objective:
Subjective:

NURSING INTERVENTIONS RATIONALE

PATIENT TEACHING PATIENT OUTCOME

CARE PLAN
STUDENT NAME: Steve Randolph
MEDICAL DX: GERD
DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage.
SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus.

NURSING ASSESSMENT NURSING DIAGNOSIS

Objective: Withdrawn, tearful, anxiety, tachpnea, Psychological: Fear related to possible

anorexia, tachycardia, marked nervousness, self fundoplication surgery to alleviate symptoms of
destructive behaviour. GERD
Subjective: Patient states,” I’m scared out of my
head; I have never had surgery before! What if I
don’t make it?”

NURSING INTERVENTIONS RATIONALE

1. Provide opportunities to express concerns, fears, 1. Providing an environment of openness and
feelings, and expectations through therapeutic therapeutic communication my help calm the
communication. patient.
2. Assess available or useful past and present 2. Assesses level of coping ability and past
coping mechanisms. successful coping methods.
3. Encourage patient to identify own strengths and 3. During crises, patients may not be able to
abilities. recognize their strengths. Fostering awareness can
4. Provide information the patient wants and needs, expedite use of these strengths.
not provide more than patient can handle. 4. Patients who are coping ineffectively have
5. Reduce stimuli in environment that could be reduced ability to assimilate information.
misinterpreted as threatening. 5. Patients are exposed to new equipment and
environments that may be perceived as threatening.
PATIENT TEACHING PATIENT OUTCOME
1. Use of support groups may help patient and Patient will experience a lowered level of fear
family understand they are not alone. through therapeutic communication as evidenced
2. Teach use of relaxation, exercise, and diversion lower level of anxiety and tearfulness.
activities as methods to cope with stress.
3. It is ok to let people know how you feel.
4. Include family in decision making process
concerning care being received.

CARE PLAN
STUDENT NAME: Steve Randolph
MEDICAL DX: GERD
DEFINITION OF MEDICAL DX: Gastric secretions reflux into the esophagus, causing damage.
SYMPTOMS: Heartburn, regurgitation, nausea, dysphagia, bleeding of esophagus.

NURSING ASSESSMENT NURSING DIAGNOSIS

Objective: Heatburn, chest pain, nausea vomiting, Psychological: Knowledge deficit related to
guarded position, facial grimacing, repeated heartburn as evidenced by not taking
Subjective: Patient states,” The doctor said I have medications insufficient knowledge of disease and
GERD, What is GERD? Is this why I always have proper lifestyle changes.
heartburn?”
And ,” It seems it gets worse when I get back from
the bar everynight.”

NURSING INTERVENTIONS RATIONALE

1. Assess patient’s knowledge of the disease. 1 Helps assess what the patient knows to help
2. Identify any existing misconceptions regarding formulate a teaching plan.
material to be taught. 2. This provides an important starting point in
3. Determine cultural influences on health education.
teaching. 3. Providing a climate of acceptance allows patients
4. Explore attitudes and feelings about changes. to be themselves and to hold their own beliefs as
5. Provide a quiet atmosphere without interruption appropriate.
4. Assists in understanding how learner may
respond to information and possibly how successful
the patient may be with the expected changes.
5. This allows patient to concentrate more
completely.
PATIENT TEACHING PATIENT OUTCOME
1. Teach patient the causes of GERD to his level of Patient will be more sufficient in self care as
understanding. evidenced by less heartburn and making positive
2. Information on medication and proper dosage of lifestyle changes through education.
medication.
3. Foods to avoid that may cause symptoms to get
worse.
4. Proper positioning during hours slept.
5. Proper diet and nutrition: low fat, low acidic or
spicy foods. high fiber, lean protein and small
frequent meals.
6. Lifestyle changes such as cessation of smoking
and refraining from alcohol.