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Nursing Care Plan Assessment Health And Social Care Essay

Info: 4036 words (16 pages) Nursing Essay
Published: 11th Feb 2020

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Gastroesophageal reflux is also referred to as GERD. It is caused by your esophagus becoming agitated by acidic substances coming from the stomach. It is a condition in which the stomach contents leak backwards from the stomach into the esophagus (referred to as reflux) which can cause inflammation and damage to the lining of the esophagus. This action can irritate the esophagus, causing heartburn as well as other symptoms. GERD is associated with failure of the lower esophageal sphincter to properly close. The outcome is reflux of acid into the unprotected lining of the esophagus which can be uncomfortable and painful to the patient. The pathophysiology of GERD indicates that the inner lining of the esophagus does not have the protection that is found in the stomach and therefore the acid could cause harm to the esophagus. The signs and symptoms a patient experiences are caused by the contact of unprotected lining of the tissue (esophageal) to acid. GERD is a chronic condition, once a patient has experienced the onset most likely they will deal with it the rest of their life. One major symptom experienced is acid reflux and heartburn,indigestion lasting up to two hours however; these two symptoms alone are not sole indicators of the diagnosis. GERD may also manifest as chest pain, tightness of the throat, difficulty swallowing, regurgitation, dysphagia, dry cough and a persistent cough. Other symptoms include feeling that food may be trapped behind breastbone, hiccups, regurgitation of food, and nausea after eating, and hoarseness in the voice.

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3. Clinical manifestation from text:

Gastroesophageal reflux occurs when food is passed from the pharynx into the esophagus (located behind the posterior trachea) by a peristalsis which is a propelling motion. The food is then carried from the esophagus to the stomach where acid production is created. What occurs next is that the esophagus produces bicarbonate and mucus that will from a protective barrier. This process creates a higher pH that the stomach. If the sphincter muscle does not close well, liquid, food and stomach acid can leak backward into the esophagus. The esophagus is divided into an upper and lower sphincter. The upper prevents air from entering during respirations and will open when food needs to pass. The lower sphincter opens while food is being passed to the stomach (i.e. LES). When the esophagus is in a healthy state, there are three mechanisms that keep acid out while swallowing. They include the following: Swallowed saliva which helps neutralize stomach acid. Next, sweeping muscles contractions where the motion cleanses the lower esophagus stomach acid. Some main contributing factors that interfere with the LES working properly is obesity, pregnancy and asthma. Excess weight actually puts extra pressure on the diaphragm and stomach. In pregnancy the pressure on the stomach has a higher level of progesterone hormone which in turn relaxes the LES muscle as well as other muscle groups. It is unclear as to why asthma is a contributing factor to interference of the LES mechanisms but it is believed that coughing may lead to the pressure changes on the diaphragm. Some identified risk factors for reflux include hiatus hernia. This is a condition in which part of the stomach moves above the diaphragm (muscle separating the chest and abdominal cavities). Medications may cause or worsen GERD symptoms. They include the following medications: Anticholinergics, Beta-blockers (high blood pressure meds), Bronchodilators (asthma), Calcium channel blockers (BP medication), Dopamine-active drug for Parkinson’s disease, Progestin for abnormal menstrual bleeding, Sedatives used for insomnia or anxiety and finally Tricyclic antidepressants. .

4. Diagnostic Evaluation from text:

1. Review of History

Obtain a detailed inquiry about the patient’s normal pattern of diet, and any other symptoms the patient may be experiencing. This is also a good time to question if they are taking any OTC medications. It is important to assess the duration of the problem. Next ask how long the patient has been experiencing reflux which will provide useful causative information. Determine what foods the patient is consuming, if they exercise, how much fluid intake daily, and most importantly if they are smoking -which inhibits saliva and may also increase acid production and weaken the LES. Certain exercise and bending may increase the abdominal pressure. Also wearing tight clothing (increase abdominal pressure) or lying flat after a meal may relax the muscles causing reflux. Ask about the patient’s diet and educate them on foods to avoid. For example, foods high in fat and greasy take longer to digest. Chocolate, peppermint, spearmint, weaken the LES. In addition, Carbonated and alcoholic beverages increase the acidity in the stomach. Warn patient to consume smaller meal because large meals produce large acid levels. Other foods to avoid are citrus, onions and tomatoes. In general, all foods which contain a high acidic level may be irritating to the esophagus. Document any abnormal findings in patient record or MAR. Question the patient’s family history of disease and initial onset or exacerbation of episode. Finally, the evaluation should include the patient’s description of sensation of the symptoms.

2. Laboratory /Diagnostic Tests

The most commonly used diagnostic tests include the following lab tests:-esophageal pH monitoring, esophageal manometry, the acid perfusion (Bernstein) test and the gastric analysis. A barium swallow and a Radionuclide scintigraphy may also be ordered by the MD. Specialty Lab tests CDSA 2.0 with parasitology, Detoxification Profile, Standard and Menopause Profile. Diagnostic tests use to diagnose GERD include: Barium swallow, Endoscopy, Esophageal motility studies, ambulatory pH monitoring and Esophageal manometry.

5. Therapeutic Management from text:

Although GERD can be treated in several different ways most physicians will recommend antacids and changing the diet to a healthier one. Other methods of treatment include alternative medicines such as acupuncture and herbal tonics which promote proper function to the lower esophageal sphincter and acid production of the stomach. If recommended by a physician, surgery is an option for those with serious complication. The most common surgery is the Nissen Fundoplication. This surgery involves wrapping the fundus of the stomach around the lower esophagus and sutures the fundus to itself. Available therapies include a combination of the following types of medication: Benzodiazepines, Theophylline, and Narcotics containing codeine, Calcium channel blockers, Nitroglycerine, Anticholinergics, Potassium supplements, Iron supplements, NSAIDS, Fosamax, and Erythromycin. Patient Education: We want to educate the patient on how to prevent future flair ups. Because foods play an important role we will educate the patient to avoid: chocolate, alcohol, caffeine, citrus fruits and vegetables, spicy or fatty foods, full fat dairy products, peppermint and spearmint Gastroesophageal Reflux Disease. PubMed. Retrieved February 2011, from www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001311/. Other preventative measures we can encourage pt’s to do is to avoid bending over after eating and avoid tight fitting waist bands on clothing. Also instruct pt not to lie down with a full stomach. It is extremely important to encourage them not to smoke and if they are smokers educate them on smoking cessation. If a patient is overweight, encourage an exercise regimen designed and individualized specifically for the pt. Weight loss and eating smaller meals in key to their diet change. Also have patient refrain from eating 3 hours after bedtime and stay upright position two hours after each meal. Inform the patient that the head of the bed must be raised approximately 6 inches. It is important to let pt know about OTC and presription options. Some medications available are Proton pump inhibitors which are the most potent acid inhibitors. Prilosec, Prevacid, Zantac, Tigamet and Protonix

Common Nursing Diagnosis and Interventions:

Altered Nutrition: less than body requirements R/T vomiting: Educate patient on importance of eating healthy and increasing caloric intake as necessary.

Nausea R/T gastric irritation food AEB vomiting after meals: Dietary changes to decrease frequency of nausea

Risk for Aspiration: Assist in correcting factors that can lead to aspiration

Deficit Fluid Volume: Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated medically. Assess V/S respirations, (temp & pulse may be elevated). Note change in functional behavior (i.e. confusion, falling, lethargy, dizziness).



Subjective: “My energy level is very low recently” and “I don’t exercise very often”. Patient reports that she only exercise she gets lately is, “while I am working on my hobbies, not much walking mostly standing”, Patient denies any chest pain but does experience a shortness of breath upon exertion. Patient admits that she lives a very sedentary lifestyle. Patient states she is totally independent with activities of daily living ADL’s and has no difficulty performing usual ADL’s. Patient states her leisure activities include: taking photos and enjoying my art work of painting. Patient does not use any assisted devices for walking and does not exercise daily.

Objective: 1.Patient has no VTE risk factors and can ambulate fully and independently with daily ADL’s. No fall risk identified and pt reports she does not do any physical activity such as exercising while at home. Diet: Patient is on NPO for stress test ordered today. Abdomen is soft, non distended, and non tender, bowel sounds are present in all four quadrants. Patient activity order is full ambulation, full weight bearing and activity. Impairments include decreased mobility and experiences SOB on excretion. Energy level is described good but easily fatigued with high level of exertion 2. Hygiene: fully independent-sponge washed independently. Respiratory data indicates no SOB while speaking, patient able to carry long conversations without difficulty. MD ordered continuous O2 via nasal cannula; no fall precautions were ordered. Upon auscultation of lung sounds anterior and posterior were auscultated, on auscultation lung sounds clear bilaterally. Chest is non tender to the touch. Respiratory: No cough, no dyspnea noted (O2 2liters). Alert and oriented. Assessment Cardio Vascular: Regular rate rhythm, no chest pain, no palpations, pt denies SOB at resting; Chest: Lungs Clear bilaterally; Cardiac auscultation indicates regular rhythm, no murmurs, P 68. BP 154/84. RR 18, O2 SAT 94% on O2 2 liter via nasal cannula, T 97.1 (orally). Radial pulse is palpable on both sides, strong and equal bilaterally. Abdomen: bowel sounds present, soft, non distended, non tender upon palpation. Pt denies any pain in abdomen.

ROM (active/passive) assessment revealed no signs of pain (0/0 pain scale) on when force applied during passive range of motion. Muscle strength RUE 5/5 and LUE 5/5 RLE 5/5 and LLE 5/5. Although no weakness noted in upper and lower extremities, patient states that stressing her muscles for a long period of time increases her fatigue. CSM: Color pink and even, full sensation and patient able to wiggle toes without difficulty. TEMP: warm to the touch. A Capillary refill test done on UE indicates normal blood return (less than 3 second return).

Medications ordered: Acetaminophen 650 mg PO every 4 hours, Aspirin enteric coated 81 mg PO daily, Atorvastatin PO 10 QHS, Maalox-Alumina, Magnesia, S PRN PO every 6 hours, Pantoprazole 40mg PO twice daily, Metoprolol Tartate PO 25 mg twice daily, Ibuprofen PO 400mg ever 6 hours and Bactrim DS PO 1 tab twice daily.

Nursing Diagnosis: Impaired physical mobility related to SOB with intense activity and inability to move purposefully within the environment.

Outcome: Pt will verbalize understanding of importance of exercise activity to increase abdominal muscle strength to strengthen muscle groups and increase breathing ability.


Subjective: Patient states, “I was awoken by chest pain that went to the back of my jaw…I had very spicy food for dinner and thought it was heartburn or my GERD acting up” Patient recalls why she was admitted to hospital, “I got up and thought it would be best for my husband to bring me to the ER”. “At first I thought it was the usual reflux pain but it ended up getting a lot worse”.

Objective: Patient alert and oriented x3, speech is clear with no slur or stutter. Pt has no difficulty expressing ideas and feelings clearly and concisely. Patient is well oriented to place and time is and shows no signs of confusion or disorientation. Pt appears comfortable and verbalizes she does not currently have any level of pain. Patient PMH: Esophageal ulcers, High Cholesterol, high blood pressure, Fibromyalgia, Ulcers in esophagus,? MRSA in left leg when pt had cellulites in the past.

Nursing Diagnosis: Sedentary lifestyle related to shortness of breath during activities AEB pt weight gain.

Outcome: Patient will have full understanding of importance of increase activity and importance of low fat diet.

Nutrition Metabolic

Subjective: Patient Diet: on NPO due to scheduled Stress Test. Patient states that prior to patient being hospitalized she was totally dependent with feeding herself and states, “I usually only eat lunch and dinner and usually skip breakfast”. “I love food so I pretty much eat anything”. Patient reports burning in esophagus and can feel acid coming up in the past and take OTC drugs to control if necessary.

Objective: Pt on NPO diet, no deficits noted, patient over weight (wt 211.6 lbs). Patient complains of not eating the right foods daily. Encouraged patient to increase fluids to 2,000 mLs everyday and choose beverages low in calorie (i.e. diet soda and water). Assessment of integumentary skin: no rashes, no lesions or broken skin or erythemia noted one bruise on left lower extremity. No fever, no chills, no sore throat. Gastro: the pt has history of GERD and esophageal ulcers. Genitourinary: no hematuria, no dysuria, no frequency, no urgency. Encourage a well balanced diet, and adequate fluid intake to promote peristalsis. Edema test done to ankles (no trace or pitting edema noted =normal).

Nursing Diagnosis: Risk for deficient fluid volume related to inefficient H2O intake as evidenced by complaints of dry mouth and pt verbal cues.

Outcome: Patient will increase fluid intake to 2,000 mL’s to increase hydration prior to discharge.

Coping and Stress

Subjective: “I want to get better and know that I need to work on my diet and make changes in my lifestyle. Patient states that she only slept a total of 5 hours.

Objective: Pt denies and feeling of depression and is happy in home life with husband. Patients EMR indicated that her behavior was cooperative. Patient verbally expressed appreciation and gratitude when educating her on some relaxation techniques (i.e. deep meditative breathing).

Nursing Diagnosis: Readiness for enhanced

Outcome: Pt to demonstrate relaxation techniques prior to discharge.

Health Perception/ Health Management

Subjective: “I try to take care of all my health needs but I don’t always feel good about my food choices”. “I know that if I don’t start watching my weight, I am going to get diabetes.” Patient indicated that he regularly follows up with his PCP and dentist and all medical appointments as necessary.

Objective: Pt is alert and oriented, has overall good hygiene and likes to be well groomed. She shows ability to perform activities of daily living (ADL’s) independently and was very cooperative, allowing me to take V/S and examine her feet which soft, pink and adequately maintained. Patient demonstrates full independence with hygiene activities such as bathing; dressing and toileting require no assistance. General foot appearance of patient is good, with her nails trimmed, hair is maintained. Patient wanted to wash her hair which indicates a healthy perception of hygiene and was appreciative when given a shampoo cap to use. Admission Labs: HGB:13.2 g/dL, HCT: 41.1%, WBC: 13.7 (elevated), RBC: 4.87, MCH: 27.0, MCV 84.4, MXHX 32.0, RDW 14.0, Plt count 211, MPV 7.5l , Neutrophils 70, Lymphocytes 26, Atypical Lymphs 14, Monocytes 1L, Eosinophils 3, Absolute neutrophil 4.5, Lymphocytes 8.3 (high), Monocytes 0.4, Eosinophils 0.2, Basophils 0.2, Platelet estimate – adequate. Admission V/S BP 143/74, (T)97.8 orally, (P)69, R:19, SaO2 (96% on RA).

Nursing Diagnosis: Readiness for enhanced therapeutic regimen

Outcome: Patient will maintain responsibility for planning and achieving self care goals

Self Perception/Self Concept

Subjective: “I am aware when I need medical attention and will get medical treatment and see my doctor when necessary”. Patient expressed that she always follows up with her healthcare needs and does not ignore signs and symptoms of being ill.

Objective: Pt exhibits positive self esteem and currently has no worries in life except the possibility of developing diabetes because of her weight gain. When I questioned her about her knowledge of the disease she stated that she knew it was a disease that occurred when people were overweight and ate junk food. She indicates a strong determination when discussing the willingness to change her eating habits and developing a healthier lifestyle (i.e. walking more and being more active). She shows some indications of embarrassment for letting herself gain weight over the years.

Nursing Diagnosis: Readiness for enhanced self care.

Outcome: Patient will maintain responsibility for planning and achieving self care goals


Subjective: “I’ had a bowel movement this morning”.

Objective: Bowel habits: soft, formed. Medium, brown BM x1 every day. Bladder habits: voids x3 -5 times a day. Patient denies any burning, pain, urgency, or dribbling during urination. Patient also states that she does not usually have issues with having bowel movement. Prior to hospital admission patient denies taking any laxatives. Patient is able to independently toilet self. No abdominal distention noted upon palpation. Bowel Sound: present in all 4 quadrants.

Nursing Diagnosis: Risk for constipation

Outcome: Patient will have a regular BM once daily


Subjective: “I have a wonderful husband and one son.” Patient’s participation in group social activities has been relatively healthy most of her life. “I love my artwork and previously had a shop which has been closed for several years now…I thought was time to retire.”

Objective: Patient lives with husband and son frequently visits and she speaks very highly of them both. Patient appears to be overall in good spirits and satisfied with home life. Patient did not have any visitors but received phone calls from family members. Pt also made phone call on two occasions to check up on husband during my interview.

Nursing Diagnosis: Risk of caregiver role strain.

Outcome: Pt will be able to provide clues to potential stressors and possible supportive interventions before discharge.

Sleep Rest

Subjective: Pt complains of sleep deprivation last night, “I just couldn’t fall asleep, probably because I’m not in my own bed. “I think I only slept a total of 4 hours.”

Objective: Patient complains that she sometimes does not sleep at night and her MAR indicates poor sleep habits. Pt could benefit with sleep aid to help her sleep through the night. Pt complains of pain and discomfort while trying to sleep (Fibromyalgia…”skin sometimes hurts”). Patient describes sleep pattern at home usually only needing six hours of sleep daily. Patient denies taking any sleep aide medications while at home.

Nursing Diagnosis: Risk of sleep deprivation related to bilateral lower extremity pain.

Outcome: Patient to practice healthy sleep patterns while in hospital within 1 day.

Value Belief

Subjective: “I go to church, but not as often as I use to especially in the cold”

Objective: Pt declined discussing spirituality and value system.


Subjective: “I don’t see how these questions relate to my health”.

Objective: Pt declined to discuss this topic with me during the interview.

Nursing Care Plan

Nursing Diagnosis: Sedentary lifestyle R/T lack of training for accomplishment of physical exercise AEB by patient verbal cues and demonstrating physical deconditioning.

Goal: Patient will verbally understand the importance of regular exercise to general well being by discharge.


1. Abdomen inspection, auscultation, percussion, palpation and measurement of abdominal girth.

1. Will provide objective data on the patient’s bowel elimination status. (Craven 1126)

2. Encourage daily exercise regimen

2. Will provide education on importance of maintaining a healthy lifestyle.

3. Encourage daily fluid intake of 2000 to 3000 ml/day, if not contraindicated medically.

3.Will assist in peristalsis and segmentation of stool Patients, (Craven 1122)

4. Encourage increased activity and patient to exercise or increase daily activity.

4. Ambulation and/or abdominal exercises strengthen abdominal muscles help facilitate defecation and will help increase peristalsis. (http://www.mayoclinic.com/health)

5. Position bed in lowest position, with side rails up

5. Low position of bed minimizes distance to the floor so if client falls, side rails maintain patient safety (Craven, 675)

6. Place client call light within reach and explain the call system as assess the ability to use it.

6. A call light allows the patient to call for help if needed (Craven, 675).

7. Promote normal bowel health

Assess usual pattern of elimination; compare with present pattern. Include size, frequency, color, and quality.

7. “Normal” frequency of passing stool varies from twice daily to once every third or fourth day. It is important to ascertain what is “normal” for each individual. (Craven, p. 1117)

8. Encourage a regular time for elimination. Many persons defecate following first daily meal or coffee, as a result of the gastrocolic reflex; depending on the person’s usual schedule, any regular time is fine.

8. Many persons defecate following first daily meal or coffee, as a result of the gastrocolic reflex; depending on the person’s usual schedule, any time, as long as it is regular, is fine. (Craven, 1117)

9. Assess orthostatic hypotension before taking the client OOB to chair, if any signs of dizziness or lightheadedness.

9. Rationale: allows nurse to be aware of orthostatic hypotension upon standing which may result in a fall. (Craven, 457)

10. Place patient call light with reach, and explain the system and assess the ability to use it

10. Promotes safety and decreases stress for patient & allows pt to call for help If needs assistance to toilet after given stool softener or enema. (Craven 675)


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