Gastroesophageal Reflux Disease (GERD) Current trends in the management of gastroesophageal reflux disease: a review.

OBJECTIVES Understand the basic pathophysiology of GERD Identify the symptoms of GERD Understand proper medical and nursing interventions

PATHOPHISIOLOGY Caused by the relaxation of the lower esophageal sphincter (LES) Gastric juices move back through the LES into the esophagus Can cause erosion of the esophageal mucosal layer http://www.youtube.com/watch?v=o8iShP84HP4 (Nowkediuko, 2012) http://www.youtube.com/watch?v=o8iShP84HP4 From article Nowkediuko, S. C., (2012, July 11). Current trends in the management of gastroesophageal reflux: a review. ISRN Gastroenterol, 2012. doi: 10.5402/2012/391631

SYMPTOMOLOGY Heartburn Regurgitation Sleep disturbances Cough Hoarseness Asthma Dental erosions (Nowkediuko, 2012) - Nowkediuko, S. C., (2012, July 11). Current trends in the management of gastroesophageal reflux: a review. ISRN Gastroenterol, 2012. doi: 10.5402/2012/391631

PREVALANCE Most common upper gastrointestinal disease in western countries 10%-20% of people in western countries experience symptoms 8.9 million people diagnosed (Perry, 2012) Seen mostly in older Caucasian males (Nowkediuko, 2012) Nowkediuko, S. C. (2012, July 11). Current trends in the management o gastroesophageal reflux: a review. ISRN Gastroenterol, 2012. doi: 10.5402/2012/391631 Peery, A.F., & Dellon, E. S. (2012, November). Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology, 143(5): 1179-1187. doi: 10.1053/j.gastro.2012.08.002.

RISK FACTORS Genetic factor Obesity Alcohol abuse Smoking (Nowkediuko, 2012) Nowkediuko, S. C., (2012, July 11). Current trends in the management of gastroesophageal reflux: a review. ISRN Gastroenterol, 2012. doi: 10.5402/2012/391631

MEDICAL INTERVENTIONS Acid Suppressive Therapy Histamine 2 receptor antagonists (H2RAs) Proton pump inhibitors (PPI) Antacids Surgery Transoral incisionless fundoplication Nissen’s fundoplication (Nowkediuko, 2012) Nowkediuko, S. C., (2012, July 11). Current trends in the management of gastroesophageal reflux: a review. ISRN Gastroenterol, 2012. doi: 10.5402/2012/391631

NURSING INTERVENTIONS Pain management Assess pain level frequently Administer medications Risk for aspiration Monitor respiratory rate, depth, and effort When eating look for signs of aspiration including coughing, choking, and spitting food (Ackley, 2010) Ackley, B. J., Ladwig, G. B. (2011). Nursing diagnosis handbook. St. Louis, MO: Mosby Elsevier

PATIENT TEACHING For patients that are obese encourage weight loss. Avoid alcohol, chocolate, citrus juice, tomato-based products, peppermint, coffee, and onion. Smaller sized meals more frequently throughout the day. (Nowkediuko, 2012) Nowkediuko, S. C., (2012, July 11). Current trends in the management of gastroesophageal reflux: a review. ISRN Gastroenterol, 2012. doi: 10.5402/2012/391631

PATIENT SCENARIO- HPI The patient is a 58 year-old white female who complains of gastroesophegeal reflux. She states that the esophageal reflux began approximately 10 years ago and had nissen fundoplication surgery to fix the problem. Esophageal reflux pain began again 8 months ago in the stomach, esophagus, and back. Patient reports pain as constant, burning, and an 8/10 on 0/10 scale. Tried 4-5 different medications, none made her symptoms better. Symptoms worsened after eating.

PATIENT MEDICATIONS Lovenox Insulin Dilaudid Phenol topical (chloraseptic spray) Patient was not taking any acid suppressive therapy medication or antacids to relieve symptoms http://www.adultmeducation.com/images/Overview.jpg Lovenox is prevention of DVT- blood thinner

LABS AFTER SURGERY Glucose 155 (higher than normal range) After surgery glucagon can be released from the pancreas with decreased production of insulin HGB 10.8, HCT 34.0 (lower than normal range) Hemoglobin and hematocrit values are commonly low after surgery WBC 7.4, PLT 217 (within normal range) Indicates no infection

PATIENT SCENARIO- INTERVENTIONS Medical Transoral incisionless fundoplication Nursing Pain control with medication Increasing comfort of patient by adjusting bed to comfortable position

NURSING DIAGNOSIS Pain r/t recent surgery a.e.b patient complaints of pain 5/10 and grimacing Impaired swallowing r/t pain from recent surgery a.e.b grimacing while swallowing Risk for imbalanced nutrition r/t difficulty swallowing and lack of desire to eat

NCLEX QUESTIONS 1 Gastroesophageal reflux disease (GERD) weakens the lower esophageal sphincter, predisposing older persons to risk for impaired swallowing. In managing the symptoms associated with GERD, the nurse should assign the highest priority to which of the following interventions?  A. Decrease daily intake of vegetables and water, and ambulate frequently B. .Drink coffee diluted with milk at each meal, and remain in an upright position for 30 minutes. C. Eat small, frequent meals, and remain in an upright position for at least 30 minutes after eating. D. Avoid over-the-counter drugs that have antacids in them. Tabloski, P. B. (2010). NCLEX review questions. Retrieved from http:// wps.prenhall.com/chet_tabloski_gerontolog_1/40/10305/2638168.cw/ content/index.html C

NCLEX QUESTION 2 Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophgeal reflux disease (GERD)?
A.    Lettuce
B.    Eggs
C.    Chocolate
D.    Butterscotch Basic care and comfort nclex practice test. (2010, July 22). Retrieved from http://nclexreviewers.com/nclex-sample-questions/basic-care-and- comfort/basic-care-and-comfort-nclex-practice-test.html C

NCLEX QUESTION 3 The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions? A. Development of laryngeal cancer B. Irritation of the esophagus C.Esophageal scar tissue formation D. Aspiration of gastric contents Student nursing study blog [Web log message] . (2010). Retrieved from http:// amy47.com/nclex-style-practice-questions/gastro/gastro-3/ 17.  D. Clients with GERD can develop pulmonary symptoms such as coughing, wheezing, and dyspnea that are caused by the aspiration of gastric contents. GERD does not predispose the client to the development of laryngeal cancer. Irritation of the esophagus and esophageal scar tissue formation can develop as a result of GERD. However, GERD is more likely to cause painful and difficult swallowing.

NCLEX QUESTION 4 The surgical procedure of choice for older patients with GERD and Barrett's esophagus that is not reversible with medical management is: Esophagectomy. Nissen’s fundoplication Tota laryngectomy. Labyrinthectomy. Tabloski, P. B. (2010). NCLEX review questions. Retrieved from http:// wps.prenhall.com/chet_tabloski_gerontolog_1/40/10305/2638168.cw/ content/index.html B

NCLEX QUESTION 5 The RN has finished teaching a patient about treatment of GERD. The RN knows the patient has understood the teaching if she states:
A.    “I should eat a small bedtime snack each night.”
B.    “I should lie flat in bed.”
C.    “I can have red wine with dinner.”
D.    “I should eat six small meals daily.” Physiological adaptation nclex RN practice test. (2010, August 23). Retrieved from http://nclexreviewers.com/nclex-sample-questions/physiological- adaptation/physiological-adaptation-nclex-rn-practice-test.html D

REFERENCES Ackley, B. J., Ladwig, G. B. (2011). Nursing diagnosis handbook. St. Louis, MO: Mosby Elsevier Basic care and comfort nclex practice test. (2010, July 22). Retrieved from http://nclexreviewers.com/nclex-sample-questions/basic-care-and- comfort/basic-care-and-comfort-nclex-practice-test.html Nowkediuko, S. C., (2012, July 11). Current trends in the management of gastroesophageal reflux: a review. ISRN Gastroenterol, 2012. doi: 10.5402/2012/391631 Peery, A.F., & Dellon, E. S. (2012, November). Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology, 143(5): 1179-1187. doi: 10.1053/j.gastro.2012.08.002. Physiological adaptation nclex RN practice test. (2010, August 23). Retrieved from http://nclexreviewers.com/nclex-sample-questions/physiological- adaptation/physiological-adaptation-nclex-rn-practice-test.html Student nursing study blog [Web log message] . (2010). Retrieved from http:// amy47.com/nclex-style-practice-questions/gastro/gastro-3/ Tabloski, P. B. (2010). NCLEX review questions. Retrieved from http:// wps.prenhall.com/chet_tabloski_gerontolog_1/40/10305/2638168.cw/ content/index.html