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

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

3. 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
(Nowkediuko, 2012)
From article
Nowkediuko, S. C., (2012, July 11). Current trends in the management of gastroesophageal reflux: a review. ISRN Gastroenterol, doi: /2012/391631

4. 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, doi: /2012/391631

5. 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, doi: /2012/391631
Peery, A.F., & Dellon, E. S. (2012, November). Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology, 143(5): doi: /j.gastro

6. 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, doi: /2012/391631

7. 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, doi: /2012/391631

8. 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

9. 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, doi: /2012/391631

10. 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.

11. PATIENT MEDICATIONS Lovenox Insulin Dilaudid
Phenol topical (chloraseptic spray)
Patient was not taking any acid suppressive therapy medication or antacids to relieve symptoms
Lovenox is prevention of DVT- blood thinner

12. 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

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

14. 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

15. 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 wps.prenhall.com/chet_tabloski_gerontolog_1/40/10305/ cw/ content/index.html C

16. 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 comfort/basic-care-and-comfort-nclex-practice-test.html C

17. 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 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.

18. 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 wps.prenhall.com/chet_tabloski_gerontolog_1/40/10305/ cw/ content/index.html B

19. 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 adaptation/physiological-adaptation-nclex-rn-practice-test.html D

20. 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 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, doi: /2012/391631
Peery, A.F., & Dellon, E. S. (2012, November). Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology, 143(5): doi: /j.gastro
Physiological adaptation nclex RN practice test. (2010, August 23). Retrieved from adaptation/physiological-adaptation-nclex-rn-practice-test.html
Student nursing study blog [Web log message] . (2010). Retrieved from amy47.com/nclex-style-practice-questions/gastro/gastro-3/
Tabloski, P. B. (2010). NCLEX review questions. Retrieved from wps.prenhall.com/chet_tabloski_gerontolog_1/40/10305/ cw/ content/index.html