Gastro-esophageal reflux disease

 GERD, is a common condition characterized by prolonged reflux of hydrochloric acid, pepsin, and bile salts in esophagus, oral cavity, or respiratory system leading to esophagitis.  Causes are related to the weakness or inappropriate prolonged / frequent transient relaxation of the LES, or delayed gastric emptying.  The chief symptom of GERD is frequent and prolonged retrosternal heartburn (dyspepsia) and regurgitation (acid reflux) in relationship to eating or activities. Key points

 Other symptoms can include:  chronic cough,  dysphagia,  belching (eructation),  flatulence (gas),  atypical chest pain, and  asthma exacerbations  If untreated; GERD leads to inflammation, breakdown, and long-term complications. diet and lifestyle changes  The primary treatment of GERD is diet and lifestyle changes, advancing into medication use (antacids, H2 antagonists, and proton pump inhibitors). Key points

 Any factor that relaxes the LES (smoking, caffeine, alcohol, or drugs).  Any factor that increases the abdominal pressure (obesity, tight clothing at the waist, ascites, or pregnancy.  Older age and/or a debilitating condition that weakens the LES tone.  Contributing factors  Diet: Excessive ingestion of foods that relax the LES include:  Fatty and fried foods.  Chocolate.  Caffeinated beverages such as coffee.  Peppermint.  Spicy foods.  Tomatoes.  Citrus fruits.  Alcohol. Etilogy

 Distended abdomen from overeating or delayed emptying  Increased abdominal pressure (obesity, pregnancy, bending at the waist, ascites or tight clothing at the waist)  Drugs that relax the LES, such as theophylline, nitrates, calcium channel blockers, anticholinergics, and diazepam (Valium)  Drugs, such as NSAIDs, or events (stress) that increase gastric acid  Debilitation or age-related conditions resulting in weakened LES tone  Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance)  Lying flat Etiology

 History: Symptoms 4 to 5 times per week on a consistent basis  Improvement after a 6-week course of proton pump inhibitors (PPI)  Diagnostic interventions taken to differentiate GERD from gastritis and from gastric/peptic ulcer (ulceration of gastric mucosa)  Barium meal: pre & post Nsg responsibilities  Endoscopy is used while the client is under conscious sedation to observe for tissue damage (Nsg responsibilities).  Esophageal manometry is used to measure muscle tone of LES and pH monitoring. Diagnostic Procedures and Nursing Interventions

 Surgery (fundoplication) may be indicated for clients who fail to respond.  The surgeon wraps the fundus of the stomach around and behind the esophagus through laparoscopy to create a physical barrier.  New option: Stretta procedure uses radiofrequency energy, applied by laparoscopy, to the LES muscle. This causes the tissue to contract and tighten. Therapeutic Procedures and Nursing Interventions

 Classic symptoms:  Dyspepsia, especially after eating an offending food/ fluid, and  regurgitation.  Other symptoms: Symptoms from throat irritation (chronic cough, laryngitis), hypersalivation, eructation, flatulence, or atypical chest pain from esophageal spasm. Chronic GERD can lead to dysphagia (difficulty swallowing). Assessments

 Assess the client’s:  Dietary intake patterns, paying particular attention to foods containing caffeine and fat.  Smoking history.  Alcohol use.  Weight. Assessments

 Acute pain  Deficient knowledge NANDA Nursing Diagnoses

 Educate the client regarding:  Diet  Avoid offending foods.  Avoid large meals.  Remain upright after eating.  Lifestyle  Avoid tight-fitting clothing around the middle.  Lose weight, if applicable.  Elevate the head of the bed 15.2 to 20.3 cm (6 to 8 in) with blocks. The use of pillows is not recommended, as this rounds the back, bringing the stomach contents up closer to the chest. Nursing Interventions

 Medications  Encourage consistent appropriate use of prescribed medications:  Antacids, should be administered when the acid secretion is highest (1 to 3 hr after eating and at bedtime).  Antacids should be separated from other medications by at least 1 hr.  Histamine2 receptor antagonists (ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), and cimetidine (Tagamet), reduce the secretion of acid. The onset is longer than antacids, but the effect has a longer duration.  Proton pump inhibitors (PPI), omeprazole (Prilosec) reduce gastric acid by inhibiting the cellular pump necessary to secrete it. Studies show that PPI are more effective than H2 antagonists.  Medications such as metoclopramide hydrochloride (Reglan), increase the motility of the esophagus and stomach.  Prokinetic; promote gastric emptying Nursing Interventions

 Pain Management  N&V management  Nutritional needs management  Assess for bleeding Nursing Interventions

 Risks associated with aspiration include:  Asthma exacerbations from inhaled aerosolized acid.  Frequent upper respiratory, sinus, or ear infections.  Aspiration pneumonia.  Formation of esophageal strictures (scarring).  Erosive esophagitis, ulceration, and hemorrhage.  Barrett’s epithelium (premalignant) and esophageal adenocarcinoma. Complications and Nursing Implications

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