Nursing Diagnoses

Nursing diagnoses differ from medical diagnoses. Simply put by NANDA (North American Nursing Diagnosis Association); "A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes." (1)

Nursing diagnoses are statements explaining the problem with relation to the source and if patient interaction has taken place, the addition of evidence (signs/symptoms) to support is preferred. For example, a person medically diagnosed with asthma could have a nursing diagnosis of ineffective airway clearance related to bronchial constriction, as evidenced by increased mucus and wheezing. Many medical diagnoses are one word pathologies. Nursing diagnoses are statements which include more depth, making the problem individualized to each patient. 

1. Altered comfort; dyspepsia related to reflux of gastric content
2. Risk for GI bleed related to ulcerated esophagus
3. Risk for cancer related to cell transformation due to recurrent tissue trauma.
4. Risk for nutrition deficit related to pain when eating.
5. Ineffective health maintenance related to deficient knowledge regarding self-care with disease.

Altered comfort; dyspepsia related to reflux of gastric content: 

Actual or potential goals	Related to	Plan and outcome	Nursing intervention
·         Patient will verbalize a desire to quit smoking and limit alcohol intake ·        Patient will eliminate high fatty foods ·         Patient will adhere to medication regimen	·       Alcohol intake ·      Fatty foods ·       Smoking	·         Feelings of indigestion will become rare  ·        Lifestyle changes will reverse symptoms and lessen the need for medications	·         Keep HOB elevated 2-3 hours after meals ·         Provide small frequent meals rather than large ones ·         Administer antacid and PPI/H2 blockers as ordered

(2)

References:

1.     (2015, March 1). Retrieved February 26, 2015, from http://kb.nanda.org/article/AA-

              00266/0/What-is-the-difference-between-a-medical-diagnosis-and-a-nursing-diagnosis-.html

2.     Elsevier (2012). Retrieved May 22, 2015. from 

             http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=326

Nursing Care for GERD

Elsevier provides the following nursing role in regards to the nursing diagnosis of altered comfort: dyspepsia (indigestion/heartburn). These cover the importance of assessment and identification, patient teaching, and treatment.

1. Assess client for signs and symptoms of dyspepsia (e.g. reports of epigastric discomfort, heartburn, nausea, or feeling of fullness or bloating; frequent eructation).
2. Determine if particular foods/fluids contribute to dyspepsia.
3. Implement measures to reduce dyspepsia:
1. perform actions to reduce gastroesophageal reflux:
1. keep head of bed elevated for 2-3 hours after meals
2. provide small, frequent meals rather than large ones
2. perform actions to restore fluid balance (see Diagnosis 2) in order to promote the resolution of ascites and subsequently reduce abdominal pressure and the associated gastroesophageal reflux and feeling of fullness and bloating
3. instruct client to ingest foods and fluids slowly
4. encourage client not to smoke
5. encourage client to avoid the following foods/fluids:
1. those high in fat (e.g. fried foods, gravies, butter, cream, ice cream)
2. carbonated beverages
3. gas-producing foods (e.g. beans, onions, cabbage)
4. those that may cause gastric irritation (e.g. spicy foods; caffeine-containing beverages such as coffee, tea, and colas; alcohol)
6. administer the following medications if ordered:
1. antacids, histamine₂ receptor antagonists (e.g. famotidine, nizatidine, ranitidine), or proton-pump inhibitors (e.g. omeprazole, lansoprazole, rabeprazole) to reduce acidity of gastric contents and subsequently also reduce esophageal irritation if reflux occurs
2. cytoprotective agents (e.g. sucralfate, misoprostol) to protect the gastric mucosa
3. antiflatulents (e.g. simethicone)
4. antiemetics (phenothiazines should be used cautiously).
4. Consult appropriate health care provider (e.g. clinical nurse specialist, physician) if above measures fail to control dyspepsia.

References:

1.      Elsevier http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=326

Treatment

Determining which treatment options to pursue depends upon the severity of the disease.

Lifestyle changes are always encouraged and should be implemented no matter the severity to help prevent disease progression and alleviate symptoms. Some of these include losing weight if indicated, limit use of NSAIDs (ibuprofen, aspirin, etc…as these are harmful to the GI tract), limit alcohol intake, and eat small portions throughout the day rather than a few large meals.  

Medications are commonly used to treat the symptoms of heart burn. Unfortunately these do not cure the disease, but rather make it more comfortable to live with. The most popular and accessible of these are antacids, such as Tums. Antacids provide short term relief after meals. The two classes of drugs which are most commonly prescribed for long term treatment are proton pump inhibitors (PPIs) and Histamine-2 receptor blockers (H2 blockers). These both work to limit the amount of acid present in the stomach. Each function in a different location within the acid production pathway in the body, but the goal is to reduce the amount produced and secreted into the stomach.  Common side effects of these drugs are diarrhea or constipation, nausea, and headaches.

If the disease has become severe and lifestyle changes are not sufficient, anti-reflux surgery may be an option. The procedure is called fundoplication. If a hiatal hernia is present, the surgeon will resolve this issue by moving the bulging stomach portion back into place and stitching the hiatus (opening in the diaphragm muscle) to make the opening smaller in hopes to prevent the recurrence of a hernia. Part two involves stitching the upper portion of the stomach to the bottom of the esophagus. This technique places pressure on the esophagus in a way that prevents the reflux of contents.

References:

1. Gastroesophageal Reflux Disease. (2015, April 9). Retrieved May 6 , 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000265.htm

Signs and Symptoms

Many of us have experienced heart burn, that burning feeling in your chest after a certain meal is a common symptom which becomes chronic with individuals suffering from GERD. The severity/frequency of the symptoms depend on the severity of the disease. Other symptoms may include difficulty swallowing, sore throat, regurgitation of food or liquid (that horrible feeling when you throw up in your mouth). Symptoms are the sensations which the person feels, while signs are what can be observed. GERD may be visualized through some of the procedures mentioned in last weeks post, like endoscopy for example. The esophagus may present with abnormal redness, or ulceration. In severe cases, Barrett's esophagus can occur, which is when the tissue cells in the throat change and resemble the cells in the intestine. When cells mutate like this the incidence of cancer increases. 

References: 

May Clinic. http://www.mayoclinic.org/diseases-conditions/heartburn/basics/definition/con-     20019545

https://www.youtube.com/watch?v=aLc4PBdBu0A

Diagnostics

How is GERD diagnosed? There are multiple methods used to determine whether a person has GERD or not. If symptoms become worse/frequent enough, and a person seeks medical attention to figure out what is going on, the provider will likely choose one or multiple of the following exams.

pH testing can be done with a catheter placed through the nose and into the catheter. This is typically left in place for 24 hours and records the pH into a portable computer device which would be kept on the person for the examination period. As we know stomach pH is more acidic than the pH in our esophagus, this can provide information about the presence of acid in the esophagus and how often it is refluxing.

X-rays are another way of obtaining a visual of the anatomy in the digestive tract. This is usually done with a liquid substance (barium) which the patient drinks before the x-ray. The barium coats the GI tract and creates a more distinct visual when the x-ray is performed. This will provide anatomical information and could help determine if the GERD is being caused by a hiatal hernia, for example.

Another common exam is an endoscopy, this is when the doctor views the inside of the esophagus and stomach with a camera attached to a small tube. The tube is inserted into the throat and down the esophagus to search for any abnormal/inflamed tissue and/or problems with the sphincter. If problem areas are identified, this procedure allows for an opportunity to take a biopsy (extraction of a small portion of tissue) to test for disease.

Based on the results from these exams the provider can make a more accurate diagnosis and determine the best treatment option.


A brief overview of what an endoscopy procedure looks like:

What causes GERD?

Etiology is the term used for causes of a disease process. We know that GERD results from gastric reflux into the esophagus, but there are several ways this can occur.

The esophageal sphincter, a ring like muscle, which normally prevents back-flow of content from the stomach may be defective. When this is unable to adequately seal the opening, the esophagus is at risk for being exposed to acid.

Hiatal hernias can also cause GERD. This is when a portion of the stomach slips up through the diaphragm (a large muscle separating the chest and abdominal cavities). The stomach is then overwhelming the esophagus and exposes the area to gastric content.

 Pregnancy can cause GERD as well. If we simply consider the changes in anatomy during pregnancy it is easy to understand why this would occur. As the fetus grows and the woman's belly enlarges, the abdomen and chest are being squished and may place pressure on the stomach, causing acid reflux.

Other causes may include a variety of medications, obesity, alcohol, and smoking.

GERD is the progressed form of frequent heart burn. So if a person has GERD it's a chronic problem that can lead to further, more serious problems. If not controlled well, GERD can cause ulcers in the esophagus, if these are bad enough they may increase the risk of esophageal cancers. With the presence of ulcers and tissue trauma comes the risk of infection as well.








References:

1. Gastroesophageal Reflux Disease. (2015, April 9). Retrieved April 16, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000265.htm

Who is effected? Where is it common?

Epidemiology is a branch of medical science which focuses on the populations and regions effected by specific diseases. We will look into the epidemiology of GERD. There are two important terms to understand when identifying epidemiological data; prevalence and incidence. Prevalence is the proportion of a given population which are positive for the condition, in this case GERD. It may be helpful to think of this as a fraction or percentage. Incidence is the number of newly identified occurrences in a given time period. If 100 people were being evaluated for GERD over a two year period and 25 of them were positive for GERD at the end of two years, the incidence would be 25%.

In the US, the prevalence of GERD is 10-20% of the population. Although all ages and races are at risk, the greatest concentration of GERD occurs in the age range of 50-70 year olds. This will likely increase the prevalence of GERD as this age range is the fastest growing and life expectancy continues to prolong (1). East Asia holds the lowest rate of prevalence (2.5-7.8%), with all other nations falling in the range of approximately 10-30%. (2)

It is difficult to capture an accurate prevalence of GERD, as this disease is often self-treated by patients with over the counter medication, unless it progresses to a level requiring medical attention. In comparison to heart attacks or cancer, which are more frequently reported as they require emergent medical attention or the inability to self-treat is obvious.




References:

1. Gastroesophageal Reflex Disease (GERD). Upper GI and General Surgery. Retrieved from http://www.surgery.usc.edu/uppergi-general/gastroesophagealrefluxdisease-epidemiologypathophysiology.html

2. El-Seraq HB., & Sweet S., & Winchester CC., & Dent J. (June 13, 2013). Update on the epidemiology of gastro-esophageal reflux disease: a systemic review. PubMed. Retreived from http://www.ncbi.nlm.nih.gov/pubmed/23853213