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