GERD Nursing Diagnosis & Care Plan

Gastroesophageal reflux disease (GERD) is a chronic digestive condition where stomach acid frequently flows back into the esophagus, causing symptoms that affect a patient’s daily life. This nursing diagnosis guide provides comprehensive care planning for patients with GERD, including assessment strategies, interventions, and expected outcomes.

Causes (Related to)

GERD can result from various physiological and lifestyle factors that affect the lower esophageal sphincter (LES) function. Common causes include:

• Anatomical factors
  • Hiatal hernia
  • Weakened LES muscle
  • Obesity
  • Pregnancy
• Dietary factors
  • Spicy or fatty foods
  • Citrus fruits
  • Chocolate
  • Coffee and carbonated beverages
  • Large or late meals
• Lifestyle factors
  • Smoking
  • Alcohol consumption
  • Lying flat after meals
  • Tight-fitting clothes
• Medical conditions
  • Scleroderma
  • Diabetes
  • Asthma
  • Delayed gastric emptying

Signs and Symptoms (As evidenced by)

Patients with GERD typically present with various symptoms that can significantly impact their quality of life.

Subjective: (Patient reports)

• Heartburn
• Regurgitation
• Chest pain
• Difficulty swallowing (dysphagia)
• Chronic cough
• Hoarseness
• Sleep disturbances
• Anxiety about eating

Objective: (Nurse assesses)

• Dental erosion
• Bad breath
• Weight loss
• Poor nutritional intake
• Esophagitis on endoscopy
• Abnormal pH monitoring results
• Chronic throat clearing
• Voice changes

Expected Outcomes

The following outcomes indicate successful management of GERD:

• The patient will report reduced frequency and severity of reflux symptoms
• The patient will maintain adequate nutritional status
• The patient will demonstrate an understanding of lifestyle modifications
• The patient will adhere to the prescribed medication regimen
• The patient will report improved sleep quality
• The patient will show no signs of complications

Nursing Assessment

1. Obtain a comprehensive health history

Collect information about symptom onset, frequency, and severity: document triggering factors and current management strategies.

2. Assess dietary habits

Evaluate meal timing, portion sizes, and types of food consumed. Note any correlation between specific foods and symptom occurrence.

3. Monitor weight and nutritional status

Track weight changes and assess for signs of malnutrition or dehydration.

4. Evaluate medication history

Review current medications, including over-the-counter drugs, that might exacerbate GERD symptoms.

5. Assess lifestyle factors

Document smoking status, alcohol consumption, eating patterns, and sleeping positions.

6. Physical examination

Check for signs of complications such as dental erosion or throat inflammation.

7. Review diagnostic tests

Analyze results of endoscopy, pH monitoring, or other diagnostic procedures.

Nursing Interventions

1. Implement dietary modifications

• Teach the patient to avoid trigger foods
• Recommend smaller, frequent meals
• Advise against lying down for 2-3 hours after eating

2. Promote lifestyle changes

• Assist with smoking cessation
• Recommend weight loss if appropriate
• Suggest elevated head of bed
• Advise against tight clothing

3. Medication management

• Administer prescribed medications
• Teach proper timing of medications
• Monitor for side effects
• Ensure compliance with the medication regimen

4. Provide education

• Explain GERD pathophysiology
• Teach symptom management strategies
• Demonstrate proper positioning
• Review warning signs requiring medical attention

5. Monitor complications

• Assess for signs of Barrett’s esophagus
• Watch for signs of aspiration
• Monitor for esophageal strictures

Nursing Care Plans

Nursing Care Plan 1: Acute Pain

Nursing Diagnosis Statement:
Acute Pain related to esophageal irritation secondary to gastric acid reflux as evidenced by reports of burning sensation in chest and throat.

Related Factors:

• Increased gastric acid production
• Compromised LES function
• Dietary triggers
• Stress factors

Nursing Interventions and Rationales:

1. Assess pain characteristics using a standardized scale
   Rationale: Establishes baseline for monitoring intervention effectiveness
2. Administer prescribed medications as scheduled
   Rationale: Maintains therapeutic levels of acid-reducing medications
3. Teach relaxation techniques
   Rationale: Reduces stress-induced acid production
4. Position patient in semi-Fowler’s position
   Rationale: Decreases reflux by utilizing gravity

Desired Outcomes:

• The patient will report pain level ≤ 2 on a 0-10 scale within 2 hours of interventions.
• The patient will demonstrate the use of non-pharmacological pain management techniques.
• The patient will identify and avoid pain triggers

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Nursing Care Plan 2: Imbalanced Nutrition: Less than Body Requirements

Nursing Diagnosis Statement:
Imbalanced Nutrition: Less than Body Requirements related to difficulty eating secondary to GERD symptoms as evidenced by weight loss and decreased intake.

Related Factors:

• Fear of triggering symptoms
• Early satiety
• Dysphagia
• Poor appetite

Nursing Interventions and Rationales:

1. Monitor daily caloric intake
   Rationale: Ensures adequate nutritional status
2. Provide small, frequent meals
   Rationale: Prevents gastric distention and reduces reflux
3. Collaborate with dietitian
   Rationale: Develop appropriate meal plans that minimize symptoms
4. Document weight changes
   Rationale: Tracks nutritional status and intervention effectiveness

Desired Outcomes:

• The patient will maintain a stable weight
• The patient will consume adequate calories daily
• The patient will report a decreased fear of eating

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Nursing Care Plan 3: Disturbed Sleep Pattern

Nursing Diagnosis Statement:
Disturbed Sleep Pattern related to nocturnal GERD symptoms as evidenced by frequent nighttime awakenings and daytime fatigue.

Related Factors:

• Nocturnal acid reflux
• Horizontal position during sleep
• Evening meal timing
• Anxiety about symptoms

Nursing Interventions and Rationales:

1. Elevate the head of the bed 6-8 inches
   Rationale: Reduces nocturnal reflux through gravity
2. Advise against eating 2-3 hours before bedtime
   Rationale: Allows for gastric emptying before sleep
3. Implement relaxation routine
   Rationale: Promotes better sleep quality
4. Monitor sleep patterns
   Rationale: Evaluate the effectiveness of interventions

Desired Outcomes:

• The patient will report improved sleep quality
• The patient will demonstrate proper sleep positioning
• The patient will maintain an appropriate evening meal schedule

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Nursing Care Plan 4: Knowledge Deficit

Nursing Diagnosis Statement:
Knowledge Deficit related to lack of information about GERD management as evidenced by inappropriate dietary choices and poor medication compliance.

Related Factors:

• Limited previous exposure to information
• Misunderstandings about condition
• Complex management regimen
• Language or cultural barriers

Nursing Interventions and Rationales:

1. Provide structured education sessions
   Rationale: Ensures comprehensive understanding of the condition
2. Demonstrate proper medication administration
   Rationale: Promotes medication effectiveness and compliance
3. Review lifestyle modifications
   Rationale: Empowers patient in self-management
4. Assess understanding regularly
   Rationale: Identifies areas needing reinforcement

Desired Outcomes:

• The patient will verbalize understanding of GERD management
• The patient will demonstrate proper medication administration
• The patient will identify appropriate lifestyle modifications

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Nursing Care Plan 5: Anxiety

Nursing Diagnosis Statement:
Anxiety related to fear of complications secondary to GERD as evidenced by expressed concerns about cancer risk and repeated healthcare-seeking behavior.

Related Factors:

• Chronic nature of the condition
• Fear of serious complications
• Impact on daily activities
• Social implications

Nursing Interventions and Rationales:

1. Provide emotional support
   Rationale: Reduces anxiety and promotes coping
2. Teach stress management techniques
   Rationale: Helps control anxiety-induced symptoms
3. Connect with support resources
   Rationale: Provides ongoing emotional support
4. Address specific fears and concerns
   Rationale: Helps patient develop realistic expectations

Desired Outcomes:

• The patient will report decreased anxiety levels
• The patient will utilize appropriate coping mechanisms
• The patient will verbalize a realistic understanding of the prognosis

References

1. Gyawali, C. P., & Fass, R. (2023). Management of Gastroesophageal Reflux Disease. Gastroenterology, 164(4), 662-678.
2. Hunt, R., et al. (2023). World Gastroenterology Organisation Global Guidelines: GERD Global Perspective on Gastroesophageal Reflux Disease. Journal of Clinical Gastroenterology, 57(1), 1-34.
3. Kellerman, R., & Kintanar, T. (2022). Gastroesophageal Reflux Disease. Primary Care: Clinics in Office Practice, 49(1), 23-39.
4. Ness-Jensen, E., & Lagergren, J. (2023). Epidemiology and Risk Factors for GERD: Current Understanding and Implications. Nature Reviews Gastroenterology & Hepatology, 20(1), 41-53.
5. Sandhu, D. S., & Fass, R. (2023). Current Trends in the Management of Gastroesophageal Reflux Disease. Gut and Liver, 17(1), 1-15.
6. Vaezi, M. F., et al. (2023). ACG Clinical Guideline: Diagnosis and Management of Gastroesophageal Reflux Disease. American Journal of Gastroenterology, 118(1), 27-53.