NCM 116: Care of Clients with GERD & Hiatal Hernia

NCM 116: Care of Clients with Acute and Chronic Problems

• Course focuses on nutrition, gastrointestinal, internal, metabolism, and endocrine functions.

Course Outline - Part 1: Disturbances in Ingestion

• Gastroesophageal Reflux Disease (GERD):
  • Characterized by gastric or duodenal contents flowing back into the esophagus, causing symptoms and/or esophageal damage.
  • Pathophysiology: Includes factors like impaired esophageal clearance, hiatal hernia, transient inappropriate LES relaxation, and gastric acid/pepsin secretion levels (normal or elevated).
  • Assessment: Includes laboratory and diagnostic examinations
  • Treatments: Specific to the individual case.
  • Nursing diagnosis: Focused on care related to the identified needs.
• Hiatal Hernia:
  • An opening in the diaphragm is enlarged, causing a portion of the stomach to bulge above the diaphragm.
  • Pathophysiology: Includes factors like impaired esophageal clearance and reduced resting pressure in the LES.
  • Assessment: Includes laboratory and diagnostic examinations.
  • Treatments: Specific to the individual case.
  • Nursing diagnosis: Focused on care related to the identified needs.
• Achalasia:
  • Characterized by absent or ineffective peristalsis in the distal esophagus and an inability of the esophageal sphincter to relax in response to swallowing.
  • Pathophysiology: Includes loss of nerve cells in the esophagus, inappropriate smooth muscle contraction in the distal esophagus, and incomplete LES relaxation.
  • Assessment: Includes laboratory and diagnostic examinations.
  • Treatments: Focused on care related to the identified needs.
  • Nursing diagnosis: Focused on care related to the identified needs.
• Acute Pain: Nurses need to incorporate an NCP for patients with this immediate problem.

Gastrointestinal System Introduction

• Digestive system has 6 main parts:
  • Mouth
  • Esophagus
  • Stomach
  • Small Intestine
  • Large Intestine
  • Rectum
• Accessory Organs:
  • Salivary glands
  • Liver
  • Pancreas
  • Gallbladder

GI Tract Functions

• Digests food
• Absorbs nutrients
• Propels food through the gut
• Eliminates waste products

Digestive Juices and Enzymes

• Different digestive juices and enzymes are responsible for breaking down different food substances:
  • Saliva: Starch digestion into maltose
  • Gastric Juice: Protein digestion into partially digested proteins
  • Pancreatic Juice: Protein and fats digestion into peptides, amino acids, fatty acids, and glycerol.
  • Intestinal Enzymes: Complete digestion of various substances into their basic units (e.g., sucrose into glucose and fructose).

Ingestion vs. Digestion

• Ingestion: Taking food into the body
• Digestion: Breaking down complex food molecules into simpler substances.

GERD Predisposing and Precipitating Factors

• Predisposing factors: Often long-term conditions that increase the likelihood of GERD. Examples: Obesity, Hiatal Hernia, Pregnancy, H. Pylori infection, Aging, and COPD.

• Precipitating factors: Triggers that can cause GERD symptoms or exacerbate existing symptoms. Examples: Smoking, Eating large meals or eating late, Fatty or fried foods, Alcohol and caffeinated drinks, Medications.

GERD Hallmark Signs and Symptoms

• Symptoms like Epigastric burning (worse after eating), Heartburn, Burping/Flatulence, Sour taste in the mouth (often worse in the morning), Nausea, Bloating, Cough due to reflux high in esophagus, Sore throat, Hoarseness or change in voice.

GERD Common Laboratory or Diagnostic Procedures

• Twenty-four-hour pH monitoring: measures the pH of the esophagus over 24 hours to detect acid reflux.
• Barium swallow test/upper GI study: imaging test showing how big the hiatal hernia is and if there is twisting of the stomach.
• Endoscopy (or EGD): visual examination of the esophagus using a camera to check for esophageal irritation, cellular changes associated with chronic reflux, and Barrett's esophagus.
• Esophageal Manometry: measurement of pressure in the esophagus and the lower esophageal sphincter.

GERD Non-Pharmacologic Treatment

• Low-fat diet: To reduce the production of acid.
• Avoid alcohol, milk, caffeinated, and carbonated drinks: These items can irritate the stomach.
• Avoid foods containing peppermint or spearmint: These substances can trigger reflux.
• Avoid eating or drinking 2 hours prior bedtime: To limit acid production.
• Eat six small meals rather than three large ones: This will help keep the abdomen from becoming too distended, which could irritate the sphincters.
• Stop smoking: Smoking irritates the esophagus and hinders the function of the LES
• Maintain a normal weight: Obesity increases intra-abdominal pressure
• Avoid tight-fitting clothes: Tight clothing increases intra-abdominal pressure
• Elevate the head of the bed (HOB) at least 30 degrees: Especially after eating.

GERD Pharmacologic Treatments

• Antacids: Neutralize stomach acid; includes Maalox, Mylanta, Tums, Gaviscon.
• H2 blockers: Decrease acid production; examples: Ranitidine, famotidine, nizatidine, cimetidine.
• Proton pump inhibitors (PPIs): Reduce acid production; examples: Omeprazole, esomeprazole, pantoprazole, rabeprazole, lansoprazole
• Promtility agents: Improve digestion and movement of contents through stomach; examples: metoclopramide, domperidone.

Nursing Diagnoses

• Actual Physiologic (e.g., Acute Pain, Chronic Pain, Impaired Comfort, Knowledge Deficit)
• Potential Physiologic (e.g., Risk for Imbalanced Nutrition, Risk for Aspiration)
• Actual Behavioral (e.g., Mild/Moderate Anxiety, Ineffective Coping, Impaired Mood Regulation)
• Potential Behavioral (e.g., Risk for Severe Anxiety, Risk for Powerlessness)

Assessment of Findings

• Collection of subjective and objective data, including specific symptoms of discomfort or pain
• Includes physiological parameters like blood pressure, respiratory rate and heart rate, to assess for changes in physiological health.

Nursing Care Plan for Acute Pain related to Irritated Esophageal Mucosa

• A plan of interventions developed based on nursing diagnoses, assessment findings, and evaluation criteria, tailored to the individual patient needs.

Achalasia Nursing Diagnoses for Actual and Potential Physiologic and Behavioral problems

Achalasia Pathophysiology and Predisposing/Precipitating Factors

Achalasia Treatments and Interventions

Relevant Diagnostic Procedures for Achalasia

Additional Information

• Includes other conditions, such as hiatal hernia, concerning the esophagus and/or stomach.
• There is additional education for other conditions, such as specific nursing care for situations involving specific problems or patient populations.
• Dietary recommendations for clients with acute pain from irritated esophageal mucosa.