The patient is a 54-year-old male who presents with heartburn occurring up to 4 times daily as well as indigestion and pain on swallowing. Diagnostic tests revealed gastroesophageal reflux disease (GERD) and damage to the esophageal mucosa. His symptoms are likely due to an incompetent lower esophageal sphincter exacerbated by obesity. Treatment involves lifestyle modifications, medication, and potentially surgery if conservative measures fail. Nursing care focuses on pain management, dietary changes, weight loss, and patient education about GERD management.

1. Gastroesophageal reflux
disease
*Prepared by : ola saryrah .
Supervised by :Dr. Nuha Zayadee
suhimat

2. At the end of this case, my Classmates will
be able to:
• Understand GERD +pathophysiology of the disease .
• Determine the clinical manifestation and complication of
GERD .
• How to manage GERD (conservative therapy and surgical
therapy).

3. Demographic data:
Client
initials:
Age: Gender: Marital
status:
Number of
cheldren:
S 54 male married 3boys.
2girls.

4. • *Chief complaint :
He told me “heartburn” up to 4 times daily. Other
symptoms reported by the patient were indigestion and pain
on swallowing . (He has intermittent chest pain with substernal
burning which radiates to his mid-back).He describes this pain
as stabbing.
• *Onest :before 6 months.
• *Duration : until now.
• *medical diagnosis: gastroesophageal reflux disease.

5. Client health history:
• The patient states that the symptoms occur after he has eaten a large meal and in
the middle of the night, which often wakes him from his sleep. He awakens with
shortness of breath, coughing, and a bitter taste in his mouth. His complaints
“heartburn” up to 4 times daily. Other symptoms reported by the patient were
indigestion and pain on swallowing.
• Past Medical History: hypertension for 10 years and type 2 diabetes for 15 years.
• Past Surgical History: Cholecystectomy since 8 years ago .
• He is smoker.
Health family:
Family Medical History: father type 2 diabetes,
mother hypertension.

6. VS Results Normal range
Temperature 98.3 F° (normal) (96.8_100.4 )F°
Pulse 98 Beatsmin (normal) (60_100) beatsmin
Blood pressure 14095 mmHg (HTN Stage 1) (120_13080_85) mmHg
Respiratory rate 20 breath/mint (normal) (18_22) breathsmin
Physical examination
• 1. *Pulse oximetry 93% ( Normal SpO2 values are 95% to 100%)
• 2. Lungs: clear to auscultation
• 3. Heart: Rate and rhythm regular, no murmurs
• 4. Abdomen : soft ( Normal abdomen is described as soft abdomen).
• 5. weight: 90 Kg
Height:165cm *BMI=37.5(Obesity)
Vital signs :
Diagnostic tests:
Endoscopy showed damage to the esophageal mucosa as a result of exposure to bile.

7. Signs and symtoms:
Signs(objective data): Symptoms(subjective data):
shortness of breath, intermittent chest pain.
BP 140/95 mmHg. Pyrosis (substernal burning which radiates to his
mid-back).
coughing indigestion and pain on swallowing.
a bitter taste in his mouth
Lab Results:
Test Results Normal range:
Hemoglobin: 11 gm/dl (low ,anemia) (13.6_17.5)gmdl
Glucose (fasting) 100 mg/dl (normal) (65_110)mgdl
HbA1c 8 (high / uncontrolled DM ) less than 6%
Creatinine 0.6 mg/dl (normal) (0.6-1.2)mgdl
Blood urea nitrogen 40 mg/dl (high) 7 to 20 mgdl
Sodium 140 mg/dl (normal) (135_145)mgdl
Potassium 4.5mg/dl(normal ) (3.5_5) mgdl
Total cholesterol 240 mg/dl (high
,, hyperlipidemia)
<200 mgdl

8. • gastroesophageal reflux (backflow of gastric or duodenal
contents into the esophagus) is normal in both adults
and children.
• Excessive reflux may occur because of an incompetent
lower esophageal sphincter, pyloric stenosis, or a
motility disorder.
• The incidence of GERD seems to increase with aging.
• Acidic gastric secretions cause irritation and
inflammation (esophagitis).
• Degree of inflammation depends on amount and
composition of gastric reflux and on esophagus’s
mucosal defense mechanisms.
GERD

9. Etiology and Pathophysiology
*No single cause.
*Predisposing factors:
• Hiatal hernia
• Incompetent lower esophageal sphincter
• Decreased gastric emptying (motility disorder)
• pyloric stenosis.
*risk factors :
• Obesity
• Pregnancy
• Cigarette smoking
• Incidence increase with aging

10. Clinical Manifestations:
* Vary from person to person.
• Pyrosis (burning sensation in esophagus)
• Heartburn (occurs after ingestion of food or drugs )
• Dyspepsia (indigestion) : pain or discomfort centered in upper abdomen
• Regurgitation: described as hot, bitter, or sour liquid coming into throat
or mouth
• dysphagia or odynophagia (pain on swallowing)
• Hypersalivation
• Esophagitis
• symptoms may mimic those of heart attack(Non-cardiac chest pain)

11. Complications:
• Esophagitis
• Esophageal stricture (scar tissue) due to repeated exposure
• Respiratory problems ( Due to irritation of upper airway by secretions).
Potential for asthma, bronchitis, pneumonia
• Dental erosion
Diagnostic Studies:
*Barium swallow
• Endoscopy
• Biopsy and cytologic specimens.

12. GERD Management
1.Lifestyle modifications (Avoid triggers).
2. Nutritional therapy (eat a low-fat diet; to avoid caffeine, tobacco, beer, milk,
foods containing peppermint or spearmint, and carbonated beverages; to avoid
eating or drinking 2 hours before bedtime; to maintain normal body weight; to avoid
tight-fitting clothes)
• Maintain normal body weight
• Weight reduction
• Elevate upper body on pillows

13. Cont of GERD Management:
Amaryl (glimepiride)
- Dose : 1 tab
- Frequency :3 times daily .
- Classification :second generation sulfonylureas .
- Indication :Type 2 diabetes .
- Side effects : dizziness , hypoglycemia , headache , nausea ,asthenia .
- Nurse alert : with breakfast or the first main meal of the day .Take the tablet with a full glass of
water.Your blood sugar will need to be checked often.
famotidine
Dose : 40mg
- Frequency :1 tab twice day.
- Classification :Histamine (H2)- receptor blockers .
- Indication :GERD , PUD, dyspepsia
- Side effects : can cause hypotension . diarrhea , headache , dizziness ,muscle pain. .
- Nurse alert :be aware of hypersensitivity to the drug components

14. Concor:
Dose : 5 mg
- Frequency :1 tab daily .
- Classification : beta –adrenoceptor blocking drugs .
- Indication :hypertension .
- Side effects : nausea ,diarrhea , bronchospasm , hypotension .
- Nurse alert : it is not given to pt with a heart attack and be aware of
hypersensitivity to the drug components .
Angiotic :
Dose : 10 mg .
- Frequency : 1 tab daily .
- Classification : Angiotensin-converting enzyme (ACE) inhibitor
- Indication : HTN , congestive heart .
- Side effect :headache , hypotension ,rash ,dizziness.
- Nurse alert :be aware of hypersensitivity to the drug components ,It should not
be used by patients with angioedema

15. Motillium:
Dose : 10 mg .
- Frequency : 1 tab twice daily .
- Classification : prokinetic agent
- Indication : Antiemetic activity and It is also used to encourage lactation
- Side effect :It leads to the development of heart rhythm disturbances
- Nurse alert : be aware of hypersensitivity to the drug components
Clopram :
Dose : 10 mg .
- Frequency : 1 tab twice daily .
- Classification :Antiemetics
- Indication : Antiemetic activity and GERD and Emptying the stomach of its
contents to prepare for surgery.
- Side effect :fatigue
- Nurse alert : be aware of hypersensitivity to the drug components

16. Novagel:
- Frequency : 3 tab times daily .
- Classification :Aluminium Hydroxide
- Indication : It helps in relieving the symptoms of acidity and ulcers such
as nausea, stomach pain or irritation. It also neutralizes excessive acid
in the stomach and helps in easy passage of gas.
- Side effect :he most common side effects are chalky taste, dryness in
mouth, diarrhea, and constipation.
- Nurse alert : is taken without food in a dose and duration as advised by
the doctor.The dose you are given will depend on your condition and how
you respond to the medicine .

17. • If Conservative and medical therapy fails
• Hiatal hernia present
• Esophageal stricture and stenosis
• Chronic esophagitis
• Bleeding.
*we resort to surgical therapy :
Reduce reflux of gastric contents by enhancing integrity of LES
Nissen fundoplication (wrapping of portion of gastric fundus around sphincter area of
esophagus).

18. Nursing process .
NANDA NOC NIC evaluation
Acute pain (chest)
RT back flow of
gastric
contents AMB regurg
itation of acid .
-Acute pain (on
swallowing) RT back
flow
of gastric contents A
MB dysphagia.
-The pt will get
rid of
regurgitation
causing chest
pain.
- Carefully assess
pain location.
- avoid
situations that
decrease lower
esophageal
sphincter pressure
or cause
esophageal
irritation.
Achived (pt got
rid of the pain).

19. Imbalanced Nutrition:
MoreThan Body
Requirements RT
obesity AMB body
weight more ideal
weight
-The patient
will lose
weight to the
required
weight
-The patient
is instructed to
eat a low-fat diet .
-Identify amount
of weight loss
needed for
optimal body size
.
-Consult with
dietician for meal
planning and
food preparation.
Not yet
completed.
Deficient knowledge
RT obesity
AMB body weight more
ideal weight

20. Patient education:
• Management begins with teaching the patient to avoid
situations that decrease lower esophageal sphincter pressure
or cause esophageal irritation.The patient is instructed to eat
a low-fat diet; to avoid caffeine, tobacco, beer, milk, foods
containing peppermint or spearmint, and carbonated
beverages; to avoid eating or drinking 2 hours before bedtime;
to maintain normal body weight; to avoid tight-fitting
clothes; to elevate the head of the bed on 6- to 8-inch (15- to
20-cm) blocks; and to elevate the upper body on pillows.