As healing occurs, the cells that replace the normal squamous cell epithelium may be more resistant to reflux but may also be a premalignant tissue that can lead to adenocarcinoma. Repeated exposure may also lead to fibrosis and scarring, which can cause esophageal stricture to occur. Stricture leads to difficulty in swallowing. Chronic reflux is often associated with hiatus hernia.
Barrett esophagus is a condition thought to be caused by the chronic reflux of gastric acid into the esophagus. It occurs when squamous epithelium of the esophagus is replaced by intestinal columnar epithelium, a situation that may lead to adenocarcinoma. Barrett esophagus is present in approximately 10% to 15% of patients with GERD.
The causes of GERD are not well understood. Many patients with GERD have normal resting LES pressure and produce normal amounts of gastric acid. Possible explanations for GERD include delays in gastric emptying, changes in LES control with aging, and obesity. Environmental and physical factors that lower tone and contractility of the LES include diet (fatty foods, peppermint, alcohol, caffeine, chocolate) and drugs (nicotine, beta-adrenergic blockers, nitrates, theophylline, anticholinergic drugs).
Nursing care plan assessment and physical examination
Elicit a history of contributing factors, including the regular consumption of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, or peppermint. Take a drug history to determine if the patient has been taking drugs that may contribute to GERD: beta-adrenergic blockers, calcium channel blockers, nitrates, theophylline, diazepam, anticholinergic drugs, estrogen, and progesterone.
Little relationship appears to occur between the severity of symptoms and the degree of esophagitis. Some patients have minimal evidence of esophagitis, whereas others with severe, chronic inflammation may have no symptoms until stricture occurs. Patients may describe the characteristic symptom of heartburn (also known as pyrosis or dyspepsia). The discomfort is often a subor retrosternal pain that radiates upward to the neck, jaw, or back. Patients describe a worsening pain when they bend over, strain, or lie flat. With severe inflammation, discomfort occurs after each meal and lasts for up to 2 hours. Patients may describe coughing, hoarseness, or wheezing at night. Patients may also report regurgitation, with a sensation of warm fluid traveling upward to the throat and leaving a bitter, sour taste in the mouth. Other symptoms may include difficulty swallowing (dysphagia) and painful swallowing (odynophagia) during eating, as well as eructation, flatulence, or bloating after eating.
Generally, the patient’s physical appearance is unchanged by GERD. On rare occasions, some patients may experience unexplained weight loss.
Psychosocial assessment should include assessment of the degree of stress the person experiences and the strategies she or he uses to cope with stress.
Nursing care plan primary nursing diagnosis: Pain related to esophageal reflux and esophageal inflammation.
Nursing care plan intervention and treatment plan
Although diet therapy alone can manage symptoms in some patients, most patients can have their GERD managed pharmacologically. Dietary modifications that may decrease symptoms include reducing intake of fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, and peppermint. Reducing the intake of spicy and acidic foods lets esophageal healing occur during times of acute inflammation. Encourage the patient to eat five to six small meals during the day rather than large meals. Ingestion of large amounts of food increases gastric pressure and thereby increases esophageal reflux. Both weight loss and smoking cessation programs are also important for any patients who have problems with obesity and tobacco use.
Surgical procedures to relieve reflux are generally reserved for those otherwise healthy patients who have not responded to medications. Three major surgical procedures are used: Nissen fundoplication (surgeon wraps fundus of the stomach around esophagus to anchor the LES area below the diaphragm), Hill’s repair (anchors gastroesophageal junction to the median arcuate ligament), and Belsey’s repair (transthoracic approach with a fundic wrap around the distal esophagus).
Many patients experience nighttime reflux because of the recumbent position and infrequent swallowing. Changing the patient’s position by elevating the head of the bed during sleep may mitigate symptoms. Place 6-inch blocks under the head of the bed or place a wedge under the mattress to enhance nocturnal acid clearance. Encourage the patient to avoid food for 3 hours before going to sleep, and advise the patient to eat slowly and chew food thoroughly.
Lifestyle changes to reduce intra-abdominal pressure may be helpful to relieve symptoms. Encourage the patient to avoid the following: restrictive clothing, lifting heavy objects, straining, working in a bent-over position, and stooping. Support the patient’s efforts to stop smoking and lose weight. Make appropriate referrals to the dietician to provide the knowledge essential for weight control.
Nursing care plan discharge and home health care guidelines
Teach the patient how to maintain adequate nutrition and hydration and to manage medications. Make sure that the patient and family understand all aspects of the treatment regimen. Review dietary limitations, recommendations to reduce weight and cut out tobacco, and dosage and side effects of all medications. Make sure the patient understands the need to change position at nighttime and that he or she has the supplies required to do so.