GERD (Gastroesophageal Reflux Disease)

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Overview

  1. Backward movement of gastric contents into esophagus

Nursing Points

General

  1. Causes
    1. Relaxed or incompetent lower esophageal sphincter
    2. Pyloric stenosis
    3. Increased gastric volume
    4. Motility disorder
  2. Diagnosis
    1. pH test of regurgitation
    2. Esophagoscopy used to rule out malignancy

Assessment

  1. Heartburn
    1. Exacerbated by bending over, straining, or recumbent position
    2. Differentiate between heartburn and cardiac chest pain
  2. Regurgitation
  3. Hypersalivation
  4. Difficulty swallowing
  5. Dyspepsia (discomfort in upper abdomen)

Therapeutic Management

  1. Avoid medications that ↓ gastric emptying (anticholinergics)
  2. Medications
    1. Antacids
      1. Calcium carbonate
    2. H2 receptor antagonists
      1. Famotidine
    3. Proton pump inhibitor
      1. Omeprazole

Nursing Concepts

  1. Comfort
    1. Elevate HOB while sleeping
    2. Do not eat within 2 hours of bedtime
  2. Nutrition
    1. Avoid food that reduce lower esophageal sphincter tone
      1. peppermint
      2. chocolate
      3. carbonated beverages
      4. smoking
      5. fried and fatty foods
    2. Eat a low fat, high fiber diet

Patient Education

  1. Adhere to dietary instructions
  2. Take medications as prescribed
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Nursing Care Plan for Gastroesophageal Reflux Disease (GERD)

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Video Transcript

In this lesson we’re going to talk about GERD, or gastroesophageal reflux disease.

Now, we really want you guys getting in the habit of using your Medical Terminology skills to try to figure out what’s going on, even in a disease process you’ve never heard of. So, let’s break this down. Gastro – think Gastric – means stomach. Esophageal refers to the esophagus, right? Reflux means when something goes backwards from where it should go. And then, of course, it’s a disease or disorder.

So, GERD, by definition, is backwards movement (that’s the “reflux” part) of gastric contents into the esophagus. Gastro. Esophageal. Reflux. Disease. So what causes this backward movement? Well remember from the anatomy of the stomach that there is a sphincter that separates the esophagus from the stomach. If this sphincter gets weakened or can’t close all the way, the gastric contents can reflux backwards into the esophagus. This can also happen if there’s increased gastric volume or if you just plain eat way too much. Other things that can cause this are pyloric stenosis and decreased gastric motility. This is the pyloric valve here…if it is stenosed, meaning it’s narrowed or tight, it’s difficult for the stomach to empty normally. And if our motility is affected, then there won’t be enough peristalsis to empty the stomach efficiently. Both of these things, again, will lead to an increased gastric volume and pressure upwards into the esophagus.

So what does this look like in a patient? Well remember that gastric contents can have a pH as low as 2 – that’s extremely acidic. The stomach has its own mucosal lining to protect it from that acidity, but the esophagus doesn’t. If this acid starts to make its way into the esophagus, the patient is going to have a good bit of discomfort. The most common symptom is what patients will call heartburn. It’s a sharp or burning pain that is midepigastric and might even radiate into the chest. Now, it’s extremely important at this point when your patient reports heartburn that you don’t forget to dig deeper in case this is actually cardiac chest pain. I actually had a patient once who thought she was just having heartburn and literally finished an entire tennis match before telling anyone she was in pain. She actually had a significant occlusion in her coronary arteries and had to have a stent placed. So, if this really is GERD, that heartburn will be accompanied by other symptoms like dyspepsia (that’s like when they say “I’m sick to my stomach”), they may have regurgitation of food or fluids. They could also have hypersalivation or excess saliva and possibly even difficulty swallowing. We’ll also see that these symptoms are all worse after eating and worse when lying down or bending over, because more of that gastric acid will creep up the esophagus just because of gravity. That typically isn’t true of cardiac chest pain, so that helps us to differentiate – that’s why those detailed pain assessments are important.

We diagnose GERD by sampling any regurgitated fluids for pH – if we see extreme acidity, we know that this is actually gastric contents coming back up. The other thing we can do is called an esophagoscopy. This is when we insert a camera through their mouth and down into their esophagus. Not only can we visualize where the sphincter should be and possible even see evidence of reflux, but we can also sample or biopsy to test for any malignancies. As far as medications, it’s important that we avoid medications that decrease gastric emptying. The most common class here would be anticholinergics. If you think about it, cholinergics are parasympathetic drugs, so they stimulate Rest & Digest, right? So if it’s Anti- or we’re blocking that, then it’s going to decrease that digestive activity. We want those gastric contents moving forward, so we’re going to avoid those if at all possible. We can also give antacids like calcium carbonate to help neutralize the acid, or we can give medications to decrease gastric acid secretion altogether. The meds we give for this are H2 receptor antagonists like famotidine (these are your -dines), and proton pump inhibitors like omeprazole (these are your -prazoles). Both of those will help decrease secretion of gastric acid, which can help decrease the symptoms of reflux.

When it comes to nursing care, our big priorities are decreasing their pain and dealing with their nutritional restrictions. We want to teach them not to eat within 2 hours of bedtime, and honestly not to lie down within an hour or two of eating. Again, this can be exacerbated by lying down, so if they eat and then lay flat, their pain will be worse. On the same lines, we can encourage them to elevate their head while sleeping, or we can do so with the hospital bed. When this gets really bad, many patients end up sleeping in a recliner or on the couch to decrease their pain and other symptoms. When it comes to nutrition, we want to encourage a low fat, high fiber diet. This does two things: it decreases the excess acid secretion needed to process fats, and it helps keep things moving forward. The last thing we need is excess acid and slower gastric emptying, right? And finally, there are actually some foods that can decrease the tone of that esophageal sphincter and therefore can make the reflux worse. It’s things like coffee, soda, tea, chocolate, peppermint, and fried or fatty foods. The other thing that can make the reflux worse is smoking, so as always, make sure you encourage smoking cessation – there is really NO situation in which we would be okay with our patients smoking.

Again, keep in mind your priority nursing concepts for a patient with GERD are comfort and nutrition. Make sure you check out the care plan attached to this lesson to see more specific nursing interventions and rationales.

So, let’s recap – GERD or gastroesophageal reflux disease is essentially acid reflux. Literally, something is causing the stomach acid to reflux into the esophagus. It usually has to do with an incompetent sphincter or an overfull stomach – that could be due to pyloric stenosis or motility issues. Think of it like a pot of boiling water, if the pot is too full or it’s boiling too hard or if the lid isn’t on tight enough, it’s going to boil over and you’re going to get burned. So, patients will present with heartburn, but we need to make sure we distinguish it from cardiac chest pain by assessing for other symptoms and whether it’s worse when eating or lying flat. We will give medications to neutralize the acid, decrease pain, and decrease stomach acid secretion altogether, while avoiding anticholinergics that can affect gastric emptying. And finally we want to encourage patients to avoid foods that can make their reflux worse and make sure they’re consuming a low fat, high fiber diet.

That’s it for GERD, it’s pretty straight forward so make sure you check out all the other resources attached to this lesson and let us know if you have any questions! Now, go out and be your best selves today. And, as always, Happy Nursing!