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    GERD Charting

    Uploaded by

    Krisianne Mae Lorenzo Francisco
    John Pacual, 33, was admitted to the hospital on April 10, 2021 with gastroesophageal reflux disease (GERD). He reported severe abdominal pain and a burning sensation in his chest. On examination, he had a sore throat, cough, difficulty swallowing, abdominal pain rated 7/10, and back pain. His vital signs were stable. The nurse implemented interventions to reduce his pain, including elevating the head of his bed, advising dietary and lifestyle changes, and administering medication. After 4 hours, his pain was reduced to a rating of 3/10. One month later, he reported weight loss and difficulty eating. Examination found continued GERD symptoms and weight loss to 102 pounds.

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    GERD Charting

    Uploaded by

    Krisianne Mae Lorenzo Francisco
    301 views4 pages
    John Pacual, 33, was admitted to the hospital on April 10, 2021 with gastroesophageal reflux disease (GERD). He reported severe abdominal pain and a burning sensation in his chest. On examination, he had a sore throat, cough, difficulty swallowing, abdominal pain rated 7/10, and back pain. His vital signs were stable. The nurse implemented interventions to reduce his pain, including elevating the head of his bed, advising dietary and lifestyle changes, and administering medication. After 4 hours, his pain was reduced to a rating of 3/10. One month later, he reported weight loss and difficulty eating. Examination found continued GERD symptoms and weight loss to 102 pounds.

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    John Pacual, 33, was admitted to the hospital on April 10, 2021 with gastroesophageal reflux disease (GERD). He reported severe abdominal pain and a burning sensation in his chest. On examination, he had a sore throat, cough, difficulty swallowing, abdominal pain rated 7/10, and back pain. His vital signs were stable. The nurse implemented interventions to reduce his pain, including elevating the head of his bed, advising dietary and lifestyle changes, and administering medication. After 4 hours, his pain was reduced to a rating of 3/10. One month later, he reported weight loss and difficulty eating. Examination found continued GERD symptoms and weight loss to 102 pounds.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    301 views4 pages

    GERD Charting

    Uploaded by

    Krisianne Mae Lorenzo Francisco
    John Pacual, 33, was admitted to the hospital on April 10, 2021 with gastroesophageal reflux disease (GERD). He reported severe abdominal pain and a burning sensation in his chest. On examination, he had a sore throat, cough, difficulty swallowing, abdominal pain rated 7/10, and back pain. His vital signs were stable. The nurse implemented interventions to reduce his pain, including elevating the head of his bed, advising dietary and lifestyle changes, and administering medication. After 4 hours, his pain was reduced to a rating of 3/10. One month later, he reported weight loss and difficulty eating. Examination found continued GERD symptoms and weight loss to 102 pounds.

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    © All Rights Reserved
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    Name and Age: John Pacual, 33 yrs old

    Date and Time Admitted: April 10, 2021, 8:00 am

    Gastroesophageal Reflux Disease

    SOAPIE CHARTING
    SUBJECTIVE

    “nagigising po ako sa sobrang sakit po ng tiyan ko at mainit na pakiramdam sa dibdib


    ko.”

    OBJECTIVE
     sore throat
     cough
     dysphagia
     abdominal pain with pain scale of 7/10
     facial grimace with arms against the stomach
     Heart burn
     Regurgitation
     Mid-thoracic, bilateral back pain

    Vital signs
     BP: 132/78mmHg
     PR: 80 bpm
     RR: 18 bpm
     BT: 37.3 ⁰C

    ASSESSMENT

     Acute Pain related to irritated esophageal mucosa as evidenced by verbalization of pain,


    cough, heartburn, dysphagia, and abdominal pain.

    PLANNING

    After 4 hours of nursing intervention, the client will report relieved of pain.

    INTERVENTION

     Placed the head of the bed on 4 to 8 inches blocks to relieve heartburn sensation.
     Advised the client to avoid food or drink 2 hours before bedtime or lying down after
    eating which helps to control reflux and causes less irritation from reflux action into
    esophagus.
     Encouraged the patient to avoid activity and remain upright for 1 to 4 hours after each
    meal to prevent reflux.
     Advised the patient to avoid tight fitting clothes to enhance breathing pattern this may
    contribute in relieving pain.
     Instructed the patient to eat slowly and chew food thoroughly to promote proper digestion
    of food.
     Administered medication as prescribed by the physician.
    - Omeprazole20 mg/tab OD 
     Discussed with family members to provide patient small, frequent feedings, effect of
    irritants such as tobacco and alcohol and avoid very hot or cold foods, spices, fats, coffee,
    chocolates, and citrus juices.
     Discussed the importance of quitting from alcohol intake in the condition of the client
    and advised him to quit from drinking alcohol.

    EVALUATION

    After 4 hours of nursing intervention, the client reported decreased of pain as evidenced
    by the pain scale from 7/10 into 3/10. Goal met.
    SUBJECTIVE

    “pakiramdam ko po nangangayayat na po ako kasi hindi po ako nakakakain ng maayos


    ng isang buwan.”

    OBJECTIVE
     sore throat
     dysphagia
     Heart burn
     Abdominal pain
     Regurgitation
     increasing postprandial fullness
     early satiety
     Weight loss from 190 lbs to 102 lbs.

    Vital signs
     BP: 132/78mmHg
     PR: 80 bpm
     RR: 18 bpm
     BT: 37.3 ⁰C
     Height: 65 inches
     Weight: 102 lbs
     BMI: 16 (underweight)

    ASSESSMENT

    Imbalanced Nutrition: Less Than Body Requirements related to lack food intake due to reflux as
    evidenced by dysphagia, abdominal pain, regurgitation, weight loss, postprandial fullness and
    early satiety.

    PLANNING

    After 4 hours of nursing intervention, the client will verbalize change in eating habits to meet his
    nutritional needs.

    INTERVENTION

     Obtained a nutritional history to determine the feeding habits of the client thatcan provide
    a basis for establishing a nutritional plan.
     Weighed the patient to monitor patient’s nutritional status.
     Advised the client to avoid food or drink 2 hours before bedtime or lying down after
    eating
     Encouraged the patient to avoid activity and remain upright for 1 to 4 hours after each
    meal.
     Advised the patient to avoid tight fitting clothes.
     Instructed the patient to eat slowly and chew food thoroughly.
     Administered medication as prescribed by the physician and monitor the patient
    regularly.
    - Hydrochlorothiazide 25 mg/tab BID 
    - Omeprazole20 mg/tab OD 
     Discussed with family members to provide patient small, frequent feedings.
     Discussed with the family members the effect of irritants such as tobacco and alcohol.
     Discussed with the family members to avoid very hot or cold foods, spices, fats, coffee,
    chocolates, and citrus juices.

    EVALUATION

    After 6 hours of nursing intervention, the client verbalized change in eating habits as evidenced
    by eating small, frequent meal; eating slowly and chewing food thoroughly; and avoiding
    irritants. Goal met.

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