REMEDIOS TRINIDAD ROMUALDEZ MEMORIAL SCHOOLS

MAKATI MEDICAL CENTER

College of Nursing
Makati City

Care of a PATIENT having PAIN due to Gasto-Esophageal Reflux Disorder (GERD)

-------------A Case History Submitted to:
Prof. Gretel S. Viray RN, M.A.N
Clinical Instructor
-------------In Partial fulfillment of the Requirements in
N200 Skills Laboratory

Submitted by:
Alipon, Abiel Dominic D.
Eguia, Debbie Jane B.
Esta, Mark Louie B.
Figura, Elmer Jr. DL.
Garcia, Bianca Alexis S.
Gonzales, Justine Denise Q.
Morales, Maria Renica C.
Palomaria, Patricia Loiuse R.
Pastor, Maria Celina Therese B.
Raymundo, Nicole F.
Recana, Monella Nina Z.
BSN III-C
Group 3
Date Submitted:
May 21, 2009

TABLE OF CONTENTS
Page
CHAPTER I
Introduction . 1
Purpose and Objectives
Significance of the study
Scope and Limitation
Background of the Study
CHAPTER II
Client Presentation .. 11
Nursing Theory .. 15
Nursing Process Part I Concept Map ... 21
Assessment
Nursing Diagnosis
Planning
Nursing Process Part II Nursing Care Plan . 22
Intervention
Evaluation
BIBLIOGRAPHY
APPENDICES
Appendix A: Nursing Health History Form
Appendix B: Physical Examination Form
Appendix C: Clustering (ex. Gordons, Body System, Maslows)

CHAPTER I

INTRODUCTION

Gastroesophageal reflux disease (GERD), Gastro-oesophageal reflux disease (GORD),

Gastric reflux disease, or Acid reflux disease is defined as chronic symptoms or mucosal damage
produced by the abnormal reflux in the esophagus. GERD is caused by a weakened or immature
Lower Esophageal Sphincter (LES).
This is commonly due to transient or permanent changes in the barrier between the
esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter,
transient lower esophageal sphincter relaxation, impaired expulsion of gastric reflux from the
esophagus, or a hiatus hernia. The action of the lower esophageal sphincter (LES) is perhaps the
most important factor (mechanism) for preventing reflux. The esophagus is a muscular tube that
extends from the lower throat to the stomach. The LES is a specialized ring of muscle that
surrounds the lower-most end of the esophagus where it joins the stomach. The muscle that
makes up the LES is active most of the time. This means that it is contracting and closing off the
passage from the esophagus into the stomach. This closing of the passage prevents reflux. When
food or saliva is swallowed, the LES relaxes for a few seconds to allow the food or saliva to pass
from the esophagus into the stomach, and then it closes again.
Several different abnormalities of the LES have been found in patients with GERD. Two
of them involve the function of the LES. The first is abnormally weak contraction of the LES,

CHAPTER II
CLIENT PRESENTATION

This case is about D.E., 18 years old, a student nurse. She belongs to a family of 8 but has
been residing with her grandmother and eldest sister in South Cembo, Makati since her
childhood.
The client verbalized Masakit ang tiyan ko everytime na kumakain ako. Basta malamanan siya,
para akong nasusuka. She also stated Mga 3rd week ng April, kapag kumakain ako parang
akong nasusuka, pero nung Friday that week nagsuka ako twice. When asked about the
characteristic of the vomitus she described, Sinuka ko rin ung kinain ko, medyo matubig . Ang
natatandaan ko kanin at inihaw na baboy ang kinain ko.
Vital signs were taken as follows: Temperature: 37.3C, PR: 105bmp, 20cycles per
minute, 120/80 mmHg taken at the arm while in a sitting position, pain is moderate to severe.
The client has been diagnosed with Gastroesophageal reflux disease. Pain is felt in the
epigastric region, radiating from the stomach to the esophagus, characterized by a burning
sensation with a pain scale of 5 (moderate). The onset is sudden but the symptoms last for 30-60
minutes. The pain is recurrent and is felt after every meal. The client is positive of facial
grimace and guarding behaviour. When asked which factors aggravate the pain the client
verbalized, Kapag nagugutom ako at pag biglaang nabusog, and when asked about relieving
factors she stated, dati pahinga lang, ngayon with prescribed medications na. Associated
symptoms are nausea , vomiting, and heartburn.
The clients history of illnesses notes that she has had Rubella, Chicken Pox, Anemia,
Urinary Tract Infection, hyperacidity , astigmatism of 180 and tonsillitis. Her history also

BIBLIOGRAPHY
- Doenges et. Al. Nurse s Pocket Guide Eleventh Edition, 2006.
- Kozier et. Al. Foundations of Nursing, Eight Edition, 2005.
- Linton et. Al. Introduction to Medical- Surgical Nursing Fourth Edition, 2007, pp. 760763.
- Gulanick et. Al. Nursong Care Plans, Third Edition, 1994
- Octaviano, Thomas F. RN, RM, MN, EDD and Balita, Carl E. RN, RM MAN, DRHUM.
Theoretical Foundations of Nursing: The Philippine Perspective.
- Smeltzer et. Al. Textbook of Medical-Surgical Nursing, Ninth Edition, 2000, pp. 25-26.
- RTRMS Student Handbook, 2008-2009
- http://health.yahoo.com/gerd-overview/gastroesophageal-reflux-disease-gerd-topicoverview/healthwise--hw99179.html
- http://www.answers.com/topic/gastroesophageal-reflux-disease
- http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/page2.htm
- http://www.informaworld.com/smpp/content~content=

APPENDICES