GERD (Gastroesophageal Reflux Disease) : Nursing Care Plan

 

Nursing Care Plan – GERD (Gastroesophageal Reflux Disease)

1. Assessment Data PrompterIQ

Subjective:

  • Reports of heartburn after meals and at night
  • Complaints of regurgitation and sour/bitter taste in the mouth
  • Discomfort when lying flat

Objective:

  • Observed frequent belching
  • Possible chronic cough or hoarseness
  • Acidic odor to breath
  • Endoscopy results showing esophagitis

2. Nursing Diagnosis

Acute Pain related to irritation of esophageal mucosa secondary to reflux of gastric contents.

Imbalanced Nutrition: Less than Body Requirements related to pain and discomfort during eating.

Deficient Knowledge related to lack of information about disease process and self-care measures.

3. Goals / Expected Outcomes

Short-term:

  • Patient will verbalize relief of heartburn within 48 hours.
  • Patient will identify dietary and lifestyle modifications to reduce reflux.

Long-term:

  • Patient will maintain nutritional status without weight loss.
  • Patient will demonstrate adherence to prescribed treatment and preventive measures.

4. Nursing Interventions & Rationale  Digital Mind & Human Soul

Pain Management

  • Assess characteristics, onset, duration, and aggravating factors of heartburn → helps evaluate severity and trigger foods.
  • Elevate head of bed 6–8 inches → uses gravity to reduce reflux during sleep.
  • Encourage small, frequent meals instead of large meals → prevents excessive gastric distention.
  • Avoid late-night snacks, alcohol, caffeine, chocolate, peppermint, and high-fat foods → these lower LES (lower esophageal sphincter) pressure and worsen reflux.

Nutritional Support

  • Monitor weight weekly → detects early signs of nutritional deficiency.
  • Encourage nutrient-dense, low-acid foods → minimizes irritation and supports healing.
  • Collaborate with dietitian → ensures balanced diet without triggering symptoms.

Patient Education

  • Teach wearing loose-fitting clothing → reduces abdominal pressure.
  • Advise to avoid lying down 2–3 hours after eating → decreases reflux episodes.
  • Review prescribed medications (antacids, PPIs, H2 blockers) → improves adherence and symptom control.
  • Explain need for follow-up care and monitoring for complications like Barrett’s esophagus.

5. Evaluation   Extra Read

  • Patient reports reduced frequency and intensity of heartburn.
  • Patient demonstrates correct dietary and lifestyle modifications.
  • No significant weight loss noted during follow-up.

 

NURSING CARE PLAN – Gastroesophageal Reflux Disease (GERD)

Assessment

Goals / Expected Outcomes

Nursing Interventions

Rationale

Evaluation

Subjective:
- Complaints of heartburn after meals and at night
- Reports sour/bitter taste in mouth

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Objective:
- Frequent belching
- Acidic odor to breath
- Endoscopy shows esophagitis

Short-term:
- Patient reports relief of heartburn within 48 hrs.
- Patient identifies trigger foods.
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Long-term:
- Maintains nutritional status without weight loss.
- Demonstrates adherence to treatment and lifestyle changes.

1. Assess onset, duration, and aggravating factors of heartburn.
2. Elevate head of bed 6–8 inches.
3. Encourage small, frequent meals; avoid large meals.
4. Avoid lying down 2–3 hrs after eating.
5. Educate on avoiding alcohol, caffeine, chocolate, peppermint, fatty/spicy foods.
6. Monitor weight weekly.
7. Collaborate with dietitian.
8. Teach importance of wearing loose clothing.
9. Review correct use of prescribed medications.

1. Helps identify and manage triggers.
2. Reduces reflux episodes during sleep via gravity.
3. Prevents gastric distension and reflux.
4. Minimizes post-meal reflux.
5. Prevents LES relaxation and symptom worsening.
6. Detects early signs of malnutrition.
7. Ensures balanced diet without trigger foods.
8. Reduces abdominal pressure.
9. Improves adherence and symptom control.

- Patient reports reduced frequency and severity of heartburn.
- No significant weight loss.
- Patient verbalizes and practices dietary/lifestyle changes.

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