Week 3 Nursing 676-B
Week 3 Nursing 676-B
The case study depicts Marty, a 66-year-old male chef with a history of severe reflux symptoms for the past couple of weeks. He reports that the reflux exacerbates at night. The patient had similar symptoms two to three years ago that alleviated when he quit drinking alcohol. He states that he has remained abstinent from alcohol, but his symptoms have relapsed. The purpose of this paper is to discuss the additional information to obtain from the patient, medications for the symptom, and the assessment and plan of care.
Additional Information to Obtain
Additional information that the clinician should obtain from the above patient includes the presence of other symptoms associated with GERD. The clinician should ask Marty if he experiences any of the following symptoms: heartburn, dysphagia, coughing or wheezing, hoarseness, or a sore throat (Savarino et al., 2020). The clinician should also obtain information on the alleviating factors, including pharmacological and non-pharmacological measures the patient takes to relieve the reflux. The degree to which these measures alleviate the reflux should also be noted. In addition, the clinician should inquire on the presence of factors or lifestyle practices associated with reflux such as: Eating within three hours of bedtime; Intake of strong stimulants of acid secretion like coffee and carbonated drinks; Consumption of specific foods such as high-fat foods and chocolate; Smoking (Savarino et al., 2020). Besides, the clinician should inquire on the use of drugs known to lower esophageal sphincter (LES) pressure, such as anticholinergics, tricyclic antidepressants, antihistamines, calcium channel blockers, and nitrates.
Medications to Consider For the Symptoms
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Medications that can be considered for the patient’s reflux include Proton pump inhibitors (PPIs), H2 receptor blockers, and Antacids. PPIs are the most commonly prescribed medication due to their superiority in providing heartburn and regurgitation relief and promoting improved healing (Savarino et al., 2020). PPIs are the most potent medications for treating GERD. PPI options include omeprazole, esomeprazole, lansoprazole, and rabeprazole. H2 receptor blockers are considered the first-line agents in mild to moderate GERD and for grades I-II esophagitis (Savarino et al., 2020). Available H2 receptor blockers include cimetidine, famotidine, and nizatidine. Antacids are effective in managing mild reflux symptoms. They should be taken after each meal and at bedtime.
Assessment and Plan of Care
Assessment of the patient will include an upper endoscopy. Endoscopy is the most commonly used objective diagnostic procedure for visualizing the esophageal mucosa. Endoscopy should be performed as soon as possible for persons with GERD symptoms who also exhibit alarm symptoms such as weight loss, dysphagia, vomiting, bleeding, or anemia (Katz et al., 2021). Besides, an endoscopic biopsy is the only diagnostic test that constantly identifies columnar mucosal changes of Barrett’s esophagus. The patient’s plan of care will comprise pharmacological approaches and lifestyle modification.
The patient’s medication plan will include: Esomeprazole 20 mg PO once daily for four weeks; take medication at least 30 minutes before breakfast. The American College of Gastroenterology (ACG) recommends treatment with PPIs over treatment with H2 receptor blockers for treating erosive esophagitis (Katz et al., 2021). ACG also recommends treatment with PPIs over H2 receptor blockers to maintain healing from erosive esophagitis. It recommends the administration of PPIs 30–60 minutes before a meal instead of during bedtime to control GERD symptoms.
The ACG recommends weight loss in overweight and obese persons to improve GERD symptoms. Thus, if the patient is overweight or obese, he will be recommended healthy weight loss approaches, including physical exercises at least 30 minutes per day for a minimum of five days a week. He will also be educated on dietary modification to promote weight loss, including caloric restriction. In addition, the patient will be advised to avoid meals within 2–3 hours of bedtime to minimize reflux (Newberry & Lynch, 2019). The ACG recommends restricting trigger foods to control GERD symptoms (Katz et al., 2021). The patient will be advised on cessation of foods that potentially exacerbate reflux symptoms, such as chocolate, coffee, carbonated beverages, spicy foods, high-fat food, and acidic foods such as citrus and tomatoes (Mehta et al., 2020). In addition, the patient will be recommended for smoking cessation if he smokes tobacco. Smoking cessation was established to alleviate GERD symptoms. Lastly, the patient will be instructed to elevate the head of the bed to control nighttime GERD symptoms. A study by Allampati et al. (2017) showed improvement in nocturnal GERD symptoms and esophageal acid exposure with an elevation of the head of the bed or sleeping on a wedge.
Additional information from the patient will inquire more about the symptoms and presence of factors that exacerbate reflux. Diagnostic assessment will include upper endoscopy. The patient’s plan of care will consist of medication therapy with esomeprazole, a PPI potent for alleviating GERD symptoms. He will also be educated on lifestyle modification, including weight loss, smoking cessation, and diet changes.
Allampati, S., Lopez, R., Thota, P. N., Ray, M., Birgisson, S., & Gabbard, S. L. (2017). Use of a Positional Therapy Device Significantly Improves Nocturnal Gastroesophageal Reflux Symptoms. Diseases of the esophagus: official journal of the International Society for Diseases of the Esophagus, 30(3), 1-7. . https://doi.org/10.1111/dote.12495
Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., Yadlapati, R., & Spechler, S. J. (2021). ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Official Journal of the American College of Gastroenterology| ACG, 10-14309. https://doi.org/10.14309/ajg.0000000000001538
Mehta, R. S., Song, M., Staller, K., & Chan, A. T. (2020). Association between beverage intake and incidence of gastroesophageal reflux symptoms. Clinical Gastroenterology and Hepatology, 18(10), 2226-2233. . https://doi.org/10.1016/j.cgh.2019.11.040
Newberry, C., & Lynch, K. (2019). The role of diet in the development and management of gastroesophageal reflux disease: why we feel the burn. Journal of thoracic disease, 11(Suppl 12), S1594. . https://doi.org/10.21037/jtd.2019.06.42
Savarino, V., Marabotto, E., Zentilin, P., Furnari, M., Bodini, G., De Maria, C., … & Savarino, E. (2020). Pathophysiology, diagnosis, and pharmacological treatment of gastroesophageal reflux disease. Expert review of clinical pharmacology, 13(4), 437-449. https://doi.org/10.1080/17512433.2020.1752664
Marty is a 66-year-old male chef who has been experiencing severe reflux symptoms for the past several weeks that seem to be worsening at night. He had similar symptoms two to three years ago that went away when he stopped drinking alcohol. He claims to remain abstinent, but his symptoms have returned. What additional information should you obtain? What medications should you consider for his symptoms? Discuss your assessment and plan of care including clinical guidelines that support your decision.