Nursing Care Plan for Gastroesophageal reflux disease

How to Complete Nursing Care Plan for Gastroesophageal reflux disease

Gastroesophageal reflux disease Template

Episodic/Focused SOAP Note Template and Care Plan

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American female). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, vaping, tobacco and alcohol use (previous and current use, how many times a day, how many years), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available.

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (gravida and Parity), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), gender sexual preference, and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: Burning on urination. Pregnancy. LMP: MM/DD/YYYY. Breast-lumps, pain, discharge? No reports of vaginal discharge, pain?. sexually active?

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Primay and Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

SOLUTION: Nursing Care Plan for Gastroesophageal reflux disease

Gastroesophageal Reflux Disease Care Plan

Master of Science in Nursing

PRAC 6552: Advanced Nurse Practice in Reproductive Health Care Practicum

OB Episodic Visit Focused Soap Note

University

Date 

Patient Information:

Initials: PH       Age: 35       Sex: Female       Race: Hispanic

S.

CC: “I feel sick, I cannot keep anything down.”

HPI: PH is a 35-year-old Hispanic female who presents to the clinic today for 30^th -week obstetrics check. She is 30 weeks/4 days pregnant. She has history of a liver disorder in the late second and early third trimester of pregnancy. She reports severe nausea, vomiting, and diarrhea which started one week ago. She states that symptoms started abruptly and she has vomited several times in the office today. She describes her vomiting as being made up of mainly undigested food and bile. The patient denies having vomited blood. However, she also states that she has heartburns which is accompanied by nausea and vomiting. She reports moderate generalized itching. She states that nothing makes her symptoms better or worse. She denies any vaginal bleeding or unusual discharge or cramping. Fetal movement present as stated by the patient. Her medical history shows that she is also type II diabetic, depression, obesity, and sleep apnea.

Current Medications

• Multivitamin: Prenatal (PNV Prenatal plus oral Tablet) 1 tab PO daily for supplement
• Folic acid: Folic acid 0.8mg oral tablet) 1 tab PO, qAM for supplement
• Lantus Solostar : 44 units, Daily, Subcutaneous To treat type 2 diabetes
• Clonazepam 2mg Tab(Rivotril), 2MG, 1TAB, HS, PO, PRN for Sleep
• Sertraline (sertraline 50mg oral tablet) 1 tab PO daily for depression

Allergies

Cephalexin – Skin rash

Denies food or environmental allergies

PMHx

Depression

Anxiety

Cholestasis in pregnancy (premature labor, preterm premature rupture of membranes) (2021)

Miscarriage x3 (2010, 2013, 2015)

Migraine

Heartburn

Obesity

Immunizations

Current on immunizations. Last tetanus 5/2020.

Soc & Substance Hx

Patient identifies as a female, heterosexual and is married. She lives with her spouse, child, and a roommate in a three-bedroom apartment. She works at Berry Plastics. She reports that her spouse and roommate are her support system. She denies alcohol, tobacco, use, vaping and illicit drug use. She states that she always uses a seat belt, does not use a phone while operating a vehicle and has working smoke detectors in their apartment. She endorses safe home environment that is free from emotional abuse and physical hazards. Patient reports that she walks 1-2 times per week.

Fam Hx

Mother: Alive; history of diabetes mellitus

Father- Alive; history of diabetes mellitus

Paternal and maternal grandparents- Deceased, unknown medical history, and year of death

Paternal aunt- Thyroid disease

Sister- Alive, no known medical complications

Child- Alive, no known medical complications

Surgical Hx

Cholecystectomy 2018

Dilation and Curettage (D&C)- 2021

Left oophorectomy- 2021

Tonsilectomy-1997

Mental Hx

Reports hx of anxiety and depression

Denies having thoughts of self-harm/suicide or homicidal ideations. And/or self-harm practices.

Violence Hx

Denies any concerns over safety

Reports that she is safe at home and reports that she has a great support system.

Reproductive Hx

G5P10131

LMP – 11/10/2021, EDD 8/17/2022.

Endorses  use of condoms before pregnancy

Sexually active with her male husband – Intercourse – vaginal.

Denies any sexual concerns

Denies history of HPV/STD, chlamydia, or genital herpes.

Reports last PAP smear was completed in 2021, negative

Performs self-breast exam monthly

ROS:

GENERAL:  Reports fatigue, weakness, loss of appetite and weight loss over 1 week. Denies fever or chills

HEENT: Head: Denies head injury. Reports hx of migraines. Eyes: no visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, or difficulty hearing, sneezing, congestion, runny nose, or sore throat.

SKIN:  Reports itching (pruritus), no rashes.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. Denies palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: Reports severe nausea and vomiting. Denies abdominal pain, diarrhea, or  hematochezia.

NEUROLOGICAL: Denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies back pain, muscle pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Reports history of anxiety and depression.

ENDOCRINOLOGIC: Denies cold or heat intolerance. No polyuria or polydipsia.

GENITOURINARY/REPRODUCTIVE: Denies burning/ pain/foul odor on urination. G5P10131. LMP: 11/10/2021. EDD 8/17/2022. Sexually active with her male husband. Intercourse- vaginal. Breast- Denies lumps, pain, discharge.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

VITAL SIGNS: B/P 122/78 , HR 106, RR 20, SPO2 98% on room air, Pain 0/10. Weight 100.2kg, Height 162cm, BMI 38.2

GENERAL: Patient appears neat. Lethargic, sitting in the chair actively vomiting. Patient is alert and oriented x4, responds to all questions appropriately without any complications.

HEENT: Normocephalic and atraumatic. No bumps/lesions. Healthy hair growth, face symmetrical. PERRLA noted. Ear canals patent and clean. Pink nasal mucosa without any septal deviation. No redness or swelling noted on throat.

NECK: Trachea midline, no masses, or abnormal cervical nodes. No JVD. Supple without adenopathy

LUNGS/CV: Symmetrical chest rise, Respirations is even and unlabored. Clear to auscultation in bilateral field lobes. No cough or dyspnea noted. Heart rate regular, tachycardic HR 106 without murmur.

BREAST: Soft, without masses, dimpling or discharge.

ABDOMEN: Soft and nontender. Bowel sounds present in all quadrants.

ADNEXA: Without masses per ultrasound

Diagnostic tests

• Ultrasound- Patient has hx of cholestasis with severe nausea and vomiting. Ultrasound ordered to check the wellbeing of fetus. Results WNL- 28% ( 1857g), AC 33.1%, Active fetus BPP 8/8, vertex, AFI 15.12cm, s/d ratio is WNL, posterior placenta, Rt and Lt adnexa appear WNL, CX 4.11cm.
• Physical- Vital signs- BMI 38.2
• CBC, COMP, Liver Function Tests- AST ,ALT, Bile acids and Serum alkaline phosphatase

Other tests recommended per epocrates

• Fasting serum cholesterol – Pt has a BMI 38.2

A.

1. Intrahepatic cholestasis of pregnancy (ICP) (K83.1)- It is a pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and the placenta. The cause is a combination of hormonal, genetic and environmental factors. Signs and symptoms include nausea, vomiting, fatigue, loss of appetite and itching. ( epocrates). I chose this diagnosis as my primary diagnosis because SC reports loss of appetite, nausea, vomiting and itching. SC also has history of Intrahepatic Cholestasis in pregnancy and labs reveals elevated bile acids of 32 and Serum alkaline phosphatase of 330 unit/L indicative of ICP.
2. Gastroesophageal reflux disease (K21) – GERD which is also known as heartburn occurs when the muscle in your esophagusthat opens and closes when you swallow does not work properly. When this happens, food and digestive fluids, which contain acid, return into the esophagus. Acid reflux can cause a burning feeling in your chest and throat which may lead to nausea and vomiting. SC reports history of heartburn and severe nausea and vomiting.
3. 32 weeks gestation of Pregnancy (Z3A.32)- SC is in 3^rd trimester of pregnancy. EDD 8/17/2022. Ultrasound consistent with 32 weeks of pregnancy.
4. 4. Obesity (E66.9) – The definitive diagnosis of obesity is BMI greater than 30. It is a chronic adverse condition due to an excess amount of body fat. Obesity can increase risk of so many diseases especially cardiovascular disease (epocrates). SC has a BMI of 38.2 ( Class II obesity).

Diagnostic  tests results

• Ultrasound- Patient has hx of cholestasis with severe nausea and vomiting. Ultrasound ordered to check the wellbeing of fetus. Results WNL- 28% ( 1857g), AC 33.1%, Active fetus BPP 8/8, vertex, AFI 15.12cm, s/d ratio is WNL, posterior placenta, Rt and Lt adnexa appear WNL, CX 4.11cm.
• Physical- Vital signs- BMI 38.2
• CBC, COMP, Liver Function tests (AST &ALT)- WNL , Elevated Bile acids 32 umol/L and Serum alkaline phosphatase 330 unit/L – Indicative of Intrahepatic cholestasis of pregnancy.

Referrals

No referrals needed at this time.

Therapeutic interventions

Patient was sent to Labor and delivery unit for the following:

Lactated Ringers IV Solution 1000ml for dehydration

Ondansetron (Zofran 4mg/2ml injection) 10mg, 2ml IV push once for Nausea and vomiting

Betamethasone acet-betamethasone and phosphate ( betameth/NaPhos 6mg/ml in IM ONLY) 12mg/2ml IM once – risk of preterm birth to help with fetal respiratory system.

Patient prescribed the following medications to take at home

Ursodiol (ursodiol 300mg oral capsule) 1 cap PO daily for  Intrahepatic cholestasis in pregnancy

Ondansetron (Zofran 4mg oral tablet) 1 tab PO q8hr for nausea and vomiting.

Pantoprazole (Protonix 20mg oral delayed release tablet) 1 tab PO daily. for GERD/Heartburn.

Hydroxyzine (hydroxyzine hydrochloride 25 mg oral tablet) 1 tab PO q6hrs PRN for pruritus.

Nontherapeutic interventions

• Soak itchy areas in cool or lukewarm water.
• Utilize oatmeal baths, creams, and lotion to help with itching.
• Education
• Eat a healthy balanced diet with plenty of fresh fruits and vegetables. ( Avoid fast/greasy foods, sugars, and highly refined foods e.g., white bread, corn syrup, soy products, processed meats, full fat dairy produce).
• Exercise often as tolerated.
• Increased fluid intake ( 8-12 glasses of water and avoid sodas).
• Take prescribed medications as prescribed.
• Biophysical profile (BPP) will be performed with each visit to detect fetal compromise.
• Patient educated that due to ICP, hx of ICP and preterm labor, will plan early delivery at week 36-37 depending on fetal progress. The timing of delivery will depend on balancing the risk of fetal death as opposed to the potential risks of prematurity. (ACOG)
• Patient encouraged to call the clinic if any concerns or questions.

Disposition and Follow up visits

Patient transferred or sent to Labor and delivery Unit for IV fluids for dehydration  and IV Zofran for severe nausea and vomiting. Patient will return home with prescribed medications and will return the following day for dose 2 of IM Betamethasone. Patient will follow up at the clinic in 2 weeks for her 34-week OB check. Patient encouraged to call the clinic if any concerns or questions. Patient advised to go to the ER if any serious symptoms occur e.g., vaginal bleeding, intense cramping, uncontrolled nausea, and vomiting.

Reflection

I learned that Intrahepatic Cholestasis of Pregnancy (ICP) is the most common liver disorder in pregnancy and is associated with increased risk of adverse obstetrical outcomes which include stillbirth, respiratory distress syndrome, meconium passage, fetal asphyxiation and/or sudden fetal demise. ICP is a disorder in the late second and early third trimester of pregnancy. It is characterized by pruritus with increased serum bile acids and other liver function tests. The most sensitive and specific marker for ICP is total serum bile acid using a cut-off value of 10 micromol/L. Other liver function tests include ALT, AST, and serum alkaline phosphate. Etiology of ICP is multifactorial. Genetic susceptibility, hormonal, and environmental factors have been proposed as possible mechanisms. According to research, women on estrogen contraceptives are at high risk of ICP. Estrogen reduces expression of nuclear hepatic bile acid receptors and hepatic biliary canalicular transport proteins in genetically susceptible women causing impairment of hepatic bile acid homeostasis and subsequent increased level of bile acids. ICP is also noted to be more prevalent in women with a low level of Selenium and Vitamin D. It is common in some countries in winters when Selenium and Vitamin D may be low.

Studies show that women with history of ICP have higher risk. Once the diagnosis of ICP is confirmed, immediate treatment is necessary, and the primary therapy is to decrease the risk of perinatal morbidity and mortality and to alleviate maternal symptoms. Ursodeoxycholic acid (Ursodiol) is the drug of choice for the treatment of ICP. It has no detrimental impact on the fetus. Most side effects of Ursodiol are nausea, vomiting and diarrhea. Geenes et al (2016). According to American College of Obstetricians and Gynecologists, they recommend delivery between 36-37 weeks of pregnancy to reduce the risk of sudden fetal demise. The timing of delivery will depend on balancing the risk of fetal death as opposed to the potential risks of prematurity (ACOG).

References

Definition of term pregnancy. ACOG. (n.d.). Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/11/definition-of-term-pregnancy

Fellow. (n.d.). Intrahepatic cholestasis of pregnancy: A review of… : Obstetrical & Gynecological Survey. LWW. Retrieved from https://journals.lww.com/obgynsurvey/Abstract/2018/02000/Intrahepatic_Cholestasis_of_Pregnancy__A_Review_of.18.aspx

Geenes, V., Williamson, C., & Chappell, L. C. (2016). Intrahepatic cholestasis of pregnancy. The Obstetrician & Gynecologist, 18(4), 273–281. https://doi.org/10.1111/tog.12308

Obesity in women. Epocrates Web. (n.d.). Retrieved from https://online.epocrates.com/diseases/21142/Obesity-in-adults/Treatment-Options

Problems of the digestive system. ACOG. (n.d.). Retrieved from https://www.acog.org/womens-health/faqs/problems-of-the-digestive-system

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