What should be one of the nursing strategies when the client has gastroesophageal reflux?

This NCLEX review will discuss GERD (gastroesophageal reflux disease).

As a nursing student, you must be familiar with GERD and how to care for patients who are experiencing this condition.

These type of questions may be found on NCLEX and definitely on nursing lecture exams.

Don’t forget to take the GERD quiz.

You will learn the following from this NCLEX review:

• Definition of GERD
• Pathophysiology
• Signs and Symptoms
• How it is diagnosed
• Treatment
• Nursing Interventions for GERD
• Medications

Lecture on GERD

GERD stands for Gastroesophageal Reflux Disease and it is a chronic condition where stomach contents flows back up into the esophagus which is mainly due to a damaged/weak lower esophageal sphincter.

GERD is sometimes referred to as “acid reflux disease” as well.

Some people have random episodes of acid reflux and it goes away, but GERD is when it occurs more than twice a week for a long period of time.

Why is GERD happening? In a nutshell, the LES (lower esophageal sphincter) is not staying closed but opening. This allows backwash of stomach contents and acids into the esophagus, and this leads to major irritation to the esophagus. See below the reasons for a weak/damaged LES.

First let’s cover what happens in normal swallowing:

Physiology of swallowing food:

Digestion starts in the mouth when food is chewed. Then it is swallowed. The food is then squeezed down into the esophagus and the lower esophageal sphincter relaxes to let the food into the stomach and then it CLOSES again to prevent the food from back flowing. Parietal and chief cells are stimulated from the food to produce acid and digestive enzymes to break down the food. In GERD, the acids and food can flow back into the esophagus.

Key Players in GERD

Esophagus: the tube that connects to the stomach to allow food to enter into the stomach. It squeezes food down into the stomach each time we swallow and the lower esophageal sphincter opens. It plays a role in GERD if the esophagus is unable to perform this role correctly due to impaired motility.

• Lower esophageal sphincter: collection of circular muscles at the end of the esophagus that closes and prevents toxic acids and GI contents from flowing back into the esophagus once it enters the stomach. The LES can become:
  • weak from pressure: due to delayed gastric emptying (anticholinergics can delay gastric emptying), hiatal hernia, pregnancy, obesity, overeating (stomach distention), or medications: antihistamines, calcium channel blockers, antidepressants, sedatives, smoking
    • How does a hiatal hernia cause GERD? A hiatal hernia happens when the stomach pushes through a weak diaphragm and sits on top of it. All the stomach should be below the diaphragm and the esophagus should be above the diaphragm. When a hernia forms there is pooling of gastric acid/contents in the herniated area and this increases pressure and causes the LES to become weak.
  • closes at irregular times due to impaired motility

Esophageal mucosal lining: erodes and becomes damaged over time from the constant backwash of acids/contents and ulcer/sores form…hence “esophagitis”….complications: esophageal cancer, Barrett’s esophagus, narrowing of the esophagus, bleeding

Stomach Acid & Contents: erodes the esophagus….if the acid and contents makes it pass the upper esophageal sphincter it can enter into the lungs causing pneumonia, aggravate asthma signs and symptoms, coughing, ear infections, voice changes, chronic cough, and night time coughing…..called laryngopharyngeal reflux (GERD can lead to this)

Complications of GERD

• Inflammation of the esophagus (increased risk of cancer from the chronic inflammation)
• Narrowing of the esophagus: strictures
• Lung problems: asthma, pneumonia, voice changes, wheezing, fluid in the lungs
• Barrett’s esophagus: lining of the esophagus is replaced with similar lining that makes up the intestinal lining…increase risk of cancer.

Signs and Symptoms of GERD

Note: not all people with GERD will have heartburn but may have chronic cough, recurrent pneumonia, regurgitation of food

• Gastric pain (upper)
• Excess regurgitation of food… bitter taste in the back of the throat
• Regular, occurring burning sensation in the chest or abdomen (it can be so intense it feels similar to a MI)
• Dry cough (frequent)…worst at night
• Nausea
• Problems Swallowing…feels like a lump is in the throat
• Lung Infections

How is GERD Diagnosed?

• Endoscopy: used to assess the esophagus for changes…erosions, strictures etc.
• Esophageal Manometry: looks at the function of the esophagus’ ability to squeeze the food down and how to the lower esophageal sphincter closes
• pH monitoring: measures the acid amounts in the esophagus for a 24 hour period as the patient performs normal activities of daily living…small tube stays in the esophagus to help measure the acid amounts

Treatment of GERD: lifestyle changes, medications, surgery such as: fundoplication which is where the fundus of the stomach is placed around the lower part of the esophagus (most severe cases)

Nursing Interventions for GERD

• Assess patient for signs and symptoms of GERD, educating, administering medications per MD order

Assess quality and characteristic of the pain and differentiate the signs and symptoms from a heart attack?

Assess for other signs and symptoms rather than heartburn…do they have respiratory changes, dry cough that is worst when lying down, hoarseness of the voice? Is the pain aggravated when eating a heavy meal? What food makes it worst? (help develop a diet plan to decrease signs and symptoms) What medications are they taking?

Assess for signs and symptoms of aspiration? Coughing, voice changes, lower oxygen saturation, increase respiration, abnormal lung sounds

Education for GERD

• Eat small meals rather than large ones (prevents over eating)
• Avoid foods that relax the LES: greasy, fatty, ETOH, soft drinks (increase pressure on the LES and cause regurgitation), and coffee, peppermint/spearmint
• Avoid eating right before bed (last meal should be 3 hours before bed)
• Sit up after eating for at least 1 hour
• Weight loss
• Smoking cessation
• Watch acidic foods: citrus and tomatoes

Medications for GERD

• Antacids, H2 blockers, PPIs, prokinetics

Antacids: neutralizes acid

• Types: Magnesium Hydroxide, Calcium Carbonate…these are chewed thoroughly and then swallowed
• Interferes with MANY drugs: PO antibiotics, mucosal healing, H2 blockers…. so always give alone and allow for 1-2 hours before administering other medications

Histamine-receptor blockers: decreases secretion of gastric acid

• Types: “Ranitidine HCL “Zantac” or Famotidine “Pepcid”
• End in “tidine”
• Short-term or PRN basis
• How do they work? They block histamine. When histamine is released it causes the parietal cells to release HCL but this response will be blocked so gastric acid secretion will be decreased.
  • Avoid giving at the same time with antacids or Carafate

Proton-pump Inhibitors (PPIs): decreases stomach acid and helps esophagus heal

• Types: “Omeprazole “Prilosec” or Pantoprazole “Protonix”
• end in “prazole”
• Long-term usage but there are risks: increased risk for bone fractures
• How do they work? Attaches to the “proton pump” on the parietal cells which is the hydrogen/potassium (H+, K+) ATPase enzyme and blocks the release of hydrogen ions. These ions would mixed with the chloride ions and form gastric acid but this is blocked so there is a decrease in gastric acid.

Prokinetics: prevent delayed gastric emptying by improving pressure in LES and peristalsis of the GI tract:

• Types: “Bethanechol” Urecholine or Reglan “Metoclopramide”

More NCLEX Reviews

References

1. “Barrett’s Esophagus | NIDDK”. National Institute of Diabetes and Digestive and Kidney Diseases. Web. 4 Apr. 2017.
2. “Definition & Facts For GER & GERD | NIDDK”. National Institute of Diabetes and Digestive and Kidney Diseases. Web. 3 Apr. 2017.