hi, kcmochika and welcome to allnurses!
i am a former resident of nkcmo!
gerd is a medical diagnosis and really is not much help to you here.
the way to get an appropriate nursing diagnosis for your patient is to follow the steps of the nursing process. the way the doctor determined this patient had gerd was to follow the steps of the medical decision making process. now, it's your turn to use the nursing process to determine this patient's nursing diagnoses.
look at your assessment data that you collected from doing your physical exam and review of the patient's medical record (chart). some of the information is not normal. you want to list out that abnormal data. some of this abnormal information, we're going to call them symptoms now, will be the same symptoms the doctor found as well when he did his history and physical examination and that's ok. from that list of abnormal data, or symptoms, you can now look for nursing diagnoses.
just like every medical diagnosis has signs and symptoms, every nursing diagnosis also has signs and symptoms. nanda (north american nursing diagnosis association) has already figured them all out for us and written them up in a nice little work called nanda-i nursing diagnoses: definitions & classification 2007-2008
. this information from nanda has been reprinted in care plan and nursing diagnosis books that are currently published and sold in every bookstore in the country. so, if you have a care plan book or nursing diagnosis book you'll be able to find the following information for most of the current 188 nursing diagnoses: it's definition, defining characteristics (symptoms) and related factors (etiology or cause). what you want to do is find nursing diagnoses where the definition sounds like it might pertain to what your patient is experiencing and where your patient has one or more of the defining characteristics listed with that nursing diagnosis. this means you're going to have to thumb through the pages of the book. if you've got some matches, then you've found and diagnosed your patient with a nursing diagnosis.
now, 3sodapop has given you 4 suggestions for nursing diagnoses. i am going to tell you that they may or may not pertain to your patient because your patient may or may not have the defining characteristics that fit with these nursing diagnoses. your patient may also have other problems that don't even meet the criteria for the nursing diagnoses that 3sodapop mentioned. this is why you must go through the process i described above to pick the correct nursing diagnoses.
you can find more information on the process of choosing a nursing diagnosis for a patient on these two threads on the nursing student forums:
if you still need help choosing a diagnosis for this patient, please post a list of your patient's symptoms for me and i will show you how to choose the nursing diagnoses for him.