New nursing student Pls help with GERD care plan

[mysticlad]

I am a new nursing student who is also new to this forum so pardon me if i make mistakes or don't observe appropriate protocol.

I am trying to formulate a diagnosis for a Patient with a medical diagnosis of GERD.

Symptoms are Heartburn, Dyspepsia, and chest pain.

I came up with Chronic chest pain related to ineffective digestion.

and Imbalanced nutrition less than body requirements related to impaired food digestion.

Is this right?

I was wondering if i could say Imbalanced nutrition related to regurgitation or chest pain related to regurgitaion or reflex.

Interventions: for pain

1.Analgesics

2. Music theraphy.

3.Massages

4. Guided Imagery.

5. Breathing Exercises.

Can anyone pls help me with better ones if mine are wrong or help me think through it.

Also for the 2nd Diagnosis i thought that letting pt sit up at least 30 mins after a meal would help. Does anyone have more suggetion?

[Daytonite, BSN, RN]

a nursing care plan is the determination of the patient's nursing problems. diagnosis of those nursing problems is based on the assessment you make. assessment includes information you gather from:

• a health history (review of systems)
  
• performing a physical exam - what you listed was heartburn (when does this occur and how often? what foods cause it?), dyspepsia (this is the same as heartburn), chest pain (where, when, how long does it last, what brings it on, what relieves it), regurgitation
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to look up the pathophysiology of gerd to understand what is going on with this condition and why the symptoms occur.
  
  • http://www.merck.com/mmpe/sec02/ch012/ch012g.html
    

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

from the data you collect you review the abnormal information. that becomes the evidence of the nursing problems that you put a label on which you call nursing diagnoses.

now, you are suggesting that this patient has two nursing problems (i put them in priority order):

1. imbalanced nutrition less than body requirements related to impaired food digestion.
   
   • definition of imbalanced nutrition: less than body requirements: intake of nutrients insufficient to meet metabolic needs
     
   • the problem with diagnosing this is that you presented no data that the patient is eating less than their metabolic need. you have no data that they have lost weight, a calorie count to indicate that they are eating less than their daily required need or evidence of anorexia.
     

[*]chronic chest pain related to ineffective digestion.

• definition of chronic pain: unpleasant sensory or emotional experience arising from actual or potential tissue damage or described in terms of such damage
  
• ineffective digestion is not going to be the cause of any actual or potential tissue damage with gerd. this is why you need to read about the disease and understand the pathophysiology going on in order to word the related factor for this diagnosis correctly.
  

you can see some suggestions for interventions for a diagnosis of pain on this previous thread: https://allnurses.com/nursing-student-assistance/nrsg-dx-total-376731.html - nrsg dx for total hip replacement

[mysticlad]

Thank you so much Daytonite. I am about to start all over again. With a clearer understanding this time.