Gastroesophageal Reflux Nursing Essay
Gastroesophageal Reflux Nursing Essay
Assignment: Practicum – SOAP Note #3: Comprehensive
* 8 years old boy with Gastroesophageal reflux.
With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient or parent provide regarding personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. Gastroesophageal Reflux Nursing Essay
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
please see the attached rubric file.
Subjective, Objective, Assessment, and Plan (SOAP) Note Evaluation of an 8 Year-Old Caucasian Boy with Gastroesophageal Reflux Disease (GERD). Gastroesophageal Reflux Nursing Essay
Initials: E.M. Age: 8 Years Sex: Male Race: Caucasian
C.C: Frequent burning pain in the substernal region after constant regurgitation of food material from the stomach. It is very uncomfortable and has been there for the last one week.
HPI: This is an 8 year-old Caucasian male child who presented with burning pain in the substernal area. He denies any fever, as well as his mother. It started one week ago and is sharp and burning. It is associated with regurgitation and some vomiting (the vomiting occurs just some of the time). The burning pain typically occurs after meals and is slightly relieved by taking a glass of milk, which does not however make it completely better. The child rates the pain 8/10 on the pain scale.
Current Medications: He is currently being given grated ginger root juice mixed with a glass of warm water as a natural remedy or alternative therapy.
Allergies: Mother denies any medication or food allergies causing angioedema or anaphylaxis, as well as any environmental allergies or sensitivities.
Past Medical History: The boy has not suffered or been admitted for any major illness except recurrent episodes of mild influenza. He was given immunization in 2012 for pertussis, measles, tuberculosis, tetanus, and diphtheria. In 2014 he received immunization for pneumonia. He was also given FluMist quadrivalent influenza vaccine two doses one month apart in 2019. Mother denies any childhood or chronic conditions. No history of surgery. Gastroesophageal Reflux Nursing Essay
Soc Hx: He is from a middle class family and is the only child. The father and mother are both non-smokers, although they both drink occasionally over the weekends. They live in a sparsely populated upmarket residential suburb with adequate space. They always wear seatbelts while in the car.
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Family History: Mother denies history of chronic illnesses in the family on both sides. No death of a first degree relative linked to a hereditary or chronic disease.
Review of Systems (ROS)
General: Denies feeling hot at any time. Has not lost weight and is experiencing no fatigue or weakness.
HEENT: No headache, blurred vision, or yellowing of the eyes. No hearing impairment, tinnitus, runny nose, sneezing, or sore throat.
Integumentary: Has no rashes or eczema. No itching.
Cardiovascular: Reports no pain in the chest or palpitations.
Respiratory: Has no cough or difficulty in breathing. No hemoptysis.
Gastrointestinal: Reports occasional nausea and vomiting after regurgitation of stomach contents. No diarrhea, but intense burning pain in the substernal area on regurgitation which is regular and involuntary. Last bowel movement experienced two days ago.
Genitourinary: No pain on micturition or a burning sensation.
Neurological: Reports no dizziness or fainting attacks. No paralysis or unstable gait. No numbness in the extremities and bowel and bladder control unaffected.
Musculoskeletal: Has no joint stiffness and muscle or back pain of any sort.
Hematologic: He has no bruising or overt anemia.
Lymphatics: No observably enlarged lymph nodes and no previous surgery to remove the spleen.
Psychiatric: No history of inattention or anxiety, delayed milestones, or difficulties with learning.
Endocrinologic: Reports no excessive diaphoresis or heat intolerance. Not passing excessive amounts of urine or drinking a lot of water.
Allergic/ Immunologic: He has no history of seasonal allergies or asthma. He gets occasional rhinitis only when he has influenza.
Note: There are no observable discrepancies in what the child and the mother are saying. Gastroesophageal Reflux Nursing Essay
Constitutional: The boy appears overtly overweight or obese, but is well groomed and clean. His vital signs are Temperature: 98.5 °F; Respiratory rate: 19; Heart rate: 86; Blood pressure 112/80 mmHg; Weight: 64.2 lb; Height: 49.5 inches; and Body Mass Index or BMI: 18.4 (88th percentile). The boy is overweight (CDC, 2018). There are no overt growth or psychosocial issues.
HEENT: The boy’s head is normocephalic and the pupils are both equal, round, and reactive to light and accommodation. Eyes not pale. The ear is clean with no erythema or discharge and the tympanic membrane is intact. The nostrils are symmetric with no tenderness. Throat shows no exudate.
Gastrointestinal: The abdomen is soft, non-tender, and not distended. Bowel sounds are present. There is no rebound tenderness or guarding. However, slight tenderness demonstrable around the epigastric area. No masses or hepatosplenomegally.
Respiratory: No dullness to percussion, no crackles, no rhonchi, no rales, no crepitations. No wheezing and no increase in breath sounds noted.
Cardiovascular: Regular rate and rhythm. S1 and S2 heard. No S3 or S4. No murmurs, rubs, or gallops heard.
Neurological: All cranial nerves intact.
Genitourinary: No precocity or double gender noted.
Integumentary/ Extremities: No clubbing, edema, or cyanosis noted.
Hematologic: No pallor and no ecchymosis or bleeding noted.
Lymphatics: No nodes can be seen or felt in palpation.
Psychiatric: Mood and effect congruent with context. Oriented and coherent in speech.
Endocrinologic: No dwarfism or excessive growth noted.
Musculoskeletal: Appropriate gait with no obvious physical disabilities.
Allergic/ Immunologic: No evidence of a rash or eczema on observation and exposure.
Diagnostic results: Esophageal pH monitoring for 24 hours (Mousa & Hassan, 2017). With pH monitoring, a drop in the pH below a value of 4 will indicate that indeed acidic invasion has occurred in the esophagus. However, the recommendation for practice is that the diagnosis of GERD in children should be made primarily based on the history and physical examination (Baird et al., 2015). Gastroesophageal Reflux Nursing Essay
Gastroesophageal reflux disease (GERD) (Mousa & Hassan, 2017; Hammer & McPhee, 2018; Huether & McCance, 2017).
Helicobacter pylori gastritis (Hammer & McPhee, 2018; Huether & McCance, 2017).
Peptic ulcer disease (Hammer & McPhee, 2018; Huether & McCance, 2017).
The most likely diagnosis is GERD because the history and physical examination closely supports it. The fact that the symptoms get worse after eating also supports the diagnosis. It is clear that this was a normal physiological gastroesophageal reflux (GER) that has now turned pathological.
This child will need management that includes both nonpharmacological lifestyle changes and medical treatment. If both of these fail, then surgery can be considered as the last resort (Mousa & Hassan, 2017; Ayerbe et al., 2019). The first line of management as per recommendations for practice and practice guidelines will be conservative, involving primarily lifestyle changes (Rosen et al., 2018; Baird et al., 2015). Since obesity and overweight has been recognized as one of the predisposing factors to GERD in both adults and children, one of the lifestyle changes that the boy has to go through is weight loss (Mousa & Hassan, 2017). The other measures are that the child should eat smaller food portions at a time, should sleep with the upper body slightly elevated, and should avoid fatty foods (Huether & McCance, 2017; Hammer & McPhee, 2018).
Pharmacologic management will be tried if the conservative management fails to reduce the symptoms. It will entail giving the boy a proton pump inhibitor (PPI) for a period of four weeks. This is the medication recommended by the current guidelines (Rosen et al., 2018; Baird et al., 2015). Prokinetics like metoclopramide or domperidone (Ayerbe et al., 2019; Katzung, 2018; Mousa & Hassan, 2017) are prohibited for use in pediatrics (Rosen et al., 2018; Baird et al., 2015). PPIs (like omeprazole) prevent the stomach from producing too much acid. For the boy, therefore, the mother will have to stop the ginger root juice then:
Start omeprazole (Prilosec) 20 mg orally once a day (Mousa & Hassan, 2017; Katzung, 2018; Ayerbe et al., 2019).
Surgery after endoscopy (third option) in the form of laparoscopic fundoplication will be indicated if the above pharmacologic management also fails to stop the symptoms (Mousa & Hassan, 2017).Gastroesophageal Reflux Nursing Essay
My “aha” moment was the realization that GERD can actually mimic other gastrointestinal tract (GIT) conditions, necessitating great care when making the diagnosis and using diagnostic procedures to rule these out. In this case, what I could have done differently is to exclude the prokinetic domperidone from the treatment since there is little empirical evidence to support its efficacy in the management of pediatric GERD (Mousa & Hassan, 2017).
Ayerbe, J.I.G., Hauser, B., Salvatore, S., & Vandenplas, Y. (2019). Diagnosis and management of gastroesophageal reflux disease in infants and children: From guidelines to clinical practice. Pediatric Gastroenterology, Hepatology & Nutrition, 22(2), 107-121. Doi: https://doi.org/10.5223/pghn.2019.22.2.107
Baird, D.C., Harker, D.J., & Karmes, A.S. (2015). Diagnosis and treatment of gastroesophageal reflux in infants and children. American Family Physician, 92(8), 705-717. https://www.aafp.org/afp/2015/1015/p705.html
Centres for Disease Control and Prevention [CDC] (2018). BMI percentile calculator for child and teen. Retrieved 1 April 2020 from https://www.cdc.gov/healthyweight/bmi/calculator.html
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. New York, NY: McGraw-Hill Education.
Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. St. Louis, MO: Elsevier, Inc.
Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. New York, NY: McGraw-Hill Education.
Mousa, H. & Hassan, M. (2017). Gastroesophageal reflux disease. Pediatric Clinics of North America, 64(3), 487–505. Doi: http://dx.doi.org/10.1016/j.pcl.2017.01.003
Rosen, R., Vandenplas, Y., Singendonk, M., Cabana, M., Di Lorenzo, C., Gottrand, F., … & Tabbers, M. (2018). Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Journal of Pediatric Gastroenterology and Nutrition, 66(3), 516-554. Doi: 10.1097/MPG.0000000000001889 . Gastroesophageal Re