CASE SCENARIO: GASTROESOPHAGEAL REFLUX DISEASE

GROUP C

Dan, is a 16 y/o grade 10 student admitted in the Pedia Medical Ward with the chief complains of
intrabdominal fullness & heartburn after meals. He claimed that the said abdominal discomforts
occurred 3 yrs.ago but he did not pay attention for it because it was on & off, so no medical consultation
was done & no medications taken to relieve the discomfort.
For this hospitalization, his mother just brought him for check at the OPD of Hospital X because he
noticed that heartburn is becoming severe, there is sudden decreased in his body weight. & observed
that Dan consumes a small amount of foods because whenever he eats, he feels fullness of his stomach
even small volume of food is consumed He also claimed that he experiences pain upon swallowing.
With the above complains, the physician who examined him informed the mother that Dan needs to be
admitted for further evaluation & management., hence Dan was admitted & brought to pedia medical
ward.

ER DEPT.NOTES:

- Dan was examined awake, conscious with the following v/s: BP- 110/70, Temp.36.8 degree
Celsius, HR – 82 bpm, RR - 24 bpm, O2 sat.- 95%.
- He looks weak, with facial grimace,, skin dry, fair turgor but appears reduced in body weight
compared to a normal individual of his. age.

DOCOTR’S ORDERS: June 16, 2020, 9 a.m.

- Pla admit to pediatric medical ward

- For CBC, U/A, S/A
- V/S q 4 hrs
- Start PLR I L regulate at 30 gtts/min.
- Omeprazole 40 mg IVTT stat, then 80 mg in 90 cc PNSS via volumetric set sidedrip to ongoing IVF
to be given in 10 hrs
- Metoclopromide 1 ampule IVTT stat
- Soft low fat, high protein diet as tolerated.
- Schedule for Esophagoscopy tomorrow at 8:00 a.m.
- Secure consent
- NPO post midnight
- Give Metoclopromide 1 amp IVTT 30 mins.be given at 8:00 a.m.
- I & O every shift & record.
Signed: Dr. xy

June 17, 2020 7:00 A.M.

- Seen patient awake, have taken a bath, with ongoing IVF of PLR I L infusing at 30 gtts/min. V/S:
BP – 110/80, Temp. 36.8, HR – 84 bpm, RR – 25 cpm, O2 sat. 95%.
Lab.results: CBC – Hgb. 12.5 g/dl, WBC – 9,580 /ul, neutrophils – 60%, eisonophils- 3%,
lymphocytes – 30%.
DOCTOR’S ORDERS: June 17, 2020

- Maintain IVF PLR I L at same rate.

- v/s q 4 hrs.
- Maintain NPO for Esophagoscopy today at 8:30 a.m.
- May resume diet after procedure once gag reflex is positive.
- To consume Omeprazole drip.
- May start Ranitidine 300 mg 1 tablet OD at HS once omeprazole drip is consumed

Signed: DR. XY
 June 18, 2020, 2:00 p.m

- Seen patient awake, sitting at bedside chair, appears with improved condition. Claimed to have
better appetite, heartburn is relieved, with no pain upon swallowing. v/s : BP – 110/80, Temp.-
36.5, HR- 82, RR – 24, o2 SAT. 97%.

DOCTOR’S ORDERS:, 8:00 A.M.

- Full, low fat, high protein diet, no acidic foods, no chocolates, no caffeine
- Consume IVF, then terminate.
- Ranitidine 300 mg 1 tablet at H.S.
- V/S q 4 hrs.
- I & o q shift

Signed: DR. XY

QUESTIONS:

1. IDENTIFY FACTORS THAT HAVE CONTRIBUTED TO THE HEALTH CONDITION OF THE PATIENT

2. What were the significant laboratory & diagnostic exams done to confirm the diagnosis to
Include nursing responsibilities in the preparation of the patient.

3. Make a pharmacologic study of the drugs prescribed to the patient.

4. Make a diagram on the concept map of GERD as presented in the scenario to include
significant laboratory & diagnostic exams results, and s & s .

4. Formulate a comprehensive nursing diagnosis to identify 3 priority problems related to the

case scenario.
5. Make a discharge planning for the patient.