8. Gastroesophageal reflux disease (GERD): inappropriate relaxation of the lower esophageal sphincter (LES) in response to unknown stimulus.
   1. Pathophysiology: gastric volume or intraabdominal pressure elevated, or LES tone decreased-frequent episodes of acid reflux-breakdown of mucosal barrier-esophageal inflammation, hyperemia, and erosion-fibrotic tissue formation-esophageal stricture-impaired swallowing.
   2. Risk factors:
      1. Hiatal hernia.
      2. Diet-foods that lower pressure of LES (fatty foods, chocolate, cola, coffee, tea).
      3. Smoking.
      4. Drugs (calcium channel blockers, NSAIDs, theophylline).
      5. Elevated intra-abdominal pressure (obesity, pregnancy, heavy lifting).
   3. Assessment:
      1. Subjective data:
         1. Heartburn (pyrosis)-substernal or retrosternal; may mimic angina; 20 minutes to 2 hours after eating.
         2. Regurgitation-sour or bitter taste not associated with belching or nausea.
         3. Dysphagia or odynophagia (difficult or painful swallowing)-severe cases.
         4. Belching, feeling bloated.
         5. Nocturnal cough.
      2. Objective data:
         1. Hoarseness, wheezing.
         2. Diagnostic tests: 24 hours pH monitoring; barium swallow with fluoroscopy; endoscopy.
   4. Analysis/nursing diagnosis:
      1. Pain related to acid reflux and esophageal inflammation.
      2. Knowledge deficit (learning need) related to modifications needed to control reflux.
   5. Nursing care plan/implementation:
      1. Goal: promote comfort and reduce reflux episodes.
         1. Medications as ordered:
            1. Antacids to neutralize gastric acid.
            2. Histamine (H₂) receptor antagonists (cimetidine, ranitidine, famotidine) to reduce gastric acid secretion and support tissue healing.
            3. Proton pump inhibitor (omeprazole [Prilosec]) to inhibit gastric enzymes and suppress gastric acid secretion.
         2. Diet: avoid strong stimulants of acid secretion (caffeine, alcohol); avoid foods that reduce LES competence (fatty foods, onions, tomato-based foods); increase protein; restrict spicy, acidic foods until healing occurs.
         3. Activity: avoid heavy lifting, straining, constrictive clothing, bending over.
         4. Position: elevate head of bed 6-12 inches for sleeping. Reflux more likely on right side.
      2. Goal: health teaching.
         1. Weight reduction if indicated.
         2. Smoking cessation.
         3. Diet modification: avoid overeating-eat 4-6 small meals.
         4. Medication administration.
         5. Potential complications if uncontrolled (hemorrhage, aspiration).
   6. Evaluation/outcome criteria:
      1. No heartburn reported.
      2. Changes diet as instructed.
      3. No complications of continued reflux.