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    0orpilla Jomark C. Gerd - Fdar

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    Aphrill Pearl Pacis
    1) A 48-year-old male patient presented with heartburn, difficulty swallowing, and pain. He was found to be obese with a BMI of 31.7. 2) The patient was assessed for heartburn and pain. Metoclopramide and non-pharmacological measures were used to manage his pain. He was prepared for an EGD. 3) Throughout the night, the patient was monitored for vomiting and provided medication. He was instructed on dietary and lifestyle modifications to manage his reflux and improve nutrition. By the end of the night, the patient reported relief from pain and understood how to better manage his condition.

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    0orpilla Jomark C. Gerd - Fdar

    Uploaded by

    Aphrill Pearl Pacis
    67 views2 pages
    1) A 48-year-old male patient presented with heartburn, difficulty swallowing, and pain. He was found to be obese with a BMI of 31.7. 2) The patient was assessed for heartburn and pain. Metoclopramide and non-pharmacological measures were used to manage his pain. He was prepared for an EGD. 3) Throughout the night, the patient was monitored for vomiting and provided medication. He was instructed on dietary and lifestyle modifications to manage his reflux and improve nutrition. By the end of the night, the patient reported relief from pain and understood how to better manage his condition.

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    0ORPILLA-JOMARK-C.-GERD_FDAR

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    1) A 48-year-old male patient presented with heartburn, difficulty swallowing, and pain. He was found to be obese with a BMI of 31.7. 2) The patient was assessed for heartburn and pain. Metoclopramide and non-pharmacological measures were used to manage his pain. He was prepared for an EGD. 3) Throughout the night, the patient was monitored for vomiting and provided medication. He was instructed on dietary and lifestyle modifications to manage his reflux and improve nutrition. By the end of the night, the patient reported relief from pain and understood how to better manage his condition.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    67 views2 pages

    0orpilla Jomark C. Gerd - Fdar

    Uploaded by

    Aphrill Pearl Pacis
    1) A 48-year-old male patient presented with heartburn, difficulty swallowing, and pain. He was found to be obese with a BMI of 31.7. 2) The patient was assessed for heartburn and pain. Metoclopramide and non-pharmacological measures were used to manage his pain. He was prepared for an EGD. 3) Throughout the night, the patient was monitored for vomiting and provided medication. He was instructed on dietary and lifestyle modifications to manage his reflux and improve nutrition. By the end of the night, the patient reported relief from pain and understood how to better manage his condition.

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    PATIENT NAME: P.

    T
    AGE: 48
    GENDER: Male
    C/S: SINGLE
    BED #: ROC
    DATE/SHIFT/ FOCUS ACTION
    TIME
    02/ 24/ 2022
    Received patient sitting in a
    ROC, who feels stressed,
    exhibits guarding behavior,
    and reports difficulty
    swallowing and pain with a
    chief complaint of
    heartburn. The patient
    verbalized, “Idi nalpas nak
    nakipangan ket sumru
    metten nga agsalat ti
    barulong ko. Kasla
    nagapges. Napalalwak
    samet ti lechonen. The
    patient was found to be
    obese, with a BMI of 31.7.

    V/S as follows:
    BP: 140/90 mmHg
    RR: 20 cpm
    TEMP: 37.6˚C

    3:30 pm Pain -Established rapport.


    -Assessed for heartburn
    -Assessed the patient’s pain
    -Assessed V/S q2
    4:30 pm - Administered
    Metoclopramide prn
    -Encouraged the use of
    non- pharmacological pain
    relief measures:
    • Distraction
    • Massage
    • Music therapy
    5:30 pm Heartburn -Prepared patient for EGD
    -Administered pantoprazole
    qid x 4 weeks
    6:00 pm
    6:30 pm Vomiting - Metoclopramide prn
    -Instructed to chew food
    thoroughly.
    -Provide an emesis basin
    within easy reach of the
    patient.
    -Advised patient to avoid
    eating within 3 hours
    before sleeping at night
    7:00 pm Imbalanced Nutrition: Greater -Instructed to chew food
    than body requirements thoroughly.
    7:15 pm -Instructed to avoid foods
    that relax the LES.
    7:45 pm -Administered pantoprazole
    qid x 4 weeks
    -Administered Maalox
    175mg/200mg oral
    suspension 5 ml 4x daily

    9:00 pm -Advised patient to avoid


    eating within 3 hours
    10:30 pm before sleeping at night.
    -Elevated the head of the
    bed.

    10:45 pm -The patient verbalized


    relief from pain, with a
    scale of 2/10, increased
    knowledge of actions that
    reduce reflux, and ingested
    daily nutritional
    requirements in accordance
    to his activity level and
    metabolic needs.
    Jomark C. Orpilla

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