A.

DESCRIPTION OF THE LEARNER

The learner is a
year old and currently residing at
is a high school graduate, married and a Roman Catholic. The patient was diagnosed of Colon
Cancer and was admitted in SLU Hospital for his 2nd cycle of chemotherapy.
B. LEARNING DIAGNOSIS:
Knowledge deficit: Management of GERD (Heartburn) related to inadequate information.
C. LEARNING NEEDS: According to the patient he is not aware of the following:
Information about GERD (Heartburn)
-causes
-diet
-eating habits
-activities that can trigger
D. GOALS
To provide information about Heartburn.
To be able to educate patient regarding on the foods that prevents heartburn.
To teach patient as well as significant others about possible management of heartburn.

E. TEACHING PLAN

. He

LEARNING
OBJECTIVES

LEARNING CONTENT

LEARNING
STRATEGIE
S

TIME
ALLOTMEN
T AND
RESOURCE
S NEEDED

SPECIFIC
OBJECTIVES:
After 15 minutes
of
nurse-patient
interaction,
the
patient will be
able to:
1. Define
GERD
(Heartburn)
.

2. Identify
cause

of

EVALUATION

FULLY MET IF
After 15 minutes
of nurse-patient
interaction was able
to:

GERD (Heartburn)
Heartburn is a disease that
occurs when gastric contents
flow backward from the stomach
into the esophagus. It is also
termed
reflux
and gastroesophageal
reflux
disease (GERD).An
uneasy burning sensation in
the stomach,typically extending t
oward the esophagus, andsometi
mes associated with the eructati
on of anacid fluid.

The cause of heartburn is excessive

flow of gastric contents back into the
esophagus. Normally, there is an

Lecture and
discussion

Lecture and
discussion

2 minutes
(pamphlet)

2 minutes
(pamphlet)

a. Understand
heartburn
b. Know the
cause of
heartburn
c. State the
foods and
activities
that trigger
heartburn.
d. Identify
ways to
prevent
heartburn
PARTIALLY MET
IF:
Patient answered
correctly some of
the health

GERD.

occasional backflow into the esophagus

with no symptoms. The acidic gastric
contents, when present in large
amounts,
irritate
the
esophagus
(usually the lower part) and cause the
symptoms of heartburn

3. Enumerate
foods that
can trigger
heartburn.

Foods
that
heartburn

that

can

Lecture and
discussion

3 minutes
(pamphlet)

Lecture and
discussion

2 minutes
(pamphlet)

Lecture and
discussion

6 minutes
(pamphlet)

trigger

Garlic and onions.

Alcohol.
Chocolate.
Fried and fatty foods.
Citrus fruits.
Tomato sauces.
Peppermint and spearmint.
Coffee, cola drinks, and other
carbonated beverages

Activities
the
heartburn

4. State
activities
that
can
trigger
heartburn.

can

objectives.

trigger

Smoking.
Overeating.
Wearing
tight
clothing
around the waist.

NOT MET IF:

Patient is noncomplaint and does
not participate in
health teaching.

5. Identify
ways
on
how
to
prevent
heartburn.

HEARTBURN PREVENTION

Change how you eat.

It's best to eat several
small meals instead of two
or three large meals.
After you eat, wait 2 to 3
hours before you lie down.
Late-night snacks aren't a
good idea.
Chocolate,
mint,
and
alcohol
can
make
heartburn
worse.
They
relax the valve between
the esophagus and the
stomach.
Spicy foods, foods that
have a lot of acid (like
tomatoes and oranges),
and coffee can make
heartburn
symptoms
worse in some people. If
your symptoms are worse
after you eat a certain
food, you may want to
stop eating that food to
see if your symptoms get
better.
Do not smoke or chew
tobacco.
If you get heartburn at

night, raise the head of

your bed 6 in. (15 cm)to 8
in. (20 cm) by putting the
frame on blocks or placing
a foam wedge under the
head of your mattress.
(Adding extra pillows does
not work.)
Do not wear tight clothing
around your middle. Lose
weight if you need to.
Losing just 5 to 10 pounds
can help.
10 WAYS TO STOP HEARTBURN
Don't Overeat
Don't Eat Too Quickly
Don't Eat the Foods That Can
Trigger Your Heartburn
Don't Go Out To Eat Unprepared
Don't Go To Bed Too Soon After
Eating
Don't Lay Flat When You Sleep
Don't Smoke
Don't Drink Too Much Alcohol
Don't Wear Clothes That Are Too
Tight
Don't Get Too Stressed

REFERENCES: National Cancer Institute (2013)

http://heartburn.about.com/od/dailylife/tp/10-Things-To-Stop-Doing-If-Have-Heartburn.htm
Gilson, S.,2014; About Health
http://www.emedicinehealth.com/heartburn/article_em.htm
http://www.rxlist.com/heartburn/drugs-condition.htm
http://www.patienteducationcenter.org/articles/preventing-heartburn/

Saint Louis University

School of Nursing
Baguio City

TEACHING CARE PLAN

(SLU HOSPITAL PALLIATIVE WARD)
February 19, 2015

Submitted by: Arlyn R. Nicomedez

BSN4-B1
Submitted to: Mrs. Maria Elena Garcia
Clinical Instructor

. Don't Overeat

Large meals expand your stomach and

increase upward pressure against thelower
esophageal sphincter (LES - the valve between
your esophagus and your stomach), which can
lead to heartburn. Try these tips:
Eat 6 smaller meals each day instead
of 3 larger ones. This will help keep the
stomach from becoming too full, and will also
help prevent excessive production of stomach
acid.

Three smaller meals and three snacks

can also help.
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Put your fork or spoon down between

bites

Chew your food thoroughly before

swallowing

Chew 20 times or count to 20 before

the next bite

2. Don't Eat Too Quickly

Take smaller bites

3. Don't Eat the Foods That Can Trigger
Your Heartburn

When we eat too fast, it is harder for

our digestive system to perform the way it
should. We could end up suffering from poor
digestion and increases your chances of
experiencing heartburn.
Some way to help you slow down while eating:

There are a couple reasons why some foods

cause heartburn: 1) When the lower
esophageal sphincter relaxes when it shouldn't;
or (2) when the stomach produces too much
acid.

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When the LES is the culprit, food and stomach

acid come back up into your esophagus. Some
of the foods that can relax the LES include:

prepared, avoid certain beverages, and

watch portion sizes, you can prevent the
heartburn.
What you should look for and ask for when in a
restaurant:

Fried (greasy) foods

High-fat meats

White meat

Creamy sauces

Lean cuts of meat

Whole-milk dairy products

Chocolate

Peppermint

6. Don't Lay Flat When You Sleep

Caffeinated beverages (e.g., soft

drinks, coffee, tea, cocoa)
Foods that may stimulate acid production and
increase heartburn include:
Caffeinated beverages

Carbonated beverages

Alcohol

Spicy foods

Citrus fruit and juices (e.g., orange,

grapefruit)

Tomato-based products
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Sandwiches with turkey, chicken, or

roast beef on whole grain bread

Grilled foods
Broth-based soups

Steamed vegetables

Baked potatoes topped with low-fat

salad dressing
Low-fat or no-fat salad dressings
Lighter desserts, such as angel food
cake
Dining at Chinese, Mexican, or Italian
restaurants may be more difficult, since food at
these restaurants may contain more
ingredients that can trigger your heartburn. It
is possible to enjoy dining there if you know
what to avoid. This information and more is
included in this article on eating out without
heartburn.
5. Don't Go To Bed Too Soon After Eating

Wait at least two to three hours after

eating to go to bed
Avoid late night snacking
If one of your meals ends up being
larger than the others, aim to eat that meal for
lunch instead of supper
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Lying down flat presses the stomach's contents

against the LES. With the head higher than the
stomach, gravity helps reduce this pressure.
You can elevate your head in a couple of ways:
You can place bricks, blocks or
anything that's sturdy and securely under the
legs at the head of your bed
You can use wedge-shaped pillow
under your head and shoulders
7. Don't Smoke
If you smoke, you should consider quitting.
Smoking can cause many health problems, and
heartburn is one of them. This is especially true
of those persons with GERD. Some of the
ways smoking can increase the odds of
suffering from heartburn include:
Reduced Saliva Production
Saliva is alkaline, so it can help neutralize
stomach acid. Saliva can also relieve heartburn
by bathing the esophagus and lessening the
effects of acid refluxed into the esophagus by
washing it back down to the stomach.

Changes in Stomach Acid

Smoking can increase the production of
stomach acid. It may also promote the
movement of bile salts from the intestine to
the stomach, which makes the stomach acids
more harmful.

Impairs the Functioning of the

Lower Esophageal Sphincter
Smoking can weaken and relax the LES, which
is a valve at the junction between esophagus
and stomach. If the LES isn't working properly
or relaxes inappropriately, stomach contents
can reflux back up into the esophagus.

Lying down with a full stomach can cause

stomach contents to press harder against the
lower esophageal sphincter (LES), increasing
the chances of refluxed food. Try these tips:

4. Don't Go Out To Eat Unprepared

Knowing what is safe for you to eat and what
you need to avoid is as important for eating out
in restaurants as it is for eating at home. You
need to know what to ask for and what you
should avoid. When you ask how the food is

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Damage to the Esophagus

Smoking may directly injure the esophagus,
making it even more susceptible to
furtherdamage from acid reflux.
8. Don't Drink Too Much Alcohol
Alcohol increases the amount of acid the
stomach produces, and relaxes the lower
esophageal sphincter (LES). If you do want to
have some alcohol during your festivities, try
the following tips:

Dilute alcoholic beverages with water

or club soda.

Limit alcohol consumption to 1 or 2

mixed drinks, no more than 16 ounces of wine,
or and no more than 3 beers.

Drink white wine instead of red wine.

Choose non-alcoholic beer or wine.

Keep track of which alcoholic drinks

aggravate your heartburn, and avoid them as
much as possible.
9. Don't Wear Clothes That Are Too Tight

Clothing that fits tightly around the abdomen,

such as tight belts and waistbands, can
squeeze the stomach, and force food up
against the LES. This can cause stomach
contents to reflux into the esophagus.
10. Don't Get Too Stressed
Stress hasn't been shown to actually cause
heartburn. It can, however, lead to behaviors
that can trigger heartburn. During stressful
times, routines are disrupted and you may not
follow your normal routines in regards to
meals, exercise and medication. Since your
stress may indirectly lead to heartburn, it is
important to find ways to alleviate the stress,
and thus make stress-related heartburn less
likely.

Mechanism of action
Amlodipine is a dihydropyridine calcium antagonist (calcium ion antagonist or slow-channel blocker) that inhibits the movement of calcium ions into vascular
smooth muscle cells and cardiac muscle cells. Experimental data suggest amlodipine binds to both dihydropyridine and nondihydropyridine binding sites. The
contractile processes of cardiac muscle and vascular smooth muscle are dependent upon the movement of extracellular calcium ions into these cells through
specific ion channels. Amlodipine inhibits calcium ion influx across cell membranes selectively, with a greater effect on vascular smooth muscle cells than on
cardiac muscle cells. Negative inotropic effects, or decreased heart muscle contractility, can be detected in vitro, but such effects have not been seen in intact
animals at therapeutic doses. Serum calcium concentration is not affected by amlodipine. Within the physiologic pH range, amlodipine is an ionized compound
(pKa = 8.6), and its interaction with the calcium channel receptor is characterized by a gradual rate of association and dissociation with the receptor binding
site, resulting in a gradual onset of effect.

Amlodipine is a peripheral arterial vasodilator that acts directly on vascular smooth muscle to cause a reduction in peripheral vascular resistance and reduction
in blood pressure. Also, as a calcium channel blocker amlodipine is expected to inhibit the currents of L-type Cav1.3 channels in the zona glomerulosa of
the adrenal cortex, reducing aldosteroneproduction and corroborating to lower blood pressure.
Amlodipine belongs to a class of medications called calcium channel blockers (CCBs). These medications block the transport of calcium into the smooth
muscle cells lining the arteries of the heart (coronary arteries) and other arteries of the body. Since the action of calcium is important for muscle
contraction, blocking calcium transport relaxes arterial muscles and expands (dilates) coronary arteries and other arteries of the body. By dilating
coronary arteries, amlodipine increases the flow of blood to the heart and is useful in preventing heart pain (angina) resulting from reduced flow of
blood to the heart caused by coronary artery spasm (contraction). Relaxing the muscles lining the arteries in the rest of the body lowers blood pressure,
which reduces the work that the heart must do to pump blood to the body. Reducing the work of the heart also lessens the heart muscle's need for
oxygen, and thereby further helps to prevent angina in patients with coronary artery disease.

y it is prescribed (Indications) :
This combination medication contains proton pump inhibitor and an antidopaminergic agent, prescribed for dyspepsia and gastro-esophageal reflux disease.
When it is not to be taken (Contraindications):
Hypersensitivity and lactation.
Pharmacokinetics
Pantoprazole acts by selectively inhibiting the H+/K+-ATPase enzyme in the secretory canaliculus of the stimulated parietal cell. Domperidone stimulates GI
activity by acting as a competitive antagonist at dopamine D2-receptors.
Pantoprazole 40mg and Domperidone 30mg Sustained release (SR) Capsule containing Sodium.
The sodium bicarbonate works by slowing the breakdown of the PPI in the stomach, which helps to increase absorption of the PPI.
2 in 1 combination tablet of Pantoprazole 40mg +Domperidone 30mg.
Mechanism of Action[edit]
Domperidone is a peripheral dopamine (D2) and (D3) receptor antagonist. It provides relief from nausea by blocking receptors at the chemo-receptor trigger
zone (a location in the nervous system that registers nausea) at the floor of the fourth ventricle (a location near the brain). It increases motility in the upper
gastrointestinal tract to a moderate degree and increases [4] lower esophageal sphincter pressure by blocking dopamine receptors in the gastric antrum and
the duodenum. It blocks dopamine receptors in the posterior pituitary gland increasing release of prolactin which in turn increaseslactation.[5][6] Domperidone
may be more useful in some patients and cause harm in others by way of the genetic characteristic of the person, such aspolymorphisms in the drug
transporter gene ABCB1, the potassium channel KCNH2 gene, and 1Dadrenoceptor ADRA1D gene
Altered comfort: dyspepsia
related to:

1.

impaired fat digestion associated with bile flow

obstruction;

2.

reflux of gastric contents associated with increased intraabdominal pressure resulting from ascites;

3.

impaired gastrointestinal functioning associated with

venous congestion in the gastrointestinal tract (portal
hypertensive gastropathy) resulting from portal
hypertension;

4.

D.

encourage client not to smoke

E.

encourage client to avoid the following foods/fluids:

esophagitis/gastritis associated with the irritant effect of

chronic alcohol ingestion on the esophageal and gastric
mucosa.
Desired Outcome

The client will verbalize relief of dyspepsia.

Nursing Actions and Selected Purposes/Rationales

1.

Assess client for signs and symptoms of dyspepsia (e.g. reports of

epigastric discomfort, heartburn, nausea, or feeling of fullness or
bloating; frequent eructation).

2.

Determine if particular foods/fluids contribute to dyspepsia.

3.

Implement measures to reduce dyspepsia:

A.

perform actions to reduce gastroesophageal reflux:

I.

keep head of bed elevated for 2-3 hours after

meals

II.

provide small, frequent meals rather than large

ones

B.

perform actions to restore fluid balance (see Diagnosis

2) in order to promote the resolution of ascites and
subsequently reduce abdominal pressure and the
associated gastroesophageal reflux and feeling of
fullness and bloating

C.

instruct client to ingest foods and fluids slowly

F.

I.

those high in fat (e.g. fried foods, gravies,

butter, cream, ice cream)

II.

carbonated beverages

III.

gas-producing foods (e.g. beans, onions,

cabbage)

IV.

those that may cause gastric irritation (e.g. spicy

foods; caffeine-containing beverages such as
coffee, tea, and colas; alcohol)

administer the following medications if ordered:

The Food and Drug Administration warned today that people who
take the blood thinner clopidogrel (Plavix) should not take the
heartburn drugs omeprazole (Prilosec, Prilosec OTC, and
generics) and esomeprazole (Nexium) because two new studies
confirm that the combination could have dangerous
consequences. The studies show that omeprazole and
esomeprazoleboth members of a class of stomach acidreducing drugs called proton pump inhibitors, or PPIscan lower
the effectiveness of Plavix , putting people at risk of heart attacks
or strokes.
Plavix is given to people after a heart attack to help reduce the
risk of blood clots that can trigger another attack. The drug can be
hard on the stomach and cause gastrointestinal bleeding, so
people are often prescribed a PPI treatment, which reduces the
amount of acid in the stomach and lowers the risk of stomach
bleeding. But previous studies suggested this drug combination

may actually increase the risk of having another heart attack. The
FDAs warning is based on two new studies from the makers of
Plavix that show that both omeprazole and esomeprazole reduce

the drugs effectiveness because they block an enzyme in the

body called CYP 2C19