LUQ pain, Hx of GERD, and aggravated pain with movement

[jadilla]

I am a nursing student and I am doing my clinicals now.  I have to construct a nursing care plan for my patient, but I am a little confused.  
   I know that aggravation with GERD is supposed to diminish if the pt. sits upright and does not lay down right after eating.  However, my patient's pain worsens with position changes, and his pain seems to correlate with Fowler's rather than supine positioning.  He guards the LUQ and says that the pain is sharp and intermittent.  He is 94 years old, has Hx of renal failure, glaucoma, cataracts, prostatic hypertrophy, diabetes, HTN, hypothermia, and vertigo.  He fell at the nursing home, and they sent him to MedSurg. The doctor d/c'd his sugar pill and changed his insulin orders to sliding scale about a week ago.  Enzyme levels were elevated in his liver. No Hx of smoking, no adventitious lungs sounds, though his lung sounds are diminished in the LLL and RLL.  His RR is irregular as well.  He breathes through his mouth and uses accessory muscles for breathing. His breaths are shallow and rapid.  His BP is WNL, and his SpO2 is 99% room air, RR is 25 BPM, P is 64 irreg, predictable rhythm, T 96.2, BP 106/62

I don't know what to teach him because I don't know why the pain increases rather than diminishes when he is sitting upright.  He has so much going on with him that I can't figure out what may be causing the pain in Fowler's position.

[nurseaudrea]

You say his pain worsens after he eats? Have gall bladder disease or ulcers been ruled out? Sometimes what you eat can cause stomach pains to worsen , especially with GERD. With ulcers, though, eating sometimes helps to relieve the pain. Tuck had some great advice. I also noticed you said his liver enzymes were elevated as were his RR. Maybe the pain is causing the increased RR .The use of accessory muscles would make me think he's working harder to breathe. Have you tried to get him to use an inspirometer? That would help him learn to use the lower lobes as well. You sound like you are really trying your best to figure this out and make the best plan possible for your patient. You will make a great nurse because how much you care really shows through. Like Tuck said, we need more like you in the field. Too many nurses have gotten cold and have forgotten what it's like to be the patient.

[jadilla]

thank you very much.  You really helped me a lot. As a matter of fact, I have noticed that his pain usually follows meals.  I think that the high respiratory rate may be related to his pain.  When conversing, he sometimes pauses to inhale more.  I asked him if he can breathe through his nose, and he can and does while I am taking his temp.  I don't know about the diminished breath sounds.  The only thing I can think of is lack of activity in the bottoms of his lungs because of his breathing pattern and because of his limited ambulatory abilities. I hope not, though, because he may catch pneumonia!  I will teach him to lay on his right side, too.  I never thought about teaching him that.  
Thanks again, and good luck to you in the future!  I would have never reached a solution without your help.  I feel better now because I konw how to help him without hurting him.

[Tuckamore]

Hello Jadilla,

I hope you are aware that there are no physicians or professionals on this forum. Our members have a wealth of personal knowledge and experience. And they rock when you need support.

With that said I have been were you are. Clinicals and instructors can be challenging but what a learning process!! I have severe GERD (refused surgery) and a hiatal hernia. I know everyone is different but my symptoms increase when I am supine only if I have eaten a large or tomatoe based meal.

I question if his LUQ pain is actually related to his GERD or if he has something else going on that has not been diagnosised. I bet you are having the same questions. His VS are all basically WNL other than the 25BMP. Is that being attributed to pain? And is there a diagnosis that accounts for diminished breath sounds in his lower lobes? Could he have a inflammatory process such as Tietze syndrome, costochondritis, arthritis or a similar process going on that could account for his pain? At 94 I am guessing that no heroic are desired and this may just be a comfort admission to stabilize him for return to the Nrsg Home. I do hope they are treating his pain.

If you followed GERD protocol your patient teaching would include maintaining a similarity to the Fowler's position. If your patient is more comfortable supine than Fowler's there is research that concludes there is more GERD (including symptoms)when positioned supine, right lateral compared to supine and left lateral positions. I'm sure that has to due with the structure of the stomach. Sometimes we have to teach what is right for our patients and in your 94 year old patients case I would instruct him to that is supine is most comfortable than ask him to at least lay on his right side. At his age comfort is the name of the game.

I would also make the supervising nurse aware of his symptoms and your concerns. His PCP may decide to preform a few more diagnostics. Although I am sure you have already gone that route. Your concern and caring for your patients comes through in your post. You will make the health care system a better place when you enter it. Good luck to you.  Peace, Tuck