Video Case Study - Gastroesophageal Reflux Disease

Nurse Max works in a primary care office and is caring for Anuja, a 54-year-old woman with a history of gastroesophageal reflux disease, or GERD, who's being seen for a three-month follow-up appointment. After settling Anuja in her room, Nurse Max goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Anuja's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Max recognizes important cues including vital signs which are temperature 98.2 F or 36.9 C, heart rate 76 beats per minute, respirations 14 breaths per minute and regular, blood pressure 128/84 mmHg, and oxygen saturation 98 percent on room air. Nurse Max asks Anuja if she's having pain, and she reports a burning in her mid upper abdomen after eating, despite taking her prescribed medication.

Next, Nurse Max analyzes these cues. They review the electronic health record, or EHR, and note Anuja has been on proton pump inhibitor, or PPI, therapy for three months to treat her GERD. Nurse Max then talks to Anuja about her lifestyle modifications.

Nurse Max: I'm glad you've been taking your PPI every day and I'm sorry it hasn't been working for you. I want to figure out what might be happening. What time do you take your medication?

Anuja: I take it every night after dinner. I set an alarm, so I don't forget.

Nurse Max: Setting an alarm is a great idea! What do you typically eat at home?

Anuja: I've been making a noodle dish lately with lots of fresh jalapenos drizzled with sriracha, my family loves it!

Now, using the information they've gathered, Nurse Max chooses a priority hypothesis of knowledge deficit.

Then, they generate solutions to address this problem that will include pharmacologic and nonpharmacologic interventions, and they establish the outcome that after intervening, Anuja will verbalize an understanding of GERD management.

Nurse Max then takes action to implement these solutions. Max can tell from the conversation that Anuja has misunderstood the initial instructions about medication administration and lifestyle modifications for GERD. They know she needs additional education to manage her condition at home.

Nurse Max: You're right to take your PPI every day, but it'll be more effective if you take it before the first meal of the day.

Anuja: Okay, I can do that. I'll change the time of the alarm I've set.

Nurse Max: Great! It'll also improve your symptoms if you adjust your diet. It seems like you really like spicy foods, but unfortunately this can make your GERD worse.

Anuja: I do love spicy foods, but I can make those changes if it'll help. Is there anything else I should do?

Nurse Max: You also should avoid eating three hours before you go to bed and avoid lying down after meals. There are some other lifestyle modifications you can make, but first, let me get a pamphlet to explain everything and then we can review it afterwards.

Then, Nurse Max evaluates the outcome of their interventions. Anuja verbalizes an understanding of the education and states she'll bring home the pamphlet to reference when needed. Nurse Max also ensures Anuja has an active prescription for her PPI and instructs her to monitor her symptoms to check back in three weeks to see if the lifestyle changes and PPI adherence have helped.

Alright, as a quick recap…. Nurse Max recognized and analyzed cues related to Anuja's knowledge deficit and prioritized hypotheses and generated solutions to address this problem. They then took action to implement pharmacologic and nonpharmacologic measures to address Anuja's GERD and evaluated outcomes by comparing them to the expected outcomes. Since Anuja verbalized understanding of the education, Anuja Nurse Max concludes their plan of care was successful.