# A nurse is developing a care plan for a client diagnosed with gastroesophageal reflux disease (GERD) who reports frequent heartburn and regurgitation, especially at night. Which intervention is most appropriate to include in the client's plan of care?

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> subject: Adult Health

## 문제

A nurse is developing a care plan for a client diagnosed with gastroesophageal reflux disease (GERD) who reports frequent heartburn and regurgitation, especially at night. Which intervention is most appropriate to include in the client's plan of care?

## 보기

1. Elevate the head of the bed 6-8 inches **✔ 정답**
2. Administer antacids 30 minutes before meals
3. Encourage the client to drink milk to neutralize stomach acid
4. Advise the client to lie down immediately after eating

**정답: 1**

## 해설

Elevating the head of the bed uses gravity to prevent nocturnal reflux, making it the most effective non-pharmacological intervention. Other options are less appropriate: antacids are given after meals, milk can stimulate acid secretion, and lying down after eating increases reflux risk.

## 심화 해설

Understanding the Pathophysiology

Gastroesophageal reflux disease (GERD) occurs when the lower esophageal sphincter (LES) relaxes inappropriately or has reduced tone, allowing acidic stomach contents to flow back into the esophagus. This leads to the classic symptoms of heartburn and regurgitation. In an upright position during the day, gravity helps keep gastric contents in the stomach. However, when a client lies flat, especially at night, this gravitational protection is lost, and the supine position facilitates the passive reflux of acid, causing nocturnal symptoms and potential esophageal damage .

Why Elevating the Head of the Bed is the Priority Intervention

The most appropriate non-pharmacological, lifestyle-modification intervention for nocturnal GERD symptoms is to elevate the head of the bed by 6-8 inches. This is a cornerstone of GERD management . The mechanism is purely physical: by raising the upper body, gravity is used to retain gastric contents in the stomach and promote esophageal acid clearance. This simple mechanical barrier to reflux is highly effective for preventing nighttime symptoms without the need for immediate medication. It directly addresses the client's chief complaint of heartburn and regurgitation "especially at night."

Analysis of Incorrect Options

- Option 2: Administer antacids 30 minutes before meals. While antacids are a pharmacologic agent used in GERD management, their standard timing for symptom relief is typically 1 hour after meals and at bedtime, not before meals. Administering an antacid before a meal would neutralize existing acid but would be quickly overwhelmed by the acid produced in response to the meal itself, providing minimal benefit for postprandial heartburn .

- Option 3: Encourage the client to drink milk to neutralize stomach acid. This is outdated and counterproductive advice. While milk may initially buffer stomach acid, its high calcium and fat content subsequently stimulates gastric acid secretion, leading to a rebound effect that can worsen heartburn. This intervention is not supported by current evidence-based lifestyle modifications for GERD .

- Option 4: Advise the client to lie down immediately after eating. This instruction would exacerbate GERD symptoms. Lying down after a meal eliminates the effect of gravity, increases intra-abdominal pressure on a full stomach, and promotes reflux. The evidence-based recommendation is to remain upright for at least 3 hours after eating and to avoid late-night meals .

Integrating Evidence into Practice

The management of GERD is built upon a foundation of lifestyle modifications, with head-of-bed elevation being a primary, evidence-based intervention for nocturnal symptoms . While pharmacologic therapy, such as proton pump inhibitors (PPIs), is central to treatment, addressing mechanical factors is equally critical, especially for patients who remain symptomatic despite acid suppression . A care plan that combines this positional therapy with other modifications, such as avoiding recumbency after meals, provides a comprehensive non-pharmacological strategy to reduce esophageal acid exposure and improve sleep quality .

## 임상 시나리오

Non-Pharmacological Management of Nocturnal GERDPrioritizing Gravity-Dependent Positioning
The cornerstone intervention for nighttime reflux is elevating the head of the bed by 6-8 inches using blocks or a wedge. This uses gravity to keep gastric contents in the stomach and is more effective than stacking pillows, which can increase intra-abdominal pressure.

Lifestyle modifications should be taught alongside positioning. Advise the client to avoid recumbent positions for at least 3 hours after meals and to identify and eliminate dietary triggers such as fatty foods, caffeine, and chocolate.

CautionDo not recommend milk as an antacid. Although it provides initial buffering, its high calcium and protein content stimulates rebound gastric acid secretion, which can paradoxically worsen symptoms.

## 핵심 개념

- **GERD** — Gastroesophageal reflux disease; a chronic condition where stomach acid flows back into the esophagus due to lower esophageal sphincter dysfunction.
- **Lower Esophageal Sphincter (LES)** — A ring of muscle at the junction of the esophagus and stomach that normally prevents reflux by maintaining a high-pressure zone.
- **Gravity in GERD Management** — An upright or elevated position uses gravity to help retain gastric contents in the stomach and promote esophageal acid clearance.

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