A Case Study on

Achalasia

In Partial Fulfillment of the Requirement in

Related Learning Experience 109

Submitted to:

Ms. Jane Wisdom Gallana

Clinical Instructor

Submitted by:
Jennifer B. Lorenzana
Trizia Deanne L. Omol
Jean anthonette P. McGinley
Ryan Greg L.Molina
March 31, 2022

TABLE OF CONTENTS:

1
I. ABSTRACT ----------------------------------------------------------------------- 4

II. ACKNOWLEDGEMENT ----------------------------------------------------- 5

III. INTRODUCTION -------------------------------------------------------------- 6●

Background of the study
● Reasons of choosing such case for presentation
● The significance of the case study in relation to the theme
● Scope and Limitations of the Study

IV. SIGNIFICANCE OF THE STUDY -------------------------------------------- 10

● Nursing Education
● Nursing Practice
● Nursing Research

V. OBJECTIVES OF THE STUDY -------------------------------------------- 11 ●

General Objectives
● Specific Objectives

VI. PATIENT’S PROFILE ---------------------------------------------------- 12 - 16 ●

Demographic Data
● Vital Signs
● Input and Output
● Nursing Health History
● Physical Assessment
o Diagram of Body
● Developmental Data

● VII. ANATOMY AND PHYSIOLOGY ------------------------------------------- 17

VIII. PATHOPHYSIOLOGY ---------------------------------------------------- 18 ●

Narrative
● Diagram

IX. DIAGNOSTIC TESTS ----------------------------------------------------

X. MEDICAL AND SURGICAL MANAGEMENT ------------------------- 23- 26

● Ideal
● Actual
o Drug study
o Procedures / Surgeries

XI. NURSING CARE MANAGEMENT ------------------------------------------- 44 - 49 ●

Nursing Care Plan #1
● Nursing Care Plan #2
● Nursing Care Plan #3

XII. DISCHARGED PLAN ------------------------------------------------------------- 28-31●

Long term goal discharge plan
● Medication
● Treatment therapy
● Health teachings hygiene
● Outpatient
● Diet

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 ● Spirituality

XIII. EVALUATION, RESULTS, AND DISCUSSION ------------------------- 32

XIV. APPENDICES
● Definition of terms
● Bibliography

I. Abstract

This is a case study of a 63-year-old male, who was admitted in Capitol

3
University Medical Center last March 23, 2022 with the diagnosis of Achalasia and
complained nausea and vomiting, his pain scale was 7/10. Achalasia is a rare disorder
that makes it difficult for food and liquid to pass from the swallowing tube connecting
your mouth and stomach (esophagus) into your stomach. Achalasia occurs when
nerves in the esophagus become damaged. As a result, the esophagus becomes
paralyzed and dilated over time and eventually loses the ability to squeeze food down
into the stomach. Food then collects in the esophagus, sometimes fermenting and
washing back up into the mouth, which can taste bitter. Some people mistake this for
gastroesophageal reflux disease (GERD). However, in achalasia the food is coming
from the esophagus, whereas in GERD the material comes from the stomach.
The study made use of the three C‘s (core, care cure) management approach,
anchored to the nursing theory of Lydia Hall. This case study includes the ideal and
actual interventions related to the disease condition. Significant limitations to the study
included the inadequacy of the facilities available at the clinical settingMedical surgical
book volume 2 was able to identify various factors that contributed to the present
condition by understanding the pathophysiology of the disease. From this, appropriate
medical and nursing interventions were derived. This study will benefit the nursing
profession both in the clinical area and the nursing students in Capitol University.
Management of patients with achalasia and similar conditions can still be improved. At
best, these occurrences can be prevented given the proper management.

Keywords: achalasia, Gerd, esophagus

II. ACKNOWLEDGEMENT

Throughout the rotation, the group had gained knowledge from the experiences
they had on the medical ward. The memories were also worth keeping and sharing. As
a result, our group would like to express its sincere appreciation to the individuals and

4
organizations listed below for their contributions to the group's achievement in
conducting the case presentation.
First and foremost, we thank our Almighty God for providing us with insight,
knowledge, guidance, love, and strength, which greatly aided the group in completing
our case presentation. Despite the group's hardships and stumbling blocks. He
continues to give us optimism that we will be able to complete this study successfully.

To Mrs. Jane Wisdom J: Gallana RN, USRN, our clinical instructor, for her
competence, patience, and unwavering support during our tasks, and for serving as role
models for excellent and holistic nursing care. Thank you for sharing your knowledge
and bringing discipline to the academic and clinical settings with your skills. Because of
your leading nature, the group learned a lot during our hospital exposure and was able
to complete the case study. And lastly, to all the staff of the Capitol University Medical
Center - Medical Ward, for being willingly responding to the researcher's questions and
for being accommodating during our duty. We offer this success and completion of our
case study to these people.

III. INTRODUCTION
Case
“A 63-year old patient who was recently diagnosed with achalasia reported nausea and

5
vomiting. The 2 years prior patient had onset of epigastric discomfort associated with
substantial pain and regurgitation. 5 day prior still with epigastric discomfort associated
with utilization 6-8 times a day.

According to Lydia Hall‘s Care, Core and Cure Model ―Nursing is participation in care,
core and cure aspects of patient care, where CARE is the sole function of nurses,
whereas the CORE and CURE are shared with other members of the health team. The
major purpose of care is to achieve an interpersonal relationship with the individual that
will facilitate the development of the core” In this same thought, we as health providers
are called to the responsibility of promoting health through providing strategic care to
patients and to actively involve in the development of the nursing profession. It is in the
light of this cause this case study was made.

Background of the study

● Difference between achalasia and Gerd

Achalasia is a motility disorder characterized by esophageal aperistalsis and

nonrelaxation of the lower esophageal sphincter (LES).
Gastroesophageal reflux disease (GERD) is a condition that develops when reflux of
gastric contents causes symptoms and complications.

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Definition

Achalasia is a rare disorder that makes it difficult for food and liquid to pass from the
swallowing tube connecting your mouth and stomach (esophagus) into your stomach.

Achalasia occurs when nerves in the esophagus become damaged. As a result, the
esophagus becomes paralyzed and dilated over time and eventually loses the ability to
squeeze food down into the stomach. Food then collects in the esophagus, sometimes
fermenting and washing back up into the mouth, which can taste bitter. Some people
mistake this for gastroesophageal reflux disease (GERD). However, in achalasia the
food is coming from the esophagus, whereas in GERD the material comes from the
stomach.

Achalasia is a rare disorder that mostly affects adults between the ages of 25 and 60
years. However, this disorder may occur at any age, including during childhood.
Achalasia affects males and females in equal numbers except in cases that appear to
reflect an inherited form. The disease was unique since it is a no cure disease which
means it will be researched for a long time.

Etiology

According to (Ifeanyi I. Momodu1; Jason M. Wallen2.) Achalasia is thought to occur from the
degeneration of the myenteric plexus and vagus nerve fibers of the lower esophageal
sphincter. There is a loss of inhibitory neurons containing vasoactive intestinal peptide
(VIP) and nitric oxide synthase at the esophageal myenteric plexus, but in severe
cases, it also involves cholinergic neurons. The exact etiology of this degeneration is
unclear though many theories have been proposed. These theories include an
autoimmune phenomenon, viral infection, and genetic predisposition. Most cases seen
in the United States are primary idiopathic achalasia; however, secondary achalasia
may be seen in Chagas disease caused by Trypanosoma cruzi, esophageal infiltration
by gastric carcinoma, eosinophilic gastroenteritis, lymphoma, certain viral infections,
and neurodegenerative disorders.

Causes

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The exact cause of achalasia is poorly understood. Researchers suspect it may be
caused by a loss of nerve cells in the esophagus. There are theories about what causes
this, but viral infection or autoimmune responses have been suspected. Very rarely,
achalasia may be caused by an inherited genetic disorder or infection.

Signs and symptoms

Achalasia symptoms generally appear gradually and worsen over time. Signs and
symptoms may include:

● Inability to swallow (dysphagia), which may feel like food or drink is stuck in your
throat
● Regurgitating food or saliva
● Heartburn
● Belching
● Chest pain that comes and goes
● Coughing at night
● Pneumonia (from aspiration of food into the lungs)
● Weight loss
● Vomiting

Reason for choosing the case

The main reason for choosing Achalasia as our case topic is because achalasia is a
rare condition that is rarely associated in the Philippines and this topic will definitely
broaden our knowledge and enhance our nursing practice. The group chose this topic
because this can help us as nurses manage the complication and make assessments to
help the client.

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The significance of the case study in relation to the theme

This case study will help us better understand the disease process of the patient.This
also helps us in identifying the primary care need of the patient with achalasia. After
identifying such needs and health problems, we can now formulate a nursing care plan
for the patient that would address these needs and problems effectively. Through the
effective management of the problem present it will help the patient recover faster and
maintain a holistic sense of wellness while in the hospital. This case study would equip
us with knowledge, skills, and attitude on how to manage future patients with the same
or similar problem.

Scope and Limitations of the Study

This case study is about achalasia. It includes the concept of relating to the condition
of a patient's history and profile, assessments and clinical manifestations. The anatomy
and physiology with associated factors are also included. The Medical Management
along with the discharge plans and other relevant data are also covered. The scope of
this group would be to have a broad understanding about achalasia and to have an
improved nursing management on caring with patients with this type of rare condition.
During our duty last march 27,2022 and march 28,2022. Nursing Management covers
the above mentioned dates which encompasses the client‘s Recovery Phase.
The areas of concern are limited to the discussions of achalasia and the quality of
Nursing Care to the patient.

IV. SIGNIFICANCE OF THE STUDY

Nursing Education
This study can be a useful learning guide in nursing education as this can be
used by the students as a reference for future studies regarding Achalasia. This study
will enable the nursing student to learn how to assess patients with achalasia and be
able to provide appropriate nursing care and management.It gives a great opportunity
for nursing students to learn about the nursing interventions and have an idea of a
rationale behind its actions.This condition is a rare one, so In this way, they are
acquiring more knowledge about the disease that they can use to further develop their
skills as student nurses and future nurses. It may open a new door in the practice of
getting quality care.

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Nursing Practice
This study can give a good introduction to the disorder so that an established
nursing action can be quickly utilized. And through discovering and rediscovering, and
trial after trial of innovative interventions and facilitation of this condition, a more
advanced nursing management may be developed.This study can be used as a tool
and guide for nursing practice.

Nursing Research
This case study can be used as a baseline data for further research. This might
be beneficial as a simple academic informative material, and serve as a guide for
orienting people about the substance of the disease. This study can be used as a
reference for better nursing intervention and management.

V. OBJECTIVES OF THE STUDY

General Objectives:
This case presentation seeks to enhance the student‘s knowledge regarding the general
health and condition of a patient suffering from achalasia, its process, possible
complications, treatment plan, and medical-nursing interventions.

Specific Objectives:
Aims to:
1. Accurately present a thorough general assessment of the client which includes
physical assessment and family history taking.
2. Effectively identify signs and symptoms exhibited by a patient that suffers from
achalasia.
3. Thoroughly discuss, explain and elaborate the nature of the condition and its
process.
4. Efficiently provide appropriate and proper nursing diagnosis in line with the
client‘s medical condition and skillfully formulate nursing care plans for the
problems identified.
5. Appropriately apply nursing interventions necessary for the patient‘s condition in
reference with the learned theories and concepts of the achalasia

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VI. PATIENT’S PROFILE

Demographic Data

Patient Paderog is a 63-year-old male who was born on December 23, 1958. The
patient is living with his wife in Villanueva, Misamis Oriental. His parents are both
Filipinos.

Vital Signs

The initial assessment was done last March 27, 2022. The vital signs were as follows:
Blood pressure 100/60 mmHg, Pulse Rate 72 bpm, Respiratory Rate 17 CPM,
Temperature 35.7c, 02 Saturation 93%, Intake 1020ml. Output 500ml

TIME BP HR RR O2 SAT TEMP

4 PM 100/60 72 17 93 35.7

8 PM 120/70 60 20 93 35.7

Input-Output

DATE TIME ORAL IV TPN TOTAL STOOL URINE TOTAL

03/27/2 3-11 60 640 320 1,020 0 500 500

2

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Nursing Health History

The following medical history includes a medical history of the patient's medical
condition. They considered it important to include factors that may contribute to the
patient's current health.

Chief Complaint

Patient Paderog was brought to Capitol University Medical Center (CUMC) last March
23, 2022, with the chief complaint of vomiting.

HISTORY OF PATIENT ILLNESS

2 years the prior patient had onset of epigastric discomfort associated with substernal
pain and regulation weight loss, (-) Melena sugar consult and managed of gastritis 5
days prior still with epigastric discomfort is associated with utilizing in 6-8c/day 1 day
prior: noted common stool.

FUNCTIONAL HEALTH PATTERN

Patient Paderog is not an alcohol drinker and not a cigarette smoker. He is not using
illicit drugs. Patient Paderog loves to drink coffee and can drink 2-4 glasses of coffee
and he doesn’t have any allergies.

NUTRITIONAL and METABOLIC PATTERN

Patient Paderog has a poor appetite due to vomiting, he likes to eat anything his wife
can provide at the table.

Patient is 159 cm in height and 59 kg in weight.

ELIMINATION PATTERN

Patient Paderog doesn’t have any problems with defecating, patient void 2-3 times a
day.

Activity-Exercise Pattern

Patient Paderog was able to do a range of motion exercises, he enjoys watching TV

and he also does some walkins in the room.

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Done during initial assessment March 23, 2022

ACTIVITIES OF DAILY LIVING PATIENT’S FUNCTIONAL SCORE

ABILITIES
Feeding Dependent Assisted with
person

Bathing Dependent Assisted with

person

Toileting Dependent Assisted with

person

Bed Mobility Dependent Assisted with

person

Grooming Dependent Assisted with

person

General Mobility Dependent Assisted with

person

ROM Dependent Assisted with

person

Sleep-Rest Pattern

Patient Paderog has difficulty sleeping at night due to vital sign monitoring and night
noises; he has no history of sleep disturbances; and he does not take any sleeping
medication because he has never had difficulty sleeping before.

Cognitive-Perceptual Pattern

Patient paderog does not have any hearing or vision problems. He also stated
that his memory had not changed recently and that he had no difficulty learning
simple things. When he feels pain or discomfort, he manages it by resting and
doing some activities.

Self-Perception and Self-Concept Pattern

Patient Paderog stated that he feels worried about himself and condition.He also states
there’s many changes on how he sees himself being hospitalized, and feeling like a

13
burden now. He reported being restless from abdominal pain, and having difficulty
swallowing solid and liquid food. And also worrying about the surgery but instead of
complaining he follows the doctors order and looks forward to his recovery.

Role Relationship pattern

The family lives by themselves, since hospitalization his wife and daughter look after
him, he is very close to his wife and daughter.

Value-Belief Pattern

The family is Roman Catholic. They go to church every sunday. The patient stated that
they can rely on God and to have faith in him that he will recover through his condition.

Patient Physical Assessment

Included in the physical assessment are the general health survey and head-to-toe
assessment (review systems).

Date of Assessments: March 23, 2022

Location of assessment: Capitol University Medical Center Medical Ward

GENERAL HEALTH SURVEY

Integumentary System
His skin is pallor and moist to touch. Hair is well distributed, short and clean nails were
also observed.
Head, Eyes, Ears, Nose and Throat (HEENT)
The head is normocephalic and fontanels are closed, his facial movements are
observed. Eyes are aligned and non-edematous. The conjunctiva is pink and there is a
positive blinking reflex and corneal reflex. The pupils have equal sizes. There is also a
positive reaction to light; his visual acuity is grossly normal. His pinna’s of the ears are
normoset and no discharges noted, the snares of the nose are patent and no
deformities noted, tympanic membrane is intact and the gross hearing is normal the
mucosa is pinkish and no discharges. The tongue is midline, the uvula and tonsils are
also midline and the posterior pharynx is not inflamed.

Respiratory system

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Respiration is symmetrical, with full chest expansion and a respiratory rate of 20 cpm,
which is within normal limits.

Cardiovascular System
Heart sounds are regular, with no heart murmurs present, and there is no cyanosis or
chest pain. The radial pulse is 72 beats per minute.

Gastrointestinal System

The abdomen is symmetrical with no presence of scar or lesions. Bowel sounds are
normoactive, abdomen is tympanitic there is muscle guarding and rebound tenderness
noted.

Reproductive System
Patient Paderog has no discharges and was not able to examine the penis. There are
no nodules or growths noted.

Musculoskeletal System

He has complete set fingers and toes no dimpling is observed there are equal gluteal
folds. There are no fractures and no clicks in the joints. Muscles are symmetrical and
equal muscle tone. Arms and legs are symmetrical in size and movement.

Neurological System

Patient Paderog is conscious and well-oriented; he is calm and responds to questions

well; there are no memory changes lately. There is no difficulty speaking, feelings are
well-expressed and with good facial expression. There are no learning difficulties noted.

Developmental data

Patient Paderog stated pain to his epigastric area. Guarding his abdomen when pain
occurs. Pain scale of 7/10 as patient stated verbally after the surgery.

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VII. ANATOMY AND PHYSIOLOGY

The esophagus carries food from the mouth to the stomach. The lower esophageal
sphincter is a muscular ring at the junction of the esophagus and the stomach, the
function of lower esophageal sphincter is to control flow of luminal contents between the
esophagus and stomach and to serve as a physical barrier against the occurrence of
gastroesophageal reflux (GERD) . The lower esophageal sphincter relaxes when food
from the esophagus enters the stomach.

The anatomical lower esophageal sphincter (LES) consists of 2 sphincters—the

intrinsic sphincter involving the semicircular clasp muscles and the oblique sling
muscle and the external sphincter, the crural diaphragm. Innervation is through the
preganglionic vagus nerve fibers that release acetylcholine as the neurotransmitter
affecting 2 types of postganglionic neurons in the myenteric plexus. The
postganglionic excitatory neurons release acetylcholine and substance P. The major
inhibitory neurotransmitter is nitric oxide, which promotes LES relaxation. Achalasia
results from a loss of postganglionic inhibitory innervation resulting in aperistalsis
and poor LES relaxation.

VII. PATHOPHYSIOLOGY

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Narrative

Achalasia is a rare condition that results from inflammation and degeneration of neurons
in the esophageal wall.There are two types of achalasia, the primary achalasia and the
secondary achalasia other known as pseudoachalasia. When the cause of the
inflammatory degeneration of neurons in primary achalasia is unknown, the recruitment
of neutrophils and eosinophils to nitric oxide producing neurons which result
inappropriate contraction of smooth muscle in distal esophagus that can loss of
peristalsis in distal esophagus.The cholinergic neurons involved in lower esophageal
sphincter tone are relatively spared, which can result in incomplete relaxation of lower
esophageal sphincter.

The causes of secondary achalasia are chagas disease, tumor and diabetes
mellitus. Chagas disease is life - threatening that is caused by a blood-borne parasite
that has a scientific name of trypanosoma cruzi, the parasitic invasion leads to
inflammation of the esophagus. The tumor is an esophageal carcinoma, lung cancer,
cancer of gastric cardia, etc. which result in local invasion of esophageal myenteric
plexus. Diabetes Mellitus is a chronic hyperglycemia that damages autonomic nerves
that can interfere in autonomic neuropathy involving the esophageal myenteric plexus.
All of this can result from dysfunction of the esophageal myenteric plexus.

The primary and secondary achalasia may create a lack of lower esophageal
sphincter relaxation that makes it difficult for food and water to pass. The intake of food
or water may put pressure on the esophagus that can feel a sense of fullness which
can be aspirated into the lungs that may cause complications such as pneumonia,
asphyxiation,pneumonitis and chronic cough. The lab findings may result in “bird’s
beak” sign on barium swallow x-ray, lack of peristalsis,elevated lower esophageal
sphincter pressure,on esophageal manometry, dysphasia(trouble swallowing),both
solids and liquids that may result decreased caloric intake that can cause weight
loss.Other finding of achalasia is regurgitation of undigested food which the stomach
acid irritates the esophagus may result in heartburn( epigastric/ retrosternal burning
sensation).

Diagram

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XI. Diagnostic Test

● X-ray Studies - Shows the esophageal dilation above the narrowing at the
gastroesophageal junction.

18
 ● Esophageal Manometry- A process in which peristalsis, contraction amplitudes,
and esophageal pressures is measured by radiologist or gastroenterologist,
confirms the diagnosis. It measures the motility and internal pressure of the
esophagus and can test for irregular and high-amplitude.

● Barium swallow - is a type of test used to look inside the esophagus or food pipe.

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 Barium is as white liquid that is visible on x-rays. Barium passes through the
digestive system and does not cause a person any harm. As it passes through
the body, barium coats the inside of the food pipe, stomach, or bowel causing the
outlines of the organs to appear on X-ray.

● Computed tomography - Is a useful technique for differentiating primary and

secondary achalasia.

● Flexible Upper Endoscopy - In a flexible upper endoscopy, a specialist checks

your esophagus and stomach with a thin, flexible tube called an endoscope. This
tube is put down your throat. The endoscope has a light and a tiny camera on
one end. The camera sends pictures of the inside of your esophagus to a monitor

20
 for your doctor to see. An endoscopy is needed to make sure that you do not
have a tumor in your esophagus. This condition is called pseudoachalasia
("false" achalasia). It requires different treatment.

X. MEDICAL AND SURGICAL MANAGEMENT

● Actual
Heller myotomy fundoplication - a type of minimally - invasive procedure (small incisions
of 2-3 inches long / general anesthesia) which cuts the sphincter muscles that join the
esophagus and stomach. This limits the activity of the muscle and allows food to pass
more easily into the stomach.

● Ideal
Peroral endoscopic myotomy (POEM). In the POEM procedure, the surgeon uses an

21
endoscope inserted through your mouth and down your throat to create an incision in
the inside lining of your esophagus. Then, as in a Heller myotomy, the surgeon cuts the
muscle at the lower end of the esophageal sphincter.

POEM may also be combined with or followed by later fundoplication to help prevent
GERD. Some patients who have a POEM and develop GERD after the procedure are
treated with daily oral medication.

Drug study # 1

Brand name:Reglan

Generic name:Metoclopramide

Classification:GI stimulants

Dosage:1 ampule

Route:IV

Frequency:Q8

Mechanism of action:

● Medicine that increases the movement or contractions of the stomach and intestines.

Indication:

● For prophylaxis of postoperative nausea and vomiting in those circumstances where

nasogastric suction is undesirable.

Contraindications:

● Gastrointestinal bleeding, obstruction , perforation, pheochromocytoma, seizures,

depression, parkinson’s disease, History of tardive dyskinesia

22
Adverse effect of the drugs:

● CNS: Restlessness, drowsiness, fatigue, and lassitude, insomnia, headache, confusion,

dizziness, or mental depression
● Endocrine Disturbances: galactorrhea, amenorrhea, gynecomastia
● Cardiovascular: Hypotension, hypertension, supraventricular tachycardia, bradycardia,
fluid retention, acute congestive heart failure
● GI: Nausea and bowel disturbances, primarily diarrhea
● Renal: Urinary frequency and incontinence
● Allergic reactions: rash, urticaria or bronchospasm

Nursing responsibilities/ Precautions: ·

● Do not drive or do anything else that could be dangerous until you know how this
medicine affects you.
● · Check with your doctor right away if you

Drug Study #2

Brand name: Nexium IV

Generic name:Esomeprazole

Classification:Proton Pump Inhibitor

Dosage:40 mg

Route:IV

Frequency:OD

Mechanism of Action:

● It works by decreasing the amount of acid that is produced by the stomach.

● It inhibits H+/K+ Atpase on the surface of gastric parietal acid secretion.

Indication:

● The reduction of the occurrence of gastric ulcers associated with continuous NSAIDS
therapy in patients at risk for developing gastric ulcers.

Contraindication:

● Contraindicated in patients hypersensitivity to drug or other proton pump inhibitor.

● May increase risk of hip, wrist spine fractures, hepatic impairment, and elderly.

Side effects of the drug:

23
 ● CNS: headache, dizziness, drowsiness
● GI: Abdominal pain, Constipation, diarrhea,dry mouth, flatulence, Nausea

Nursing responsibilities/Precautions:

● · Assess epigastric/abdominal pain

● · Question history of hepatic impairment, impairment, pathologic bone fractures
● · Evaluate the therapeutic response (relief of GI symptoms)
● · Report headache
● · Take at least 1 hour before eating

Drug Study # 3

Brand Name: Zegen

Generic name:Cefuroxime

Classification:Antibiotic

Dosage:750 mg

Route:IV

Frequency:Q8H

Mechanism of action:

● Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.

Indication:

● Treatment of septicaemia, meningitis, Perioperative infection prophylaxis, one and joint

infection, H. influenza, lower respiratory tract infection.

Contraindications:

● Contraindicated in patients hypersensitivity to drug or other cephalosporins.

● Patient allergic with penicillins

Adverse effects of the drug:

● Common: Nausea, vomiting, abdominal pain , nausea

● Nervous system: Headache, dizziness, sleepiness, somnolence, hyperactivity and
encephalopathy

24
 ● Hematologic: Decreased hemoglobin and hematocrit, neutropenia, decreased
hemoglobin concentration

Nursing responsibilities/ Precautions:

● · Monitor renal, hepatic and haematologic function

● · Discontinue if hypersensitivity reaction occurs

XI: NURSING CARE MANAGEMENT

Nursing Care Plan #1

Subjective cues: “i have difficulty swallowing solid food and liquid food ” As verbalized by
the patient.

Objective cues:

V/S:

BP: 110/80

Temp: 35.7

Spo2: 96

RR: 16

PR: 80

Weight: 59kg

Nursing diagnosis:Impaired swallowing AEB patient’s verbalization of difficulty in

swallowing

Planning :

● After 30 minutes of nursing intervention,patient will able to understand the food

consistency and choices for him
● After the end of shift,the patient will able to swallow food little by little

25
Nursing intervention:

● Assess ability to swallow a small amount of water

Rationale: If aspirated,little or no harm to the patient occurs

● Kept patient upright position for 30 to 45 minutes after a meal

Rationale: It guarantee that food stays in stomach and decreased the chance of
aspiration following meals

● Educate patient ,family, and all caregivers about the rationale for food consistency and
choices

Rationale: Disregard necessary dietary restrictions and give patient inapropriate

food that predispose to aspiration

Evaluation:

● After 30 minutes of nursing intervention,the patient is able to understand the food

choices and the medical personnel will be able to explain it.
● After the end of nursing shift,the patient is verbalize “ makakaon nako ma’am”

Nursing Care Plan #2

Subjective cues: “unsa na nga procedure ug para asa na?” as verbalized by the patient

Objective cues: Patient conscious and coherent

V/S:

BP: 110/80

HR: 80

RR:16

TEMP.35.7

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Procedure:heller’s myotomy with fundoplication

Nursing diagnosis: Deficient knowledge regarding surgical procedure may be related to lack of
information possibly evidenced by statements of concern,questions, and misconception

Planning:

● After 8 hrs. of nursing intervention,the patient will able to verbalize understanding of

disease procedure/preoperative Process and postoperative expectations
● After 1 day of nursing intervention the patient will able to correctly inform the necessary
procedure and explain reasons for the action

Nursing intervention:

● Reviewed specific pathology and anticipated surgical procedure.verify that appropriate

consent has been signed

Rationale: Provide knowledge base from which patient can make informed therapy and
consent for procedure

● Explain the expected or transient reaction

Rationale: Minor effect of immobilization and positioning should resolve in 24 hrs

● Discuss the individual post-operative pain management plan

Rationale: To increase likelihood of successful pain management

Evaluation:

● After 8 hrs. Of nursing intervention,the patient is able to fully verbalize the understanding of
disease procedure and postoperative expectation
● After 1 day of nursing intervention ,the patient is fully correctly informed of the necessary
procedure and fully understands the reasons for the action.

Nursing Care Plan #3

Subjective cues: “ Medyo masakit ang aking operasyon” as verbalized by the patient

Objective cues:

BP: 110/80

HR: 80

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RR: 16

TEMP.: 35.7

Pain Scale : 6/10

Restlessness

Nursing Diagnosis: Acute pain may be related to operative procedure

Planning:

● After 30 minutes of nursing intervention,the patient will be able to verbalize sense of

control from pain of 7 reduce to 4
● After 8 hrs of nursing intervention ,the patient will be able to report pain is relieved or
control

Nursing intervention:

● Note location of surgical procedures

Rationale: This can influence the amount of postoperative pain experienced

● Perform pain assessment each time pain occurs

Rationale: Demonstrate improvement in status or identify worsening of

underlying condition developing complication

● Encourage adequate rest period

Rationale: To prevent fatigue that can impair ability to manage or cope with
pain

evaluation :

● After nursing intervention,the patient is able to verbalize sense of control of

response to acute situation and report pain is relieved as evidenced by patient
response “ hindi na masakit ang aking operasyon”

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XII. DISCHARGED PLAN
Long term goal

Goals

PATIENT CARE: Some patients with achalasia benefit from eating slowly, taking small
bites, and avoiding swallowing large volumes of food or liquid. Patient education centers
on adaptations the patient may make to avoid esophageal pain, regurgitation, and
weight loss.

Meds

● Metoclopramide/GI stimulants

● Cefuroxime/Antibiotic

● Esomeprazole/Proton Pump Inhibitor

Therapy

Achalasia treatment focuses on relaxing or stretching open the lower esophageal

sphincter so that food and liquid can move more easily through your digestive tract.

Specific treatment depends on your age, health condition and the severity of the
achalasia.

Exercise

● Achalasia treatment focuses on relaxing or stretching open the lower esophageal

sphincter so that food and liquid can move more easily through your digestive tract.
Specific treatment depends on your age, health condition and the severity of the
achalasia.
● Take a deep breath and hold it. Keep holding your breath while you swallow. ...
● Inhale and hold your breath very tightly. Bear down (like you are having a bowel
movement). ...
● Take a breath. ...
● Hold your breath tightly. ...

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 ● Hold your breath tightly.

Non surgical treatment

● Pneumatic dilation. A balloon is inserted by endoscopy into the center of the

esophageal sphincter and inflated to enlarge the opening. This outpatient procedure
may need to be repeated if the esophageal sphincter doesn't stay open. Nearly one-
third of people treated with balloon dilation need repeat treatment within five years. This
procedure requires sedation.
● Botox (botulinum toxin type A). This muscle relaxant can be injected directly into the
esophageal sphincter with an endoscopic needle. The injections may need to be
repeated, and repeat injections may make it more difficult to perform surgery later if
needed.
Botox is generally recommended only for people who aren't good candidates for
pneumatic dilation or surgery due to age or overall health. Botox injections typically do
not last more than six months. A strong improvement from injection of Botox may help
confirm a diagnosis of achalasia.

Health teachings

Instruct the patient how to have a healthy lifestyle, right foods to eat and foods to avoid.
Instruct the family members to prepare a low sodium and low fat diet. Instruct the
patient’s family to provide a safe environment Instruct the patient and family members
to take medicine exactly as directed. Don’t skip doses. Instruct patients to begin an
exercise program. Ask the healthcare provider how to get started. Ask how much
activity you should try to get everyday or week. can benefit from simple activities such
as walking or gardening. Instruct the patient to limit how much alcohol he/she drinks.

Outpatient

● Keep your medical appointments. Close follow-up is important to stroke

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 rehabilitation and recovery.
● Keep follow-up appointments for any blood tests ordered by the healthcare
provider

Diet

Diet and Nutrition

● In the hospital, you will be on a liquid diet after your surgery.

● When you leave the hospital, you will start a soft esophageal diet. This diet
● helps keep food from getting stuck in the area where your surgery was
● done.
● You will stay on this soft diet for 4 to 6 weeks.
● Follow your dietitian's instructions on what foods you can eat at
● home after your surgery. Call your dietitian if you have questions.
● Try soft foods like mashed potatoes, eggs, cottage cheese, and thick
● soups.
● Instead of eating 3 large meals, eat 5 to 6 small meals a day. Take
● small bites, chew them well, and eat slowly. Stop when you feel full.
● Do not drink carbonated liquids or use a straw to drink.
● Most patients lose about 10 pounds after this surgery. You will gain
● this weight back unless you try not to.
● You will shift to a regular diet in 4 to 6 weeks.

XIII. EVALUATION, RESULTS, AND DISCUSSION

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On the last day of assessment on March 23, 2022, the patient was still admitted at the
hospital, also the patient stated pain after the surgery pain scale of 7/10 . There are no
significant changes in his condition. His vital signs on the last day of assessment were
the following: T-35.7 degrees Celsius; P- 60 bpm; R- 20 cpm; Bp-120/70; O2 sat-93%.
There are no signs of serious complications Certain limitations to the case management
are apparent and inevitable; hence Our group made use of "what was only available”.

Our group was able to compare the actual and ideal nursing and medical interventions.
Based on mystudy, there are various ideal medical management that can be done to
facilitate his complete recovery.

For future case studies, our group recommends a full-blown thorough assessment not
only of the patient but also of his significant others is essential in understanding the
course of the condition.

XIV. APPENDICES

Definition of words
● Achalasia: is a rare disorder that makes it difficult for food and liquid to pass
from the swallowing tube connecting your mouth and stomach (esophagus) into
your stomach.

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 ● myenteric plexus: a network of nerves between the layers of the muscularis
propria in the gastrointestinal system.
● Normocephalic: Having a normal-sized head
● Gerd: gastroesophageal reflux disease.

● Pseudoachalasia: is an achalasia-pattern dilatation of the esophagus due to the

narrowing of the distal esophagus from causes other than primary denervation.

● esophageal sphincter: is a bundle of muscles at the low end of the

esophagus, where it meets the stomach.
● Genetic predisposition: Increased likelihood or chance of developing a
particular disease due to the presence of one or more gene mutations and/or a
family history that indicates an increased risk of the disease.

Bibliography
BOOK SOURCES:
Saunder Nursing Drug Handbook 2021 By Robert J. Kizior.
Nurse's Pocket Guide Diagnosis, Prioritized Interventions and Rationales: by Marilynn
E.
Doenges, Mary
Frances Moorhouse, Alice C. Murr. Edition 15

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Medical Surgical Nursing: by Bruner and Suddarth Edition 14
Medical Surgical Nursing 14th edition By Janice L. Hinkle and Kerry H. Cheever
Volume2
Nurse's Pocket Guide 15th edition By Marilyn E. Doenges et al.

webs:
Achalasia - Diagnosis and treatment - Mayo Clinic
O'Neill, O. M., Johnston, B. T., & Coleman, H. G. (2013). Achalasia: a review of clinical
diagnosis, epidemiology, treatment and outcomes. World journal of gastroenterology,
19(35), 5806–5812. https://doi.org/10.3748/wjg.v19.i35.5806
National Organization for Rare Disorders. Achalasia. (https://rarediseases.org/rare-
diseases/achalasia/) Accessed 11/9/2021.

Achalasia (Esophagus Disorder): Symptoms, Causes, Treatments

Achalasia: Practice Essentials, Background, Pathophysiology
Images copy
https://www.google.com/imghp?hl=en

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