Ruby Jane Smith
Ruby Jane Smith
Occupational Performance Deficits
Damage to esophageal structures has resulted in relaxation of the lower esophageal sphincter muscle while at rest. Disturbance in sleep will result because of discomfort, heartburn, acid reflux, or irritation in the upper chest area of the client.
The client has difficulty after the bolus travels to the distal section of the esophagus where reflux results after eating. Inflammation to the esophagus results in pain and discomfort. The client may refrain from eating because of the symptoms that result from eating food.
The client consumes whatever food she desires without recognition of nutrition management to improve symptoms of Gastricesophageal Reflux Disease (GERD). The medication being taken for GERD is ineffective.
The client does not know how to treat the symptoms of GERD and is at risk of developing pneumonia from saliva entering the airways.
Engagement in activities with family and friends will be limited because of symptoms of pain and discomfort in the lower part of the esophagus.
Activities that the client enjoys will be affected by pain and discomfort. The client will stop performing in activities that are meaningful to the client if she cannot enjoy them because of the symptoms that are manifested by GERD.
Eat smaller meals more frequently rather than three large meals to decrease amount of pressure in the stomach. o
Eat six small meals a day and small snacks in between.
Eat four small sized meals and a snack in between each meal.
Avoid foods that are highly acidic or greasy, alcohol, coffee, peppermint/spearmint, and soft drink to avoid irritation and prevent acid build up or an increase in pressure.
The client chooses non-acidic and appropriate foods for 6 meals each day. The client self-selects appropriate foods without a nutritional list for guidance.
The client chooses non-acidic and appropriate foods for 2 meals per day with help on the an additional two meals. The client uses a nutritional list to select appropriate foods.
3. Sleep preparation-
Eat last meal three hours before bedtime to decrease the amount of pressure while lying down. o
The client eats at the appropriate time without a reminder or alarm.
The client uses an alarm and visual reminder to for her to eat at the scheduled time before bed.
4. Health management-
Sit up for one hour after meals. o
The client stands and performs leisure activities for an hour with proper body mechanics post meal time.
The client sits upright for an hour with proper body mechanics post meal time.
5. Sleep participation-
Sleep with the head of bed elevated greater than 30 degrees to reduce the likelihood of acid reflux or development of pneumonia from saliva entering the airways.
The client sleeps the entire night with head elevated at 45 degrees.
The client sleeps half of the night with head elevated at 30 degrees.
6. Medication management-
The client should establish a routine of taking medication to reduce GERD. Medications such as antacids, histamine H2 receptor antagonists, and proton pump inhibitors should be administered to the client to act as a neutralizer for acid.
The client takes medication 2 times per day as prescribed 30 minutes prior to eating, and appropriately uses the as needed medications for symptom management. The client follows a scheduled routine without any reminders.
The client takes medication 1 time per day and follows a visual schedule and an alarm to take the medication at appropriate times.
Reduce pain and control the symptoms that are involved with GERD.
Reduce chronic cough
Prevent any problems with swallowing because of age
Improve quality of life by lifestyle changes that provide a means to complete daily occupations without any deficits in her ability to perform in her daily roles/routines. This may include body position, appropriate nutrition, scheduled medication intake, and scheduled mealtimes.
reflux of food because of the failure of the lower esophagus to fully close.
Gastroesophageal reflux disease (GERD)
-Ineffective lower esophageal sphincter contraction. Acid irritates the lining of the esophagus resulting in discomfort at the chest.
- The client is 86 years old and could have a cumulative of comorbidities with the diagnosis of gastroesophageal reflux disease (GERD).
The distal 3-4 cm segment of the esophagus is damaged which prevents contraction when at rest.
Lower esophagus is distended and includes granularity of the mucosa (thickened folds, erosions, and stricture in mid esophagus).
Head and neck control appear to function within normal limits. Upper extremity gross motor and fine motor movement/sensation are normal.
Inner and outer oral motor and sensation are within normal limits. She has the ability to close her lips and manipulate bolus within her mouth.
The diaphragmatic crura that encircle the esophagus and phrenoesophageal ligament structures are within normal limits in appearance and function.
- The client’s pharynx and elevation of the larynx are within functional limits.
Several occupational therapy assessments can aid in Ruby’s assessment to determine her taste perception and motor performance. However, it would be ideal to measure what activities of daily living are most affected from GERD. The consideration of using multiple assessments with the client is vital to determine how age has impacted the client’s ability to consume and digest food.
Canadian Occupational Performance Measure (COPM)-
An interview to help identify what the client perceives as problems with occupational performance. The client will prioritize with the occupational therapist on problems relative to how important each problem is within her environment.
The Numeric Pain Rating Scale
- The pain is ranked from 0 to no paint to 10 as extreme pain. The average of three scores helps determine chronic pain and help direct therapy on when the client experiences pain.
Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire (GERD-HRQL)-
It is a questionnaire to help measure changes that are found with GERD symptoms.
- The occupational therapist will examine the oral structures, the tongue, and how she swallows. The tongue will be examined for any deviation or pull to a stronger side that may be affected. Manipulation of the tongue forward to backward and from side to side will be examined for a firm feel.
In 2 days, the client will physically demonstrate how to sleep, with > 3 verbal cues, using proper body mechanics and with the head of bed elevated 30-45 degrees, for 2 consecutive nights, per week.
In 2 days, the client will select 3 appropriate foods on the GERD diet for meal time routine, with > 2 verbal cues, using an alarm clock as a reminder to eat 3 hours before bedtime, for 2 consecutive days, per week.
In 1 week, the client will demonstrate how to sleep, with <2 verbal cues, using proper body positions and elevating her head 30-45 degrees, for 3 consecutive nights, per week.
In 1 week, the client will follow a multi-step meal time routine by selecting appropriate foods, with supervision, 3 hours before bedtime, for 3 consecutive days, per week.
Blanchard, S., Barker, C. J., & Hyde, S. (2016). Oral health for aging adults. In K. Barney, & M. Perkinson (Eds.), Occupational therapy with aging adults (pp. 196-213). St. Louis, MI: Elsevier.
Hom, C., & Vaezi, M. (2013). Extra-Esophageal Manifestations of Gastroesophageal Reflux Disease: Diagnosis and Treatment. Drugs, 73(12), 1281-1295. doi: 10.1007/s40265-013-0101-8
MacFarlane, B. (2018). Management of gastroesophageal reflux disease in adults: A pharmacist’s perspective. Integrated Pharmacy Research and Practice, 7, 41-52. Retrieved from
Mehranghiz, E., Siamak, S., Manouchehr, K., Seyed Rafi, A., & Maryam, S. (2017). Total diet, individual meals, and their association with gastroesophageal reflux disease. Health Promotion Perspectives, 7(3), 155-162. doi:10.15171/hpp.2017.28
Tierney, W. S., Gabbard, S. L., Milstein, C. F., Benninger, M. S., & Bryson, P. C. (2017). Original Contribution: Treatment of laryngopharyngeal reflux using a sleep positioning device: A prospective cohort study. American Journal of Otolaryngology--Head and Neck Medicine and Surgery, 38, 603-607. doi:10.1016/j.amjoto.2017.06.012