I.

INTRODUCTION

Which organ is the most important organ in the body? Most people would say
the heart or the brain, completely overlooking the gastrointestinal tract (GI tract).
Though definitely not the most attractive organs in the body, they are certainly
among the most important. The 30+ foot long tube that goes from the mouth to the
anus is responsible for the many different body functions which will be reviewed in
this chapter. The GI tract is imperative for our well being and our life-long health. A
non-functioning or poorly functioning GI tract can be the source of many chronic
health problems that can interfere with your quality of life. In many instances the
death of a person begins in the intestines.

The old saying "you are what you eat" perhaps would be more accurate if
worded "you are what you absorb and digest.

The GI tract starts with the mouth and proceeds to the esophagus, stomach,
small intestine (duodenum, jejunum, ileum), and then to the large intestine (colon),
rectum, and terminates at the anus. You could probably say the human body is just
like a big donut. The GI tract is the donut hole.

The Gastrointestinal System is responsible for the breakdown and absorption

of various foods and liquids needed to sustain life. Many different organs have
essential roles in the digestion of food, from the mechanical disrupting of the teeth
to the creation of bile (an emulsifier) by the liver. Bile production of the liver plays a
important role in digestion: from being stored and concentrated in the gallbladder
during fasting stages to being discharged to the small intestine.

There are many diseases involving the gastrointestinal system one of which
is acute gastroenteritis. Gastroenteritis is a nonspecific term for various pathologic
states of the gastrointestinal tract. The primary manifestation is diarrhea, but it may
be accompanied by nausea, vomiting, and abdominal pain. A universal definition of
diarrhea does not exist, although patients seem to have no difficulty defining their
own situation. Although most definitions center on the frequency, consistency, and
water content of stools, the author prefers defining diarrhea as stools that take the
shape of their container.
 The severity of illness may vary from mild and inconvenient to severe and life
threatening. Appropriate management requires extensive history and assessment
and appropriate, general supportive treatment that is often etiology specific.
Diarrhea associated with nausea and vomiting is referred to as gastroenteritis.

Though often considered a benign disease, acute gastroenteritis remains a

major cause of morbidity and mortality in children around the world, accounting for
1.8 million deaths annually in children younger than 5 years, or roughly 17% of all
child deaths. Because the severity of the disease can vary widely depending on the
volume of fluid loss, accurately assessing and treating dehydration in children
presenting with acute gastroenteritis remains a critical skill for every emergency
physician. Luckily, most cases of dehydration in children can be accurately
diagnosed by a careful clinical examination and treated with simple, cost-effective
measures

Gastroenteritis is a condition that causes irritation and inflammation of the

stomach and intestines (the gastrointestinal tract). An infection may be caused by
bacteria or parasites in spoiled food or unclean water. Some foods may irritate the
stomach and cause gastroenteritis. Lactose intolerance to dairy products is one
example.

Many people who experience the vomiting and diarrhea that develop from
these types of infections or irritations think they have "food poisoning," which they
may, or call it "stomach flu," although influenza has nothing to do with it.

Travelers to foreign countries may experience "traveler's diarrhea" from

contaminated food and unclean water.

The severity of infectious gastroenteritis depends on individual’s immune

system’s ability to resist the infection. Electrolytes (these include essential
elements of sodium and potassium) may be lost as a person vomits and experience
diarrhea.

Most people recover easily from a short bout with vomiting and diarrhea by
drinking fluids and easing back into a normal diet. But for others, such as babies
and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration,
which is a life-threatening illness unless the condition is treated and fluids restored.

Reasons For Choosing Such Case For Presentation

The group decided to accomplish a case study about Acute Gastroenteritis in

order to be familiar with this kind of disease condition since it is extensive in our
country. Also the group would want to acquire some in-depth knowledge about
Acute Gastroenteritis. The group also found it to be useful if they would gain
knowledge of how to describe the following about this disease; its etiology,
pathophysiology, clinical manifestation, diagnostic procedures and its management.
It is also important that we know how to state and recognize nursing diagnoses and
related expected patient are outcomes usually applicable to a patient with Acute
Gastroenteritis as well as to clarify the basis for assessment of nursing care
provided to a patient with Acute Gastroenteritis. For the group’s future encounter
with this kind of disease, they would be knowledgeable and skilled enough to
manage this disease and facilitate patients in attaining their finest level of
performance.

II. NURSING ASSESSMENT

Personal Data

To keep the confidentiality of the patient, she will be named “Mrs. Lola”. In
gathering significant data, Mrs. Lola was the primary source. The daughter of Mrs.
Lola was also there to answer some of the questions asked by the student nurse.

Mrs. Lola, a 78 year old female, was admitted in AUFMC on January 05, 2011
and have experienced AGE with moderate dehydration. She is a Filipino and a
devoted Roman Catholic. Mrs. Lola is widowed for 10 year, she is currently resides
with her married daughter in Angeles City. Mrs. Lola is the eldest among 8 siblings.
She was born on March 04, 1932 in Arayat, Pampanga. She finished college in
Manila, with a degree of BSEED (Bachelor of Science in Elementary Education).

The house that Mrs. Lola currently lives in is mostly concrete, has three
bedrooms, a living room, a kitchen which is also their dining area, and a bathroom
with a non-septic tank toilet facility. Mrs. Lola fetches water from a pitcher pump,
the water gathered is used for bathing, washing dishes, flushing the toilet and other
activities. For their drinking water, they buy purified water from a nearby refilling
station at least twice a week. The house has adequate ventilation because there are
a total of eight windows, each room having two windows, the bathroom with two
windows, the dining area having two windows, and the living room having two
windows. As for their lighting system, the house has four fluorescent lights and
three bulb lights. They have two electric fans which are used only when necessary.

Mrs. Lola’s financial support is mainly from her husband’s pension and from
her eldest daughter. Her husband’s pension is 4000 pesos monthly. And she
receives 3000 a week from her daughter.

Mrs. Lola’s daughter usually goes to the market to buy food, and then she will
be the one to cook it. They prefer eating fish, chicken and vegetables. As for health
beliefs, they also believe in “not taking a bath during first day of menstruation.”
According to Mrs. Lola, they usually utilize OTC drugs like paracetamol to remedy
certain conditions like headache, colds or fever.
 Pertinent Family History

Father Side Mother Side

Grand Father Grand Mother

(-) HPN (-) HPN

Mrs. Male Male Male

Lola 74 y.o 70 y.o 64 y.o

Male Male Femal Female

(-) 72 y.o e 62 y.o
with
DM

Legend:

(+) = living

(-) = dead

Based from the schematic diagram, both parent and second eldest sibling of
Mrs. Lola experienced hypertension causing their death. Among eigth siblings, Mrs.
Lola and her youngest sibling who acquired Diabetes Mellitus.
History of Past Illness

Mrs. Lola also experiences cough, colds, headache, and fever occasionally
especially during cold or rainy season. To remedy the mentioned conditions, he
buys OTC drugs. She usually buys Paracetamol for headache and for colds. She also
experienced of diarrhea, she used leaves of guava and steams it then extract the
juice. She also said that whenever she has colds she drinks plenty of water.

In year 1995, she was hospitalized in Angeles City and was diagnosed of
having CAD (Coronary Artery Disease). She was then referred to the Heart Center,
she was assessed by a specialist and gave her medication such as Atorvastatin and
Digoxin.

In year 1999, she was hospitalized again in Angeles City, was diagnosed of
having Diabetes Mellitus and was given medication such as Janumet.

History of Present Illness

Two days prior to the admission, the client was noted with vomiting and LBM
10x with a soft to watery texture of stool.

Mrs. Lola was admitted to AUFMC on the month of January 05, 2011 at 12:17
pm. She had an admitting diagnosis of AGE with moderate dehydration and with
chief complaint of LBM and vomiting.
Physical Assessment

January 05, 2011

Physical Assessment upon Admission: Data are lifted from the patient’s chart
and as follows:

 With weakness
 (+) pallor on skin
 (+) pallor on palpebral conjunctiva, yellowish anicter sclera
 With limitation on movement
 Vital Signs taken as follows:

o BP: 120/90 mmHg

o T: 36°C / axilla
o PR: 78 bpm
o RR: 22 bpm

January 06, 2011

A. General Appearance:

Patient was conscious and coherent. She was oriented to the time and place.
She was wearing a hospital gown. She speaks with a low tone of voice. She was
cooperative all throughout the assessment period.

B. THE INTEGUMENT

• Skin

She has a dark skin complexion with no presence of odor. Her skin is intact and has
normal skin turgor.

• Hair

She has short white hair which is thick and is evenly distributed with no presence of
lice and flaking. She also has a variable amount of body hair.
• Nails

She has a normal shape of nails which is smooth, with pale in color. There were
no presence of inflammation or damage on the epidermis and when pinched, the
color returns in less than 3 seconds, hence, she has normal capillary refill.

C. THE HEAD

• Skull

She has a round, normocephalic and symmetrical skull. There are absences of
nodules or masses and depressions upon assessing her skull.

• Face

Her face is smooth and uniform in consistency. There are absences of nodules or
masses and facial movements are symmetric.

D. EYES AND VISION

• Eyebrows

Hair is evenly distributed and is symmetrically aligned. When asked to lower and
raise her eyebrows, equal movement was noted.

• Eyelashes

Her eyelashes are equally distributed and are curled slightly outward.

• Eyelids

Skin is intact with no discharges. Lids close symmetrically and are involuntary.

• Bulbar conjunctiva

There were no lesions present and it is transparent in color. Sclera is white.

• Palpebral conjunctiva

It appears to be smooth, shiny with no presence of lesions; with pale in color

• Lacrimal gland, lacrimal sac, nasocrimal duct

No edema or tearing was not during palpation.

• Cornea

Cornea appears to be transparent, shiny and not rough. The details of the iris are
visible.

o Corneal sensitivity test

The client blinked as the cornea was touched by a cotton ball thus determining the
function of the 5th cranial nerve.

• Pupils

Black in color and equal in size. Borders are smooth and the iris appears to be flat
and round.

o Direct and consensual reaction to light

The pupils constricts when a penlight is shined on it.

o Reaction to accommodation

Pupils did not fail to react. They constrict when looking at a nearby object and dilate
at far objects. As we moved the penlight towards her nose, the pupils converge
normally.

• Visual fields

She can successfully determine whether an object is moving or not by the use of
her peripheral vision as they covered one of her eyes. She can also see objects in
the periphery when looking straight ahead.

• Extraocular muscle tests

Both eyes are seen to be coordinated and have unison movement with parallel
alignment as evidence by the ability to follow the movement of the penlight to the 6
cranial fields of gaze.
• Visual acuity

She is able to read large fonts written on a paper 14 inches away without the use of
glasses.

E. THE EARS AND HEARING

• Auricles

Her auricles have the same color with his facial skin. They are symmetrical, firm and
not tender.

• Gross hearing acuity tests

o Watch tick test

She can hear ticking in both ears.

F. THE NOSE AND SINUSES

• Nose

Her nose is symmetric and straight with the absence of discharges and lesions. It
has a uniform color and is not tender to touch.

• Nasal cavity

Air movement is not restricted on one or both nares as they instructed her to
breathe through one naris while covering the other.

• Facial sinuses

Mucosa appears to be pink and there were no lesions present. Facial sinuses were
not tender to touch.

G. MOUTH AND OROPHARYNX

• Lips and buccal mucosa

She has pink lips, soft and dry. They are symmetric and she is able to purse her lips.

• Teeth and gums

She has complete set of teeth. There is presence of dental carries, plaque and
tartar.

• Tongue and floor of mouth

Her tongue appears smooth red and wet.

• Palates and uvula

Her uvula and soft palate moved upward when she says “ah”.

• Oropharynx and tonsils

She has a pink and smooth posterior wall.

• Gag reflex

She was able to elicit Gag reflex as the student nurses press the posterior tongue
with a tongue depressor.

H. NECK

• Neck muscles

Her muscles are equal in size and her head is properly centered. Coordinated
movements were observed as we instructed her to move and turn her head on
different directions.

• Lymph nodes

Lymph nodes were not palpable.

• Trachea

Her trachea is located in the midline of her neck with space equal on both sides. No
visible enlargement of the thyroid lymph node.

• Thyroid gland
Enlargement of the gland was not visible upon inspection. As they instructed her to
swallow, the glands ascend as they palpated but are not visible.

I. THORAX AND LUNGS

• Posterior thorax

o Spinal alignment

Her spinal column is straight, both shoulders and hips are of the same height.

o Vocal (tactile) fremitus

Vibration is felt when she says “Ninety-nine”.

o Diaphragmatic excursion

There is the movement of thumbs away from the midline when she inhaled and
there is the return of thumbs towards the midline when she exhaled.

o Posterior chest

Upon percussion, the chest cavity is resonance in sound. Her breathing pattern is
regular and no presence of crackles.

• Anterior thorax

o Vocal (tactile) fremitus

Vibration is felt when she says “Ninety-nine”.

o Anterior chest

Upon percussion, the chest cavity is resonance in sound. Her breathing pattern is
regular and no presence of crackles.

J. PERIPHERAL VASCULAR SYSTEM

• Peripheral perfusion

o Capillary refill test

When nails are pinched, the color returns in less than 3 seconds, hence, she has
normal capillary refill.

K. ABDOMEN

Skin is unblemished with uniformed color. She has a round shaped abdomen with
audible bowel sounds. There is also absence of arterial bruits and friction rubs upon
auscultation.

M. MUSCLES

She has equal muscle size on both sides of her body. No contractures were seen on
the muscles and tendons. Muscle tonicity is normally firm with smooth coordinated
movements.

N. BONE

No deformities were found on the structure of the skeleton. There were also
no tenderness or swellings in any areas.

O. JOINTS

Her joints move smoothly and there are no swellings, tenderness or nodules
upon inspection and palpation.

P. MOTOR FUNCTION

• Walking Gait

She was not able to walk unaided and not able to maintain her
balance.

• Finger-To-Nose Test

She was able to touch her nose repeatedly and rhythmically.

• Alternating Supination and Pronation of Hands on Knees

She can alternately supinate and pronate hands at rapid pace.

• Fingers to Nose and to the Nurse’s Finger

 She was able to perform it with coordination and rapidity.

• Fingers to Fingers

She was able to perform it with accuracy and rapidly.

• Finger to Thumb (Same Hand)

She was able to touch her fingers to thumb with each hand rapidly.

• Heel Down Opposite Shin

She was able to demonstrate bilaterally with equal coordination.

• Toe or Ball of Foot to the Nurse’s Finger

She was able to perform it with coordination and moves it smoothly.

• Light-touch Sensation

Her response was in accordance to every test done to her by the student
nurse. She was able to determine the spot where the wisp of cotton was on
different parts of her body.

• Pain sensation

She was able to distinguish sharp and dull sensations.

• Temperature Sensation

She was able to distinguish hot and cold sensations.

• Position or Kinesthetic Sensation

She is able to determine the position of her toes and fingers as the student
nurse held it in different ways.
Cranial Nerve Type Procedur Normal Actual
e findings findings

1: Olfactory Sensory The student Client will be able to She was able to
Function: nurse asked the identify the different identify the
Smell client to close odors presented different odors
both of her eyes with eyes closed. presented with
and asked to eyes closed.
identify different
aromas such as
perfume,
vinegar, and
coffee.

2.Optic Sensory The student Client will be able to She able to read
nurse asked the read newsprint and newsprint and
Function:
client to read able to see objects able to see
Vision
some printed and identify colors objects and
words from a identify colors.
newspaper and
identify some
colors.

3: Oculomotor Motor The client was Pupils react to light Her pupils react
asked to look and accommodation, to light and
Function:
straight. Then able to close and accommodation,
Extra-ocular
with the use of open eyelids. able to close and
movement and
penlight, light open eyelids.
movement of
was focused on
pupils
the right and
was removed to
DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic/La Date Indication or Results Normal Values Analysis and
boratory Ordered Purpose (units in the Interpretation of
Procedures hospital) results

Date
Results in

1. Urinalysis DO: To screen the Color: Color: Urine color is within

patient’s urine normal range of color.
01-05-11 yellow yellow or amber
for renal or
urinary tract
disease andto Appearance: Turbid urine may contain
DR: Appearance:
evaluate overall RBCs or WBCs, bacteria,
Slightly turbid
01-05-11 body function. To Clear fat, or chyle and may
detect metabolic reflect infection.
or systemic
disease
unrelated to
renal disorders.
PH: Urine ph is within normal
To detect PH:
range.
substances. 6.0
4.5-8

Specific Urine specific gravity is

gravity: Specific gravity: within normal range.

1.015 1.010-1.030

Presence of pus cells

suggests infection.
Pus cells/HPF: Pus cells/HPF:

1-2 None

Blood in urine indicates

NURSING RESPONSIBILITIES:

1. URINALYSIS

Before:

• Check the physician’s request to verify test and time requested,

patient’s name and client’s identification number.
• Explain to the patient that this test aids in the diagnosis of renal or
urinary tract disease and helps evaluate overall body function.
• Inform patients that foods or fluids need to be restricted before the
test.
• Notify the laboratory or the physician of the medication of the patient,
they might interfere with the test result and may need to be restricted.

During:

• Collect a urine sample enough for urinalysis.

• Make sure that the urine collected is not contaminated.
• Cover it immediately.
• Clean and cover the genital area of the patient after collecting the
sample.
• If the patient is to perform the collection, explain the proper collection
of specimen.

After:

• Submit the collected specimen to the laboratory immediately.

• Instruct the patient to resume his normal diet and medication as
ordered.
Diagnostic/L Date Indicatio Results Normal Values Analysis and
aboratory Ordered n or (units in the Interpretation of results
Procedures Purpose hospital)

Date
Results in

2. DO: Hemoglo Hemoglobin: Hemoglobin: The Hemoglobin level is

Hematology bin- this within normal range. This
01-05-11 140 123-153
test indicates theres no alteration
evaluates in the function of red blood
blood loss, cells to pick up and release
DR:
erythropoi oxygen.
01-06-11 etin
ability,
anemia
and
response
to therapy.
Hemoglobi
n is an
important
componen
t of RBC
that
carries
oxygen
and
carbon
dioxide to
and from
tissues. Its
purpose is
Hematocrit: Hematocrit:
to
measure 0.41 0.36-0.45 The hematocrit level is within
the the normal range.
severity of
anemia
and to
monitor
response
to therapy.

Hematocr
it-
measures Platelet: Platelet:
the The platelet count is within
concentrat 265x10^9/L 150-400x10^9/L
ion of RBC the normal range.
within the
blood
volume. It
is used to
aid
diagnosis
of
abnormal
states of
dehydratio
n,
polycythe
mia, and
anemia
NURSING RESPONSIBILITIES

Hematology

Before:

• Check the doctor’s order.

• Explain the procedure to the client.

• Explain to the client that cross matching could cause pain from the needle
puncture.
• Inform the patient that he does not need to fast before the procedure.

• Inform the patient of who will perform the procedure, where and when.

• Explain to the patient that this test will ensure him that the blood that he will
be receiving is compatible with the donor.

During:

• Draw 1ml of blood sample from the patient

• Avoid hemolysis
• Do not aspirate strongly
• Apply pressure to the puncture site

After:

• Apply pressure to the venipuncture site.

• Encourage enough rest if she is experiencing fatigue.

• Observe for signs of further bleeding on the venipuncture site.

• Chart time of collection of blood specimen.

• Attach result to the chart as soon as they are available.

ANATOMY AND PHYSIOLOGY

The Human Digestive System

Digestive System, series of connected organs whose purpose is

to break down, or digest, the food we eat. Food is made up of large,
complex molecules, which the digestive system breaks down into
smaller, simple molecules that can be absorbed into the bloodstream.
The simple molecules travel through the bloodstream to all of the
body's cells, which use them for growth, repair, and energy.

Digestion generally involves two phases: a mechanical phase

and a chemical phase. In the mechanical phase, teeth or other
structures physically break down large pieces of food into smaller
pieces. In the chemical phase, digestive chemicals called enzymes
break apart individual molecules of food to yield molecules that can be
absorbed and distributed throughout the body. These enzymes are
secreted (produced and released) by glands in the body.

The digestive system of most animals consists mainly of a long,

continuous tube called the alimentary canal, or digestive tract. This
canal has a mouth at one end, through which food is taken in, and an
anus at the other end, through which digestive wastes are excreted.
Muscles in the walls of the alimentary canal move the food along. Most
digestive organs are part of the alimentary canal. However, two
accessory digestive organs, the liver and pancreas, are located outside
the alimentary canal. These organs contribute to chemical digestion by
releasing digestive juices into the canal through tubes called ducts.

The Oral Cavity

Mouth, opening in an animal's body used for taking in food.

Mouths are also typically used for making sounds, such as barks,
chirps, howls, and in humans, speech. In most animals, the mouth is
found on the face, near the eyes and nose.
 Lips, which form the mouth's muscular opening, are an
especially familiar part of the body for humans. Lips help hold food in
the mouth and are used to form words during speech. They also help
form facial expressions, such as smiling and frowning. Lips open wide
during a yawn and squeeze together during a whistle. Lips are darker
than the surrounding skin because of the many extremely small blood
vessels, called capillaries, which show through the skin.

The cheeks form the sides of the mouth. They are composed of
muscle tissue that is covered on the outside by skin. Like the lips, the
cheeks help hold food and they also play a role in speech.

Inside the mouth is the large, muscular tongue. This extremely flexible
muscle is used for eating and swallowing and also for talking. It is
attached to the floor, or bottom, of the mouth. Its upper surface is
covered with tiny projections, called papillae, which give the tongue a
somewhat rough texture. The papillae contain tiny pores that are the
site of taste buds, the receptor cells responsible for our sense of taste.
There are four kinds of taste buds that are grouped together on certain
areas of the tongue’s surface—those that are sensitive to sweet, salty,
sour, and bitter flavors.

The roof, or top, of the mouth is called the palate. It separates

the mouth from the nasal passages above it. The front part of the
palate—the part closer to the lips—is made of bone covered with moist
tissue, called mucous membrane. This part of the mouth is known as
the hard palate. Behind the hard palate is the soft palate, a small area
composed mainly of muscle tissue. During swallowing, the soft palate
presses against the back of the throat, preventing food or liquid from
moving upward into the nasal passages.

Teeth are used for biting into and chewing food. Their
interaction with the lips and tongue helps a person speak clearly.
Children have 20 primary teeth, which begin to erupt, or break through
the gums, at about six months of age. At six years of age, the primary
teeth start to fall out, as permanent teeth replace them. The number of
 permanent teeth is 32. The crown, or top, of each tooth is covered with
enamel, the hardest substance in the human body.

The mouth also contains three pairs of salivary glands. These

glands secrete a watery fluid called saliva, which moistens food and
the tissues of the mouth. Saliva contains amylase, a digestive enzyme
that starts to break down carbohydrates in food even before it is
swallowed. Saliva also contains a specialized protein, or enzyme, called
lysozyme, which fights bacteria.

The Pharynx

Pharynx, muscular tube located in the neck, lined with mucous

membrane, that connects the nose and mouth with the trachea
(windpipe) and esophagus and serves as a passageway for both air
and food. About 13 cm (5 in) long in humans, it lies in the front of the
spinal column. The pharynx contains the tonsils and, in children, the
adenoids. Because it begins in the back of the nasal cavity, the upper
part of the pharynx is called the nasopharynx. The lower part, or
oropharynx, refers to the area in the back of the mouth. The pharynx
ends at the epiglottis, a flap of cartilage that prevents food from
entering the trachea but allows it to enter the esophagus.

The Esophagus

The presence of food in the pharynx stimulates swallowing,

which squeezes the food into the esophagus. The esophagus, a
muscular tube about 25 cm (10 in) long, passes behind the trachea
and heart and penetrates the diaphragm (muscular wall between the
chest and abdomen) before reaching the stomach. Food advances
through the alimentary canal by means of rhythmic muscle
contractions (tightenings) known as peristalsis. The process begins
when circular muscles in the esophagus wall contract and relax (widen)
 one after the other, squeezing food downward toward the stomach.
Food travels the length of the esophagus in two to three seconds.

A circular muscle called the esophageal sphincter separates the

esophagus and the stomach. As food is swallowed, this muscle relaxes,
forming an opening through which the food can pass into the stomach.
Then the muscle contracts, closing the opening to prevent food from
moving back into the esophagus. The esophageal sphincter is the first
of several such muscles along the alimentary canal. These muscles act
as valves to regulate the passage of food and keep it from moving
backward.

The Stomach

Most animals, like humans, have a single stomach. The outer surface
of the stomach is smooth; the inner surface is folded into numerous
complex ridges, which assist in the mixing of food with digestive juices
and channel this material through the stomach into the intestines. Only
water, alcohol, and certain drugs seem to be absorbed from the
stomach; most food absorption takes place in the small intestine.

In humans the stomach is situated in the upper part of the abdominal

cavity, mostly to the left of the midline. The large, domed end of the
stomach, the fundus, lies in the left vault of the diaphragm; the
esophagus enters the upper side, or lesser curvature, a short distance
below the fundus. The region immediately below the fundus is called
the body. The upper part of the stomach, spoken of as the cardiac
portion, includes the fundus and body. The lower, or pyloric, portion
curves downward, forward, and to the right and includes the antrum
and pyloric canal. The latter is continuous with the upper part of the
small intestine, the duodenum.

The tissues of the stomach include an outer fibrous coat derived

from the peritoneum and, beneath this, a coat of smooth muscle fiber
arranged in diagonal, longitudinal, and circular layers. At the junction
of the esophagus and stomach the circular muscles are much
enlarged, forming the esophageal sphincter. Contraction of this muscle
prevents the regurgitation of gastric contents into the esophagus. A
similar structure, the pyloric sphincter, is found at the junction of the
pylorus and the duodenum. Another layer of the stomach, the
submucosa, is made up of loose connective tissue in which are found
numerous blood and lymph vessels and nerves of the autonomic
nervous system. The innermost layer, the mucosa, contains secretory
cells. One type secretes hydrochloric acid, which not only neutralizes
the alkaline reaction of the saliva, but also renders the gastric contents
distinctly acid and activates the gastric digestive juices. A different
type of cell secretes these juices. The enzymes found in gastric juice
are pepsin, which in the presence of acid splits proteins to peptones;
rennin, which curdles milk; and perhaps lipase, which splits fats to
fatty acids and glycerol. A third type of cell secretes mucus for the
protection of the stomach from its own products.

The tissues of the stomach are digestible by the gastric juices,

as is mucus. Under normal conditions, however, the mucous coating is
renewed more rapidly than it is removed. When a pathological or
psychosomatic condition prevents the proper secretion of mucus, the
gastric mucosa becomes eroded and an ulcer forms. If neglected, this
ulcer may perforate the gastric wall and allow the stomach contents to
escape into the abdominal cavity, causing peritonitis.

The introduction into the stomach of meat extracts, cooked

grains, and partly digested products of proteins stimulates the flow of
gastric juice. These agents, which are called secretagogues, cause the
formation of a hormone, gastrin, in the pyloric end of the stomach.
Gastrin, when absorbed, stimulates the secretory glands. Gastric
secretion also may be stimulated by the mere sight or smell of food.
This is called cephalic or reflex stimulation.

The walls of the empty stomach are in contact with each other.
As food enters the organ, the walls yield and the cavity enlarges
 without change in intragastric pressure. The cardiac portion of the
stomach stores the ingested food. Waves of contraction of the circular
muscle, preceded by waves of relaxation (peristalsis), start about
midway in the body of the stomach and travel downward, ending just
before reaching the pyloric canal. Such waves of contraction, which
may occur at a rate of three per minute, macerate and thoroughly mix
the food with gastric juice.

The periodic discharge of food from the stomach into the

duodenum is caused by the contraction of the muscles in the stomach
wall. These muscles are innervated by the cranial vagus nerves, which
stimulate contraction of the gastric musculature and allow the
sphincter between the stomach and the duodenum to open. Because
severing these nerves leads to paralysis lasting only a few days, the
stomach, like the heart, must be regarded as an automatic organ.
Whether the automaticity is determined in the musculature or in an
intrinsic nerve mechanism is unknown. Sympathetic nerve fibers in the
splanchnic nerves have opposite effects to the vagal nerves,
preventing gastric emptying.

The Small Intestine

Intestine is the portion of the digestive tract between the stomach and
anus. In humans the intestine is divided into two major sections: the
small intestine, which is about 6 m (20 ft) long, where the most
extensive part of digestion occurs and where most food products are
absorbed; and the large intestine, which has a larger diameter and is
about 1.5 m (5 ft) long, where water is absorbed and from which solid
waste material is excreted.

The small intestine, which is coiled in the center of the

abdominal cavity, is divided into three sections. The upper portion
includes the pylorus, the opening at the lower part of the stomach,
through which the contents of the stomach pass into the duodenum.
 The duodenum is a horseshoe-shaped section surrounding part of the
pancreas and the pancreatic duct, as well as ducts from the liver and
gall bladder that open into it. The middle part of the small intestine,
extending from the duodenum to the ileum, is called the jejunum, and
the terminal portion is the ileum, which leads into the side of the first
part of the large intestine, the cecum. The lining membrane, or
mucosa, of the small intestine is especially suited for the purpose of
digestion and absorption. The mucosa is folded; the folds are covered
with minute mucosal projections called villi. Each villus is a small tube
of epithelium surrounding a small lymphatic vessel, or lacteal, and
many capillaries. Tiny glandular pits, called the crypts of Lieberkühn,
open at the bases of the villi; these pits secrete the enzymes
necessary for intestinal digestion. Digested carbohydrates and proteins
pass into the capillaries of the villi and then to the portal vein, which
enters the liver; digested fats are absorbed into the lacteals in the villi,
and they are transported through the lymphatic system into the
general bloodstream. The lining of the small intestine also secretes a
hormone called secretin, which stimulates the pancreas to produce
digestive enzymes.

The Liver

Liver is the largest internal organ of the human body. The liver,
which is part of the digestive system, performs more than 500 different
functions, all of which are essential to life. Its essential functions
include helping the body to digest fats, storing reserves of nutrients,
filtering poisons and wastes from the blood, synthesizing a variety of
proteins, and regulating the levels of many chemicals found in the
bloodstream. The liver is unique among the body’s vital organs in that
it can regenerate, or grow back, cells that have been destroyed by
some short-term injury or disease. But if the liver is damaged
repeatedly over a long period of time, it may undergo irreversible
changes that permanently interfere with function.
 The human liver is a dark red-brown organ with a soft, spongy
texture. It is located at the top of the abdomen, on the right side of the
body just below the diaphragm—a sheet of muscle tissue that
separates the lungs from the abdominal organs. The lower part of the
rib cage covers the liver, protecting it from injury. In a healthy adult,
the liver weighs about 1.5 kg (3 lb) and is about 15 cm (6 in) thick.

Despite its many complex functions, the liver is relatively simple

in structure. It consists of two main lobes, left and right, which overlap
slightly. The right lobe has two smaller lobes attached to it, called the
quadrate and caudate lobes.

Each lobe contains many thousands of units called lobules that are the
building blocks of the liver. Lobules are six-sided structures each about
1 mm (0.04 in) across. A tiny vein runs through the center of each
lobule and eventually drains into the hepatic vein, which carries blood
out of the liver. Hundreds of cubed-shaped liver cells, called
hepatocytes, are arranged around the lobule's central vein in a
radiating pattern. On the outside surface of each lobule are small
veins, ducts, and arteries that carry fluids to and from the lobules. As
the liver does its work, nutrients are collected, wastes are removed,
and chemical substances are released into the body through these
vessels.

Unlike most organs, which have a single blood supply, the liver
receives blood from two sources. The hepatic artery delivers oxygen-
rich blood from the heart, supplying about 25 percent of the liver's
blood. The liver also receives oxygen-depleted blood from the hepatic
portal vein. This vein, which is the source of 75 percent of the liver's
blood supply, carries blood to the liver that has traveled from the
digestive tract, where it collects nutrients as food is digested. These
nutrients are delivered to the liver for further processing or storage.

Tiny blood vessel branches of the hepatic artery and the hepatic
portal vein are found around each liver lobule. This network of blood
vessels is responsible for the vast amount of blood that flows through
 the liver—about 1.4 liters (about 3 pt) every minute. Blood exits the
liver through the hepatic vein, which eventually drains into the heart.

One of the liver’s primary jobs is to store energy in the form of

glycogen, which is made from a type of sugar called glucose. The liver
removes glucose from the blood when blood glucose levels are high.
Through a process called glycogenesis, the liver combines the glucose
molecules in long chains to create glycogen, a carbohydrate that
provides a stored form of energy. When the amount of glucose in the
blood falls below the level required to meet the body’s needs, the liver
reverses this reaction, transforming glycogen into glucose.

Another crucial function of the liver is the production of bile, a

yellowish-brown liquid containing salts necessary for the digestion of
lipids, or fats. These salts are produced within the lobules. Bile leaves
the liver through a network of ducts and is transported to the
gallbladder, which concentrates the bile and releases it into the small
intestine.

The Pancreas

Pancreas is a conglomerate gland lying transversely across the

posterior wall of the abdomen. It varies in length from 15 to 20 cm (6
to 8 in) and has a breadth of about 3.8 cm (about 1.5 in) and a
thickness of from 1.3 to 2.5 cm (0.5 to 1 in). Its usual weight is about
85 gm (about 3 oz), and its head lies in the concavity of the
duodenum.

The pancreas has both an exocrine and an endocrine secretion.

The exocrine secretion is made up of a number of enzymes that are
discharged into the intestine to aid in digestion. The endocrine
secretion, insulin, is important in the metabolism of sugar in the body.
Insulin is produced in small groups of especially modified glandular
cells in the pancreas; these cell groups are known as the islets of
Langerhans.
The Large Intestine

The large intestine serves several important functions. It

absorbs water—about 6 liters (1.6 gallons) daily—as well as dissolved
salts from the residue passed on by the small intestine. In addition,
bacteria in the large intestine promote the breakdown of undigested
materials and make several vitamins, notably vitamin K, which the
body needs for blood clotting.

The large intestine is divided into the cecum, ascending colon,

transverse colon, descending colon, sigmoid colon, and rectum. The
cecum is a swollen sac located in the lower right-hand portion of the
abdominal cavity; it is very large in herbivorous animals. The two
important parts of the cecum in humans are the vestigal vermiform
appendix, which often becomes diseased; and the ileocecal valve, a
membranous structure between the cecum and the small intestine that
regulates the passage of food material from the small intestine to the
large intestine and also prevents the passage of toxic waste products
from the large intestine back into the small intestine. The ascending
colon rises along the right side of the abdominal cavity; the transverse
colon runs across the body to the left side, where the descending colon
travels downward. The sigmoid colon is the S-shaped portion of the
large intestine as it enters the pelvic cavity. The rectum, about 15 cm
(6 in) long, is the almost straight, terminal portion of the large
intestine. At the exit of the rectum, called the anus, is a round muscle,
the anal sphincter, which closes the anus. The large intestine has a
smooth mucosal lining (only the rectum has folds) that secretes mucus
to lubricate the waste materials.
 Food and waste material are moved along the length of the
intestine by rhythmic contractions of intestinal muscles; these
contractions are called peristaltic movements. The entire intestine is
held in place in the abdominal cavity by membranes called
mesenteries.

The human digestive

system is a complex
series of organs and
glands that processes
food. In order to use the
food we eat, our body
has to break the food
down into smaller
molecules that it can
process; it also has to
excrete waste.

Most of the digestive organs (like the stomach and intestines) are tube-like
and contain the food as it makes its way through the body. The digestive
system is essentially a long, twisting tube that runs from the mouth to the
anus, plus a few other organs (like the liver and pancreas) that produce or
store digestive chemicals.

The Digestive Process:

The start of the process - the mouth: The digestive process begins in the
mouth. Food is partly broken down by the process of chewing and by the
chemical action of salivary enzymes (these enzymes are produced by the
salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus - After being chewed and
swallowed, the food enters the esophagus. The esophagus is a long tube that
runs from the mouth to the stomach. It uses rhythmic, wave-like muscle
movements (called peristalsis) to force food from the throat into the stomach.
This muscle movement gives us the ability to eat or drink even when we're
upside-down.

In the stomach - The stomach is a large, sack-like organ that churns the
food and bathes it in a very strong acid (gastric acid). Food in the stomach
that is partly digested and mixed with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the
duodenum, the first part of the small intestine. It then enters the jejunum and
then the ileum (the final part of the small intestine). In the small intestine,
bile (produced in the liver and stored in the gall bladder), pancreatic
enzymes, and other digestive enzymes produced by the inner wall of the
small intestine help in the breakdown of food.

In the large intestine - After passing through the small intestine, food
passes into the large intestine. In the large intestine, some of the water and
electrolytes (chemicals like sodium) are removed from the food. Many
microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia
coli, and Klebsiella) in the large intestine help in the digestion process. The
first part of the large intestine is called the cecum (the appendix is connected
to the cecum). Food then travels upward in the ascending colon. The food
travels across the abdomen in the transverse colon, goes back down the
other side of the body in the descending colon, and then through the sigmoid
colon.

The end of the process - Solid waste is then stored in the rectum until it is
excreted via the anus.
Digestive System Glossary:

anus - the opening at the end of the digestive system from which feces
(waste) exits the body.
appendix - a small sac located on the cecum.
ascending colon - the part of the large intestine that run upwards; it is
located after the cecum.
bile - a digestive chemical that is produced in the liver, stored in the gall
bladder, and secreted into the small intestine.
cecum - the first part of the large intestine; the appendix is connected to the
cecum.
chyme - food in the stomach that is partly digested and mixed with stomach
acids. Chyme goes on to the small intestine for further digestion.
descending colon - the part of the large intestine that run downwards after
the transverse colon and before the sigmoid colon.
duodenum - the first part of the small intestine; it is C-shaped and runs from
the stomach to the jejunum.
epiglottis - the flap at the back of the tongue that keeps chewed food from
going down the windpipe to the lungs. When you swallow, the epiglottis
automatically closes. When you breathe, the epiglottis opens so that air can
go in and out of the windpipe.
esophagus - the long tube between the mouth and the stomach. It uses
rhythmic muscle movements (called peristalsis) to force food from the throat
into the stomach.
gall bladder - a small, sac-like organ located by the duodenum. It stores and
releases bile (a digestive chemical which is produced in the liver) into the
small intestine.
ileum - the last part of the small intestine before the large intestine begins.
jejunum - the long, coiled mid-section of the small intestine; it is between
the duodenum and the ileum.
liver - a large organ located above and in front of the stomach. It filters
toxins from the blood, and makes bile (which breaks down fats) and some
blood proteins.
mouth - the first part of the digestive system, where food enters the body.
Chewing and salivary enzymes in the mouth are the beginning of the
digestive process (breaking down the food).
pancreas - an enzyme-producing gland located below the stomach and
above the intestines. Enzymes from the pancreas help in the digestion of
carbohydrates, fats and proteins in the small intestine.
peristalsis - rhythmic muscle movements that force food in the esophagus
from the throat into the stomach. Peristalsis is involuntary - you cannot
control it. It is also what allows you to eat and drink while upside-down.
rectum - the lower part of the large intestine, where feces are stored before
they are excreted.
salivary glands - glands located in the mouth that produce saliva. Saliva
contains enzymes that break down carbohydrates (starch) into smaller
molecules.
sigmoid colon - the part of the large intestine between the descending
colon and the rectum.
stomach - a sack-like, muscular organ that is attached to the esophagus.
Both chemical and mechanical digestion takes place in the stomach. When
food enters the stomach, it is churned in a bath of acids and enzymes.
transverse colon - the part of the large intestine that runs horizontally
across the abdomen.

Oral Cavity

In humans, the mouth is an integral part of digestion, speech,

and breathing. Food enters the mouth to be broken down both by
the teeth and by enzymes secreted by three salivary glands—the
sublingual gland, the submandibular gland, and the parotid gland.
The tongue pushes food down the pharynx. The tongue and nasal
 cavity modify sound waves
to produce the sounds of
speech, while the tongue
and teeth work together to
form words.

Stomach

Located on
the left side of the
body, under the
diaphragm, the
stomach is a
muscular, saclike
organ that connects
the esophagus and
small intestine. Its
main function is to
break down food.
Cells in the stomach
lining secrete enzymes, hydrochloric acid, and other chemicals
to continue the digestive process begun in the mouth and
produce mucus to keep these substances from digesting the
lining itself.
Small Intestine

The small intestine is

where most digestion takes
place. The inner lining, or
mucosa, is folded and covered
with tiny finger-like projections
called villi, a design that
maximizes the absorptive
surface area of the intestine.
Rhythmic contraction of the
muscular walls moves food
along while bile, enzymes, and
other secretions break it down.
Nutrients absorbed into the
intestine’s many blood vessels
are carried to the liver to be
distributed to the rest of the body.

Large Intestine

Anchored in the
abdomen, the large
intestine is the final
section of the digestive
tract. Undigested
material passes from
the small intestine as
 liquid and fiber. The muscular walls of the large intestine push this
material through the intestine into the rectum. Cells in the smooth
walls absorb vitamins, minerals, and water. Condensed waste,
called feces, leaves the body through the rectum and anal canal.

Liver

The largest internal

organ in humans, the
liver is also one of the
most important. It has
many functions, among
them the synthesis of
proteins, immune and
clotting factors, and
oxygen and fat-carrying
substances. Its chief
digestive function is the
secretion of bile; a
solution critical to the
liver has two main lobes,
located just under the
diaphragm on the right side of the body. It can lose 75 percent of its
tissue (to disease or surgery) without ceasing to function.
Pancreas

The pancreas has both a

digestive and a hormonal
function. Composed mainly of
exocrine tissue, it secretes
enzymes into the small
intestine, where they help
break down fats,
carbohydrates, and proteins.
Pockets of endocrine cells
called the islets of Langerhans
produce glucagon and insulin,
hormones that regulate blood-sugar level.
NURSING CARE PLAN
Problem # : Deficit Fluid Volume r/t Active Fluid Loss
Expected
Assessmen Nursing Scientific Nursing
Objectives Rationale Outcome
t diagnosis explanation interventions

S> Ø Deficient During the Short term: Short term:

> Identify > To identify the
Fluid Volume occurrence of possible cause or
r/t Active After 4 hours of underlying After 4 hours
gastroenteritis, underlying
Fluid Loss as NI, patient will condition of NI, patient
O> Patient a hindrance in
evidenced by condition.
manifested loose watery be able to shall be able
the functions of
the stool and dry verbalize to verbalize
the large
mucous understanding understanding
following: intestine is
membrane. > To assess for of
of the causative the
noted, where in >Note
>Dry factors and fluid loss causative
there is possible
mucous purposes of the factors and
decrease causes of fluid
membrane therapeutic purposes of
absorption of volume deficit
>Body regimen. the
fluids and
Malaise therapeutic
nutrients and
regimen.
therefore
>3x >To verify the
causing
passage of >Note condition of the
diarrhea and Long term:
loose, physical signs patient Long term:
increase fluid
unformed of
stool. loss resulting to After 3 days of dehydration. After 3days of
fluid imbalance. NI, patient will NI, patient
>with pale
maintain a fluid shall maintain
conjunctiva
volume at a > To determine a fluid volume
>with pale functional level the balance at a functional
>Monitor Input
nailbeds as evidenced by between the level as
and Output.
adequate urine fluids intake and
evidenced by
output, stable fluid loss.
Pt. May vital signs and adequate
manifest: moist mucous urine output,
membrane stable vital
>decrease
signs and
urine > Monitor >To asses for fluid
moist mucous
output.
weight daily loss and water membrane.
>altered
retention
level of
consciousn
ess.

>dizziness.
>Change > To avoid
>cyanosis. Patient’s impairing the skin
position integrity or
 formation of
ulcers.

> Perform skin

care > To maintain skin
Integrity

> To immediately
>Regulate
replace the fliud
intravenous
loss and
fluid as
electrolytes
ordered

> To avoid drying

>Instruct
and fissuring of
client to keep
the mouth.
the mouth
wet.

> To replace fluid

loss and prevent
>Encourage further electrolyte
client to imbalance.
increase the
fluid intake
when
indicated

>to maintain
cleanliness of the
food and potability
>Provide
of the water.
health
teachings
regarding
proper

handling of
food and
water.
Problem # : Nutritional Imbalance: less than body requirement
Expected
Assessmen Nursing Scientific Nursing
Objectives Rationale Outcome
t diagnosis explanation interventions

S> θ Nutritional Nutritional Short term: Short term:

>Assess > To provide
imbalance: imbalance in
less than After 4 hours of weight, age comparative After 4 hours
acute gastro-
body NI, the patient and body build baseline of NI, the
O> Patient requirements enteritis is a
will demonstrate patient shall
r/t inability of result of
manifested techniques on demonstrate
the GIT to
the decrease
absorb identifying >Determine > To prevent techniques on
following: nutrient. nutrient
nutritious food. ability to chew aspiration identifying
absorption due
and swallow nutritious
>Weakness to irritated GIT
foods.
cause by the
>Poor Long term:
invading micro-
muscle > Note daily
organisms and After 3 days of > To assess for
tone intake Long term:
increase Nursing changes in the
> passing peristaltic Interventions client’s dietary After 3 days of
out loose movement that the patient will intake Nursing
watery can lead to demonstrate Interventions
stool = 3 diarrhea and progressive the patient
times. decrease motor gait. > To increase the shall
>Instruct the
 nutrient use of client’s appetite demonstrate
absorption. flavoring progressive
Pt. May gain through
agents such as motor gait
manifest: effective
lemon
feeding.
>decrease
> To prevent
urine gain through
further elimination
output. > Limit fiber effective
intake
>altered feeding.
level of > To increase or
consciousn enhance intake
> Provide
ess.
relaxing
>dizziness. environment

>cyanosis.
> To replace water
> Instruct the as well as
So to give nutrients being
food and water eliminated
the patient per
demand.
>Provide
health
> To avoid
teachings
reoccurrence of
regarding
the disease and to
proper
prevent further
handling of
nutritional
food and
imbalance
water.
SOPIES:

January 06, 2011

Problem: Deficient Fluid Volume

S> θ

O> Received patient on bed, conscious and coherent, with an ongoing IVF of
1L PNSS x 80cc/hour, infusing well on left hand, with no infiltration noted.

>passed out watery stool 3 times

>body malaise

>decrease urine output

>dry mucous membrane

>Vital Signs taken:

Temperature: 36 C

Pulse rate: 84 bpm

Respiratory rate: 16cpm

Blood Pressure: 140/90mmHg

A> Deficient Fluid Volume r/t Active Fluid Loss as evidenced by loose watery
stool and dry mucous membrane.

P> After 4 hours of Nursing Interventions the patient will verbalize

understanding of the causative factors and purpose of the therapeutic
regimen and interventions

I> Established rapport

>Monitored and Recorded vital sign

>Noted possible cause of fluid volume deficit

>Monitored/ recorded all sources of fluid loss such as urine and stool

>Noted physical signs of dehydration

>Provided rest periods

>Encouraged frequent hand washing

> Instructed patient to keep mouth wet

>Encouraged/ Instructed Patient to increase the oral fluid intake with SAP

>Emphasized to patient the importance of personal hygiene

>Encouraged patient to give the patient foods rich in Vitamin C and Zinc

>Assisted patients in rendering Care

>Changed clothing to loose light fitting clothes

>Due meds given

E> Goal met as evidenced by the patient verbalized understanding of the

causative factors and purpose of the therapeutic regimen and interventions.

January 07, 2011

Problem: Nutritional Imbalanced: Less than Body requirements

S> θ

O> Received patient on bed, conscious and coherent, with an ongoing IVF of
1L PNSS x 80cc/hour, infusing well on left hand, with no infiltration noted.

> With pale conjunctiva

> With pale lips and mucous membrane

> With previous vomiting and diarrhea

> Vital signs taken:

Temperature=36 C

Pulse rate=79 bpm

Respiratory rate=20 cpm

Blood pressure: 120/90mmHg

A>Nutritional imbalance: less than body requirements r/t inability of the GIT
to absorb nutrient as evidenced by passage of loose watery stool

P> After 4 hours of NI, the patient will demonstrate techniques on how to
prepare nutritious foods

I> Established rapport

>Monitored and assessed vital signs

>Discussed eating habits including food preferences

>Instructed the SO to give the patient a food per demand

> Assessed weight, age and body build

>Provide health teachings regarding proper handling of food and water

> Regulated IVF

> Administered meds as ordered

> Due meds given

E> Goal met AEB the patient demonstrated techniques on how to prepare
nutritious foods.
CLIENT’S DAILY PROGRESS IN THE HOSPITAL

Client’s Daily Progress Chart

DAYS Admission Discharge

Janary 05, January 06, January 07, January 08,

2011 2011 2011 2011

Nursing
Problems

/ / - -
Deficient fluid
Volume

/ / - -
Nutritional
imbalance:
less than body
requirements

Vital Signs

Temp: 36 36 36 -

PR: 78 84 79 -

RR: 22 16 20 -

BP: 120/90 140/90 120/80

Lab Procedures Urinalysis

Hematolog
y

Medical HGT HGT HGT -

Management
PNSS PNSS PNSS -

Drugs
 DISCHARGE PLANNING

Home Medications:
1. Lifezar 50mg tab ½ tab OD
2. Lipitor 40mg tab ½ tab OD
3. Levimar 20 ‘u’ SQ OD in AM- resume if patient is able to tolerate oral
feeding sufficiency.
4. Imax 500mg 1 tab TID
5. Plavix 75mg 1tab OD
6. Nexium 40mg tab 1tab OD.

Other Instructions:

 Lactulose free diet

 FBS on follow up (no food and drinks 6-8 hours prior to blood test).

Clinic Visit:
 Follow up at Garcia Hospital (doctors clinic on Saturday at 1pm)