final ncp hannah.docx
TRANSCRIPT
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CUES NURSING
DIAGNOSIS
RATIONALE GOALS AND
OBJECTIVES
INTERVENTION RATIONALE EVALUATION
Subjective:
Objective:
Decreased
hemoglobin,
Pale lips and
conjunctiva,
(+)anemic
Decreased tissue
perfusion related to
decreased
hemoglobin
concentration in the
blood from anemia
Decrease in o!"gen
resulting in the
failure to nourish
the tissues at the
capillar" level
(#issue perfusion
problems can e!ist
$ithout decreasecardiac output%
ho$ever, there ma"
be a relationship
bet$een cardiac
output and tissue
perfusion)
#ransport of o!"gen
is impaired $ith
anemia
&emoglobin is
lac'ing or thenumber of *s is
too lo$ to carr"
adeuate o!"gen to
the tissues and
h"po!ia develops
#he bod" attempts
to compensate for
tissue h"po!ia b"
increasing the rate
of * production,
increasing cardiac
output b"
increasing stro'e
volume heart rate,
redistributing blood
from tissues $ith
high o!"gen needs
S&O# #-.:
/fter 0 hours of
nursing
intervention:
a) ill be able to
prevent the
occurrence ofh"povolemic
shoc'
b) Prevent the
occurrence of
h"po!ia
2O34 #-.:
/fter 5 months ofcollaborative
intervention, the
patient $ill be able
to:
a) .aintain
hemoglobin level in
normal range
INDEPENDENT:
67nvestigate
changes in level of
consciousness,
reports of di88iness
or headache
6lood transfusion
as ordered
67nvestigate
reports of chest
pain 3ote location,ualit", duration,
and $hat relieves
pain
6/uscultate apical
pulse .onitor
cardiac rate or
rh"thm if
continuous -*4 is
available
indicated
6*hanges ma"
re9ect inadeuate
cerebral perfusion
as a result of
reduced arterial
blood pressure
Note: change insensorium may also
refect elevated
ammonia levels or
hepatic
encephalopathy in
clients with liver
disease.
6#o correct anemia
6.a" re9ectcardiac ischemia
related to
decreased
perfusion 3ote:
7mpaired
o!"genation status
resulting from blood
loss can bring on .7
in clients $ith
cardiac disease
6D"srh"thmias and
ischemic changes
can occur as a
result of
h"potension,
h"po!ia, acidosis,
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(.edical Surgical
3ursing 0th edition
b" lac' and
&a$'s, p 5;;
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pallor, redness
.assage gentl"
$ith lotion *hange
position freuentl"
6-ncourage patient
to eat foods rich in
iron, such as:a. Malunggay
b. Alugbati
c. Dilis
d Ganas
DEPENDENT:
6Provide
supplemental
o!"gen if indicated
6/dminister 7@
9uids as indicated
6#ransfuse blood as
ordered (S*)
6/dminister
Aerrous Sulfate
(AeSOB)
COLLABORATIVE:
6epeat ** post
#
to vasoconstrictive
therap", bleeding
into biliar" tract, or
perforation or onset
of peritonitis
6*ompromised
peripheral
circulation
increases ris' ofs'in brea'do$n
6#o aid in
maintenance of
normal hemoglobin
level
6#reats h"po!emia
and lactic acidosis
during bleeding
6.aintains
circulating volume
and perfusion
67n order to regain
the normal
hemoglobin level
6#o prevent
e!cessive 9uid
volume in the bod"
6#o treat and
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CUES NURSING
DIAGNOSIS
RATIONALE
GOALS AND
OBJECTIVES
INTERVENTION
prevent 7ron
De=cienc" /nemia
6#o monitor if there
is an improvement
in the &emoglobin
level in the bod"
RATIONALE
EVALUATION
Subjective:
Objective:
is' for 7nfection
related to poor
$ound healing
S&O# #-.:
/fter 0 hours of
nursing
intervention, the
patient $ill be able
to:
a 7dentif"
behaviors toprevent or reduce
ris' of infection
2O34 #-.:
INDEPENDENT:
6Perform or
promote meticulous
hand$ashing b"
caregivers and
client
6.aintain strict
aseptic techniue$ith procedures or
$ound care
6-ncourage
freuent position
6#o prevent cross
contamination or
bacterial
coloni8ation
6educe ris' of
bacterial
coloni8ation orinfection
6#o promote
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/fter 5 months of
collaborative
intervention, the
patient $ill be free
from an" ris' of
infection
change or
ambulation,
coughing and
D*-
6.onitor
temperature 3ote
presence of chills,
tach"cardia, $ith
or $ithout fever
Collaborative:
6Obtain specimens
for culture and
sensitivit" as
indicated
6/dminister topical
antiseptic%s"stemic
antibiotics
ventilation of the
lung segments
6e9ective of
in9ammator"
process or infection,
reuiring evaluation
and treatment
6@eri=es presence
of infection,
identi=es speci=c
pathogens, and
in9uence choice of
treatment
6.a" be used
proph"lacticall" to
reduce coloni8ationto treat speci=c
infectious process
CUES NURSING
DIAGNOSIS
RATIONALE GOALS AND
OBJECTIVES
INTERVENTION RATIONALE EVALUATION
Subjective: /n!iet" related to
recurrence of
melena
/ vague, uneas"
feeling or feeling of
fear to$ardssomething that is
not familiar or is not
ne$ to the patient
S&O# #-.:
/fter 0 hours ofnursing
intervention, the
patient $ill be able
to :
INDEPENDENT:
6-ncourage
verbali8ation ofconcerns /ssis
client in e!pressing
feelings b" activel"
listening
6-stablish a
therapeuticrelationship, assist
client in dealing
$ith healings, and
provides
opportunit" to
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Objective:
a nderstand his
conditions and the
treatment available
that can help him
b /ppear rela! and
report an!iet" is
reduced to a
manageable level
2O34 #-.:
/fter 1 month of
collaborative
intervention, the
patient $ill be able
to:
a e $orr"free
about his condition
6/c'no$ledge that
this fearful situation
and that other have
e!press similar
fears
6Provide accurate,concrete
information about
$hat is being done
6Provide a calm
restful environment
DEPENDENT:
6/dministermedications as
indicated
clarif"
misconception
6hen the client is
e!periencing o$n
fear, the validation
that this feelings
are normal, can
help client to feel
less isolated
67nvolves client in
plan of care and
decreases
unnecessar"
an!iet" about
un'no$n
6emoving client of
outside stressors,
promotes
rela!ations andma" enhance
coping s'ills
6Sedatives or anti
an!iet" agents ma"
be used on
occasion to reduce
an!iet" and
promote rest
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CUES NURSING
DIAGNOSIS
RATIONALE GOALS AND
OBJECTIVES
INTERVENTION RATIONALE EVALUATION
Subjective:
Objective:
7mbalance nutrition:
2ess than bod"
reuirements
related to
inadeuate diet
2iver cirrhosis
particularl" a>ects
protein metabolism
$ith reduction in
s"nthesis of
transport proteins
such as albumin
#his is caused b" acombination of
decreased
functional liver
mass and
alterations in amino
acid demands
educed gl"cogen
storage also
increases amino
acid needs for
gluconeogenesis
$hile ongoingin9ammation alters
the pattern of
amino acid
reuirements,
precipitating
speci=c amino acid
shortages #his
problem is then
made $orse b" a
reduced capacit"
for transamination
reaction, $hich $illallo$ the liver to
generate amino
acids in shorts
suppl" form those
available /s a
S&O# #-.:
/fter 0 hours of
nursing
intervention, the
patient $ill be able
to:
a @erbali8e theimportance of good
nutrition
b Aormulated diet
modi=cations of his
choice
2O34 #-.:
/fter 5 months of
collaborativeinterventions, the
patient $ill be able
to:
a Demonstrate
progressive $eight
gain
b -!perience no
further signs of
malnutrition
c eceive adeuate
nutrition as
evidenced b" no
$eight loss and no
manifestations of
INDEPENDENT:
6.odif" the diet
6Place the client on
dail" $eight, input
and output
monitoring, and
calorie counts
6-valuate client
ris' formalnutrition
6Determine
interest in eating
and abilit" to che$,
6Diet should
provide ample
protein to rebuild
tissue but not
enogh protein to
precipitate hepatic
encephalopath"(E< gda"),
suFcient
carboh"drates to
maintain $eight
and to spare protein
stores
6#o assess 9uid
and nutritional
balance
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conseuence of all
the above, patients
$ith cirrhosis need
considerabl" high
minimum dail"
protein inta'e of
around C; gms or
(15 gms'gda") to
maintain nitrogen
balance rather than?< gms or
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acute liver disease
or decompensated
chronic liver
disease 2evels of
overall energ"
demands in
cirrhotic liver
disease are subject
to debate $ith
resting energ"e!penditure or --
studies sho$ing
con9icting results
#he largest stud" to
date in BE? patients
sho$ed that ?BH of
cirrhotics $ere
h"permetabolic or
indirect
caloriemetr" but
the causes of
elevated -- $ereunclear and
unrelated to clinical
or biochemical
assessment of
impaired liver
function #he
increased energ"
e!penditure ma"
therefore re9ect
intrahepatic events
in some liver
disease such as thes"stemic
in9ammator"
response Overt or
hidden infection
also increases --
allo$ed% avoid
those containing
ammonium
6Provide vitamin
supplements as
indicated
6estrict inta'e of
ca>eine, gas
producing or spic"
and e!cessivel" hotor cold foods
6-ncourageprovid
e freuent
mouthcare
especiall" before
meals
6Provide assistance$ith activities as
needed Promote
undisturbed rest
periods especiall"
before meals
demonstrate loss of
interests in foods
because of nausea,
fatigue, general
$ea'ness and
malaise
6Salt limitations
can help manage
9uid complicationsin cirrhosis Salts
substitutes
enhances the 9avor
of food and aid in
increasing appetite%
ammonia
penetrates ris' of
encephalopath"
6@itamins /,D,-,
and ' are suppliedif fat absorption is
adeuate
Areuentl" vit I
injections are
ordered to improve
blood clotting
factors
6/ids in reducing
gas or strict
irritation or diarrhea
and abdominaldiscomfort that ma"
impair oral inta'e or
digestion
6*lient is prone to
1;
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in cirrhotics and the
presence of ascites
per se seems to
contribute since
falls in -- are seen
$ith paracentesis
3evertheless, in
one stud"
h"permetabolism
$as still present insome patients 1
"ear after insertion
of transjugular
intrahepatic
Portos"stemic
shunts, even
though ascites had
resolved
DEPENDENT:
6/dminister
medications as
indicated:
a @itamin
supplements and
vitaminsb Digestive
en8"mes
c /ntiemetics
6.aintain in 3PO
$hen indicated
COLLABORATIVE:
6.onitor nutritional
lab studies
6*onsult $ith
sore and or
bleeding gums
$hich contributes
to anore!ia
6*onserving
energ" reduces
metabolic demands
of the liver and
promotes cellularregeneration
6*lient ma" be
vitamin de=cient
because of previous
poor dietar" habits
/lso the injured
liver is unable to
utili8e vitamins and
anemia (due to ironand folic acid
de=cienc") ma"
e!ist
647 rest ma" be
reuired in acutel"
ill clients to reduce
demands of the
liver and production
of ammonia or urea
in the 47 tract
hen this is thecase, nutrition must
be applied $ith
another method
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dietician to provide
diet that high in
calories and simple
carboh"drates
64lucose ma"
decreased because
of impaired
g"cogenesis
depleted gl"cogen
stores or
inadeuate inta'e
Protein ma" be lo$
because of impaired
metabolism,decreased hepatic
s"nthesis or loss
into peritoneal
cavit"
6&igh calorie foods
are desired in as
much as client
inta'e is usuall"
limited
CUES NURSING
DIAGNOSIS
RATIONALE GOALS AND
OBJECTIVES
INTERVENTIONS RATIONALE EVALUATION
Subjective: De=cient 9uid
volume related to
ruptured
esophageal varices
-sophageal varices
are a comple! of
longitudinal
tortuous veins at
S&O# #-.:
/fter 0 hours of
nursing
73D-P-3D-3#:
6.onitor client
inta'e% teach the
client to avoid
6large amounts of
sugars, alcohol, and
ca>eine act as
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Objective:
(+)hematemesis(+)47 related to
-@
the lo$er end of the
esophagus,
enlarged and
s$ollen as the
result of portal
h"pertension
interventions, the
patient $ill be able
to:
a
b
co>ee, tea,
grapefruit juice,
sugared drin's, and
alcohol
6.onitor output%
ensure at least
ectivel", $eights
should be measured
at the same time on
the same scale $ith
the same clothes
6#hese laborator"
studies $ill re9ect
h"dration status
67f hemorrhage
from ruptured
varices occurs,
monitor P, P, ,
and urine output
continuousl" /ssist
$ith interventions
to restore
6#o reduce ris's of
deh"dration
1?
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before fasting
6evie$ the
clientJs
medications
6.onitor for signs
of deh"dration,
di88iness, and
$ea'ness% mucous
membrane% and
inta'e versus
output
6-!plain to the
client the need to
drin' 9uids and to
use a s"stem for
reminding
himselfherself not
to rel" on thirst
6*ertain
medications can
contribute to
deh"dration
6Output ma"
e!ceed inta'e,
$hich ma" alread"be inadeuate to
compensate for
insensible losses
6#he elderl" are at
high ris' for
deh"dration due to
decreased thirst
sensation,
decreased 9uid
volume, and
decreased abilit" toconcentrate urine
(ennett, 5;;;)
6Strategies that
include verbal
prompting and
choices of 9uids $ill
increase 9uid
inta'e -lderl"
clients $ho live
alone need help to
design prompts that$ill remind them to
drin'
1B
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CUES NURSING
DIAGNOSIS
RATIONALE GOALS AND
OBJECTIVES
INTERVENTIONS RATIONALE EVALUATION
Subjective:
Objective:
(+) bod"
$ea'nessfatigue
/ctivit" 7ntolerance
related to bod"
$ea'ness
secondar" to
muscle $asting
S&O# #-.:
/fter 0 hours of
nursing
interventions, the
patient $ill be able
to%
a
b
73D-P-3D-3#:
6#a'e vital signs
eg, resting pulse,
blood pressure, and
respirations
6-ncourage
bedrest to chair rest
initiall" 2imit
activit" on basis of
pain or adverse
cardiac response
Provide nonstress
diversional
activities
6Plan rest periodsaccording to the
clientJs dail"
schedule
6#o serve as
clientJs baseline
data esponse to
activit" can be
evaluated b"
comparing
preactivit" blood
pressure, pulse, and
respiration $ith
postactivit" results
#hese, in turn, arecompared $ith
recover" time
6educes $or'load
and energ"
consumption
6est relieves the
s"mptoms of
activit" intolerance
#he dail" schedule
is planned to allo$
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67dentif" factors
that undermine the
clientJs con=dence
6&elp the client to
identif" progress
Do not
underestimate the
value of praise and
encouragement as
e>ective
motivational
techniues
for alternating
periods of activit"
and rest and is
coordinated to
reduce e!cess
energ" e!penditure
6#o promote
participation in
activities to achievea level of activit"
desired b" the
client for the
therapeutic
regimen
6Strategies that
are individuali8ed
can increase
motivation
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CUES NURSING
DIAGNOSIS
RATIONALE GOALS AD
OBJECTIVES
INTERVENTIONS RATIONALE EVALUATION
Subjective:
K Iada nasu'a a'o
hin ma" dugo,
nauro li$at a'o hin
maitomL as
verbali8ed b" thepatient
Objective:
(+)47
(+).elena
(+)&ematemesis
Decreased
hemoglobinDecreased *s
Decreased
hematocrit
7ne>ective tissue
perfusion related to
bleeding
tendencies
S&O# #-.:
/fter 0 hours of
appropriate nursing
intervention given
to patient, he $illbe able to:
a
b
Independent:
67nvestigate
sudden changes or
continued
alterations in
mentation, such asan!iet", confusion,
letharg", and
stupor
67nspect for pallor,
c"anosis, mottling,
and cool or clamm"
s'in
3ote strength of
peripheral pulses
6*erebral perfusion
is directl" related to
cardiac output and
is
in9uenced b"electrol"te and
acidbase
variations, h"po!ia,
and s"stemic
emboli
6S"stemic
vasoconstriction
resulting from
diminished cardiac
output ma" be
evidenced b"decreased s'in
perfusion and
diminished pulses
(efer to 3D: ris'
1E
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6.onitor
respirations, noting
$or' of breathing
6.onitor inta'e,
noting changes in
urine output
ecord urine
speci=c gravit", as
indicated
6.onitor for
hemorrhage
6/ssess
gastrointestinal
function, notinganore!ia, decreased
or
absent bo$el
sounds, nausea and
vomiting,
for decreased
*ardiac
Output)
6*ardiac pump
failure and ischemic
pain ma"
precipitate
respirator"
distress% ho$ever,sudden or
continued d"spnea
ma" indicate
thromboembolic
pulmonar"
complications
6Decreased inta'e
or persistent
nausea ma" result
in reduced
circulating volume,$hich negativel"
a>ects perfusion
and
organ function
Speci=c gravit"
measurements
re9ect
h"dration status
and renal function
6.onitor client for
bleeding gums,purpura, melena,
hematuria, and
hematemesis
6educed blood
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abdominal
distention, and
constipation
6-ncourage active
or assist $ith
passive lege!ercises, $ith
avoidance of
isometric e!ercises
6/ssess for pain in
lo$er e!tremit" and&omansJ sign,
er"thema, and
edema
67nstruct client in
application and
periodic removal of
antiembolic hose
$hen used
Collaborative:
6/ppl" elasticcompression
stoc'ings or
intermittent
pneumatic
compression
9o$ to mesenter"
can produce
gastrointestinal
d"sfunction, such
as loss of
peristalsis
Problems ma" be
potentiated or
aggravated b" use
of analgesics,decreased
activit", and dietar"
changes
6-nhances venous
return, reduces
venous stasis, and
decreases
ris' of
thrombophlebitis%
ho$ever, isometric
e!ercises canadversel" a>ect
cardiac output b"
increasing
m"ocardial
$or' and o!"gen
consumption
67ndicators of deep
vein thrombosis
(D@#), although calf
pain is
not al$a"s present
62imits venous
stasis, improves
venous return, and
reduces ris' of
1G
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devices, as
indicated
thrombophlebitis in
client $ho is limited
in activit"
6.a" be desired to
prevent D@#,
especiall" in client
$ho is
unable to be out of
bed or cannotambulate freel"
CUES NURSING RATIONALE GOALS AND INTERVENTIONS RATIONALE EVALUATIO
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DIAGNOSIS OBJECTIVESSubjective:
Objective:
7ne>ective tissue
perfusion related to
h"povolemia
S&O# #-.:
/fter 0 hours of
appropriate nursing
interventions, the
patient $ill be able
to:
a
b
7ndependent:
6.onitor changes
in the level of
consciousness,
complaints of
di88iness or
headaches
6/uscultate theapical pulse 4uards
heart rate and
rh"thm $hen there
is continuous -*4
6/sses the s'in to
cold, Pale, s$eating,
slo$ capillar" =lling
and peripheral pulse
is $ea'
63ote reports of
abdominal pain,
especiall" sudden
severe pain, or pain
spreading to the
shoulders
6*hange ma"
indicate inadeuate
cerebral perfusion
due to arterial blood
pressure
6*hange
d"srh"thmias andischemia can occur
as a result of
h"potension,
6@asoconstriction is
a s"mpathetic
response to the
decline in
circulation volume
and or ma" occur
as a side e>ect of
vasopressin
6Pain caused b"
gastric ulcer often
disappears after
hemorrhage due to
#he bu>er e>ects of
blood
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*-S 3S734D7/43OS7S
/#7O3/2- 4O/2S /3DOM-*#7@-S
73#-@-3#7O3S /#7O3/2- -@/2/#7O
Subjective:
Objective:
/ctivit" 7ntolerance
related to anemia
from poor nutrition
and bleeding
S&O# #-.:
/fter 0 hours of
appropriate nursing
intervention, the
patient $ill be able
to:
a
b
2O34 #-.:
73D-P-3D-3#:
6/lternate rest and
activit"
6/ssist $ith
activities of dail"
living
6.onitorhemoglobin and
hematocrit levels
/ssist $ith the
treatment of 47
bleeding
6/dminister blood
transfusions or iron
supplements as
ordered to treat
anemia
6#his conserves
energ" and reduces
demands on liver
67ncreases activit"
tolerance and
endurance
6/llo$s detection
and treatment ofgastrointestinal
bleeding
6lood transfusions
$ill immediatel"
improve hemoglobin
and hematocrit
levels, $hereas iron
replacement
therap" $ill ta'e
longer to bee>ective
6Decreased
production of
clotting factors can
#he client $ill
able to tolerate
activit" better,
perform more /
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lead to hemorrhage
and anemia
*-S 3S734
D7/43OS7S
/#7O3/2- 4O/2S /3D
OM-*#7@-S
73#-@-3#7O3 /#7O3/2- -@/2/#7O
Subjective:
Objective:
(+) stomach
guarding
*hronic pain relatedto ph"sical
response
Pain occurs fromulceration and
aeration of mucosa
of the upper
gastrointestinal
organs including the
stomach and
esophagus $hich
indicated presence
of melena,
hematemesis, or
blood in gastric
contents(3ursing *are Plan
4uidelines for
7ndividuali8ing
*lient *are /cross
the 2ife Span, 0th
edition)
/fter 0 hours ofnursing
intervention,
patient%
a verbali8es relief
from pain
b demonstrates
rela!ed bod"
posture and able to
sleeprest
appropriatel"
7ndependent%
63ote reports of
pain including its
location, duration,
and intensit" from a
pain scale of ;1;
6evie$ factors
that
aggraviatealleviate
pain
63ote nonverbal
pain cues such as:
abdominal
guarding,
reluctance to move,
restlessness,
tach"cardia,
diaphoresis,etc
6Pain is not al$a"s
present Presence of
such should be
compared $ith the
clientJs previous
pain s"mptoms
#his comparison
ma" assist in the
diagnosis of etiolog"
of bleeding and
development ofcomplications
6&elpful in
establishing
diagnosis and
treatment needs
63onverbal cues
ma" be both
ph"siological, and
ma" be used in
conjunction $ith
verbal cues to
evaluate e!tent and
severit" of the
problem
5?
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6Provide small,
freuent meals as
indicated
67dentif" and limit
foods creating
discomfort
6/ssist $ith active
and passive O.
e!ercises
Dependent:
6/dminister
medications as
indicated:
/nalgesics/cetaminophen
/ntacids
/nticholinergen
*ollaborative:
6Provide and
implement dietar"
modi=cations
6Aood has an acid
neutrali8ing e>ects
and dilutes the
gastric content
6Speci=c foods that
cause distress
varies among
certain individuals
6educe joint
sti>ness, minimi8ing
pain and discomfort
6#o help relieve
acutesevere pain
#o promote general
comfort and rest #o
decrease gastric
acidit" b"
absorption or b"chemical
neutrali8ation
6hen oral inta'e
is allo$ed, food
choices depends on
the diagnosis and
its etiologic factors