PREFACE

Praise God we pray toward the presence of the Almighty for all the grace and favor so I can finish the paper Fundamentals of Nursing 2 with the theme: "Therapeutic diet to clients with ulcers and arthritis. "The author realizes that this paper is not perfect and there are still many deficiencies, therefore the authors expect criticism and constructive suggestions to the perfection of this paper become better.Finally, the authors hope that this paper is useful for us personally and for those who need it.

Malang, May 4, 2011

Author

PEPTIC ULCERA peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus (opening between stomach and duodenum), in the duodenum (rst part of small intestine), or in the esophagus. A peptic ulcer is frequently referred to as a gastric, duodenal, or esophageal ulcer, depending on its location, or as peptic ulcer disease. Peptic ulcers are more likely to be in the duodenum than in the stomach. As a rule they occur alone, but they may occur in multiples. Chronic gastric ulcers tend to occur in the lesser curvature of the stomach (Brunner and Suddart).

Duodenal UlcerGastric Ulcer

IncidenceAge 3060Male: female 23:180% of peptic ulcers are duodenalUsually 50 and overMale: female 1:115% of peptic ulcers are gastric

Signs, Symptoms, and Clinical FindingsHypersecretion of stomach acid (HCl)May have weight gainPain occurs 23 hours after a meal; often awakened between12 AM; ingestion of food relieves painVomiting uncommonHemorrhage less likely than witgastric ulcer, but if present melena more common than hematemesisMore likely to perforate than gastric ulcersNormalhyposecretion ofstomach acid (HCl)Weight loss may occurPain occurs 12 to 1 hour after ameal; rarely occurs at night;may be relieved by vomiting;ingestion of food does nothelp, sometimes increases painVomiting commonHemorrhage more likely tooccur than with duodenalulcer; hematemesis morecommon than melena

Malignancy PossibilityRareOccasionally

Risk FactorsH. pylori, alcohol, smoking, cirrhosis, stressH. pylori, gastritis, alcohol,smoking, use of NSAIDs,stress

Peptic ulcers including gastrointestinal disease that can be controlled with diet and regular medication such as cimetidine.Cimetidine is kelasobat which is a histamine receptor antagonist that blocks the secretion of hydrochloric acid.Clients are also encouraged to avoid foods that increase stomach acidity, such as caffeine, decaffeinated coffee, milk intake is often, sour orange juice, and certain spices (pepper spicy, chili seasoning).Smoking and alcohol are not recommended.(Price and Wilson, 2006) PathophysiologyPeptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin. The erosion is caused by the increased concentration or activity of acid-pepsin, or by decreased resistance of the mucosa. A damaged mucosa cannot secrete enough mucus to act as a barrier against HCl. Clinical ManifestationsSymptoms of an ulcer may last for a few days, weeks, or months and may disappear only to reappear, often without an identiable cause. Many people have symptomless ulcers, and in 20% to 30% perforation or hemorrhage may occur without any preceding manifestations. As a rule, the patient with an ulcer complains of dull, gnawing pain or a burning sensation in the midepigastrium or in the back. It is believed that the pain occurs when the increased acid content of the stomach and duodenum erodes the lesion and stimulates the exposed nerve endings. Another theory suggests that contact of the lesion with acid stimulates a local reex mechanism that initiates contraction of the adjacent smooth muscle. Pain is usually relieved by eating, because food neutralizes the acid, or by taking alkali; however, once the stomach has emptied or the alkalis effect has decreased, the pain returns. Sharply localized tenderness can be elicited by applying gentle pressure to the epigastrium at or slightly to the right of the midline. Other symptoms include pyrosis (heartburn), vomiting, constipation or diarrhea, and bleeding. Pyrosis is a burning sensation in the esophagus and stomach that moves up to the mouth. Heartburn is often accompanied by sour eructation, or burping, which is common when the patients stomach is empty. Although vomiting is rare in uncomplicated duodenal ulcer, it may be a symptom of a peptic ulcer complication. Assessment and Diagnostic FindingsA physical examination may reveal pain, epigastric tenderness, or abdominal distention. A barium study of the upper GI tract may show an ulcer; however, endoscopy is the preferred diagnostic procedure because it allows direct visualization of inammatory changes, ulcers, and lesions. Through endoscopy, a biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Endoscopy may reveal lesions that are not evident on x-ray studies because of their size or location. Medical ManagementOnce the diagnosis is established, the patient is informed that the problem can be controlled. Recurrence may develop; however, peptic ulcers treated with antibiotics to eradicate H. pylori have a lower recurrence rate than those not treated with antibiotics. The goals are to eradicate H. pylori and to manage gastric acidity. Methods used include medications, lifestyle changes, and surgical intervention.STRESS REDUCTION AND RESTReducing environmental stress requires physical and psychological modications on the patients part as well as the aid and cooperation of family members and signicant others. The patient may need help in identifying situations that are stressful or exhausting. A rushed lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings and with the regular administration of medications. The patient may benet from regular rest periods during the day, at least during the acute phase of the disease. Biofeedback, hypnosis, or behavior modication may be helpful.SMOKING CESSATIONStudies have shown that smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, resulting in increased acidity of the duodenum. Research indicates that continuing to smoke cigarettes may signicantly inhibit ulcer repair. Therefore, the patient is strongly encouraged to stop smoking. Smoking cessation support groups and other smoking cessation approaches are helpful for many patientsDIETARY MODIFICATIONThe intent of dietary modication for patients with peptic ulcers is to avoid oversecretion of acid and hypermotility in the GI tract. These can be minimized by avoiding extremes of temperature and overstimulation from consumption of meat extracts, alcohol, coffee (including decaffeinated coffee, which also stimulates acid secretion) and other caffeinated beverages, and diets rich in milk and cream (which stimulate acid secretion). In addition, an effort is made to neutralize acid by eating three regular meals a day. Small, frequent feedings are not necessary as long as an antacid or a histamine blocker is taken. Diet compatibility becomes an individual matter: the patient eats foods that can be tolerated and avoids those that produce pain.LIFESTYLE MODIFICATIONSMany lifestyle modifications are recommended as therapy for gastroesophageal reflux disease (Table). These include the avoidance of foods that reduce lower esophageal sphincter pressure and thus predispose to reflux, the limiting of exposure to acidic foods that are inherently irritating, and the adoption of behaviors to minimize reflux or heartburn. Although trials of the clinical efficacy of dietary or behavioral changes are lacking, clinical experience suggests that particular patients may benefit from certain measures.For example, patients with sleep disturbance from nighttime heartburn may benefit from elevation of the head of the bed, but that recommendation is probably superfluous for a patient without nighttime symptoms. Weight reduction should routinely be recommended in overweight patients, giventhe strong association between an increased bodymass index and the likelihood of symptoms (Peter J. Kahrilas,2008)Dietary and Lifestyle Recommendations for the Treatmentof Gastroesophageal Reflux Disease.*Dietary avoidanceFoods that are acidic or otherwise irritativeCitrus fruitsTomatoesOnionsCarbonated beveragesSpicy foodsFoods that can cause gastric refluxFatty or fried foodsCoffee, tea, and caffeinated beveragesChocolateMintLifestyleSmoking cessationWeight reduction for patients who are overweight (BMI, 25.029.9) or obese(BMI, 30.0) or whose onset of symptoms was concurrent withweight gain within the normal range (BMI, 18.524.9)Reduction in alcohol consumptionNighttime symptomsAvoidance of eating within 3 hr before bedtimeElevation of head of bedPostprandial symptomsConsumption of smaller and more frequent mealsAvoidance of lying down after mealsAbdominal obesityAvoidance of tight garmentsSource : journal of Gastroesophageal Reflux Disease by Peter J. Kahrilas, M.D.

NURSING PROCESSTHE PATIENT WITH ULCER DISEASEAssessmentThe nurse asks the patient to describe the pain and the methods used to relieve it (e.g., food, antacids). The patient usually describes peptic ulcer pain as burning or gnawing; it occurs about 2 hours after a meal and frequently awakens the patient between midnight and 3 AM. Taking antacids, eating, or vomiting often relieves the pain. If the patient reports a recent history of vomiting, the nurse determines how often emesis has occurred and notes important characteristics of the vomitus: Is it bright red, does it resemble coffee grounds, or is there undigested food from previous meals? Has the patient noted any bloody or tarry stools?DiagnosisNURSING DIAGNOSESBased on the assessment data, the patients nursing diagnoses may include the following: Acute pain related to the effect of gastric acid secretion on damaged tissue Anxiety related to coping with an acute disease Imbalanced nutrition related to changes in diet Decient knowledge about prevention of symptoms and management of the conditionCOLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONSPotential complications may include the following: Hemorrhage Perforation Penetration Pyloric obstruction (gastric outlet obstruction)Planning and GoalsThe goals for the patient may include relief of pain, reduced anxiety, maintenance of nutritional requirements, knowledge about the management and prevention of ulcer recurrence, and absence of complications.Nursing Interventions Relieving pain Reducing anxiety Maintaining optimal nutritional statusStomach Ulcer Diet

Stomach Ulcer Diet should be observed very strictly. Eat every three to four hours in small portions. Do not overeat. Such a diet for stomach ulcer helps to reduce the increased excitability of the nervous system.Stomach Ulcer Diet strictly prohibits alcoholic beverages, even in the most minimal doses. Spirit based drinks irritate the stomach lining; it is a powerful stimulator of excessive gastric juice, which is very harmful for patients suffering from peptic ulcer before operation and after it.Basic principles of Stomach Ulcer Diet

First, the diet should contain the maximum amount of vitamins. Secondly, the diet should have adequate amount of mineral salts, mainly calcium salts, magnesium, potassium. All this must be present in the food, or as a supplement to it. Third, the diet must be followed for a long time. Fourthly, food should not be hot, not cold from 15 to 65 degrees C. Permitted:* Milk especially valuable product for patients with peptic ulcer. It contains all the necessary material needed for the recovery processes of the organism.* White bread, wheat (400 g per day), can be a small amount of crumbs.* Scrambled eggs* Milk soup, cereals, or with pasta, mashed.* Poultry, beef, veal (non-fat, fresh, without tendons) in the form of steam cutlets, souffle, mashed potatoes, etc.* Vegetables (potatoes, carrots, beets, pumpkin, zucchini), white in the form of puree, steam puddings without the crust.* Fish (lean varieties: pike-perch, perch) in boiled, steam, chopped form.* Noodles and pasta boiled.* Buckwheat, barley, oats, rice.* Butter and vegetable oil. Total fat should not exceed 100-110 grams.Prohibited:* Fatty meats, fish,* Cabbage* Strong meat and mushroom broth,* Grilled meat and fish,* Beef and pork fat, mutton fat,* Black bread,* Salty dishes* Fiber,* Spicy snacks, canned goods, sausages,* Very cold drinks, ice cream and alcohol.* Vegetable, non-acidic berry juices.* Berries (sweet varieties): raspberry, strawberry, soft fruit varieties are not binding in boiled, mashed or roasted form, creams, jellies, the butter, pureed fruit drinks.Stomach Ulcer Diet not only removes the painful symptom during exacerbation, but also promotes the healing of inflammation.http://www.slimmingdiettips.com/stomach-ulcer-diet/Lifestyle MeasuresConservative management involves both dietary and lifestyle measures. With gastritis and peptic ulcers, lifestyle changes may often be more beneficial than dietary management. Cigarette smoking should be discontinued as smokers are more likely to develop these gastritis and peptic ulcers than non-smokers. The use of nicotine replacement products (NRT) may also contribute to these conditions as stimulants tend to increase gastric acid secretion. Stress, especially emotional stress, may stimulate gastric acid secretion. The use of NSAIDs should be limited or avoided altogether. In chronic inflammatory conditions this may not be possible so the dosage of the prescribed NSAID should be reduced, proton pump inhibitors should be taken simultaneously or the typ of NSAID should be switched (COX-1 to COX-2). Helicobacter pylori infection is a major causative factor of gastritis and peptic ulcers globally. Proper hygiene like washing hands before eating and preparing food as well as sourcing clean drinking water are important measures to prevent re-infection with H.pylori following eradication therapy. These measures however, are not a guarantee that H.pylori gastritis or peptic ulcers will not recur. Excessive and constant gum chewing may also increase gastric acid secretion and should be avoided in gastritis or peptic ulcer disease. Tobacco chewing and areca nut-betel leaf chewing may also be aggravating factors.http://www.healthhype.com/gastritis-diet-peptic-ulcer-diet-foods-to-avoid-and-lifestyle.html

EnergyMost patients suffering from active peptic ulcers are undernourished and therefore need an increased energy intake. However, since they are confined to bed the energy needs for activity are not utilized and make up the extra needs. ProteinsA high protein intake is recommended to provide essential amino acids for tissue protein synthesis and thus promote healing. Proteins are also included because of their good buffering action. They may be increased by about 50 %. However meat proteins are to be avoided because meat extractives have a stimulating effect.Though milk protein has a good buffering action, the high calcium content of milk stimulates excess acid production. Therefore, a high milk intake has an adverse effect on the healing rate of ulcers. Thus milk should be used in moderation. Eggs and other protein foods need to be included to provide essential amino acids. FatsSince fat delays the emptying of stomach, an increased intake is beneficial. However, fat is only moderately increased since patients suffering from peptic ulcers are generally middle aged executives who are also prone to atherosclerosis. Emulsified fats like butter, cream etc are better tolerated. CarbohydratesCarbohydrates are included to meet the energy needs. Foods containing harsh, irritating fiber should be avoided. VitaminsRequirements of nearly all vitamins remain normal. adequate amount of vitamin C should be provided for the healing of ulcers and better iron absorption. MineralsCare should be taken to include sources of iron and calcium in the diet. Generally, blend diets are found to be low in iron and vitamin C due to the restriction in fruits and vegetables and medicinal supplements may have to be given.

DIET AND FEEDING PATTERNBland diets are recommended for patients suffering from peptic ulcers. Such diets are restricted in foods that are mechanically, chemically and thermally irritating to the gastro-intestinal mucosa.The dietary modification in bland diets are therefore based on neutralizing the gastric acid and decreasing the motility.General Dietary guidelines for peptic ulcer patientsa. Eat smaller meals more often to enable the stomach contents to be continuously diluted and neutralized. The quantity of food eaten should be small to avoid overfilling the stomach and causing distention.b. Eat slowly and savour your food in a calm environment.c. Easily digestible fats like fat of whole milk, egg yolk, cream and butter should be used in moderate amounts as they decrease the emptying time of the stomach and reduce matality.d. Try to avoid caffeine beverages such as coffee, cola and tea. Also avoid alcohol.e. Cut down on, or stop smoking cigarettes.f. Avoid excessive spices or concentrated meat broths and extractives.g. Avoid fibrous nature of cereals, fruits and vegetables.h. Avoid frequent use of aspirin or other drugs that may damage the stomach lining.i. Individual responses or tolerances to specific foods may vary. The same food may evoke different responses at different times depending on the stress factor.Diets for different Stages of Peptic UlcersStage I Diet is prescribed during the active phase of ulcers which is characterized by severe painStage II Diet is prescribed when the patient is on bed rest and their is relief from symptoms, but the ulcers are not completely healed.Stage III Diet is what the patient has to follow throughout his life as a prophylactic measure.Foods RecommendedStage I & IIStage III

Beverages like milk and fruit juice.All foods in stage I & II

Milk products - Curd, custards, mild cheeses like cottage cheeseWeak tea and coffee

Refined cereals and their products, pastas etcWell cooked cereal preparation

Washed pulses

Eggs - soft cooked, Minced meatAll milk, cheese and egg preparation

Soft cooked veggies and fruitsRaw fruits & veggies depending upon tolerance

Plain cakes and mildly flavored dishes

http://www.indiadiets.com/diets/eat%20to%20beat%20illness/peptic_ulcers.htm Monitoring and managing potential complications Promoting home and community-based care

EvaluationEXPECTED PATIENT OUTCOMESExpected patient outcomes may include the following:1. Reports freedom from pain between meals2. Feels less anxiety by avoiding stress3. Complies with therapeutic regimena. Avoids irritating foods and beveragesb. Eats regularly scheduled mealsc. Takes prescribed medications as scheduledd. Uses coping mechanisms to deal with stress4. Maintains weight5. Is free of complications

ULCERATIVE COLITIS

Ulcerative colitis is an inflammatory disease that is generally nonspecific colonic prolonged period of remission and exacerbation accompanied the flit.Abdominal pain, diarrhea, and rectal bleeding is a symptom and an important sign (price and wilson,2006)Ulcerative colitis is a recurrent ulcerative and inammatory disease of the mucosal and submucosal layers of the colon and rectum. The peak incidence is between 30 and 50 years of age. It is a serious disease, accompanied by systemic complications and a high mortality rate. Eventually, 10% to 15% of the patients develop carcinoma of the colon (Brunner and Suddart). PathophysiologyUlcerative colitis affects the supercial mucosa of the colon and is characterized by multiple ulcerations, diffuse inammations, and desquamation or shedding of the colonic epithelium. Bleed ing occurs as a result of the ulcerations. The mucosa becomes edematous and inamed. The lesions are contiguous, occurring one after the other. Abscesses form, and inltrate is seen in the mucosa and submucosa with clumps of neutrophils in the crypt lumens (ie, crypt abscesses). The disease process usually begins in the rectum and spreads proximally to involve the entire colon. Eventually, the bowel narrows, shortens, and thickens because of muscular hypertrophy and fat deposits. Clinical ManifestationsThe clinical course is usually one of exacerbations and remissions. The predominant symptoms of ulcerative colitis are diarrhea, lower left quadrant abdominal pain, intermittent tenesmus, and rectal bleeding. The bleeding may be mild or severe, and pallor results. The patient may have anorexia, weight loss, fever, vomiting, and dehydration, as well as cramping, the feeling of an urgent need to defecate, and the passage of 10 to 20 liquid stools each day. The disease is classied as mild, severe, or fulminant, depending on the severity of the symptoms. Hypocalcemia and anemia frequently develop. Rebound tenderness may occur in the right lower quadrant. Extraintestinal symptoms include skin lesions (eg, erythema nodosum), eye lesions (eg, uveitis), joint abnormalities (eg, arthritis), and liver disease. Assessment and Diagnostic FindingsThe patient should be assessed for tachycardia, hypotension, tachypnea, fever, and pallor. Other assessments include the level of hydration and nutritional status. The abdomen should be examined for characteristics of bowel sounds, distention, and tenderness. These ndings assist in determining the severity of the disease.The colon was diffusely thickened, a finding consistent with the long-standing presence of ulcerative colitis (Albert M. Ross IV, M.D., Sudha A. Anupindi, M.D., and Ulysses J. Balis, M.D, 2003)

ComplicationsComplications of ulcerative colitis include toxic megacolon, perforation, and bleeding as a result of ulceration, vascular engorgement, and highly vascular granulation tissue. In toxic megacolon, the inammatory process extends into the muscularis, inhibiting its ability to contract and resulting in colonic distention. Symptoms include fever, abdominal pain and distention, vomiting, and fatigue. Medical Management of ChronicInammatory Bowel DiseaseMedical treatment for regional enteritis and ulcerative colitis is aimed at reducing inammation, suppressing inappropriate immune responses, providing rest for a diseased bowel so that healing may take place, improving quality of life, and preventing or minimizing complications. Most patients maintain long-term well-being interspersed with short intervals of illness (Hanauer, 2001). Management depends on the disease location, severity, and complications.NUTRITIONAL THERAPYOral uids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet nutritional needs, reduce inammation, and control pain and diarrhea. Fluid and electrolyte imbalances from dehydration caused by diarrhea are corrected by intravenous therapy as neces- sary if the patient is hospitalized or by oral supplementation if the patient can be managed at home. Any foods that exacerbate diarrhea are avoided. Milk may contribute to diarrhea in those with lactose intolerance. Cold foods and smoking are avoided because both increase intestinal motility. Parenteral nutrition may be indicated.

NURSING PROCESSMANAGEMENT OF THE PATIENT WITH INFLAMMATORY BOWEL DISEASEAssessmentThe nurse takes a health history to identify the onset, duration, and characteristics of abdominal pain; the presence of diarrhea or fecal urgency, straining at stool (tenesmus), nausea, anorexia, or weight loss; and family history of IBD. It is important to discuss dietary patterns, including the amounts of alcohol, caffeine, and nicotine containing products used daily and weekly. The nurse asks about patterns of bowel elimination, including character, fre- quency, and presence of blood, pus, fat, or mucus. It is important to note allergies and food intolerance, especially milk (lactose) intolerance. The patient may identify sleep disturbances if diarrhea or pain occurs at night.Assessment includes auscultating the abdomen for bowel sounds and their characteristics; palpating the abdomen for distention, tenderness, or pain; and inspecting the skin for evidence of stula tracts or symptoms of dehydration. The stool is inspected for blood and mucus.DiagnosisNURSING DIAGNOSESBased on the assessment data, the nursing diagnoses may include the following: Diarrhea related to the inammatory process Acute pain related to increased peristalsis and GI inam- mation Decient uid volume decit related to anorexia, nausea, and diarrhea Imbalanced nutrition, less than body requirements, related to dietary restrictions, nausea, and malabsorption Activity intolerance related to fatigue Anxiety related to impending surgery Ineffective coping related to repeated episodes of diarrhea Risk for impaired skin integrity related to malnutrition and diarrhea Risk for ineffective therapeutic regimen management related to insufcient knowledge concerning the process and management of the diseaseCOLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONSPotential complications that may develop include the following: Electrolyte imbalance Cardiac dysrhythmia related to electrolyte depletion GI bleeding with uid volume loss Perforation of the bowelPlanning and GoalsThe major goals for the patient include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of uid volume decit, maintenance of optimal nutrition and weight, avoidance of fatigue, reducing anxiety, promoting effective coping, absence of skin breakdown, learning about the disease process and therapeutic regimen, and avoidance of complications.Nursing InterventionsMAINTAINING NORMAL ELIMINATION PATTERNSMAINTAINING FLUID INTAKEMAINTAINING OPTIMAL NUTRITIONFoods to Avoid when you have active Ulcerative Colitis (Flare Up)There are a number of foods which are best avoided during a flare up of Ulcerative Colitis - or when Colitis is active (i.e. blood or mucous in the stools). These are mainly foods that either include a high amount of insoluble fibre - or very high amounts of dairy fats-

Cabbage/sproutsCauliflowerBroccoliSweet CornMushroomsHigh Bran fibre items - such as wholemeal bread, and high fibre cerealRaw onionsTomatoes - especially the seedsSoya Protein (TVP)Onions - Especially raw onionsCheese/cream (tends to cause excess acid/irritation in the gut) http://www.ulcerativecolitis.org.uk/dietarychanges.htm

Ulcerative Colitis Diet PlanNatural Health SolutionsAs a follow up to part one of this series on a natural treatment program for ulcerative colitis, this article provides a specific dietary plan that many people with ulcerative colitis and other types of inflammatory bowel disease can benefit from.The following dietary plan is appropriate for people with ulcerative colitis who are not in the midst of a flare up:Breakfast Choices1. Fruit smoothie made with bananas, blueberries, and enough water to get it going.2. Bowl of porridge made out of long grain white rice (2 cups of water for 1 cup of rice), a small handful of raisins (cooked for at least 5 minutes), and a sprinkle of cinnamon and 1 teaspoon of raw or unpasteurized honey.3. Green smoothie made with 2-3 peaches, 2 tablespoons of blueberries or blackberries, 2 big handfuls of spinach, and enough water to blend everything together.4. Power SmoothieNote: if you are taking food powders like a super green food or acerola cherry powder, you can mix them in with any of these smoothies. On days when you don't make a smoothie, you can take these food powders with water.Lunch Choices1. Steamed sweet potato, avocado, and one or two soft boiled eggs.2. Steamed zucchini, avocado, and a potato-based soup. Please see our archive of healthy soup recipes for several potato-based soup ideas.3. Long grain white rice (1.5 cups of water for 1 cup of rice), steamed cabbage, and hummus.4. Quinoa (2 cups of water for 1 cup of quinoa), avocado, and steamed butternut or acorn squash.Dinner Choices - I recommend taking Carlson cod liver oil right before or with dinner.1. Long grain white rice (1.5 cups of water for 1 cup of rice) with chickpeas and avocado, dressed with extra virgin olive oil and fresh lemon juice, to taste.2. Avocado-orange salad with raw or steamed wild salmon.3. Quinoa (2 cups of water for 1 cup of quiona) with mashed garlic sweet potatoes and avocado.4. Steamed zucchini, steamed carrots, steamed red beets, and sardines.. Snacks1. Any fresh fruit in season.2. Baked potatoes, sweet potatoes, or chestnuts.3. Small handful of raw walnuts that have been soaked for at least two hours.4. Any of the smoothies listed under breakfast choices.If you are in the midst of a flare up, you can follow the same general guidelines listed above, but you should lean towards eating the food choices that are cooked rather than those that are raw.Please observe how your body reacts to each of your food choices and make adjustments accordingly.Be sure to chew all of your foods well and to follow other principles of eating for optimal digestion.Other Recommendations:1) Whenever possible, allow your skin to be exposed to sunlight. Just be sure not to get burned.2) Make it a habit to breathe deeply from your abdomen at least once every five minutes for every hour that you are awake. Doing so will help to keep your parasympathetic nervous system active and your sympathetic nervous system subdued, which is important for promoting a healthy digestive tract.3) Consider spending at least fifteen minutes each day writing any and all thoughts that come to mind in a private journal. Don't censor yourself, and be sure that no one else can see it. Write down all thoughts that pop up in your head, no matter now ridiculous they seem. This exercise can help increase your awareness of emotional stressors that may not be obvious at first thought. 4) If life circumstances allow, do something that you really enjoy every day. Think of an activity that is fun for you and make time for it.5) Each day upon awakening and before you go to sleep, spend a few minutes thinking about:Loved ones who deeply care about your well-beingFamily and friends that you deeply care forThings that you are grateful forI hope that these guidelines prove to be useful.In case you missed it, please feel free to review part one of this look at addressing inflammatory bowel disease here:http://drbenkim.com/articles-ulcerative-colitis-diet.htmPROMOTING RESTREDUCING ANXIETYENHANCING COPING MEASURESPREVENTING SKIN BREAKDOWNMONITORING AND MANAGING POTENTIAL COMPLICATIONSEvaluationEXPECTED PATIENT OUTCOMESExpected patient outcomes may include the following:1. Reports a decrease in the frequency of diarrhea stoolsa. Complies with dietary restrictions; maintains bed restb. Takes medications as prescribed2. Has reduced pain3. Maintains uid volume balancea. Drinks 1 to 2 L of oral uids dailyb. Has a normal body temperaturec. Displays adequate skin turgor and moist mucous membranes4. Attains optimal nutrition; tolerates small, frequent feedings without diarrhea5. Avoids fatiguea. Rests periodically during the dayb. Adheres to activity restrictions6. Is less anxious7. Copes successfully with diagnosisa. Expresses feelings freelyb. Uses appropriate stress reduction behaviors8. Maintains skin integritya. Cleans perianal skin after defecationb. Uses lotion or ointment as skin barrier9. Acquires an understanding of the disease processa. Modies diet appropriately to decrease diarrheab. Adheres to medication regimen10. Recovers without complicationsa. Maintains electrolytes within normal rangesb. Maintains normal sinus or baseline cardiac rhythmc. Maintains uid balanced. Experiences no perforation or rectal bleeding

OSTEOARTHRITISDegenerative Joint Disease (Osteoarthritis)OA, also known as degenerative joint disease or osteoarthrosis (even though inammation may be present), is the most common and frequently disabling of the joint disorders. OA is both over diagnosed and trivialized; it is frequently overtreated or undertreated. The functional impact of OA on quality of life, especially for elderly patients, is often ignored. OA has been classied as primary (idiopathic), with no prior event or disease related to the OA, and secondary, resulting from previous joint injury or inammatory disease. The distinction between primary and secondary OA is not always clear. Increasing age directly relates to the degenerative process in the joint, as the ability of the articular cartilage to resist microfracture with repetitive low loads diminishes. OA often begins in the third decade of life and peaks between the fth and sixth PathophysiologyOA may be thought of as the end result of many factors combining in a generalized predisposition to the disease. OA affects the articular cartilage, subchondral bone (the bony plate that supports the articular cartilage), and synovium. A combination of cartilage degradation, bone stiffening, and reactive inammation of the synovium occurs.

Clinical ManifestationsThe primary clinical manifestations of OA are pain, stiffness, and functional impairment. The pain is due to an inamed synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes, trabecular microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm. Stiffness, which is most commonly experienced in the morning or after awakening, usually lasts less than 30 minutes and decreases with movement. Functional impairment is due to pain on movement and limited motion caused by structural changes in the joints. Assessment and Diagnostic FindingsDiagnosis of OA is complicated because only 30% to 50% of patients with changes seen on x-rays report symptoms. Physical assessment of the musculoskeletal system reveals tender and enlarged joints. Inammation, when present, is not the destructive type seen in the connective tissue diseases such as RA. OA is characterized by a progressive loss of the joint cartilage, which appears on x-ray as a narrowing of joint space. In addition, reactive changes occur at the joint margins and on the subchondral bone in the form of osteophytes (or spurs) as the cartilage attempts to regenerate. Neither the presence of osteophytes nor joint space narrowing alone is specific for OA; however, when combined, these are sensitive and specific findings. In early or mild OA, there is only a weak correlation between joint pain and synovitis. Blood tests are not useful in the diagnosis of OA. Medical ManagementAlthough no treatment halts the degenerative process, certain preventive measures can slow the progress if undertaken early enough. These include weight reduction, prevention of injuries, perinatal screening for congenital hip disease, and ergonomic modications. Conservative treatment measures include the use of heat, weight reduction, joint rest and avoidance of joint overuse, orthotic devices to support inamed joints (splints, braces), isometric and postural exercises, and aerobic exercise. Occupational and physical therapy can help the patient adopt self-management strategies. Nursing ManagementThe nursing management of the patient with OA includes both pharmacologic and nonpharmacologic approaches. The nonpharmacologic interventions are used rst and continued with the addition of pharmacologic agents. Pain management and optimizing functional ability are major goals of nursing intervention. Patients understanding of their disease process and symptom pattern is critical to a plan of care. Because patients with OA are older, they may have other health problems. The current study suggests that weight loss alone or exercise alone can reverse frailty but that the combination of weight loss and exercise is more effective than either individual intervention. Therefore, weight loss and exercise may be an important therapy for frail, obese older adults. Moreover, one study has shown that weight loss and exercise reduce knee pain and improve physical function in overweight and obese older adults with osteoarthritis of the knee (Dennis T. Villareal et al, 2011). A referral for physical therapy or to an ex- ercise program for individuals with similar problems may be very helpful. Canes or other assistive devices for ambulation should be considered. Exercises such as walking should be begun in moderation and increased gradually. Patients should plan their daily exercise for a time when the pain is least severe or should plan to use an analgesic, if appropriate, before exercising. Adequate pain management is important for the success of an exercise program.

Nutrition Facts & Diet Advice for OsteoarthritisConsider the following nutrition guidelines: Eat plenty of sulphur containing foods, such as garlic and onion, and eggs. Sulphur is needed for the repair and rebuilding of bone, cartilage and connective tissue, and aids in the absorption of calcium. Eat plenty of green leafy vegetables, and vegetables of every colour, non-acidic fresh fruit. Eat whole grains (except wheat) such as spelt, kamut, millet and brown rice. Eat oily fish, such as mackerel, herring, sardine, pilchard (avoid the tomato sauce in the tins of fish). Eat fresh (not dried or tinned) pineapple when available as the enzyme Bromelain found in pineapple will help reduce inflammation. Take a tablespoon of linseeds with a couple of glasses of room temperature water every day. Apple cider vinegar is very good for people with arthritis. Reduce saturated fat from animals in your diet and avoid fried foods. Avoid all milk and other dairy produce. You may be alright with goats or sheeps yoghurt. Avoid red meat. Avoid the nightshade family of vegetables (peppers, aubergine or eggplant, tomatoes and white potatoes also tobacco). The solanine found in these foods can cause pain in the muscles to susceptible people. Avoid table salt (sodium chloride) but include the natural sodium found in foods such as celery this is needed to keep calcium in solution and not sit on top of your joints. Get your iron from food, but ensure your multimineral supplements does not contain extra iron (unless your Doctor tells you youre anaemic) there is some evidence iron may be involved in pain, swelling and joint destruction. You do need some iron though, so eat broccoli, blackstrap molasses, beetroot, peas. Check for food allergies and intolerances with a nutritional consultant or allergy specialist, and, especially if you suffer from rheumatoid arthritis, have a test done via a nutritionist to check whether you have a leaky gut you almost certainly have! NSAIDs, among other things, cause leaky gut. This can usually be healed with the help of a nutrition consultant. Also have a hair mineral analysis via a nutrition consultant. Get tested for chlamydia organism which has been linked to some cases of arthritis. Health Supplements for OsteoarthritisThere are dozens of useful supplements used in arthritis. Every person who has arthritis responds differently, so be prepared to try a few. The most successful and important are mentioned first on the list below. Essential:1 - 4 Higher Nature MSM Glucosamine Vitamin C 1000mg three times a dayHigher Nature) 1 x Advanced Antioxidant Formula (from Solgar) 1 x Vitamin B Complex (Biocare) 1 x Magnesium Pantothenate (from BioCare) (helps Adrenal Glands make anti-inflammatory cortisone hormones) 3 x True Food Calcium and Magnesium Complex (Higher Nature) 3mg Boron daily (Solgar) 4 or more capsules or dessert spoon of oil Omega 3 and 6 Essential Balance. (Higher Nature). Omega Nutrition oils are certified organic and are cold processed in the dark, without exposure to oxygen, and packaged in specially researched photon-free tubes for the ultimate protection that even dark glass cannot give. Delicious, rich in omega 3 and omega 6 essential fatty acids, and essential to health. Also try any of the following: MSM Glucosamine Joint Complex Superoxide Dismutase Silica Organic Sulphur MSM Digestive enzymes (e.g. Polyzyme Forte from BioCare) Germanium DL-Phenylalanine for pain relief (Caution: do not take if pregnant or breastfeeding, diabetic, have high blood pressure, taking anti-depressants or suffer from panic attacks, or have PKU) Shark cartilage Cats claw Ginger Feverfew Cayenne pepper Celery seed Devils claw Nettle Parsley tea Burdock root http://www.health4youonline.com/nutrition_facts_osteoarthritis.htm

In addition to this diet for osteoarthritis, we've created a page with natural arthritis remedies.

Foods that contain Beta-Carotene - This compound is an antioxidant that's been shown to help protect joints and slow down osteoarthritis. Foods that contain high levels of beta carotene are: CarrotsBoiled spinachSweet potatoes with skinKaleCollard greensWinter squashCanteloupeRomaine lettuceBroccoliDiet for Osteoarthritis - Foods that fight inflammationMuch of the pain that accompanies with arthritis is due to inflammation associated with the disease. To ease pain, you will want to add foods that are inflammation fighters. Foods with Omega 3 Fatty Acids Wild-caught salmonWalnutsFlax seedsFoods with the inflammation-fighting flavanoid, quercetin ApplesAsparagusCherries or cherry juiceGreen teaOnionsRaspberriesSpinachSpice up your diet for osteoarthritis with anti-inflammatory spices GingerOreganoRosemarySageThymeTurmericAs you can see this diet plan is heavy on healthy fruits and vegetables. Besides treating your osteoarthritis symptoms, a diet rich in fruits and vegetables will likely make you healthier overall, plus you may even lose weight. Your aching joints will be so pleased.http://www.foods-that-heal.com/diet-for-osteoarthritis.html

GOUT ARTHRITISSymptoms and PrevalenceGout is a type of inflammatory arthritis induced by the deposition of monosodium urate crystals in synovial fluid and other tissues. Gout has two clinical phases. The first phase is characterized by intermittent acute attacks that spontaneously resolve, typically over a period of 7 to 10 days, with asymptomatic periods between attacks. With inadequately treated hyperuricemia, transition to the second phase can occur, manifested as chronic tophaceous gout, which often involves polyarticular attacks, symptoms between attacks, and crystal deposition (tophi) in soft tissues or joints. (Tuhina Neogi,2011).

Lifestyle, Nutrition, and Adjunctive TherapiesObservational data indicate that nonpharmacologic approaches, such as avoiding alcohol or modifying ones diet, can reduce serum urate levels but may not be sufficient to control established gout. In one randomized trial involving persons without gout, 500 mg of vitamin C per day for 2 months resulted in serum urate levels that were 0.5 mg per deciliter (30 mol per liter) lower than in those receiving placebo. The intake of dairy milk reduced serum urate levels by approximately 10% during a 3-hour period in a small, randomized, crossover trial involving healthy volunteers. Whether these approaches would have similar effects in persons with gout, or with a longer duration of therapy, is not known. Losartan and fenofibrate, which have uricosuric effects, may be considered in patients with gout who have hypertension or hypertriglyceridemia, respectively, although it is not known whether their use reduces the frequency of gout attacks (Tuhina Neogi,2011).

Diet This diet low-purine diet, low fat, enough vitamins and minerals.This diet can lose weight, if there are signs of excess weight.

Objectives DietThe purpose of gout arthritis diet is to achieve and maintain optimal nutritional status and reduce levels of uric acid in blood and urine.

Terms DietTerms of gout arthritis diet is:

a. Energy in accordance with the needs of the body.When overweight or obesity, energy intake per day is gradually reduced as much as 500-1000 kcal of energy needs for normal to nomal weight is reached.b. Enough protein, namely 1.0 to 1.2 g / kg or 10-15% of total energy needs.c. Avoid foods that have protein sources purine content of> 150 mg / 100 g, among others, brain, liver, heart, kidney, offal, meat extract / broth, Bouillon, duck, fish, sardines, mackerel, mussels and clams.d. Fat is, ie 10-20% of total energy needs.Excess fat may inhibit spending uric acid or purines in the urine.e. Carbohydrates can be given more, ie 65-75% of total energy needs.Because most patients with gout arthritis have more weight, it is advisable to use a source of complex carbohydrates.f. Vitamins and minerals are quite in accordance with the requirementsg. The liquid is adjusted by urine issued every day.On average, the recommended fluid intake is 2-2 liters / day.

Type of Diet and Indications GivingGout arthritis diet given to patients with gout and uric acid stone or with uric acid levels> 7.5 mg / dl.This diet consisted of two types, namely:a.Low purine diet I / House I (1500 kcal)b.Low purine diet II / House II (1700 kcal)

Duration of dietDiet given until the blood uric acid levels and weight to be normal.Normal blood uric acid levels can be seen in below.Food Ingredient IngredientsDPR IDPR II

Weight (g)urtWeightt (g)urt

Rice2003 gelas nasi2503 gelas nasi

Chicken eggs501 butir 501 butir

skinless chicken501 ptg sedang501 ptg sdg

Fish501 ptg sedang501 ptg sdg

Tempe502 ptg sedang502 ptg sdg

Vegetables2502 gelas3003 gelas

Fruit4004 ptg sdg papaya4004 ptg sdg papaya

Oil151 sdm151 sdm

Sugar101 sdm101 sdm

Skim milk powder204 sdm204 sdm

(Sunitah almatsier, 2004)References

Albert M. Ross IV, et al (2003) : Case 11-2003: A 14-Year-Old Boy with Ulcerative Colitis, Primary Sclerosing Cholangitis, and Partial Duodenal Obstruction, N Engl J Med 2003;348:1464-76.

Almatsier, Sunita. 2004. Penuntun Diet. Jakarta:Gramedia.Dennis T. Villareal, et al (2011) : Weight Loss, Exercise, or Both and Physical Function in Obese Older Adults, N Engl J Med 2011;364:1218-29.

Ebook Brunner and Suddarths textbook of medical surgical nursing by Suzanne COConnel Smeltzer and Bren.Peter J. Kahrilas,. (2008) : Gastroesophageal Reflux Disease N Engl J Med 2008;359:1700-7.Price and Wilson. 2006. Patofisiologi Konsep Klinis Proses-Proses Penyakit Volume 1 edisi 6. Jakarta:EGC.Tuhina Neog,. (2011) : Gout, N Engl J Med 2011;364:443-52.http://www.slimmingdiettips.com/stomach-ulcer-diet/http://www.healthhype.com/gastritis-diet-peptic-ulcer-diet-foods-to-avoid-and-lifestyle.htmlhttp://www.indiadiets.com/diets/eat%20to%20beat%20illness/peptic_ulcers.htmhttp://www.ulcerativecolitis.org.uk/dietarychanges.htmhttp://drbenkim.com/articles-ulcerative-colitis-diet.htmhttp://www.health4youonline.com/nutrition_facts_osteoarthritis.htmhttp://www.foods-that-heal.com/diet-for-osteoarthritis.html