Digestive Functions - During: drink thru a straw & swallow

- Prepares food to be used by the cells by contrast medium (barium sulfate –

breaking it down milkshake substance); 15-30 mins; no
- Passage of food until its eliminated discomfort
- C/I: bowel obstruction (store like impaction)
Gastrointestinal Tract ▪ Monometric Studies (Esophageal Function
- 7 to 7.9m (23 to 26 feet) in length that extent Studies / Esophageal Monometry /
from the mouth to the esophagus, stomach, Esophageal Motility Studies)
small and large intestines, and rectum to the - N ° = lower esophageal sphincter pressure
terminal structure, the anus 10 – 20 mmHg
Functions: - Graphic recording of swallowing waves
1. Breakdown of food particles int the molecular (motility
form for digestion - Before: NPO 8hrs
2. Absorption into the bloodstream of small - During: Swallow 2 or 3 very tiny tubes (for
nutrient molecules produced by digestion pressure measurements) attached to a
3. Elimination of undigested unabsorbed pressure transducer; 30 mins
foodstuffs and other waste products - After: Mild sore throat
▪ Monometric Studies
- Usually contraindicated
- Is an out-pouching of mucosa and submucosa - d/t possible perforation 2-4hrs
that protrudes through a weak portion of the - Before: NPO – PM; remove dentures and
musculature of the esophagus. eyewear; instruct not to bite endoscope; oral
hygiene
Types: - During: lateral position; anesthesia to throat
1. Paraesophageal Diverticulum (topical or spray – xylocaine); sedatives; 20
- Upper area of the esophagus; – 30 mins
- Zenker diverticulum – aka pharyngoesophageal
pulsion diverticulum; Management:
- Most common type located in the • Zenker’s – Diverticulectomy: surgical removal
cricopharyngeal muscle (midline of the neck); of the diverticulum
- Increase incidence in men >60 y.o • Myotomy of the cricopharyngeal muscle –
s/s: dysphagia, fullness on the neck, regurgitation remove spasticity of muscle
of undigested food, gurgling noise after eating, • Epiphrenic and Midesophageal – surgery is
coughing, Halitosis and sour taste in the mouth only indicated if symptoms are troublesome
2. Midesophageal
- Middle area;
- Uncommon with less acute symptoms
s/s: less acute difficulty in swallowing
3. Epiphrenic - Backflow of the gastric or duodenal contents
into the esophagus which may be due to:
- Lower area just above the diaphragm;
▪ incompetent lower esophageal sphincter,
- Larger diverticula
▪ pyloric stenosis, or
s/s: one third are asymptomatic; two third complain
▪ mortality disorder
of dysphagia and chest pain
4. Intramural Border of the esophagus
Clinical Manifestations:
- Numerous small diverticula associated w/
• Pyrosis ● Esophagitis
structure of the upper esophagus
• Dyspepsia ● Hypersalivation
s/s: dysphagia
• Regurgitation or dynophagia
Assessment and Diagnostic Findings:
▪ Barium Swallow Assessment and Diagnostic Findings:
▪ Endoscopy or Barium swallow with contrast
- X-ray with contract dye
dye
- NPO 8hrs / NPO – PM
▪ Ambulatory 12 – 36 hours esophageal pH Paraesophageal Hernia
monitoring – determine the degree of acid - Maybe asymptomatic
reflux - Sense of fullness or chest pain after eating
▪ Bilirubin monitoring (Bilitec) – measure bile • Hemorrhage
reflux patterns • Obstruction
• Strangulation
Management:
- Teach client to avoid situations that decreases Assessment and Diagnostic Findings:
LES pressure or cause esophageal irritation • X-ray
➢ Low fat diet • Barium swallow
➢ Avoid caffeine, tobacco, beer, milk, • Fluoroscopy
carbonated beverages
➢ Avoid eating or drinking 2 hours prior Management:
bedtime 1. Frequent and small feeding that can pass freely
➢ Maintain normal body weight through the esophagus
➢ Avoid tight fitting clotting 2. Advice not to recline for 1 hour after eating
➢ Elevate head part of bed 6 – 8inch blocks 3. Elevate the head of the bed 4-8 inch (10 – 20
➢ Elevate upper body on pillow cm blocks
- Antacids or H2 receptor antagonists 4. Surgical hernia repair is indicated in patients
(Famotidine, Nizatidine, Ranitidine) who are symptomatic; 15% of patients
- Proton Pump Inhibitors (decrease release of 5. Paraesophageal hernia: same medical and
gastric acid) – lansoprazole, rabeprazole, surgical management with GERD however they
esomeprazole may require emergency surgery to correct
- Prokinetic agents (accelerate gastric emptying) torsion (twisting) of the stomach or other body
– Bethanechol (Urecholine), Domperidone organ that leads to restriction of blood flow to
(Motilium), Metoclopramide (Maxolon) that area
- Surgery ( Nissen Fundoplication)

_________________________________________
- A condition characterized by an opening in the
diaphragm through which the esophagus DISTURBANCES OF ABSORPTION
passes becomes enlarged, and
- part of the upper stomach moves up into the SPRUE
lower portion of the thorax
- A chronic degenerative disorder resulting from
- more common in women malabsorption of nutrients from the small
intestine
Types:
1. Sliding (Type I) or Hiatal Hernia
- 90% of patients with esophageal hiatal hernia
have a sliding hernia; - Is a disorder of malabsorption caused by an
- Upper stomach and the gastroesophageal autoimmune response to consumption of
junction are displaced upward and slide in and products that contain the protein gluten.
out of the thorax - aka gluten sensitive enteropathy gluten –
2. Paraesophageal Hernia (Type II, III, or IV) induced enteropathy
- All or part of the stomach pushes through the - genetic chronic malabsorption disorder that
diaphragm beside the esophagus results from a sensitive or abnormal
▪ Type IV has the greatest herniation immunologic

Clinical Manifestations: Gluten – is most commonly found in wheat,

Sliding Hernia barley, rye, and other grains, malt, dextrin, and
- (50%) asymptomatic brewer’s yeast.
• Pyrosis / Heart Burn
• Regurgitation - Upon indigestion of foods contain gluten,
• Dysphagia changes occur in the intestinal mucosa or villi
that prevent the absorption of foods
Causes: - A group of bowel disorders resulting in
• Immunological responses to an environmental inflammation or ulceration of the bowel lining
factor (gluten) - Cause: unknown
• Genetic factors (Children of North European - Triggered by environmental agent, NSAIDS,
background; Down Syndrome) allergies, immune d/o
- Predisposing factors:
Clinical manifestations: ➢ 15 – 30 y.o; 50 – 70 y.o
(Noticeable between 6 – 18 months old) ➢ Genetic
▪ Steatorrhea
▪ Deficiency of vitamin A, D, E, & K
▪ Malnutrition
▪ Distended abdomen - Is characterized by a subacute and chronic
▪ Ricket and hypoprothrombinemia may occur inflammation of the GI tract wall that extends
▪ IDA and hypoalbuminemia through all layers
▪ Anorexia, irritability, poor weight, and height - Prevalence: adolescence or young adult
gain smokers
▪ Skinny, with spindly extremities and wasted
buttocks but face may be plump and well Assessment and Diagnostic findings:
appearing - Proctosigmoidoscopy (recto – sigmoid area
inflammation)
Diagnosis: - Stool examination
- Serum analysis of and antibodies against gluten • (+) occult blood
(IgA antigliadin antibodies) • (+) steatorrhea
- Biopsy of intestinal mucosa (via endoscopy) - Barium swallow (most conclusive) classic
- Oral glucose tolerance test “string sign” on x-ray
- Stool – tested for increase fat content - Endoscopy, Colonoscopy, Intestinal Biopsies
- Observing response to a gluten – free diet: - Barium edema: ulcerations, fissures and fistulas
begins to gain weight steatorrhea improved, - CT scan: bowel wall thickening and fistula
irritability false formation
- Decrease Hct and Hgb
Management: - Increase WBC and ESR
- Gluten – free diet for life - Decrease albumin and protein levels
- Avoid BROW!
• Wheat flour, gravy, soups, sauces Surgical Management:
• Packaged and frozen foods usually contain - Laparascope – guided stricture plasty – blocked
gluten as fillers or narrowed sections of the intestines are
• Favorite school – age foods; spaghetti, widened, leaving the intestine intact
pizza, hotdogs, cake, cookies - Small bowel resection
• Birthday cake, turkey stuffing - Total colectomy with ileostomy
- Nutritional counseling for parents: - Intestinal transplant
• Be careful shoppers and read food labels
• Small servings
• Create incentives to eat - A chronic ulcerative and inflammatory disease
- Administration of water – soluble forms or of the mucosal and submucosal layers of the
vitamins A & D colon and rectum that is characterized by
- Iron & folate supplementation unpredictable periods of remission and
exacerbation with bouts of abdominal cramps
The disappearance of steatorrhea is a good and bloody or purulent diarrhea.
indicator that child’s ability to absorb nutrient is - Prevalence: Caucasians, Jews
improving.
Assessment and Diagnostic findings:
- Systemic manifestations: tachycardia,
hypotension, tachypnea, fever, and pallor
a) Chron’s Disease - Stool: (+) for blood
b) Ulcerative Colitis - CBC: low Hct & Hgb, increase WBC
 - Low albumin - Iron replacement
- Sigmoidoscopy, colonoscopy: inflamed mucosa - Avoids food / activities that exacerbate diarrhea
w/ exudate and ulcerations - Parenteral nutrition
- Barium enema: shortening of bowel ➢ Pharmacologic Therapy
- CT scan, MRI, ultrasound, abscesses and - Sedatives and anti – diarrhea agent
perirectal involvement ▪ ↓ peristalsis (rest the bowel)
- Amino salicylates: sulfasalazine to decrease
Surgical Management: inflammation
- Total colectomy with ileostomy - Prednisone; hydrocortisone; Budesonide
- Proctolectomy (Entocort Ec): if severe and
- Immunomodulators
CHRON’S ULCERATIVE
DISEASE COLITIS Nursing Management:
Part affected Ileum, ascending Rectum, colon a. Maintain normal elimination pattern
colon (transmural (mucosal and • Ready access to bathroom, commode or
inflammation) submucosal bed pan
inflammation • CFAC of stool
Characteristic Discontinuous Continuous • Bed pan
of lesion • Administer anticholinegic agents 30 mins
Predominant Crampy RLQ Diarrhea, passage before a meal
symptoms abdominal pain, of mucus and pus, b. Relieve pain
diarrhea LLQ pain, • Pain assessment
steatorrhea, intermittent • Intervention for pain
anorexia, weight tenesmus, rectal c. Maintain fluid intake
loss, malnutrition, bleeding, anorexia, • Accurate I&O
anemia weight loss, • Monitor daily weight
anemia, fever, • Assess for s/s of FVD
vomiting d. Maintain optimal nutrition
Complications Intestinal Anemia, abscesses • Small frequent feeding
obstruction toxic megacolon, • Parenteral nutrition
perineal disease, perforation, • Glucose monitoring
F&E imbalances, bleeding e. Promote rest
fistulas, fissures,
• Activity restriction
abscesses
• Active or passive rom exercise
Risk of
f. Reduce anxiety
developing Increased Increased
g. Enhance coping measures
colon cancer
• Stress reduction techniques
Other Accompanied by
• Counseling
characteristics systemic
h. Prevent skin breakdown
manifestation high
mortality rate • Perineal care
• Relieve pressure on bony prominences
Management of IDB: i. Monitor and manage potential complication
Goals j. Patient techniques
- Reduce inflammation
- Suppress inappropriate immune response
- Provide rest to the bowel
_________________________________________
- Improve quality of life
- Prevent on minimize
DISTURBANCES OF ANORECTUM
Medical management:
➢ Nutritional Therapy
- Oral fluids - Dilated portion of veins n the anal canal
- Lower residue, high protein, high – calorie diet - Bright red bleeding
- Vitamin supplementation
What causes hemorrhoids? - Stapled hemorrhoidopexy – use of surgical
- Chronic constipation or diarrhea staples for prolapsing hemorrhoids
- Straining during bond movements - Hemorrhoidectomy
- Prolonged sitting / standing
- Lack of fiber in the diet Care of client undergoing hemorrhoidectomy
- Weakening of the connective tissue in the ➢ PRE OP
rectum and anus that occurs with age - Low residue diet – to reduce bulk of feces
- Pregnancy - Stool softeners
- Wearing constriction clothing
- Liver cirrhosis, right sided heart failure ➢ POST OP
- Promote comfort – analgesics as prescribed
Types: - Side – lying or prone position
▪ Internal hemorrhoids - Apply ice packs over dressing for its first 12
- Not pain hours post op (best time: after BM)
▪ External hemorrhoids - Stool softeners, increase fluids, high fibers
- Severe pain fluids
- Itchy, painful
▪ Prolapse hemorrhoids can become inflamed
and thrombosed - An excavation (hollowed – out area) that forms
in the mucosal wall
Interventions:
- Cause: Erosion of the circumscribed area (may
- Good personal hygiene extend as deeply as the muscle layers or
- Avoid excessive straining upon defecation though the muscle to the peritoneum)
- To promote passage of soft, bulky stools: - Prevalence: 40 – 60 years old, males, infants
• High residue diet and children; post – menopausal stage
• Increase fluid intake
• Hydrophilic bulk – forming agents: Psyllium Types:
(Metamucil) 1. Gastric
- To reduce engorgement 2. Duodenal
• Apply cold packs followed by warm sitz bath 3. Esophageal
to relieve soreness and pain by relaxing
sphincter spasm. Significant Predisposing Factors:
- Analgesic ointments 1. Increased secretion of HCI acid – may be
- Suppositories associated with:
- Astringents (calamine, witch hazel, and zinc • Stress and Anxiety
oxide) – cause coagulation (chipping of • Indigestion of milk and caffeinated
proteins) beverages
• Smoking
Patient teaching: • Alcohol
- Set aside a time for bond movement • Spicy foods
- Heed urged to defecate ASAP 2. Familial tendency – Type O blood
- Prevent constipation 3. Co – morbid states – COPD, CKD, ZES
- Moderate exercise ▪ ZES – Zollinger Ellison Syndrome (gastrin –
producing malignant or benign tumors of the
Non – surgical treatment: pancreas)
- Infrared photocoagulation – use of heat to 4. Infection – H. pylori; acquired through ingestion
shrink hemorrhoids of food and water, direct contact or exposure to
- Bipolar diathermy – use of heat emesis
- Laser therapy - use of heat 5. Medication – NSAIDs, corticosteroids
- Injection of sclerosis agents
Pathophysiology
Surgical treatment: Increase concentration or activity of acid – pepsin
- Rubber – band ligation or decrease resistance of the mucosa
- Cryosurgical hemorrhoidectomy – freezing to
Erosion and damage to gastroduodenal mucosa
cause necrosis
 3. Pyrosis with sour eructation or burning
Decrease resistance to mucosa (common w/ empty stomach)
4. Vomiting – rare in uncomplicated duodenal
Possible infection to H. pylori ulcer but may indicate obstruction on the pyloric
orifice
Stress ulcers – acute mucosal ulceration of • Emesis often has undigested food
duodenal or gastric area that occurs after • Follows a severe bout of pain and bloating
physiologically stressful events such as burns, (abdominal distention)
shocks, severe sepsis 5. Constipation or diarrhea
6. 15% of PUD has GI bleeding – melena
Shock
Assessment and Diagnostic Findings
Decrease mucosal blood flow (ischemia) + reflux or ▪ PE (Physical Education)
duodenal contents into the stomach + increase ▪ Barium study of upper GIT – studies x – ray
release of pepsin ▪ Endoscopy – procedure of choice
▪ Stool exam for occult blood
Ulceration ▪ Gastric secretory studies – endoscopy and
histologic examination of tissue specimen
Comparison of Duodenal Ulcer & Gastric Ulcer obtain by biopsy
Incidence ▪ Serologic testing for H. pylori, urea breath test,
Age 30 -60 Usually, 50 and over tool antigen test
Male: Female = 2 – 3: 1 Male: Female = 1:1
80% of peptic ulcers are 15% of peptic ulcers and Urea – Breath Test
duodenal gastric - To determine presence of H. pylori (which
metabolizes urea rapidly)
Signs, Symptoms and 1. Ingest a capsule of carbon – labeled urea
Clinical Findings (radioactive carbon 13c)
• Hypersecretions of • Normal – hyposecretion 2. Breath sample obtained 10 – 20 min after (30 –
stomach acid (HCI) of stomach acid (HCI) 2hrs)
• May have weight gain • weight loss may occur 3. Carbon – labeled urea – absorbed quickly (+)
• Pain occurs 2 – 3 after a • Pain occurs ½ to 1 hour H. pylori
meal; after awakened after a meal; rarely occur
between 1 – 2 AM; ingestion at night, may be received Medical Management
of food relieves pain by vomiting; ingestion of ➢ Pharmacologic Therapy
• Vomiting uncommon food does not help; • For ulcer healing: H2 receptor antagonist and
• Hemorrhage less likely sometimes increase pain proton pump inhibitors (for NSAID) – induced
than with gastric ulcer, but if • vomiting common and non – H. pylori associated PUD)
present melena more • Hemorrhage more likely • H2 blockers – Ranitidine, Cimetidine,
common than hematemesis to occur then duodenal Famotidine, Nizatidine
• More likely to perforate ulcer; hematemesis more • PPIs: Omeprazole, Lansoprazole
than gastric ulcers common than melena • Initial Treatment for H. pylori
- 1st line: Triple therapy = PPI 2x/day +
Malignant Possibility Clarithromycin 2x/day or Metronidazole 2x/day
Rare Occasionally for 10 – 14 days
- 2nd line: Pepto – bismol 2 tabs 4x/day +
Risk Factors Tetracycline 4x/day for 14 days
H. pylori, alcohol, smoking, H. pylori, gastritis, alcohol, • ZES – high dose of H2 blockers + octreotide
cirrhosis, stress smoking use of NSAIDS, (Sandostatin)
stress ➢ Stress Reduction and rest
➢ Smoking cessation
Clinical Manifestation: ➢ Dietary modification – avoid extremes of
1. Pain: dull, gnawing or burning sensation in the temperature of food and beverages, diet milk
midepigastrium or back and cream
2. Sharp tenderness w/ gentle pressure at the ➢ Eat 3 regular meals per day
epigastrium or slightly right of midline ➢ Small frequent feedings are unnecessary to
client is taking antacid or H2 blockers
Surgical Management • Requires immediate surgery!
- Indicated for patients with intractable ulcers, life • s/s: sudden, sever upper abdominal pain
– threatening hemorrhages, perforation or radiating to the right shoulder; board-like
obstruction; and for those with ZES abdomen
unresponsive to treatment • Monitor for signs of peritonitis: severe
• Vagotomy with or without pyloroplasty abdominal pain, rigidity, fever
• Antrectomy – removal of the pyloric (antrum) 3. DUMPING SYNDROME
portion of the stomach with anastomosis - a group of unpleasant vasomotor and GI s/s
• Billroth caused by rapid emptying of gastric content into
Types: the jejunum
I. Billroth I – Gastroduodenostomy
II. Billroth II – Gastrojejunostomy Rapid emptying of hypertonic food from the
• Total Gastrectomy stomach
- a.k.a Esophagojejunostomy
Jejunum
Pre – Op care
- Provide psychosocial support Fluid shift from the bloodstream into jejunum
- Teach deep breathing exercises and coughing
technique (high abdominal incision cause Decreased blood volume
respiratory complications)
- Provide nutritional support (TPN Shock-like manifestations
- Inform about post – op measures
- Early s/s occur 5-30 min after eating:
• NGT
• weakness, tachycardia, dizziness, diaphoresis,
• TPN until peristalsis return
pallor, feeling of fullness or discomfort, nausea,
abdominal cramps and diarrhea
Post – Op Care
- Late s/s: occur 2-3 hrs after
- Promote patient airway and ventilation
• initially hyperglycemia then hypoglycemia
• Semi – Fowler position
- Measures that slow gastric emptying:
• Reinforce deep breathing and coughing
exercise, incentive spirometry • Eat in lying position
• Administer analgesic before activities • Left-side lying position after meals
• Splint incision before patient coughs • SFF
• Encourage early ambulation - High protein diet (CHON empties stomach
slowly in 3-4 hrs after eating)
• Promote adequate nutrition
- Limit CHO, no simple sugars
• NPO until peristalsis return
- Administer anticholinergics or antispasmodics
• Measure NG drainage accurately (reddish
30 min before meals
for first 12hrs)
• Monitor for signs of leakage of anastomosis
Nursing Diagnoses
(dyspnea, pain, fever, when oral fluids are
• Acute Pain r/t the effect of gastric acid secretion
initiated)
on damaged tissue
• Small, frequent feedings • Anxiety r/t to an acute illness
• Monitor for early safety and regurgitation • Altered Nutrition: Less than Body
• Eat less food at a slower pace Requirements, r/t changes in diet
• Monitor weight regularly • Knowledge Deficit about prevention of
symptoms and management of the condition
Potential COMPLICATIONS • Fluid Volume Deficit r/t hemorrhage
1. BLEEDING - first 24 hours, 4th to 7th day post-
op d/t non-healing Implementation
• Monitor NG drainage for blood 1. Relieving pain
• Avoid unnecessary irrigation or ▪ Administer prescribed meds.
repositioning of NGT ▪ Advise patient about irritating effects of certain
2. PERFORATION drugs and foods
• Erosion of the ulcer through the gastric ▪ Eat meals regularly at paced intervals
serosa into the peritoneal cavity without ▪ Relaxation techniques
warning 2. Reduce anxiety
▪ Give information Chronic:
▪ Relaxed manner 1. Anorexia
▪ Identify stressors, coping and relaxation 2. Heartburn after eating
methods 3. Belching
▪ Family participation 4. Sour taste in the mouth
3. Maintain optimal nutritional status 5. Nausea and vomiting
▪ Assess for malnutrition and weight loss 6. Some: mild epigastric discomfort or report
intolerance to spicy or fatty foods or slight pain
that is relieved by eating
7. Some: asymptomatic
- Inflammation of the gastric or stomach mucosa
ASSESSMENT AND DIAGNOSTIC FINDINGS
- Acute (hours to days) or chronic (resulting from ▪ Achlorhydria or hypochlorhydria (absence or
repeated exposure to irritating agents or low levels of HCl) or hyperchlorhydria (high
recurring episodes of acute gastritis levels of HCl)
▪ Upper GI x-ray series
Causes: ▪ Endoscopy
1. Acute ▪ Histologic examination of a tissue specimen
• dietary indiscretion (irritating, too highly obtained by biopsy
seasoned, contaminated with disease-causing ▪ H.pylori detection
microorganisms)
• overuse of aspirin/ NSAIDs
• excessive alcohol intake
• bile reflux
• radiation therapy
• ingestion of strong acid or alkali
• traumatic injuries, burns, severe infection,
hepatic, renal, or respiratory failure; major
surgery
2. Chronic
• Benign or malignant ulcers of the stomach
• H.pylori infection
• Autoimmune diseases i.e. Pernecious anemia
• Diet: caffeine
• Medications: NSAIDs; biphosphonates
• Alcohol and smoking
• Chronic reflux of pancreatic secretions and bile
into the stomach

PATHOPHYSIOLOGY
Causative factors

Gangrenous mucosa

Edematous & hyperemic

Superficial erosion hemorrhage

Decreased secretion of gastric juice (less acid but

much mucus)

CLINICAL MANIFESTATIONS
Acute: (hours to days)
1. Abdominal discomfort 4. Nausea, anorexia
2. Headache and vomiting
3. Lassitude 5. Hiccupping
MEDICAL MANAGEMENT
Acute:
• Capable of repairing itself (1 day)
• Refrain from alcohol and food until symptoms
subside
• Diet: non-irritating
• If symptoms persist: IVF
• If caused by strong acid/alkali: dilute &
neutralize the offending agent (aluminum
hydroxide for acids and diluted lemon juice or
diluted vinegar for alkalis); if severe: avoid
emetics and lavage
• NG intubation
• Analgesic agents, sedatives, antacids, IV fluids
• Extreme cases: emergency surgery to remove
gangrenous or perforated tissue
Chronic:
• Modify diet
• Promote rest
• Reduce stress
• Avoids alcohol and NSAIDs
• Initiate pharmacotherapy
• Treat H.pylori infection

NURSING MANAGEMENT
1. Reducing Anxiety
• Offers supportive therapy
• Prepare patient for additional diagnostic studies
• Use calm approach in assessing patient and
answering questions
• Explain all procedures
2. Promoting Optimal Nutrition
• No foods or fluids by mouth until acute
symptoms subside
• Monitor I/O and serum electrolyte levels
• Ice chips then clear liquid then solid foods
• Discourage caffeinated beverages, alcohol and
smoking
3. Promoting Fluid Balance
• Monitor I/O and electrolytes
• Monitor for hemorrhagic gastritis (inform AP
immediately)
- Hematemesis
- Tachycardia
- Hypotension
4. Relieving Pain
• Avoid irritating foods
• Correct use of medications