Providing Nursing Care for Medical & Surgical Health Problems

Gastro -intestinal system disorder

Esophageal disorder

The esophagus is the muscular tube that carries food and liquids from your mouth
to the stomach. You may not be aware of your esophagus until you swallow
something too large, too hot, or too cold. You may also notice it when something
is wrong. You may feel pain or have swallowing. The most common problem with
the esophagus is GERD (gastro esophageal reflux disease). With GERD, a muscle
at the end of your esophagus does not close properly. This allows stomach
contents to leak back, or reflux, into the esophagus and irritate it. Over time,
GERD can cause damage to the esophagus.

Gastroesophageal reflux disease (GERD)

is excessive reflux of hydrochloric acid into the esophagus.

Risk Factors

Incompetent lower esophageal

sphincter (LES), pyloric stenosis
or a motility disorder

Assessment/Clinical Manifestations/Signs and Symptoms

Pyrosis (i.e. burning sensation in the esophagus)

Regurgitation of sour-tasting secretions
Dysphagia (i.e. difficulty swallowing) and odynophagia ( i.e pain on swallowing)
Symptoms mimicking those of a heart attack

Nursing Management

Teach the client to avoid factors that increase lower esophageal irritation.

 Eat a low-fat, high-fiber diet

 Avoid irritants, such as spicy or acidic foods, alcohol, caffeine, and tobacco,
because they

 increase gastric acid production. Avoid food or drink 2 hours before bedtime or
lying down after eating

 Elevate the head of the bed on 6” to 8” bocks

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Lose weight if necessary If symptoms persist, prepare the client for surgical
repair, which includes funduplication (i.e. wrapping a portion of the gastric
fundus around the sphincter area of the esophagus) Administer medications,
which may include antacids, histamine-receptor antagonists, and proton-pump
inhibitors.

Gastric and duodenal disorder

Acute gastritis

 It is an inflammation of the stomach mucosa.

 It is most often due to dietary indiscretion.
Cause: - Ingestion of strong acids or alkalies which may cause the mucosa to
become gangrenous or to perforate.
Clinical Manifestation
 Gastric mucous membrane becomes oedematous & undergoes superficial erosion;
it secretes a scanty amount of gastric juice, containing very little acid but much
mucus.
 Abdominal discomfort, headache, nausea, anorexia & often accompanied by
vomiting & hiccough.
 It will heal by itself
 Occasionally, hemorrhage may require surgical intervention
Chronic Gastritis
 Prolonged inflammation of the stomach may be caused by either being or
malignant ulcers of the stomach, or by Helicobacter pylori ( H. pylori)

Cause: - H pylori - Autoimmune (parietal cell changes, leading to atrophy &

cellular infiltration)

Risk factors: - Hot drinks & spices use of drugs & alcohol, smoking

Clinical manifestation

 Anorexia, sour taste in the mouth

 Heart burn
 Belching, nausea & vomiting

Diagnostic Evaluation

 Endoscopy
 Upper GI x – ray series
 Histologic examination
 Serologic testing for antibodies for the H. pylari antigens.

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MANAGEMENT
1. For Acute Gastritis:
 Instruct the pt to refrain from alcohol & food until symptoms
subside.
 Recommend non irritant diet
 If symptom persist administer fluids parenterally
 Aluminium hydroxide sos 2 tsp tid
 Nasogastric intubation
 sedatives
2. For chronic Gastritis:
 Modify the pt’s diet
 Promote rest
 Reduce stress
 Treat H.pydori with (tetracycline or Amoxicillin) and bismuth salt.

Nursing Process

The patent with Gastritis

A. Assessment - Complete history (s/s of gastritis and Aggravating factors)

- P/E (abdominal tenderness, dehydration, any systemic disorder)
B. Nursing diagnosis
 Anxiety
 Altered nutrition, less than body requirement
 Risk for fluid volume deficit
 Pain
 Knowledge deficit
Plan:
 To reduce anaxiety
 To maintain adequate nutritional intake
 To maintain fluid balance
 To increase awareness of dietary Mx.
 To relieve pain

Nursing Intervention

 Reassure the pt.

 Advice an nutritional intake
 IV fluid administration
 Instruction to avoid coffee, smoking, alcohol, spicy diets
 Educate the patient.
Expected out comes

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 Anxiety & pain alleviated

 Maintained fluid balance
 Maintained nutritional status
Peptic Ulcer
Defn: It is an excavation (hollowed – out area) formed in the mucosal wall of
the stomach, the pylorus, the duodenum, or the esophagus. It is frequently
referred to as a gastric, duodenal, or esophageal ulcer, depending on its
location

Comparison of Duodenal & Gastric Ulcer

Duodenal Ulcer Gastric Ulcer

Age - Common b/n 30 - 60year Usually 50year & over
Risk factors alcohol, smoking Gastritis, alcohol, smoking, NSAID
B/d group o, stress Male: Female: - 3: Male: Female: - 2: 1
1
Stomach acid: - Hyper secretion Normal to: - Hypo secretion
Vomiting: - Uncommon common
Weight: - gain Loss may occur
Pain: -occurs 2- 3 hour after meal& Pain: ½ to 1hour after meal& relived
relived by food ingestion by vomiting
Perforation- more common Perforation- Less common
Malignancy Malignancy
Possibility: -rare Occasionall

Etiology:-

 Etiology of PUD is poorly understood, but it is associated with Gm negative

H.Pylori
 PUD occurs only in the areas of GI tract that are exposed to HCL & Pepsin.

Predisposition

 Stress or anger
 Familial tendency
 Use of NSAIDS, alcohol ingestion & excessive smoking.
 Bacterial infection (H. Pylori )
Clinical Manifestation:
- Pain (burning Sensation cramp like, gnawing pain) in the mid-
epigastrium or in the back
- Vomiting & Nausea
- Constipation & bleeding

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- Abdominal distention, Bleeding

Diagnastic Evaluation
 P/E
 Endoscopy
 X-ray
 Stool exam for occult blood
 Gastric Secretary studies ( achlorhydria )
 Biopsy & culture for

H.pylori Management :(Non drug Mx.)

 Stress reduction & rest

 Smoking Cessation
 Dietary Modification ( advice the Pt. whatever agrees with them)

Medical management of PUD

Medications are prescribed for clients with PUD for 4 major reason:-

A. To eliminate H. Pylori bacteria from the GIT

B. To reduce secretion (hypo-secretory drugs),
C. To neutralize acid (antacids)
D. To protect the mucosal barrier.

A. Antibacterial Drugs: - Regimen used for Rx of H. pylori consists of

- Clarithromycin (Biaxin), 250 mg bid for 2wk

Plus

– Metranidazole (Flagyl), 250 mg tid.

Plus

- Omeprazole (prilosec), 20 mg bid

B. Hypo-secretory Agents

 H2 – receptor Antagonists
 Prostaglandin Analogs = suppresses secretion of gastric acid & stimulate
the production of cyto-protective mucus.
 Anticholinergics
 Proton pump inhibiters

C.Antacids:-

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Action: - Buffers & neutralizes acid in GIT

Drugs: - Aluminum hydroxide
- Aluminum magnesium combinations (Maalox)
- Magnesium trisilcate

D. Mucosal Barrier & Fortifiers Action:- Stimulate mucus production,

which results in accelerated gastric ulcer healing.

Drugs:- Sucralfate ( Carofate )

Treatment regimen for PUD according to standard treatment guide line for
Ethiopian Regional Hospital is as follows:-
I) PUD only
First Line
Al(OH)3 + Mgsio3, 2tsp or 2tabs chew, P.O. between meals & at bedtime for
4weeks OR
Cimetidine, 400mg P.O twice daily, with breakfast and at night, or 800mg at
night for 4-6wk. OR Famotidine, 40mg, P.O. at night for 4-6wks.
Alternative
Ranitidine, 150mg P.O. bid or 300mg at bedtime for 4-6wk. OR
Omeprazole,20mg P.O. /day for 4wks (DU) or 8wks (GU)
II) PUD associated with H.Pylori:-
First Line
Amoxicillin, 500mgP.O. tid for 7-14days.
PLUS
Clarithromycin, 500mg P.O. bid for 7-14days.
PLUS
Omeprazole, 20mg P.O. bid for 7-14days.
Alternatives:
Amaxicillin, 500mg P.o tid for 7-10days
PLUS
Metronidazale, 500mg, P.O. tid - 7-10days
PLUS
Omeprazole, 20mg P.O. for 7-10days
Surgical Treatment for PUD
1. Intractable ulcer (those who fail to heal after 12 to 16wks of medical
Rx.)
2. Life - Threatening Hemorrhage
3. Perforation
4. Obstruction of gastric out let.
Surgical Procedures include:-
 Vagotomy:-is performed to eliminate the acid secreting stimulus
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 Vagotomy with pyloroplasty involves cutting the right & left

vagus nerves & widening the existing exit of the stomach at the
pylorus.
 Antrectomy -to reduce acid secreting portion of stomach.

NURSING INTERVENTION

Preoperative nursing care for the patient undergoing surgery for peptic
ulcer disease includes:-

1) Preparing the pt for diagnostic tests (Laboratory analysis, x-ray, & general
physical examination).

2) Attending to the pt's fluid & nutritional level & to maintain an optimal fluid &
electrolyte balance.

3) Clearing & emptying GIT.

4) Naso-gastric Suction often is required to empty the stomach in Pt. with Pyloric
obstruction

5) Limiting oral Intake

Nursing Process

The Patient with PUD

1) Assessment

- History

- P/E

2) Nursing Diagnosis
 Pain related to the effect of gastric acid secretion.
 Anxiety related to coping with an acute disease
 Knowledge deficit about prevention & treatment.
 Altered nutrition, less than body requirement, related to
pain associated with eating.
3) Plan:-
 To relief pain.
 anxiety
 Increase pts awareness
 maintain adequate nutrition

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Nursing Intervention

Administer Medication
Advise the pt to avoid foods that are irritant: -
Alcohol, caffeine & Cigarettes Reassure the pt.
Teach necessary Information
 Experiences less pain
 Free of anxiety

Evaluation:-

Complication
1) Perforation ( DU>GU)
2) Gastric out late obstruction ( Pyloric Stenosis )
Sign and symptom
 Delayed gastric emptying
 Fullness
 Vomiting
 Weight loss
 Dehydration

3) Hemorrhage

 PUD is the most common Cause of UGI bleeding

 Occurs in 20% of PUD
 NSAID drugs intake increase risk of bleeding
 States a desire to be responsible for self-care

ACUTE ABDOMEN

The acute abdomen is an abdominal condition of sudden onset that may

require immediate operative treatment. There are many conditions that give
rise to it. It can be grouped as follows:

1) Inflammatory Conditions:-
 Acute appendicitis
 Acute Cholecystitis
 Acute Salpingitis
 Acute Diverticulitis
They cause localized peritonitis, which may lead to generalized
peritonitis. The initial signs are therefore those of local peritonitis.
2) Perforations of hollow Viscera

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 Typhoid perforation of ileum

 Perforation of PUD ( DU or GU )
 Perforation of GI carcinoma
 Traumatic perforation
 Perforation of amoebic colitis

They cause generalized peritonitis and therefore give rise to signs of

generalized peritonitis such as:-

 Pain :- Sudden onset, Severe & Constant

 Nausea or vomiting occurs once or twice
 Constipation is present
 Rigidity may be board like & bowel sounds are absent. The sign are most
marked at the site of origin of perforation.
 In typhoid perforation there may be a history of diarrhea, fever &
headache before the onset of severe abdominal pain.
 In PUD there may be a history of dyspepsia
 In traumatic perforation there is history of trauma.
 In amoebic perforation there is a history of fever & diarrhea.
3) Intestinal Obstruction
 Strangulated external & internal hernia
 Bands & adhesions
 Volvulus
 Intussusception
 Tumors, strictures & foreign bodies

They present with features of obstruction. These are:-

 Colicky abdominal pain

 Vomiting &/or distention
 Absolute constipation
 Tender & irreducible swelling in a hernia orifice
 Visible peristalsis
 increased bowel sound
4) Hemorrhage
 Ruptured tubal pregnancy
 Traumatic rupture of viscera especially spleen.
 Ruptured aortic aneurysm.
 Ruptured liver cell carcinoma

They present with signs of bleeding such as:-

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- Pallor
- Sweating g
- Rising [pulse rate
- falling B/P
- Abdominal distention & tenderness

5) Acute Pancratitis

6) Colic

- Ureteric Colic
- Biliary Colics

7) Other Gynecological Conditions

- Twisted ovarian cyst

- Ruptured Graafian Follicle

8) Medical Conditions that may cause abdominal pain :-

- Gastro-enteritis
- Dysentery
- Gastritis
- UTI
ACUTE APPENDCITIS

Def: - It is an inflammation of the appendix.

- Etiology - not known

- Risk factors :- Sex (M>F)
- Age (most common b/n 10 & 30 Years)
- Economic status ( high & middle social class )

Clinical Manifestation: - Right lower quadrant pain

- Low grade fever

- Loss of appetite
- Local tenderness at McBurney's point when pressure is applied
- Rebound tenderness (production of pain when pressure is released)
- Constipation or diarrhea
- Nausea
- Rovsing's sign may be elicited by palpating the left lower quadrant,
which paradoxically causes pain to be felt in the right lower quadrant.

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- Diffused pain if appendix is ruptured.

Diagnostic Evaluation

- Complete Hx & P/E

- X-ray may reveal a right lower quadrant density or localized air -flow
levels.
- CBC -Elevated WBC > 10,000/mm3 & neutrophil count> 75%
- Ultrasound

Management:-

- Secure IV fluid & administer antibiotics

- Analgesics can be given after diagnosis is made
- Appendectomy ( surgical removal of appendix )
- Complications :-
 Perforation of appendix
 Peritonitis
 Appendial abscess

Nursing Intervention:-

 Reliving pain by administering analgesics

 Preventing fluid volume deficit by giving IV fluids
 Reassure the pt & prevent infection
 Preoperative & postoperative nursing care is the same as that of pt
undergoing major surgery.

INTESTINAL OBSTRUCTION

Intestinal Obstruction exists when blockage prevents the normal flow of

intestinal contents through the intestinal tract. It can be classified as the
following:-

A) Mechanical obstruction Vs Functional Obstruction

B) Small bowel Obstruction Vs Large bowel obstruction

C) Partial Obstruction Vs Complete Obstruction

Causes of Intestinal Obstructions

1) Causes of Small bowel obstruction

 Adhesion of intestinal wall due to:-

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 Surgery Intestinal Tuberculosis

 Inflammatory Condition of intestine.
 Paralytic ileus
 Hernia
 Gallstones ileus
 Tumor
 Ascaris bolus
 Intusscusption

Intusscusption: - It is the small bowel telescopes, as if it were swallowing

itself by invagination. It is the commonest problem in infants.

Clinical Manifestation: - Sudden Colicky pain intermittent with 10 -20 minute

Interval.

 Initial Vomiting
 Normal Stool may be passed or bloody.
 Restless, dehydration & cry
 Distention is late
2) Cause of large bowel Obstruction
 Colorectal Cancer
 Adhesion
 Paralytic Ileus
 Inflammatory bowel disease
 Volvulus

Volvulus: - It is twisting of a mobile loop bowel on its mesentery.

- It occurs mostly in sigmoid colon but it can affect small intestine &
caecum.
- Colicky lower abdominal pain
Cardinal S/S of large bowel Obstruction
- Absolute Constipation ( Flatus & Feces )
- Gross abdominal distention
- Nausea and Vomiting
- Abdominal x-ray reveals grossly distended 2 limbs of sigmoid colon
often with fluid - air level.

Table Comparison of small bowel Vs large bowel

obstruction

Small bowel Obstruction Large bowel obstruction

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Abdominal Crampy Abdominal Crampy

Vomiting early S/S Constipation is early S/S
Constipation late sign Grossly distended abdomen
Abdominal distention Fecal Vomiting
Diagnostic - Hx & P/E

1) Hx

2) P/E - pt is acutely sick looking

V/S: - B/P - decrease due to fluid loss & sepsis

- PR – Tachycardia
- To - Increases if there is complication

HEENT - dry buccal mucosa

Abdomen: - Distended

- Mild tenderness on palpation

- Visible loop but not always
- Tympanic an percussion
- Bowel sound may be absent or increase

PR - empty rectum or hard stool

3) Ix - CBC
- Hgb
- V/A
- Abdominal x-ray

Medical Management:

A) General Management :-
- Keep the patient NPO
- NG tube should be inserted for small bowel obstruction to aspirate
intestinal content.
- Secure IV line ( Normal Saline or ringer Lactate )
- Triple antibiotic ( Ampicillin, Gentamycin,& CAF )
- Sedation

Disorders of the rectum

1) Haemorrhoids

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 It is an enlarged & congested patch of mucosa & sub-mucosa at

ano-rectal junction or
 Are dilated portions of veins in the anal canal.
 Sites: - at 3, 7, 11 O'clock, on lithotomy Position.

Hemorrhoid based on its site:-

1) Internal hemorrhoid (if it is above internal sphincter.) It is painless until they

bleed.

2) External " ( if it is outside external sphincter) it is associated with severe

pain due to inflammation & edema caused by thrombosis. Clotting of blood
(thrombosis) lead to necrosis & ischemia.

Clinical manifestation

 Bright red blood occurring at the end of defecation (Late)

 Mass Per-rectum
 Peri-anal Discomfort
 Pruritus
 Mucosal Discharge
 Pain when complicated

Classification of heamorhoids based on its stage (severity)

a) 1st degree:- Bleed but no prolapsed

b) 2nd degree :- Prolapsed but reduce spontaneously

c) 3rd degree :- " but need manual replacement

d) 4th degree: - " not returned.

Etiology: - idiopathic

Predisposing factor:-

 Chronic Constipation
 Excessive use of purgative
 Pelvic masses ( Pregnancy )
 Portal HTN

Rx: - Regulating bowel by laxatives

 Avoid Constipation

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 Advice high - residue diet that contain fruit.

 Sitz bath
 Good personal hygiene & by avoiding excessive straining during
defecation haemorrhoid symptoms & discomfort can be relieved.

Non-operative Treatment:-

I. Infared Photocoagulation
II. Bipolar Diathermy
III. Laser Therapy
IV. Injecting Sclerosing Solution
A) Rubber - band ligation procedure: - The haemorthoid is visualized
through the anoscape, & its proximal portion above the muco-cutaneous
lines is grasped with an instrument. A small rubber band is then slipped
over the hemorrhoid. Tissue distal to the rubber band becomes necrotic
after several days & sloughs off.
 It may cause infection, pain & hemorrhage.
B) Cryosurgical Hemorrhoidectomy
 Involves freezing the tissue of the hemorrhoid for a sufficient time
to cause necrosis.
 Not used widely because the discharge is very foul-smelling &
wound healing is prolonged.
C) Hemorrhoidectomy, or surgical excision, can be performed to remove all
of the redundant tissue involved in the process.
Providing nursing care for the patient with hepatitis
Def: - It is an inflammation of the liver .
Cause:- Virus
 Bacteria
 Toxic substance
Types of Hepatitis: -
 viral hepatitis
 Toxic hepatitis
 Chronic hepatitis
 Alcoholic hepatitis

Viral hepatitis

i. Hepatitis type A
ii. Hepatitis type B
iii. Hepatitis type C
iv. Hepatitis type D

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v. Hepatitis type E
Hepatitis type A /Infectious hepatitis/
o It is endemic in some areas of the world, especially with poor
sanitation

Causative agent: - Infectious hepatitis virus

Mode of transmission: -

- The major route of transmision is through

- Faecal – oral route (Contaminated food, milk, polluted water)
- Spread of the disease is enhanced by crowding & poor sanitation.

Incubation: - 3-7 weeks; average 4 weeks.

Occurrence: - Worldwide – sporadic or epidemic

- Autumn & winter months

- Usually in children & young adults

Clinical Manifestation

1. Pre-icteric (Prior to period of Jaundice) Phase:

• Headache • Muscle crampy

• Pain over the liver • Anorexia
• Abdominal tenderness • Vomiting
• Fever • Backache
• Nausea
2. Icteric phase
 Urine-dark; stool often light for several days
 Liver-enlarged, often tender
 Nausea, vague Epigastric distress, heart burn, flatulence, anorexia

Hepatitis B

Causative agent: - Hepatitis B Virus

Mode of transmission: -

A. Parenteral route;
 Blood transfusion from an infected person
 Contaminated needles, syringes

B. Skin puncture – medical equipments

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C. Mucosal transmission; dental instruments

Incubation period: - 6 weeks to 6 months/ average 2.5 – 3 month

Diagnosis:-

 Count electrophoresis (CEP)

 Sandwich” Count electrophoresis (SCEP)
 Radioimmunoassay

Clinical Manifestation:-

 S/S similar to infections hepatitis, but usually more insidious in onset

 Respiratory manifestations minimal or absent

Rx: & Nursing Mx: -

 Isolate patient to minimize contacts

 Wear gloves; wash hands thoroughly
 Assist with laboratory diagnostic studies
 Handle bed pan carefully & instruct pt. to ensure meticulous personal
hygiene habit.
 Use disposable syringe & needles
 Avoid alcohol consumption
 Recognize that recovery is slow & prolonged

GIVING NURSING CARE FOR THE PATIENT WITH LIVER CIRRHOSIS

Def.: - It is a chronic disease in which there has been diffuse destruction of

parenchymal cells followed by liver cell regeneration & an increase in
connective tissue. These processes result in disorganization of the lobular
architecture and obstruction of the hepatic venous & sinusoidal channels,
causing portal hypertension.

Classification

1. Alcoholic cirrhosis of the liver (micro nodular)

A. Fibrosis – mainly around central veins & portal area

B. Most commonly due to chronic alcoholism.

2. Post necrotic (Macro nodular);

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Due to previous acute viral hepatitis or drug induced massive hepatic

necrosis.

3. Biliary;
 Scarring around bile ducts & lobes of liver.
 Result from chronic biliary obstruction (With or without infection)
 Much more rare than alcoholic & post necrotic cirrhosis
4. Post hepatic
 Fine bands of scar tissue extend from portal areas
 Usually due to chronic viral hepatitis.

Causes;

 Alcohol By far the most common

 Hepatitis virus (B & C)
 Drugs;
 Methyldopa
 Methotrexate
 Autoimmune chronic active hepatitis
 Excessive use of herbal medications
 Chronic hepatic congestion

Clinical manifestation:-

i. Weight loss, muscle wastage

ii. Flatulence, pal mar erythema
iii. Jaundice, loss of body hair, gynecomastia
iv. Oedema , Bleeding
v. Anaemia 20 to bleeding
vi. Abdominal distinction (Ascites)
vii. Hepatomegely + spleenomegally
viii. Oesophageal varices.
ix. Sign of hepatic encephalopathy.

Diagnosis

 Liver biopsy & Liver function test

 Oesophagoscopy
 Liver scan
 Paracentesis to examine ascetic fluid

Patient Assessment:-

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 History
 Physical examination

Nursing Management

A/ Nutrition;

 Maintain caloric & vitamin diet intake give protein as tolerated

 Avoid table salt, salty foods & canned foods
 Use ‘Salt’ substitutes such as lemon juice
 Offer small frequent meals
 Eliminate alcohol

B/ Medication:

 Multivitamins preparation
 Vit. K – if a tendency of bleeding is manifested such as epistaxis, melena,
hematoemesis
 Vit B12 – to correct anaemia
 Diuretics ex: - Spirinolacton
 Electrolyte fluid balance
 Avoid toxic drugs:-
 barbiturates, diazepam
 Oral contraceptive
 Alcohol

C/ Rest & activity

 If there is no ascites & sign of hepatic coma: -

 Limit amount of activity
 In advanced liver impairment:-
 Bed rest
 Frequent change of position
 Special skin care & passive exercise.

Complication of liver cirrhosis

• Hepatic comma

• Bleeding & oesophageal varices.

• Portal hypertension

• Spontaneous peritonitis

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• Asites

• Hepatic encephalopathy

• Anaemia

Giving Nursing care for patient with Hepatic Encephalopathy &

Hepatic coma

 Hepatic encephalopathy: - Results from the accumulation of

ammonia & other toxic metabolites in the blood.
 Hepatic coma: - represents the most advanced stage of hepatic
encephalopathy.
 Ammonia accumulates because damaged liver cells fait to detoxify &
convert to urea the ammonia that is constantly entering the blood
stream as a result of its absorption from the GIT & its liberation from
kidney muscle cells.
 The increased ammonia concentration in the blood causes brain
dysfunction & damage, resulting in hepatic encephalopathy

C/M: -

Early Stage Late

Stage

Euphoria Drowsiness

Depression Insomnia

Apathy Agitation

Irritability Slow & slurred speech

Memory loss Hyperactive reflex

Confusion Slow deep respiration

MX:- Vital signs are measured & recorded every 4 hours

 Serum ammonia level is monitored daily.

 Avoid constipation
 Enema to reduce ammonia absorption
 Sterilization of intestine (Neomycin sulphate)
 Lactulose is administered to reduce blood ammonia

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 If sign of impending hepatic encephalopathy occur, reduce protein

intake.

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