| INTRODUCTION

Upper gastrointestinal (GI) bleeding occurs when the inner lining (mucosa) of the esophagus, stomach, or proximal small intestine (duodenum) is injured, exposing the underlying blood vessels, or when the blood vessels themselves rupture. Upper gastrointestinal bleeding (UGIB) is defined as hemorrhage that emanates proximal to the ligament of Treitz. It is a common and potentially life-threatening condition. More than 350,000 hospital admissions are attributable to UGIB, which has an overall mortality rate of 10%. Although more than 75% of cases of bleeding cease with supportive measures, a significant percentage of patients require further intervention, which often involves the combined efforts of gastroenterologists, surgeons, and interventional radiologists.

Clinically, UGIB often causes hematemesis (vomiting of blood) or melena (passage of stools rendered black and tarry by the presence of altered blood). The color of the vomitus depends on its contact time with the hydrochloric acid of the stomach. If vomiting occurs early after the onset of bleeding, it appears red; with delayed vomiting, it is dark red, brown, or black. Coffee-ground emesis results from precipitation of blood clots in the vomitus. Hematochezia (red blood per rectum) usually indicates bleeding distal to the ligament of Treitz. Occasionally, rapid bleeding from an upper GI source may result in hematochezia.

Upper gastrointestinal bleeding (UGIB) is a significant and potentially life-threatening worldwide problem. Despite advances in diagnosis and treatment, mortality and morbidity have remained constant.1 Bleeding from the upper gastrointestinal tract (GIT) is about 4 times as common as bleeding from the lower GIT. Typically patients present with bleeding from a peptic ulcer and about 80% of such ulcers stop bleeding. Increasing age and co-morbidity increase mortality. It is important to identify patients with a low probability of re-bleeding from patients with a high probability of re-bleeding. Upper GI bleeding can range in severity from clinically in apparent (insignificant) to large-volume, life-threatening bleeding. A variety of conditions can cause GI bleeding, and effective treatment depends on identification of the source of the bleeding and expeditious administration of therapy.

Upper GI bleeding can be divided into two broad categories: variceal bleeding and non-variceal bleeding. Varices are dilated blood vessels found most frequently in the esophagus and stomach. Non-variceal upper gastrointestinal bleeding can be caused by a variety of conditions. Peptic ulcer is the most common cause. An ulcer bleeds when the blood vessels at the base of the ulcer are disrupted. Ulcers are most likely to occur in the stomach and duodenum and less frequently in the esophagus. Ulcers are caused most commonly by an infection with the bacterium Helicobacter pylori or use of nonsteroidal anti-inflammatory drugs.

Indeed, I choose this case because I want to learn why gastrointestinal bleeding occurs. To enhance my knowledge about GI bleeding. And as a health care provider I need to know more about the disease in order for me to establish rapport to my patient and how to deal with it.

| PATIENT PROFILE

PATIENT NAME: Patient X

GENDER: Female

RELIGION: Roman Catholic

CATEGORY: DEP EDM

CIVIL STATUS: Widow

ADDRESS: Bulsa San Juan Batangas

AGE: 80 years old

RACE: Brown

DATE ADMITTED: August 16, 2015

DATE OF BIRTH: May 05, 1935

PLACE OF BIRTH: Batangas

TYPE OF ADMISSION: Direct

TIME OF ADMISSION: 7:00 A.M.

CHIEF COMPLAINTS:

This a care of 80 year old EDM who care in due to episodes of hematomesis

HISTORY OF PRESENT ILLNESS / ACTIVE PROBLEMS:

History of present illness, started 2 weeks prior to admission. When the patient noted to be losing her appetite with occasional epigastric pain burning in character. Patient had no cough, no colds, no fever, and was still able to sleep well at night no consult has done. No medication taken.

In the interim, decrease in appetite was persistent with usual bottle of milk cannot be consumed completely. Patient also presented with decrease urine output evident by the decrease in the output per diaper when the patient usually consumes (2 fully soaked/day) to less than half of mildly soaked at time.

Few hours PTC, patient had episodes (>10) of hematomesis approximately measuring ½ - 1 ap. Hence, patient was brought for consult.

BP: 140/80 OR: 88 RR: 22 T: 36.5

Conscious, coherent not in distress

INITIAL DIAGNOSIS:

Upper Gastrointestinal Bleeding probably secondary to bleeding Peptic Ulcer Disease clinically diagnosed Pulmonary Tuberculosis Uresepsis Acute Kidney Injury s/p Lacunar syndrome sensorimotor (2013) Hypertensive Cardiovascular disease FC II

| PHYSICAL ASSESSMENT

ASSESSMENT DATA ASSESSMENT FINDINGS

SKIN

Color

Temperature

Turgor

Texture

Lesion

Integrity

Moist and pallor

37.7º C

Supple

Rough

(-) Rash

Intact

NAILS

Color

Texture

Shape

Capillary refill

Pale

Smooth

Concave

4 seconds

HAIR

Color

Texture

Distribution

Quantity

Black

Coarsely dry

Evenly distributed

Thin

HEAD

Shape

Size

Configuration

Headache

Round

Normocephalic

Symmetrical

None

EARS

Hearing

Tinnitus

Vertigo

Ear aches

Normal shape

Can hear whispered voice

None

No vertigo

No ear aches

Infection

Discharges

No infection

No discharges

NN NECK

Symmetry

Condition of trachea Thyroid

Lymph nodes

Symmetrical

Midline

(-) nonpalpable

LUNG

Symmetry

A: P diameter

Shape of chest

Number of breaths

Symmetrical

1:2

Barrel

23 cpm

NOSE AND SINUSES

Frequent colds

Nasal stiffness

Nose bleed

Sinus trouble

None

None

None

Sinuses are non tender

MOUTH & THROAT

Condition of teeth

Bleeding gums

Tongue

Throat

Hoarseness

Mucous membrane

Gums

Missing teeth

No bleeding

Midline

Non-tender

(-) Hoarseness

Pallor

Pallor

AUSCULTATION:

Character of respiration (+) Crackles

HEART AND NECK VESSELS:

Apical Pulse

Cardiac Sounds

55 bpm

(-) Murmurs

Apical/Radial pulse data

Blood pressure

Pulse pressure

Any special procedure done

55 bpm

130/90 mmHg

60 mmHg

None

ABDOMEN:

Configuration

Bowel Sounds

Percussion :

Palpation :

Usual urinary pattern:

Excess perspiration/ nocturnal sweats

Globular

Hypoactive

Dullness (3 clicks)

Muscle guarding

850 cc/shift

None

HEAD AND NECK:

Facial muscle symmetry

Swelling

Scars

Discoloration

Weakness

ROM

Posterior neck cervical spine

Muscle spasm

Crepitus

Symmetrical

None

None

None

(-) Weakness

Can turn head from side to side

Non-tender

(-) Spasm

(-) Crepitus heard

| ANATOMY AND PHYSIOLOGY

The digestive tract (also known as the alimentary canal) is the system of organs within multicellular animals that takes in food, digests it to extract energy and nutrients, and expels the remaining waste. The major functions of the GI tract are ingestion, digestion, absorption, and defecation. The picture to the right doesn't show the Jejunum. The GI tract differs substantially from animal to animal. Some animals have multi-chambered stomachs, while some animals' stomachs contain a single chamber. In a normal human adult male, the GI tract is approximately 6.5 meters (20 feet) long and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract.The first step in the digestive system can actually begin before the food is even in your mouth. When you smell or see something that you just have to eat, you start to salivate in anticipation of eating, thus beginning the digestive process. Food is the body's source of fuel. Nutrients in food give the body's cells the energy they need to operate. Before food can be used it has to be broken down into tiny little pieces so it can be absorbed and used by the body. In humans, proteins need to be broken down into amino acids, starches into sugars, and fats into fatty acids and glycerol.

During digestion two main processes occur at the same time:

* Mechanical Digestion: larger pieces of food get broken down into smaller pieces while being prepared for chemical digestion. Mechanical digestion starts in the mouth and continues in to the stomach.

* Chemical Digestion: several different enzymes break down macromolecules into smaller molecules that can be more efficiently absorbed. Chemical digestion starts with saliva and continues into the intestines.

Esophagus

The esophagus (also spelled oesophagus/esophagus) or gullet is the muscular tube in vertebrates through which ingested food passes from the throat to the stomach. The esophagus is continuous with the laryngeal part of the pharynx at the level of the C6 vertebra. It connects the pharynx, which is the body cavity that is common to both the digestive and respiratory systems behind the mouth, with the stomach, where the second stage of digestion is initiated (the first stage is in the mouth with teeth and tongue masticating food and mixing it with saliva).

After passing through the throat, the food moves into the esophagus and is pushed down into the stomach by the process of peristalsis (involuntary wavelike muscle contractions along the G.I. tract). At the end of the esophagus there is a sphincter that allows food into the stomach then closes back up so the food cannot travel back up into the esophagus.

The GI System

The gastro-intestinal system is essentially a long tube running right through the body, with specialised sections that are capable of digesting material put in at the top end and extracting any useful components from it, then expelling the waste products at the bottom end. The whole system is under hormonal control, with the presence of food in the mouth triggering off a cascade of hormonal actions; when there is food in the stomach, different hormones activate acid secretion, increased gut motility, enzyme release etc. etc.

Nutrients from the GI tract are not processed on-site; they are taken to the liver to be broken down further, stored, or distributed.

The Stomach

The stomach is a 'j'-shaped organ, with two openings- the oesophageal and the duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs different functions; the fundus collects digestive gases, the body secretes pepsinogen and hydrochloric acid, and the pylorus is responsible for mucus, gastrin and pepsinogen secretion.

The stomach has five major functions;

• Temporary food storage

• Control the rate at which food enters the duodenum

• Acid secretion and antibacterial action

• Fluidisation of stomach contents

• Preliminary digestion with pepsin, lipases etc.

The Small Intestine

The small intestine is the site where most of the chemical and mechanical digestion is carried out, and where virtually all of the absorption of useful materials is carried out. The whole of the small intestine is lined with an absorptive mucosal type, with certain modifications for each section. The intestine also has a smooth muscle wall with two layers of muscle; rhythmical contractions force products of digestion through the intestine (peristalisis). There are three main sections to the small intestine;

• The duodenum forms a 'C' shape around the head of the pancreas. Its main function is to neutralise the acidic gastric contents (called 'chyme') and to initiate further digestion; Brunner's glands in the submucosa secrete an alkaline mucus which neutralises the chyme and protects the surface of the duodenum.

• The jejunum

• The ileum. The jejunum and the ileum are the greatly coiled parts of the small intestine, and together are about 4-6 metres long; the junction between the two sections is not well-defined. The mucosa of these sections is highly folded (the folds are called plicae), increasing the surface area available for absorption dramatically.

The Pancreas

The pancreas consists mainly of exocrine glands that secrete enzymes to aid in the digestion of food in the small intestine. the main enzymes produced are lipases, peptidases and amylases for fats, proteins and carbohydrates respectively. These are released into the duodenum via the duodenal ampulla, the same place that bile from the liver drains into.

Pancreatic exocrine secretion is hormonally regulated, and the same hormone that encourages secretion (cholesystokinin) also encourages discharge of the gall bladder's store of bile. As bile is essentially an emulsifying agent, it makes fats water soluble and gives the pancreatic enzymes lots of surface area to work on.

Structurally, the pancreas has four sections; head, neck, body and tail; the tail stretches back to just in front of the spleen.

The Large Intestine

By the time digestive products reach the large intestine, almost all of the nutritionally useful products have been removed. The large intestine removes water from the remainder, passing semi-solid feces into the rectum to be expelled from the body through the anus. The mucosa (M) is arranged into tightly-packed straight tubular glands (G) which consist of cells specialised for water absorption and mucus-secreting goblet cells to aid the passage of faeces. The large intestine also contains areas of lymphoid tissue (L); these can be found in the ileum too (called Peyer's patches), and they provide local immunological protection of potential weak-spots in the body's defences. As the gut is teeming with bacteria, reinforcement of the standard surfacedefences seems only sensible.

Gallbladder

The gallbladder is a pear shaped organ that stores about 50 ml of bile (or "gall") until the body needs it for digestion. The gallbladder is about 7-10cm long in humans and is dark green in appearance due to its contents (bile), not its tissue. It is connected to the liver and the duodenum by biliary tract.

The gallbladder is connected to the main bile duct through the gallbladder duct (cystic duct). The main biliary tract runs from the liver to the duodenum, and the cystic duct is effectively a "cul de sac", serving as entrance and exit to the gallbladder. The surface marking of the gallbladder is the intersection of the midclavicular line (MCL) and the trans pyloric plane, at the tip of the ninth rib. The blood supply is by the cystic artery and vein, which runs parallel to the cystic duct. The cystic artery is highly variable, and this is of clinical relevance since it must be clipped and cut during a cholecystectomy.

The gallbladder stores bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile emulsifies fats and neutralizes acids in

partly digested food. After being stored in the gallbladder, the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect in fats.

| PATHOPHYSIOLOGY

PREDISPOSING FACTORS:

Gender: MaleAge: 53 y/o

PRECIPITATING FACTORS:Diet: Raw foods, grilled foods,

spicy foods. Smoking: 2 packs a day

Alcoholic Beverages drinker

Ulcers burrows

Inflammatory effect on gastric

Disruption of mucous barrier

W eakening and necrosis of

arterial

W eakened wall raptures

Developm ent of pseudo

anuerysm s

peripheral

Pale nail beds.

>4 sec

UGIBBP= 130/90RR= 22PR=55

Body weakness

| DIAGNOSTIC PROCEDURES and LABORATORY RESULTS

HEMATOLOGY REPORT

TEST RESULT UNIT REFERENCESWBC 13.8 10^3/uL 5.0-10.0RBC 5.52 10^6/uL 4.2 -5.4Hemoglobin 10.6 g/dL 12.0 – 16.0Hematocrit 33.4 % 37.0 – 47.0MCV 60.5 fL 82.0 – 98.0MCH 19.2 Pg 27.0 – 31.0MCHC 31.7 g/dL 31.5 – 35.0RDW-CV 19.0 % 12.0 – 17.0PDW 10.9 fL 9.0 – 16.0MPV 9.3 fL 8.0 – 12.0DIFFERENTIAL COUNTLymphocyte % 17.9 % 17.4 – 48.2Neutrophil % 54.9 % 43.4 – 76.2Monocyte % 5.5 % 4.5 -10.5Eosinophils % 21.6 % 1.0 – 3.0Basophils % 0.1 % 0.0 – 2.0Bands/stabs % % 1.0 – 2.0PLATELET 605 10^3/uL 150 – 400RESULT11.45.7211.535.962.820.132.021.910.48.6

16.853.08.122.00.1

517

INTERPRETATION:

An elevated WBC count occurs in infection, allergy, systemic illness, inflammation, tissue injury, and leukemia.

A Low hemoglobin and hematocrit level indicates anemia. A low MCV number in a patient with a positive stool guaiac test (bloody stool) is highly suggestive of GI cancer. A low MCH indicates that cells have too little hemoglobin. This is caused by deficient hemoglobin production

ULTRASOUND REPORT

FINDINGS:

The liver appears normal in size but with slightly increased parenchymal echogenicity. No mass or calcification seen. Intrahepatic bile ducts and common bile duct are non-dilated.

Gallbladder is normal in size. It’s wall is not thickened. No intraluminal mass or lithiasis seen.

Pancreas, spleen and abdominal aorta are unremarkable. Right and left kidneys measure 8.6 cm x 3.9cm and 9.0cm x 4.7cm, both with parenchymal thickness of 1.5cm. Central echocomplexes are intact. At least 3 tiny calcifications with the largest measuring 0.5cm is seen in the left renal cortex. No stones, mass nor calfectasia noted.

Urinary bladder is moderately filled. It’s wall is thickened to 4.0mm. No intraluminal mass or lithiasis seen.

Prostate measures 3.6cm x 2.6cm approximately 15 grams.

DIAGNOSIS:

1. Fatty liver, grade 12. Cortical calcifications, left3. Non-remarkable ultrasounds findings in the gallbladder, pancreas, spleen,

abdominal aorta, right kidney, urinary bladder and prostate.

FECALYSIS

PHYSICAL CHARACTERISTICS:

Color and character: BrownConsistency: Formed

ABNORMAL FEATURES:

Occult blood: positiveWBC:RBC:Fecal

DRUG ORDER(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OFACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME: omeprazole

BRAND NAME: Losec

CLASSIFICATION: Antisecretory drug Proton pump inhibitor

DOSE: 20 g

ROUTE: PO

FREQUENCY: BID

Gastric acid-pump inhibitor. Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final stage of acid production.

short-term treatment of active duodenal ulcer

Treatment of heartburn or symptoms of GERD

Short-term treatment of active benign gastric ulcer

Contraindicated with hypersensitivity to omeprazole or its components.

CNS: headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety

GI: diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue athropy

Respiratory: URI symptoms, cough, epistaxis

Administer before meals

Swallow the capsules whole, do not chew, open or crush

Report severe headache, worsening of symptoms, fever, chills

DRUG ORDER(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OFACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME: sucralfate

BRAND NAME: Carafate

CLASSIFICATION: Antiulcer drug

DOSE: 1 gramROUTE: PO

FREQUENCY: QID

Forms an adherent complex at duodenal ulcer sites protecting the ulcer against acid, pepsin and bile salts, thereby promoting ulcer healing; also inhibits pepsin activity in gastric ulcer.

short-term treatment of active duodenal ulcer up to 8 weeks

maintain therapy for duodenal ulcer at reduced dosage after healing.

Contraindicated with allergy to sucralfate, chronic renal failure or dialysis ( buildup of aluminum may occur with aluminum-containing product.

CNS: dizziness, sleeplessness, vertigo

GI: constipation, diarrhea, nausea, indigestion, gastric discomfort, dry mouth

Dermatologic: rash, pruritus

Other: back pain

give drug on an empty stomach, 1 hour before or 2 hour after meals at bedtime.

Monitor pain; use antacid to relieve pain

Report severe gastric pain

DRUG ORDER(Generic name, brand name, classification,

dosage, route, frequency)

MECHANISM OFACTION

INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIES/

PRECAUTIONS

GENERIC NAME: rebamipide

BRAND NAME: Mucosta

CLASSIFICATION: Antigastric ulcerDOSE: 100 mg

ROUTE: PO

FREQUENCY: TID

A mucosal protective agent and postulated to increase gastric blood flow, prostaglandin biosynthesis and decrease free oxygen radicals.

Acute gastric and acute exacerbation of chronic gastritis

Contraindicated with allergy to rebamipide

Constipation Bloating Diarrhea Nausea Vomiting Rash pruritus

administer drug before meals

report for any severe abdominal pain

ASSESMENT DATA(Subjective &

Objective Cues)

NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective Cue:

“pagtumatae ako sobrang sakit.” as verbalized.

Objective Cues:

pain scale= 7/10 sleep disturbance irritability restless

Acute pain related to underlying condition

After 8 hours of nursing intervention the patient will be able to ;

report pain is relieved/ controlled

follow prescribed pharmacological regimen

demonstrate use of relaxation skills and diversional activities.

Decrease in pain scale from 7/10 to 5-6/10

INDEPENDENT:

Teach the use of non-pharmacologic techniques such as relaxation.

Instruct client to perform deep breathing exercises

Encourage adequate rest

COLLABORATIVE: Administer pain

reliever as ordered.

.use of non-invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

To reduce tension and promote relaxation

To prevent fatigue

To alleviate pain

After 8 hours of nursing intervention goals partially met.

Verbalized that pain has lessened in degree from a 7/10 scale to 6/10

RR was still elevated

ASSESMENT DATA

(Subjective & Objective Cues)

NURSING DIAGNOSIS

(Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective Cue:

“mainit yong katawan ko” as verbalized.

Objective Cues:

Temp = 37.7 Flushed skin Restless

Hyperthermia related to inflammatory response secondary to disease process

After 30 minutes of nursing intervention the patient will be able to ;

maintain temperature within normal range (37.5)

After 8 hours of nursing intervention the patient will be able to: Remain free of

complications such as irreversible brain/neurological damage.

free of seizure activity

INDEPENDENT:

provide tepid sponge bath

promote surface cooling by means of understanding

Maintain bed rest

DEPENDENT: Administer

antipyretic medications as ordered

COLLABORATIVE: Administer

replacements of fluid and electrolytes.

Help decrease temperature

Heat loss by radiation and conduction

To reduce metabolic demands

To support circulating volume & tissue perfusion

Use of pharmacologic means will help decrease client temperature.

After 30 minutes of nursing intervention goals met.

Attained temperature within normal range

After 8 hours of nursing intervention goals met.

Remained free from any complications

Remain free from seizure

ASSESMENT DATA(Subjective &

Objective Cues)

NURSING DIAGNOSIS(Problem and

Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective Cue:

“Nahihirapan akong tumae.” as verbalized.

Objective Cues:

Hard, formed stool Hypoactive bowel

sounds Abdominal

tenderness Distended abdomen

Constipation related to irregular defecation habit

After 8 hours of nursing intervention the patient will be able to: Establish/ regain

normal pattern of bowel functioning

Participate in bowel program a indicated

Demonstrate behavior or lifestyle changes to prevent recurrence of problem

INDEPENDENT: Determine fluid

intake

Instruct the patient to void if there’s a feeling of urgency

Note general oral/dental health

DEPENDENT: Apply lubricant

COLLABORATIVE: Encourage treatment

of underlying causes.

To evaluate client’s hydration status

Prevent fullness

That can impact dietary intake

To soften

To improve organ function

After 8 hours of nursing intervention, goals partially met.

| DISCHARGE PLAN

MEDICATION Discuss/instruct to the patient with their significant other the importance as prescribe by the physician.

Emphasize on compliance to therapeutic and medication regimen and the information regarding side effect of the medications.

Patient with their significant other need to understand the occurrence of the drug effects in order to when, what and whom to report on any symptoms present.

ECONOMIC STATUS Pinpoint the patient their capability to purchase the medications.

The patient accessibility to the agency and should be considered with regards to follow-up.

It is important to know patient ability to afford the expected expenses.

This is to make sure that the compliance of the medication will be achieved.

To have immediate interventions when signs and symptoms occur.

To ensures the patient adherence instructions.

TREATMENT Encourage patient to have a vitamins supplements.

Compliance to medication regimen.

To have a fast recovery and to prevent complications.

HEALTH TEACHINGS

Instruct the significant To monitor wound

others to assess the patient’s incision and drainage system.

Encourage the patient to prevent the stressful activity and have adequate rest.

Instruct the client and the significant others to monitor presence of infection and report immediately if signs and symptoms of infection occurs such as redness, foul-smelling drainage, temperature greater than 38.4 C.

healing

To promote early recovery.

To monitor any signs of infection.

OUT-PATIENT Emphasize the patients to schedule for regular follow-up appointment, and discuss the importance of regular check up care.

To monitor any alternations in the patients status and ensure compliance to medication regimen.

DIET Instruct patient to eat high in protein such as meat

For tissue repair and faster wound healing.

23 | P a g e

Instruct patient to eat high in carbohydrate.

Instruct patient to take vitamin K

For energy

To prevent blood clot.

SPIRITUALITY Allow the patient to pray if possible all the time to God.

Have faith in God.

To provide and optimistic approach towards her problem.

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