Complex physical rehabilitation of patients with peptic ulcer of the stomach and duodenum at the stationary stage. Exercise therapy for gastric ulcer Rehabilitation for gastric and duodenal ulcers

1. Diet therapy - table number 2 (mechanically and chemically sparing diet);

2. Bed mode, then ward mode;

3. Drug therapy as prescribed by a doctor (delivery of drugs):

A. Eradication therapy:

· T. Pyloride 0.4 x 2 r / day at the end of the meal;

T. Clarithromycin 0.25 x 2 times a day;

· T. Metronidazole 0.5 x 2 times a day at the end of meals;

within 7 days;

B. Antacids:

Susp. Maalox - 15 ml. - 15 minutes after eating x 4 times a day, the last time at night;

B. Salnikov's mixture:

Sol. Novocaini 0.25%-100.0

S. Glucosae 5%-200.0

Sol. Platyphyllini 0.2%-1.0

Sol. No-Spani-2.0

Ins. – 2ED

In / in the cap x 1 time / day - No. 3;

D. Upon completion of eradication therapy:

· T. Pyloride 0.4 x 2 r / day at the end of the meal - continue;

· R-r. Delargin 0.001 - in / m - 1 time / day - No. 5.

4. Physiotherapy as prescribed by a doctor (assistance in the implementation of procedures): SMT, ultrasound on the epigastrium, novocaine electrophoresis.

5. Exercise therapy: Bed rest: At this time, static breathing exercises are shown, which enhance the processes of inhibition in the cerebral cortex. Performed in the initial position lying on the back with relaxation of all muscle groups, these exercises are able to bring the patient into a drowsy state, help reduce pain, eliminate dyspeptic disorders, and normalize sleep. Simple gymnastic exercises for small and medium muscle groups are also used, with a small number of repetitions, in combination with breathing exercises and relaxation exercises, but exercises that increase intra-abdominal pressure are contraindicated. The duration of classes is 12-15 minutes, the pace of the exercises is slow, the intensity is low. As the condition improves, when transferring to the ward regime: To the tasks of the previous period, the tasks of household and labor rehabilitation of the patient, restoration of the correct posture when walking, improvement of coordination of movements are added. The second period of classes begins with a significant improvement in the patient's condition. Exercises are performed in the prone position, sitting, kneeling, standing with gradually increasing effort for all muscle groups, still excluding the abdominal muscles. The most acceptable is the supine position: it allows you to increase the mobility of the diaphragm, has a gentle effect on the abdominal muscles and improves blood circulation in the abdominal cavity. Patients perform exercises for the abdominal muscles without tension, with a small number of repetitions. With a slow evacuation function of the stomach, more exercises lying on the right side should be included in the LH complexes, with moderate - on the left side. During this period, patients are also recommended massage, sedentary games, walking. The average duration of a lesson in the ward mode is 15-20 minutes, the pace of the exercises is slow, the intensity is low. Therapeutic exercises are carried out 1-2 times a day.

6. Taking biological samples for analysis (blood, urine, etc.), assistance in the implementation of instrumental studies (FGS (FGS control - upon admission, after 10 days, before discharge), gastric intubation, X-ray examination of the stomach, etc.) .

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Treatment of peptic ulcer of the stomach and duodenum should be comprehensive. The main areas of therapy are:

Antihelicobacter therapy, because. the latest available data (Shcherbakov, Filin, 2003) indicate that with peptic ulcer of the stomach and duodenum, HP in sick children is determined in 94% of cases;

- suppression of gastric secretion and / or its neutralization in the lumen of the stomach (this disease is, according to the position adopted in gastroenterology, a classic "acid-dependent disease");

- protection of the mucous membrane from aggressive influences and stimulation of reparative processes in it;

- correction of the state of the nervous system and the mental sphere, the dysfunction of which has a significant impact on both the development of the disease and its recurrence;

– physiotherapeutic methods of treatment;

- rehabilitation.

In the section on the rehabilitation of children and adolescents with chronic gastritis (gastroduodenitis), we set out in some detail the basic principles of the treatment of gastroduodenal diseases (see above). In the section on the medical aspects of the rehabilitation of patients with gastric and duodenal ulcers (see below), we focus doctors' attention on the most important aspects of rehabilitation programs for children and adolescents suffering from gastric and duodenal ulcers.

Dispensary observation

Patients with peptic ulcer of the stomach and duodenum are examined by a pediatrician every 3 months during 1 year of the disease and after an exacerbation, subsequently - 2 times a year. Examination by a gastroenterologist of these patients - 2 times a year, according to indications - more often. ENT doctor, dentist examine patients once a year. Psychotherapist and other specialists - according to indications.

During dynamic observation, special attention is paid to the presence or absence of manifestations of pain (duration, frequency, the presence of pain on an empty stomach, night pain, "Moynigan's" rhythm of pain, connection with food intake, localization of pain), dyspeptic syndromes (decrease or increase in appetite, nausea, vomiting , belching sour, heartburn, diarrhea, constipation), general intoxication syndrome (headaches, dizziness, fatigue, lethargy, irritability).

Examination methods: blood test, urine test - 2 times a year, coprogram - 4 times a year. FGDS with biopsy, research on HP, intragastric pH-metry or fractional gastric sounding - 1 time per year. Ultrasound of the abdominal organs with the determination of the contractile function of the gallbladder - once, then according to indications.

Deregistration of patients with peptic ulcer of the stomach and duodenum is carried out with complete clinical and laboratory remission for 5 years.

Rehabilitation (medical, physical, psychological aspects)

Polyclinic stage (continuous rehabilitation)

The main tasks of medical rehabilitation of this contingent of patients:

1) ensuring the possible complete elimination of pathological changes in the state of the gastric mucosa and duodenum and thereby preventing the recurrence of the process, i.e. stable endoscopic remission and functional normalization of the stomach and duodenum;

2) prevention of combined lesions of the digestive system;

3) preventing the occurrence of complications of the underlying disease;

4) if possible, preventing disability or reducing it;

5) improving the quality of life of patients (returning the child to his usual living conditions, study, physical education and sports).

Clinical rehabilitation groups

KRG-1.2 –– patients with newly diagnosed gastric ulcer and duodenal ulcer of uncomplicated form;

KRG-2.1- Patients with a complicated form of peptic ulcer of the stomach and duodenum;

KRG-2.2- Patients with peptic ulcer of the stomach and duodenum with damage to other organs of the digestive system (dysfunction of the gallbladder and sphincter of Oddi, cholelithiasis, pancreatitis, chronic colitis).

Characterization and assessment of vital signs

Medical aspect of rehabilitation

KRG-1.2

1. Gentle training mode, includes all the moments of the physiological age regimen with an extended time allotted for sleep. The sufficiency of rest and walks is strictly controlled, if necessary, an additional day off or shortened study days is introduced. Hardening without limits. The group of physical education classes is auxiliary without competition.

2. Feature of dietary nutrition. In children, ulcerative lesions are localized mainly in the duodenum and much less often in the stomach. With 1 or 2 stages of peptic ulcer, a strict diet is prescribed, which provides the most stringent mechanical and chemical sparing. So, table No. 1A is assigned at stage 1 for 7-10 days, at stage 2 - for 5-7 days. This table includes milk (if tolerated), fresh cottage cheese, jelly, jelly, mucous and pureed soups from cereals and milk, fish soufflé, salt in limited quantities.

The next stage of dietary measures is the appointment of table No. 1B: with stages 1 and 2 of PU for 14 days. Table No. 1B, in addition to table No. 1A, includes - crackers, meat, fish in the form of quenelles and soufflés, pureed cereals, soups from cereals in milk, salt in moderation. And only after 3 weeks from the start of the complex treatment of a newly diagnosed disease or its exacerbation, table No. 1 can be assigned, which includes a very large assortment of dishes, but subject to mechanical, chemical sparing.

In particular, table number 1 includes: white stale bread, dry biscuits, milk, cream, fresh cottage cheese, non-acidic sour cream, yogurt, eggs in the form of an omelet, vegetarian soups, pureed from vegetables, cereals; meat, chicken, fish - boiled or in the form of steam cutlets, doctor's sausage, cereals with milk and butter, noodles, pasta, vermicelli, vegetable puree or boiled vegetables, with the exception of sorrel and spinach, fruit and vegetable juices, sweet berries, fruits, boiled and pureed jelly, jelly, compotes. It is possible in a small amount of non-sharp varieties of cheese, low-fat ham. Salt - in the usual amount.

Table No. 1 is prescribed in the hospital and at home for 6-12 months. If the condition is satisfactory, after the specified time, "zigzags" are possible (with the expansion of nutrition and alternation with 1 table). Many authors recommend using table number 5 as well. It should be emphasized that in case of ulcer during the period of anti-relapse treatment, it is recommended to return to table No. 1.

3. Antihelicobacter therapy. If in chronic gastritis (gastroduodenitis) this type of treatment is carried out by HP-positive patients, then in the case of peptic ulcer, an algorithm for mandatory anti-Helicobacter treatment of all patients has been adopted. At the same time, preference in older children should be given to scheme 2 (standards of the Ministry of Health of the Republic of Belarus) with the inclusion of proton pump inhibitors (PPIs) - omeprazole. The Union of Pediatricians of Russia recommends the following HP eradication therapy regimens.

Triple therapy (at least 7 days): PPI or bismuth tripotassium dicitrate 2 times a day + clarithromycin 2 times a day + amoxicillin 2 times a day or PPI 2 times a day + clarithromycin 2 times a day + metronidazole 2 times a day or nifuratel (Macmiror) 2 times a day.

Quadrotherapy (at least 7 days): PPI 2 times a day + bismuth tripotassium dicitrate 2 times a day + 2 antibiotics (or a combination of an antibiotic with nifuratel or metronidazole). Quadruple therapy is recommended for the eradication of antibiotic-resistant strains of HP in cases where previous treatment has failed, or when susceptibility testing of the pathogen strain is not possible.

Feature of antisecretory therapy: With the ineffectiveness of eradication therapy in terms of healing of mucosal defects, frequent recurrence of the disease (3-4 times a year), complicated course of ulcerative disease, the presence of concomitant diseases requiring the use of NSAIDs, concomitant erosive and ulcerative esophagitis, maintenance therapy with antisecretory drugs is indicated (see section about gastroduodenitis) in a half dose.

Another option is “on demand” prophylactic therapy, which provides for the appearance of clinical symptoms of exacerbation (even in the absence of endoscopic signs of an ulcer), taking one of the antisecretory drugs in a full daily dose for 1-2 weeks, and then in a half dose for another 1-2 weeks.

Phytotherapy: like drug therapy, it is differentiated depending on the stage of the ulcer process. With an acute ulcer - chamomile, medicinal valerian, peppermint, common yarrow, dog rose are shown. In the stage of remission, calamus marsh, marshmallow officinalis, St. John's wort, large plantain, nettle are more appropriate. Thus, in patients with ulcerative disease, medicinal plants with anti-inflammatory, enveloping antispastic, hemostatic properties, as well as medicinal plants containing mucus and vitamins, are used.

In case of PU, the collection is effective: centaury grass (20.0), St. The decoction is taken 50-100 ml in the morning and in the evening 30-40 minutes before meals, it has a trophic, anti-inflammatory and anti-spastic effect. With neurotic reactions and long-term non-healing ulcers, a decoction of blue cyanosis is recommended, 10-20 ml 3-4 times a day between meals. With a tendency to bleeding, a collection is prescribed: chamomile (5.0), rhizome erect cinquefoil (20.0), St. John's wort (20.0). The decoction is used 10-20 ml 4-5 times a day for 40-60 minutes before meals.

Physiotherapy treatment: an alternating magnetic field (AMF) is a softly acting physical factor, which is considered one of the most effective in the treatment of chronic gastroduodenal pathology, including gastric and duodenal ulcers. The next effective method of physiotherapy is laser therapy with the impact on active points. In addition, at the stages of rehabilitation of patients with PU, low-frequency pulsed currents are widely used according to the electrosleep method, galvanization and electrophoresis with drugs of various effects, microwave therapy of CMW or UHF, and inductothermy.

Internal use of mineral waters: for drinking treatment, mineral waters of low and medium mineralization are used. Mineral water, entering the stomach, binds hydrochloric acid, as a result of which the reaction of the gastric contents becomes closer to neutral, i.e. provides an antacid effect. In the duodenum, mineral water affects its interoreceptors, causing the so-called duodenal effect of reducing acid production. At the rehabilitation stage, mineral waters are used in the period of complete or incomplete remission. Of great importance in the effectiveness of treatment with mineral waters is their temperature. Warm water reduces the increased tone of the stomach and intestines, relieves spasm. Cold water, on the contrary, enhances the motor activity of the stomach and intestines and stimulates secretory activity. In case of ulcerative disease, it is recommended to use water at room temperature, 1-1.5 hours before meals, which enhances the duodenal effect of mineral water and, as a result, reduces acid production in the stomach. Mineral water is dosed at the rate of 3 ml per 1 kg of the required body weight. You can also use the working formula: "0" is assigned to the number of years. The resulting number indicates the amount of mineral water in ml needed by the child for 1 dose. The optimal course of treatment is 5-6 weeks, with peptic ulcer it is prolonged up to 7 weeks.

Other types of treatment: are set out in the section on the rehabilitation of children and adolescents with chronic gastritis (gastroduodenitis) (see above!).

KRG-2.1

The individual rehabilitation program is generally the same as for patients referred to in KRG-1.2.

However, additional important elements of the program should be pointed out. :

1. Optimization of the daily routine- an important condition for the successful rehabilitation of children. Due to the fact that children and adolescents with a complicated form of PU often have pronounced functional disorders of the central and autonomic nervous system, it is necessary to exclude from them activities and games that lead to overwork and overexcitation. Restrictions require watching TV shows, videos, visiting discos by schoolchildren.

The ratio of sleep and wakefulness during the day in children should approach 1:1, i.e. night sleep should be about 10 hours long and daytime sleep (1-2 hours) is obligatory or, depending on age, a quiet rest. Long walks in the fresh air are extremely important. In the presence of sleep disorders, other asthenoneurotic reactions, walks in the fresh air before going to bed, as well as taking sedative herbs (valerian or motherwort), are shown.

As herbal medicine, you can use ready-made dosage forms from herbs: sanosan (a mixture of hop cones and valerian root extract), persena (capsules containing extracts of valerian, peppermint and lemon balm), altalex (a mixture of essential oils from 12 medicinal herbs, including lemon mint). These drugs have a calming effect, relieve irritation and normalize the child's sleep.

2. Limitation of physical activity and gaming activities. Group of physical education - exercise therapy.

3. Correction of motor disorders: antispasmodics against the background of increased peristalsis of the stomach and duodenum (drotaverine, papaverine, belloid, belataminal); in the presence of pathological refluxes - prokinetics (dommperidone 10 mg 2-3 times a day or cisapride 5-10 ml 2-4 times a day).

4. Improvement of metabolic processes in the mucous membrane: B vitamins, folic acid, multivitamin complexes with microelements (unicap, supradin, oligovit). Membrane stabilizing drugs are shown.

5. Administration of cytoprotectors and mucosal protection products - licorice root syrup, biogastron, sucralfate (venter), de-nol.

6. Strengthening reparative processes in coolant with the help of vegetable oils (sea buckthorn, rosehip, combined preparation "Kyzylmay").

KRG-2.2

In addition to the above rehabilitation measures:

1. Physical education group– exercise therapy (sparing complex)

2. With concomitant damage to the hepatobiliary system- hepatoprotectors and choleretic drugs (Essentiale 1 capsule 3 times a day, methionine 10-15 mg / kg / day, riboxin 1 table 3 times a day, allochol, hymecromon 50-200 mg 2-3 times a day ; with dysfunction of the gallbladder due to hypomotor dyskinesia - prokinetics for 10-14 days, 10% solution of sorbitol, 20-30 ml 2 times a day - courses of 10-14 days).

3. With concomitant damage to the pancreas- vitamin therapy in combination with enzymes (panreatin, festal, creon in age dosages).

4. With concomitant intestinal damage- exclusion from the diet of intolerable foods, milk; sedatives of plant origin (valerian extract, motherwort); enzymes (mezim-forte, etc.); biological products (bioflor, bifidum- and lactobacterin); vitamins with minerals for 3-4 weeks 2 times a year).

The psychological aspect of rehabilitation

Methods of psychological correction

KRG 1.2 – 2.2

Methods of psychological correction are applied when necessary, taking into account the available opportunities (availability of a specialist psychologist in the rehabilitation team). At the same time, individual approaches to patients are used, as well as group psychotherapy. Preliminary psychological testing is carried out with an analysis of the personal characteristics of patients according to the developed and approved methods.

Zhernosek V.F., Vasilevsky I.V., Kozharskaya L.G., Yushko V.D., Kabanova M.V., Popova O.V., Ruban A.P., Novikova M.E.

Contraindications to the appointment of exercise therapy:

1. Severe pain syndrome.

2. Bleeding.

3. Constant nausea.

4. Repeated vomiting.

Tasks of exercise therapy:

1. Normalization of the tone of nerve centers, activation of cortico-visceral relationships.

2. Improving the emotional state of the patient.

3. Stimulation of trophic processes in order to speed up and complete scarring of the ulcer.

4. Prevention of congestion in the digestive tract.

5. Normalization of the motor and secretory functions of the stomach and duodenum.

In 1 period static breathing exercises are used in the initial lying position with counting to oneself on inhalation and exhalation and simple gymnastic exercises for small and medium muscle groups with a small number of repetitions in combination with breathing and relaxation exercises. Exercises that increase intra-abdominal pressure are contraindicated. The duration of the lesson is 12-15 minutes. The pace is slow, the intensity is low.

2 period begins with a significant improvement in the patient's condition and transferring him to the ward regime.

Starting positions - lying, sitting, kneeling, standing. Exercises are used for all muscle groups, excluding the abdominal muscles (at the end of the period it is possible, but without straining, with a small number of repetitions), breathing exercises. The duration of the lesson is 15-20 minutes. The pace is slow, the intensity is low. Classes are held 1-2 times a day.

3 period- use exercises for all muscle groups with limited load on the muscles of the abdominal wall, exercises with objects (1-2 kg.), Coordination. The density of the lesson is medium, the duration is up to 30 minutes.

4 period(sanatorium-resort conditions).

The volume and intensity of exercise therapy are increasing, the health path, walking, playing volleyball, skiing, skating, and swimming are widely used. Lesson duration 30 minutes

Physiotherapy treatments:

General exposure procedures are used from the first days of hospitalization. Methods of local influence are best used on the 7-8th day, and in outpatient conditions - in the stage of fading exacerbation.

General exposure procedures:

1. Galvanization by the method of galvanic collar according to Shcherbak. The current strength is from 6 to 12 mA, the exposure time starts from 6 and is adjusted to 16 minutes. The procedure is carried out daily, the course of treatment is 10 procedures.

2. Electroanalgesia. The pulse repetition duration is 0.5 m/s, their repetition frequency is 300 - 800 Hz. Current strength 2 mA. The duration of the procedure is 20-30 minutes. The course of treatment is 10 procedures.

3. Coniferous, oxygen, pearl baths, t 36 - 37 0 C. The course of treatment - 12-15 baths.

Local exposure procedures:

1. Amplipulse therapy for the stomach and duodenum. Current strength - 20-30 mA, daily or every other day. The course of treatment is 10-12 procedures.

2. EHF-therapy on the epigastric region. Duration - 30-60 minutes. The course of treatment is 20-30 procedures.

3. Intragastric electrophoresis no-shpy, aloe. The location of the electrodes is transverse: back, abdomen. Current strength 5-8 mA. Duration 20-30 minutes. The course of treatment is 10-12 procedures.

4. Laser therapy with infrared laser radiation The technique is contact, scanning. Pulse mode, frequency 50-80 Hz. Duration 10-12 minutes, daily. The course of treatment is 10-12 procedures.

According to the WHO definition, rehabilitation is the combined and coordinated application of social, medical, pedagogical and professional activities with the aim of preparing and retraining the individual to achieve optimal working capacity.

Rehabilitation tasks:

• 1. Improve the overall reactivity of the body;
• 2. Normalize the state of the central and autonomic systems;
• 3. Provide analgesic, anti-inflammatory, trophic effect on the body;
• 4. Maximize the period of remission of the disease.

Comprehensive medical rehabilitation is carried out in the system of hospital, sanatorium, dispensary and polyclinic stages. An important condition for the successful functioning of a staged rehabilitation system is the early start of rehabilitation measures, the continuity of the stages, provided by the continuity of information, the unity of understanding the pathogenetic essence of pathological processes and the foundations of their pathogenetic therapy. The sequence of stages can be different depending on the course of the disease.

An objective assessment of the results of rehabilitation is very important. It is necessary for the current correction of rehabilitation programs, the prevention and overcoming of unwanted side effects, the final assessment of the effect when moving to a new stage.

Thus, considering medical rehabilitation as a set of measures aimed at eliminating changes in the body that lead to a disease or contribute to its development, and taking into account the knowledge gained about pathogenetic disorders in asymptomatic periods of the disease, there are 5 stages of medical rehabilitation.

The preventive stage aims to prevent the development of clinical manifestations of the disease by correcting metabolic disorders (Appendix B).

The activities of this stage have two main directions: elimination of the identified metabolic and immune disorders by dietary correction, the use of mineral waters, pectins of marine and terrestrial plants, natural and reshaped physical factors; the fight against risk factors that can largely provoke the progression of metabolic disorders and the development of clinical manifestations of the disease. You can count on the effectiveness of preventive rehabilitation only if you reinforce the measures of the first direction with the optimization of the habitat (improving the microclimate, reducing dust and gas content in the air, leveling the harmful effects of geochemical and biogenic nature, etc.), combating hypodynamia, overweight, smoking, and others. bad habits.

Stationary stage of medical rehabilitation, except for the first important task:

• 1. Saving the patient's life (provides for measures to ensure minimal tissue death as a result of exposure to a pathogenic agent);
• 2. Prevention of disease complications;
• 3. Ensuring the optimal course of reparative processes (Appendix D).

This is achieved by replenishing the deficiency of circulating blood volume, normalizing microcirculation, preventing tissue swelling, conducting detoxification, antihypoxant and antioxidant therapy, normalizing electrolyte disturbances, using anabolics and adaptogens, and physiotherapy. With microbial aggression, antibiotic therapy is prescribed, immunocorrection is carried out.

The polyclinic stage of medical rehabilitation should ensure the completion of the pathological process (Appendix D).

For this, therapeutic measures are continued aimed at eliminating the residual effects of intoxication, microcirculation disorders, and restoring the functional activity of body systems. During this period, it is necessary to continue therapy to ensure the optimal course of the restitution process (anabolic agents, adaptogens, vitamins, physiotherapy) and develop the principles of dietary correction, depending on the characteristics of the course of the disease. An important role at this stage is played by purposeful physical culture in the mode of increasing intensity.

The sanatorium-and-spa stage of medical rehabilitation completes the stage of incomplete clinical remission (Appendix G). Therapeutic measures should be aimed at preventing the recurrence of the disease, as well as its progression. To implement these tasks, predominantly natural therapeutic factors are used to normalize microcirculation, increase cardiorespiratory reserves, stabilize the functioning of the nervous, endocrine and immune systems, organs of the gastrointestinal tract and urinary excretion.

The metabolic stage includes conditions for the normalization of structural and metabolic disorders that existed after the completion of the clinical stage (Appendix E).

This is achieved with the help of long-term dietary correction, the use of mineral waters, pectins, climatotherapy, therapeutic physical culture, and balneotherapy courses.

The results of the implementation of the principles of the proposed scheme of medical rehabilitation by the authors are predicted to be more effective than the traditional one:

• - the allocation of the stage of preventive rehabilitation allows the formation of risk groups and the development of preventive programs;
• - the allocation of the stage of metabolic remission and the implementation of measures of this stage will make it possible to reduce the number of relapses, prevent the progression and chronicity of the pathological process;
• -- staged medical rehabilitation with the inclusion of independent stages of preventive and metabolic remission will reduce the incidence and improve the health of the population.

Directions of medical rehabilitation include drug and non-drug directions:

Medical direction of rehabilitation.

Drug therapy in rehabilitation is prescribed taking into account the nosological form and the state of the secretory function of the stomach.

Take before meals

Most medications are taken 30 to 40 minutes before meals, when they are best absorbed. Sometimes - 15 minutes before a meal, not earlier.

Half an hour before meals, you should take antiulcer drugs - d-nol, gastrofarm. They should be taken with water (not milk).

Also, half an hour before meals, you should take antacids (almagel, phosphalugel, etc.) and choleretic agents.

Reception at mealtime

During meals, the acidity of gastric juice is very high, and therefore significantly affects the stability of drugs and their absorption into the blood. In an acidic environment, the effect of erythromycin, lincomycin hydrochloride and other antibiotics is partially reduced.

Gastric juice preparations or digestive enzymes should be taken with food, as they help the stomach digest food. These include pepsin, festal, enzistal, panzinorm.

Along with food, it is advisable to take laxatives to be digested. These are senna, buckthorn bark, rhubarb root and joster fruits.

Reception after meals

If the medicine is prescribed after a meal, wait at least two hours to obtain the best therapeutic effect.

Immediately after eating, they take mainly drugs that irritate the mucous membrane of the stomach and intestines. This recommendation applies to drug groups such as:

• - painkillers (non-steroidal) anti-inflammatory drugs - Butadion, aspirin, aspirin cardio, voltaren, ibuprofen, askofen, citramon (only after meals);
• - acute agents are components of bile - allochol, lyobil, etc.); taking after meals is a prerequisite for these drugs to “work”.

There are so-called anti-acid drugs, the intake of which should be timed to coincide with the moment when the stomach is empty, and hydrochloric acid continues to be released, that is, an hour or two after the end of the meal - magnesium oxide, vikalin, vikair.

Aspirin or askofen (aspirin with caffeine) is taken after a meal, when the stomach has already begun to produce hydrochloric acid. Due to this, the acidic properties of acetylsalicylic acid (which provokes irritation of the gastric mucosa) will be suppressed. This should be remembered by those who take these pills for headaches or colds.

Regardless of food

Regardless of when you sit down at the table, take:

Antibiotics are usually taken regardless of food, but dairy products must also be present in your diet. Along with antibiotics, nystatin is also taken, and at the end of the course, complex vitamins (for example, supradin).

Antacids (gastal, almagel, maalox, talcid, relzer, phosphalugel) and antidiarrheals (imodium, intetrix, smecta, neointestopan) - half an hour before meals or one and a half to two hours after. At the same time, keep in mind that antacids taken on an empty stomach act for about half an hour, and taken 1 hour after eating - for 3-4 hours.

Fasting

Taking the medicine on an empty stomach is usually in the morning 20-40 minutes before breakfast.

Medicines taken on an empty stomach are absorbed and absorbed much faster. Otherwise, acidic gastric juice will have a destructive effect on them, and there will be little use from medicines.

Patients often ignore the recommendations of doctors and pharmacists, forgetting to take a pill prescribed before meals, and transferring it to the afternoon. If the rules are not followed, the effectiveness of drugs inevitably decreases. To the greatest extent, if, contrary to the instructions, the drug is taken during meals or immediately after it. This changes the rate of passage of drugs through the digestive tract and the rate of their absorption into the blood.

Some drugs may break down into their component parts. For example, penicillin is destroyed in an acidic gastric environment. Breaks down into salicylic and acetic acids aspirin (acetylsalicylic acid).

Reception 2 - 3 times a day if the instructions indicate "three times a day", this does not mean breakfast - lunch - dinner at all. The medicine must be taken every eight hours so that its concentration in the blood is evenly maintained. It is better to drink the medicine with plain boiled water. Tea and juices are not the best remedy.

If it is necessary to resort to cleansing the body (for example, in case of poisoning, alcohol intoxication), sorbents are usually used: activated carbon, polyphepan or enterosgel. They collect toxins "on themselves" and remove them through the intestines. They should be taken twice a day between meals. At the same time, fluid intake should be increased. It is good to add herbs with a diuretic effect to the drink.

Day or night

Sleeping pills should be taken 30 minutes before bedtime.

Laxatives - bisacodyl, senade, glaxena, regulax, gutalax, forlax - are usually taken at bedtime and half an hour before breakfast.

Ulcer remedies are taken early in the morning and late in the evening to prevent hunger pains.

After the introduction of the candle, you need to lie down, so they are prescribed for the night.

Emergency funds are taken regardless of the time of day - if the temperature has risen or colic has begun. In such cases, adherence to the schedule is not essential.

The key role of the ward nurse is the timely and accurate delivery of medicines to patients in accordance with the prescriptions of the attending physician, informing the patient about medicines, and monitoring their intake.

Among the non-drug methods of rehabilitation are the following:

1. Diet correction:

The diet for gastric ulcer is used as prescribed by the doctor sequentially, with surgical intervention it is recommended to start with a diet - 0.

Purpose: Maximum sparing of the mucous membrane of the esophagus, stomach - protection from mechanical, chemical, thermal factors of food damage. Providing an anti-inflammatory effect and preventing the progression of the process, preventing fermentation disorders in the intestines.

characteristics of the diet. This diet provides a minimum amount of food. Since it is difficult to take it in a dense form, food consists of liquid and jelly-like dishes. The number of meals is at least 6 times a day, if necessary - around the clock every 2-2.5 hours.

Chemical composition and calorie content. Proteins 15 g, fats 15 g, carbohydrates 200 g, calories - about 1000 kcal. Table salt 5 g. The total weight of the diet is not more than 2 kg. Food temperature is normal.

Sample set

Fruit juices - apple, plum, apricot, cherry. Berry juices - strawberry, raspberry, blackcurrant. Broths - weak from lean meats (beef, veal, chicken, rabbit) and fish (perch, bream, carp, etc.).

Cereal broths - rice, oatmeal, buckwheat, corn flakes.

Kissels from various fruits, berries, their juices, from dried fruits (with the addition of a small amount of starch).

Butter.

Tea (weak) with milk or cream.

Approximate one-day diet menu number 0

• 8 hours - fruit and berry juice.
• 10 o'clock - tea with milk or cream with sugar.
• 12 hours - fruit or berry jelly.
• 14 hours - a weak broth with butter.
• 4 p.m. - lemon jelly.
• 6 p.m. - rosehip decoction.
• 20:00 - tea with milk and sugar.
• 22 hours - rice water with cream.

Diet number 0A

It is prescribed, as a rule, for 2-3 days. Food consists of liquid and jelly-like dishes. In the diet 5 g of protein, 15-20 g of fat, 150 g of carbohydrates, energy value 3.1-3.3 MJ (750-800 kcal); table salt 1 g, free liquid 1.8-2.2 liters. The food temperature is not higher than 45 °C. Up to 200 g of vitamin C is introduced into the diet; other vitamins are added as prescribed by the doctor. Eating 7 - 8 times a day, for 1 meal they give no more than 200 - 300 g.

• - Allowed: low-fat meat broth, rice broth with cream or butter, strained compote, liquid berry jelly, rosehip broth with sugar, fruit jelly, tea with lemon and sugar, freshly prepared fruit and berry juices diluted 2-3 times sweet water (up to 50 ml per reception). When the condition improves on the 3rd day, add: soft-boiled egg, 10 g of butter, 50 ml of cream.
• - Excluded: any dense and puree-like dishes, whole milk and cream, sour cream, grape and vegetable juices, carbonated drinks.

Diet No. 0B (No. 1A surgical)

It is prescribed for 2-4 days after diet No. 0-a, from which diet No. 0-b differs in addition in the form of liquid pureed cereals from rice, buckwheat, oatmeal, boiled in meat broth or water. In the diet 40-50 g of protein, 40-50 g of fat, 250 g of carbohydrates, energy value 6.5-6.9 MJ (1550-1650 kcal); 4-5 g sodium chloride, up to 2 liters of free liquid. Food is given 6 times a day, no more than 350-400 g per reception.

Diet No. 0B (No. 1B surgical)

It serves as a continuation of the expansion of the diet and the transition to physiologically complete nutrition. The diet includes cream soups and soups, steam dishes from mashed boiled meat, chicken or fish, fresh cottage cheese, mashed with cream or milk to the consistency of thick sour cream, steam dishes from cottage cheese, sour-milk drinks, baked apples, well-mashed fruit and vegetable purees, up to 100 g of white crackers. Milk is added to tea; give milk porridge. In the diet 80-90 g of protein, 65-70 g of fat, 320-350 g of carbohydrates, energy value 9.2-9.6 MJ (2200-2300 kcal); sodium chloride 6-7 g. Food is given 6 times a day. The temperature of hot dishes is not higher than 50 °С, cold - not less than 20 °С.

Then there is an expansion of the diet.

Diet number 1a

Indications for diet No. 1a

This diet is recommended for the maximum limitation of mechanical, chemical and thermal aggression on the stomach. This diet is prescribed for exacerbation of peptic ulcer, bleeding, acute gastritis and other diseases that require maximum sparing of the stomach.

Purpose of diet No. 1a

Reducing the reflex excitability of the stomach, reducing interoceptive irritations emanating from the affected organ, restoring the mucous membrane by sparing the function of the stomach as much as possible.

General characteristics of diet No. 1a

Exclusion of substances that are strong causative agents of secretion, as well as mechanical, chemical and thermal irritants. Food is cooked only in liquid and mushy form. Steamed, boiled, pureed, pureed dishes in a liquid or mushy consistency. In Diet No. 1a for patients who have undergone cholecystectomy, only mucous soups, eggs in the form of steam protein omelettes are used. Caloric content is reduced mainly due to carbohydrates. The amount of food taken at a time is limited, the frequency of intake is at least 6 times.

The chemical composition of diet No. 1a

Diet No. 1a is characterized by a decrease in the content of proteins and fats to the lower limit of the physiological norm, a strict limitation of the impact of various chemical and mechanical stimuli on the upper gastrointestinal tract. With this diet, carbohydrates and salt are also limited.

Proteins 80 g, fats 80 - 90 g, carbohydrates 200 g, table salt 16 g, calories 1800 - 1900 kcal; retinol 2 mg, thiamine 4 mg, riboflavin 4 mg, nicotinic acid 30 mg, ascorbic acid 100 mg; calcium 0.8 g, phosphorus 1.6 g, magnesium 0.5 g, iron 0.015 g. The temperature of hot dishes is not higher than 50-55 ° C, cold - not lower than 15-20 ° C.

• - Mucous soups from semolina, oatmeal, rice, pearl barley with the addition of egg-milk mixture, cream, butter.
• - Meat and poultry dishes in the form of mashed potatoes or steam soufflé (meat cleaned from tendons, fascia and skin is passed through a meat grinder 2-3 times).
• - Fish dishes in the form of a steam soufflé from low-fat varieties.
• - Dairy products - milk, cream, steamed soufflé from freshly prepared grated cottage cheese; fermented milk drinks, cheese, sour cream, ordinary cottage cheese are excluded. Whole milk with good tolerance is drunk up to 2-4 times a day.
• - Soft-boiled eggs or in the form of a steam omelette, no more than 2 per day.
• - Dishes from cereals in the form of liquid porridge in milk, porridge from cereal (buckwheat, oatmeal) flour with the addition of milk or cream. You can use almost all cereals, with the exception of barley and millet. Butter is added to the finished porridge.
• - Sweet dishes - kissels and jelly from sweet berries and fruits, sugar, honey. You can also make juices from berries and fruits, diluting them with boiled water in a 1: 1 ratio before drinking.
• - Fats - fresh butter and vegetable oil added to dishes.
• - Drinks: weak tea with milk or cream, juices from fresh berries, fruits, diluted with water. Of the drinks, decoctions of wild rose and wheat bran are especially useful.

Excluded foods and dishes of diet No. 1a

Bread and bakery products; broths; fried foods; mushrooms; smoked meats; fatty and spicy dishes; vegetable dishes; various snacks; coffee, cocoa, strong tea; vegetable juices, concentrated fruit juices; fermented milk and carbonated drinks; sauces (ketchup, vinegar, mayonnaise) and spices.

Diet number 1b

Indications for diet No. 1b

Indications and purpose as for diet No. 1a. The diet is fractional (6 times a day). This table is for less sharp, in comparison with table No. 1a, limitation of mechanical, chemical and thermal aggression on the stomach. This diet is indicated for mild exacerbation of gastric ulcer, in the stage of remission of this process, with chronic gastritis.

Diet No. 1b is prescribed at subsequent stages of treatment with the patient remaining in bed. The timing of diet No. 1b is very individual, but on average they range from 10 to 30 days. Diet number 1b is also used subject to bed rest. The difference from diet number 1a is a gradual increase in the content of essential nutrients and caloric content of the diet.

Bread is allowed in the form of dried (but not toasted) crackers (75-100 g). Pureed soups are introduced, replacing mucous membranes; milk porridge can be consumed more often. Homogenized canned food for baby food from vegetables and fruits and dishes from beaten eggs are allowed. All recommended products and dishes from meat and fish are given in the form of steam soufflé, quenelles, mashed potatoes, cutlets. After the products are boiled to softness, they are rubbed to a mushy state. Food must be warm. The rest of the recommendations are the same as for diet No. 1a.

The chemical composition of diet No. 1b

Proteins up to 100 g, fats up to 100 g (30 g vegetable), carbohydrates 300 g, calories 2300 - 2500 kcal, salt 6 g; retinol 2 mg, thiamine 4 mg, riboflavin 4 mg, nicotinic acid 30 mg, ascorbic acid 100 mg; calcium 0.8 g, phosphorus 1.2 g, magnesium 0.5 g, iron 15 mg. The total amount of free liquid is 2 liters. The temperature of hot dishes is up to 55 - 60 ° C, cold - not lower than 15 - 20 ° C.

The role of a nurse in dietary correction:

The dietitian monitors the work of the catering department and compliance with the sanitary and hygienic regime, monitors the implementation of dietary recommendations when the doctor changes the diet, checks the quality of products when they arrive at the warehouse and kitchen, and controls the correct storage of the food supply. With the participation of the head of production (chef) and under the guidance of a dietitian, draws up a daily menu-layout in accordance with the card file of dishes. Carries out periodic calculation of the chemical composition and calorie content of diets, control of the chemical composition of actually prepared dishes and diets (protein, fat, carbohydrates, vitamins, minerals, energy value, etc.) by selectively sending individual dishes to the laboratory of the State Sanitary and Epidemiological Supervision Center. Controls the bookmarking of products and the release of dishes from the kitchen to the departments, according to the orders received, carries out the grading of finished products. Carries out control over the sanitary condition of dispensing and canteens at departments, inventory, utensils, as well as the implementation of distributing rules of personal hygiene by employees. Organizes classes with paramedical workers and kitchen staff on therapeutic nutrition. Carries out control over the timely conduct of preventive medical examinations of catering workers and the exclusion from work of persons who have not passed a preliminary or periodic medical examination.

Diet number 1

General information

Indications for diet number 1

Peptic ulcer of the stomach in the stage of fading exacerbation, during the period of recovery and remission (the duration of dietary treatment is 3-5 months).

The purpose of diet No. 1 is to accelerate the processes of reparation of ulcers and erosions, further reduce or prevent inflammation of the gastric mucosa.

This diet contributes to the normalization of the secretory and motor-evacuation function of the stomach.

Diet No. 1 is designed to meet the physiological needs of the body for nutrients in stationary conditions or in outpatient conditions during work that is not associated with physical activity.

General characteristics of diet No. 1

The use of diet No. 1 is aimed at providing a moderate sparing of the stomach from mechanical, chemical and thermal aggression with a restriction in the diet of dishes that have a pronounced irritating effect on the walls and receptor apparatus of the upper gastrointestinal tract, as well as indigestible foods. Exclude dishes that are strong causative agents of secretion and chemically irritate the gastric mucosa. Both very hot and very cold dishes are excluded from the diet.

The diet for diet No. 1 is fractional, up to 6 times a day, in small portions. It is necessary that the break between meals should not be more than 4 hours, a light dinner is allowed an hour before bedtime. At night, you can drink a glass of milk or cream. Food is recommended to chew thoroughly.

The food is liquid, mushy and denser in boiled and mostly pureed form. Since the consistency of food is very important in dietary nutrition, they reduce the amount of foods rich in fiber (such as turnips, radishes, radishes, asparagus, beans, peas), fruits with skins and unripe berries with rough skins (such as gooseberries, currants, grapes). , dates), bread made from wholemeal flour, foods containing coarse connective tissue (such as cartilage, poultry and fish skin, sinewy meat).

Dishes are cooked boiled or steamed. After that, they are crushed to a mushy state. Fish and coarse meats can be eaten whole. Some dishes can be baked, but without a crust.

The chemical composition of diet No. 1

Proteins 100 g (of which 60% of animal origin), fats 90-100 g (30% vegetable), carbohydrates 400 g, table salt 6 g, calories 2800-2900 kcal, ascorbic acid 100 mg, retinol 2 mg, thiamine 4 mg, riboflavin 4 mg, nicotinic acid 30 mg; calcium 0.8 g, phosphorus at least 1.6 g, magnesium 0.5 g, iron 15 mg. The total amount of free fluid is 1.5 liters, food temperature is normal. Salt is recommended to be limited.

• - Wheat bread from the highest grade flour of yesterday's baking or dried; rye bread and any fresh bread, pastry and puff pastry products are excluded.
• - Soups on a vegetable broth from mashed and well-boiled cereals, dairy, vegetable puree soups seasoned with butter, egg-milk mixture, cream; meat and fish broths, mushroom and strong vegetable broths, cabbage soup, borscht, okroshka are excluded.
• - Meat dishes - steamed and boiled from beef, young low-fat lamb, trimmed pork, chickens, turkeys; fatty and sinewy varieties of meat, poultry, duck, goose, canned meat, smoked meats are excluded.
• - Fish dishes are usually low-fat varieties, without skin, in pieces or in the form of cutlets; cooked with water or steam.
• - Dairy products - milk, cream, non-acidic kefir, curdled milk, cottage cheese in the form of a soufflé, lazy dumplings, pudding; dairy products with high acidity are excluded.
• - Cereals from semolina, buckwheat, rice, boiled in water, milk, semi-viscous, mashed; millet, barley and barley groats, legumes, pasta are excluded.
• - Vegetables - potatoes, carrots, beets, cauliflower, boiled in water or steam, in the form of soufflé, mashed potatoes, steam puddings.
• - Appetizers - boiled vegetable salad, boiled tongue, doctor's sausage, dairy, dietary, aspic fish on vegetable broth.
• - Sweet dishes - fruit puree, kissels, jelly, pureed compotes, sugar, honey.
• - Drinks - weak tea with milk, cream, sweet juices from fruits and berries.
• - Fats - butter and refined sunflower oil added to dishes.

Excluded foods and dishes of diet No. 1

Two food groups should be excluded from your diet.

• - Foods that cause or increase pain. These include: drinks - strong tea, coffee, carbonated drinks; tomatoes, etc.
• - Products that strongly stimulate the secretion of the stomach and intestines. These include: concentrated meat and fish broths, decoctions of mushrooms; fried foods; meat and fish stewed in own juice; meat, fish, tomato and mushroom sauces; salted or smoked fish and meat products; meat and fish canned food; salted, pickled vegetables and fruits; spices and seasonings (mustard, horseradish).

In addition, the following are excluded: rye and any fresh bread, pastry products; dairy products with high acidity; millet, barley, barley and corn grits, legumes; white cabbage, radish, sorrel, onion, cucumbers; salted, pickled and pickled vegetables, mushrooms; sour and fiber-rich fruits and berries.

It is necessary to focus on the feelings of the patient. If, when eating a certain product, the patient feels discomfort in the epigastric region, and even more so nausea, vomiting, then this product should be discarded.

Peptic ulcer is one of the most common ­ diseases of the digestive organs. The disease is characterized by a long course, a tendency to recurrence and exacerbation, which increases the degree of economic damage from this disease. peptic ulcer of the stomach and two ­ of the duodenum is a chronic, cyclically occurring, recurrent disease characterized by ulceration in the gastroduodenal zone.

Etipathogenesis of peptic ulcer disease is quite complicated and until now there is no single position on this issue. At the same time, it has been established that various lesions of the nervous system (acute psychotrauma, physical and especially mental overstrain, various nervous diseases) contribute to the development of peptic ulcer. It should also be noted the importance of the hormonal factor, in particular, a violation of the production of digestive hormones (gastrin, secretin, etc.), as well as a violation of the metabolism of histamine and serotonin, under the influence of which the activity of the acid-peptic factor increases. Of certain importance is the violation of the diet and the composition of the food. In recent years, an increasing place is given to the infectious (viral) nature of this disease. Hereditary and constitutional factors also play a certain role in the development of peptic ulcer.

Clinical manifestations peptic ulcer are very diverse. Its main symptom is pain, most often in the epigastric region, with an ulcer in the duodenum, pain is usually localized to the right of the midline of the abdomen. Depending on the location of the ulcer, pain is early (0.5-1 hour after eating) and late (1.5-2 hours after eating). Sometimes there are pains on an empty stomach, as well as night pains. Quite common clinical symptoms in peptic ulcer disease is heartburn, which, like pain, can be rhythmic, often there is sour eructation and vomiting, also with acidic contents, usually after eating. During a peptic ulcer, four phases are distinguished: exacerbation, fading exacerbation, incomplete remission and complete remission. The most dangerous complication of peptic ulcer is perforation of the wall of the stomach, accompanied by acute "dagger" pain in the abdomen and signs of inflammation of the peritoneum. This requires immediate surgical intervention.

The complex of rehabilitation measures includes medicines, motor regimen, exercise therapy and other physical methods of treatment, massage, therapeutic nutrition. Exercise therapy and massage improve or normalize neuro-trophic processes and metabolism, helping to restore the secretory, motor, absorption and excretory functions of the digestive canal.

Exercise therapy for bed rest prescribed in the absence of contraindications (severe pain, ulcer bleeding). This usually coincides with 2-4 days after hospitalization. The tasks of this period include:

1 assistance in the regulation of the processes of excitation and inhibition in the cerebral cortex;

2 improvement of redox processes.

3 counteracting constipation and congestion in the intestines;

4 improve the functions of blood circulation and respiration.

The period runs for about two weeks. At this time, static breathing exercises are shown, which enhance the processes of inhibition in the cerebral cortex. Performed in the initial position lying on the back with relaxation of all muscle groups, these exercises are able to bring the patient into a drowsy state, help reduce pain, eliminate dyspeptic disorders, and normalize sleep. Simple gymnastic exercises for small and medium muscle groups are also used, with a small number of repetitions, in combination with breathing exercises and relaxation exercises, but exercises that increase intra-abdominal pressure are contraindicated. The duration of classes is 12-15 minutes, the pace of the exercises is slow, the intensity is low.

Rehabilitation of the second period is assigned when the patient is transferred to ward regime. The tasks of the first period are supplemented with the tasks of everyday and labor rehabilitation of the patient, restoration of the correct posture when walking, improvement of coordination of movements. The second period of classes begins with a significant improvement in the patient's condition. UGG, LH, abdominal wall massage are recommended. Exercises are performed in the prone position, sitting, kneeling, standing with gradually increasing effort for all muscle groups, still excluding the abdominal muscles (Fig. 26). The most acceptable is the supine position: it allows you to increase the mobility of the diaphragm, has a gentle effect on the abdominal muscles and improves blood circulation in the abdominal cavity. Patients perform exercises for the abdominal muscles without tension, with a small number of repetitions.

With a slow evacuation function of the stomach, more exercises lying on the right side should be included in the LH complexes, with moderate - on the left side. During this period, patients are also recommended massage, sedentary games, walking. The average duration of a lesson in the ward mode is 15-20 minutes, the pace of the exercises is slow, the intensity is low. Therapeutic exercises are carried out 1-2 times a day.

The tasks of the third period include: general strengthening and improvement of the patient's body; improvement of blood and lymph circulation in the abdominal cavity; restoration of household and labor skills. In the phase of incomplete and complete remission, in the absence of complaints and the general good condition of the patient, a free regimen is prescribed. Exercises are used for all muscle groups, exercises with light weights (up to 1.5-2 kg), for coordination, outdoor and sports games. The density of the lesson is average, the duration increases to 30 minutes.

In sanatorium conditions, the volume and intensity of exercise therapy increases, all means and methods of exercise therapy are shown. Recommended U GG in combination with hardening procedures; group classes of LG (ORU, DU, exercises with objects); dosed walking, walks (up to 4-5 km); sports and outdoor games; ski trips; occupational therapy. A therapeutic massage is also used: behind - segmental massage in the back from C 4 to D 9 on the left, in front - in the epigastric region, the location of the costal arches. Massage should be gentle at first. The intensity of the massage and the duration of the procedure gradually increase from 8-10 to 20-25 minutes by the end of the treatment.