Unit 3: Diverticulitis Flashcards
Diverticulum
small, pouchlike protrusion or herniation
-most often in GI tracts, particularly the colon
What is Diverticulitis related to?
- lack of fiber in the diet
- obesity
- lack of physical activity
Risk Factors For Diverticulitis
- increasing age
- obesity
- smoking
- low-fiber diet
- heredity
- mediations (NSAIDs, acetaminophen. oral corticosteroids, and opiates)
- association w/ eating red meat and high-fat diets
Diverticulitis and Whole Fiber
do not consume whole piece of fiber; seeds, corn, and nuts
-these undigested fragments can become lodged in the diverticulum and induce an episode of diverticulitis
Pathophysiology of Diverticulitis
- generally extraluminal, occurring on the outside of the colon; “outpouching”
- often occurs in the colon; sigmoid colon
- when a patient has diverticula, the colon wall thickens and becomes rigid
- w/o adequate fiber intake, more water is absorbed from the stool; this slows transit time, makes it more difficult for the stool to pass through the colon
- this causes increased intraluminal pressure from constipation and straining, which is thought to lead to the formation of diverticula
- diverticula seem to occur at points of weakness in the intestinal wall
- food can become entrapped in the diverticula, and when it mixes with normal bacterial flora, this leads to a decreased bloody supply, forming a mass called fecalith or dried, hard, concrete-like stool
- the diverticular wall is eroded by increased intraluminal pressure or hard, dried food particles
- this process leads to inflammation and/or infection; this inflammation can spread to other areas of the intestine
Diverticulitis
an inflammation and/or infected diverticula
-often occurs in sigmoid colon
Chronic Diverticulitis
the bowel can become scarred, leading to narrowing of the lumen, which may result in intestinal obstruction
Diverticulosis
presence of diverticula that are not inflamed
- asymptomatic
- patients may not even know they have the condition
Clinical Manifestations
- abdominal pain over the area that is involved
- fever or leukocytosis (High WBC)
- palpable mass in involved area
- complain of increased flatus, anorexia, abdominal bloating/distention, diarrhea or constipation
- stool contains mucus and blood; bleeding occurs b/c of inflammation near areas of blood vessels and can range from minor to severe
Clinical Manifestations in the Older patient
- may be afebrile with a normal WBC count and minimal abdominal tenderness
- change in mental status is the first sign
- may present w/ increased confusion, falling, and anorexia
- if perforation occurred, may present w/ signs of sepsis
- if pain is more generalized over abdomen, peritonitis may have developed; displays profound guarding w/ widespread rebound tenderness
Diagnosis
- plain flat-plate abdominal x-ray
- confirmed with CT scan
- WBCs monitored for elevations initially associated w/ inflammation and possible infection but should decrease w/ treatment
- Urinalysis may show a few RBCs if ureter is near a perforated diverticulum
- should NOT have barium enema; risk of rupturing diverticula
What Diagnostic Test is contraindicated with Diverticulitis
Barium Enema
-risk of rupturing diverticula
Treatment for Uncomplicated Diverticulitis
- outpatient basis
- broad-spectrum antibiotics for 7 to 10 days but reassessed after 2-3 days of therapy
- no dietary restrictions but clear liquid diet for 2-3 days until symptoms subside, then advanced slowly as tolerated
When should the patient be admitted to the hospital?
- fever higher than 102.5 Degrees F (39* C)
- microperforation (few air bubbles outside the colon or confined to the pelvis)
- immunosuppression
- significant leukocytosis
- severe abdominal pain or diffuse peritonitis
- advanced age
- significant comorbidities
- intolerance of oral intake
- noncompliance or failed outpatient treatment
Common Antibiotics used
- Ciprofloxacin and metronidazole
- Amoxicillin-clavulanate
- Augmentin or Moxifloxacin
Treatment if the patient is admitted to the hospital
- IV fluids started
- NPO to allow bowel rest
- Nasogastric (NG) tube for bowel decompression and parenteral antibiotics
- Pain medications PRN; opiates needed
What should be avoided in the treatment of diverticulitis?
laxatives and enemas
-they increase intestinal mobility
Discharge upon hospital
as clinical manifestations resolve
- complete a course of 10 to 14 days of antibiotics and have a follow-up examination
- after manifestations completely resolve, recommended to have a colonoscopy to assess the extent of the diverticular disease
Surgical Management
failure of medical management may necessitate the need for surgical intervention
- Indications: perforation, obstruction, abscess formation which is not responding to antibiotic treatment, or fistula formation between the colon and another pelvic organ
- if develop complications, may require surgery to remove the diseased portion of colon; may have a temporary colostomy b/c re-anastomosis 3 to 6 months later is usually successful
Complications of Diverticulitis
- perforation
- microperforation
- abscess and fistula formation
- bowel obstruction
- bleeding
- inflammation can result in fistulas to other organs
Nursing Management: Assessment and Analysis
- fever often accompanies diverticulitis; ranging from a low grade fever to 101*F (38.3 *C)
- tachycardia accompanies increased temperature
- pain in LLQ; or area involved
- if abdominal pain is generalized, diverticula may have ruptures, and peritonitis should be suspected
- altered bowel habits w/ constipation, diarrhea, or both
- elevated WBC indicative of infection
Nursing Diagnoses
- acute pain r/t inflammation and distention of the colon
- knowledge deficit r/t the need to consume adequate fiber in the diet
Nursing Assessments
- Vital Signs
- Serum Potassium Levels
- Intake and Output
- Pain
- Mental status in older adults
Assessments: Vital Signs
- fever; ranging from low grade to 101 b/c of inflammation
- tachycardia accompanies increased temperature
Assessment: Serum Potassium levels
if patient has intermittent NG suction, potassium loss increases and requires monitoring and replacement if levels are below 3.5 mEq/L
Assessments: Intake and Output
- fluid volume status may be impacted by NG suction and decreased intake
- monitor urine output to determine renal perfusion
Nursing Actions
- Administer IV fluids
- Administer ordered Antibiotics
- Nasogastric Tube (NG) to low intermittent suction
- Provide oral care
Actions: Administer IV fluids
often NPO during the acute phase to allow the bowel to rest, and fluid balance must be maintained
Actions: Nasogastric Tube to low intermittent suction
gastric decompression decreases gastric motility and allows the bowel to rest until inflammation decreases
Actions: Provide Oral Care
- oral cavity may be dry d/t insensible loss, as well as increased mouth breathing in the patient with an NG tube
- apply lip balm to dry, cracked lips
Patient Teaching
- Dietary Recommendations
- Avoid Straining, bending and lifting
- Weight reduction
- Complete antibiotic therapy as prescribed; avoid rebound infection
Teaching: Dietary Recommendations
- increasing fiber from raw fruits and vegetables
- w/o adequate fiber intake, more water is absorbed from the stool; slows transit time and makes it more difficult for the stool to pass through the colon; causes increased intraluminal pressure from constipation and straining; thought to lead to formation of diverticula
- BUT, do not increase fiber intake during acute phases
Teaching: Avoid straining, bending, and lifting
these activities increase intra-abdominal pressure, which can lead to further outpouching of the diverticula
Teaching: Weight reduction
obesity is linked to increased intra-abdominal pressure, which is a risk factor for diverticulitis
Evaluating Care Outcome for Diverticulitis
- uncomplicated diverticulitis may be managed on an outpatient basis
- patient is admitted to the hospital for antibiotic therapy and bowel rest
- patient will be free of abdominal pain and fever prior to discharge
- maintaining adequate fiber in the diet may decrease recurrence or the severity of bouts of diverticulitis
Connection Check: A patient is admitted to the hospital for treatment for diverticulitis. The nurse recognizes which interventions appropriate for this patient?
A. High-fiber diet, ambulate frequently, IV fluids, pain medications
B. Antibiotics, IV fluids, NPO, NG tube, pain medications
C. Laxatives, enemas, diet, pain medications
D. Surgery w/ follow up physical therapy
B. Antibiotics, IV fluids, NPO, NG tube, pain medications
What is the Nasogastric Tube Used for?
for bowel decompression and parenteral antibiotics
