Week 12: Chp 58: Diverticulitis Flashcards
Diverticulum
a small, pouch-like protrusion or herniation, most often occurring in the gastrointestinal tract, particularly in the colon
-occurs most frequently in the left colon, most commonly sigmoid colon
A diverticulum is thought to be related to what?
a lack of fiber in the diet, obesity, and lack of physical acitivity
Risk Factors
- increasing age
- obesity
- smoking
- low-fiber diet
- heredity
- some medications (NSAIDs, acetaminophen, oral corticosteroids, and opiates)
Patients with diverticulitis should not comsume what?
whole pieces of fiber such as seeds, corn, and nuts
-these undigested fragments can become lodged in the diverticulum and induce an episode of diverticulitis
Where is Diverticulitis generally located?
extraluminal, occurring on the outside of the colon (outpouching)
Diverticulosis
the presence of diverticula that are not inflamed
-are asymptomatic and may not even know they have this condition
What is diverticulitis
inflammation and/or infection of diverticula
- most often occurs in the colon, most commonly sigmoid colon
- acute or chronic
Pathophysiology of Diverticulitis
when a patient has diverticula, the colon wall thickens and becomes rigid; without adequate fiber intake, more water is absorbed from the stool; this slows transit time and makes it more difficult for the stool to pass through the colon; this then cause increased intraluminal pressure from constipation and straining, which is thought to lead to the formation of diverticula
What does dietary fiber do?
thought to act by producing a larger, bulkier stool that results in a wider-bore colon, which is less likely to develop diverticula
Diverticula seem to occur at points of what in the intestinal wall?
points of weakness in the intestinal wall
Fecalith
mass or dried, hard, concrete-like stool
How does Fecalith develop?
food can become entrapped in the diverticula, and when it mixes with normal bacterial flora, this leads to decreased blood supply forming fecalith
What happens to the diverticular wall from fecalith?
the diverticular wall is eroded by increased intraluminal pressure or hard, dried food particles
-this process leads to inflammation and/or infection; the inflammation can spread to other areas of the intestine
Why is the sigmoid colon more frequent to herniation?
because it is the segment with the smallest diameter, and increased intraluminal pressure may predispose the area to more frequent herniation
Chronic Diverticulitis
the bowel can become scarred, leading to narrowing of the lumen, and the patient may develop an intestinal obstruction
Clinical Manifestations
- complain of abdominal pain over the area that is involved, usually sigmoid colon (LLQ)
- may experience fever or leukocytosis (WBC above normal range), and often a palpable mass felt over involved areas
- complain of increased flatus, anorexia, abdominal bloating/ distension, and diarrhea or constipation
- stools may contain mucus and blood
Why would you have bloody stool?
bleeding occurs because of inflammation near areas of blood vessels and may range from minor to severe
Older adult patients and clinical manifestations
may present afebrile with normal WBC count and minimal abdominal tenderness
- first sign may be a change in mental status
- increased confusion, falling, and anorexia
If perforation has occurred, the patient may present with?
clinical manifestations of sepsis
If peritonitis (inflammation of the peritoneum) has occurred, what will the patient display?
profound guarding with widespread rebound tenderness
Most Common diagnostic Tests
- plain flat-plate abdominal x-rays
- usually confirmed with a CT scan
- elevated WBC
- urinalysis may show a few RBCs if ureter is near a perforated diverticulum
Uncomplicated Diverticulitis Treatment
uncomplicated diverticulitis may be treated on an outpatient basis with broad-spectrum antibiotics for 7-10 days but should be reassessed after 2-3 days of therapy
-consume a clear liquid diet until symptoms subside, then advanced slowly
Common antibiotics used to treat diverticulitis
- Ciprofloxacin and metronidazole
- trimethoprim-sulfamethoxazole and metronidazole
- amoxicillin-clavulanate
- Augmentin
- Moxifloxacin
When should the patient be admitted to the hospital?
- fever higher than 102.5 F
- 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
Dietary restrictions for acute uncomplicated diverticulitis?
no restrictions
-although, limiting to clear liquid diet for 2 to 3 days is common
What happens when a person is being admitted to the hospital with diverticulitis?
- IV fluids are started and is NPO to allow the bowel to rest
- may have a nasogastric (NG) tube for bowel decompression and will receive parenteral antibiotics
- pain medications PRN and opiates are frequently needed
What should be avoided in a patient with diverticulitis?
laxatives and enemas because they increase intestinal motility
When is an inpatient discharged?
as clinical manifestations resolve and they should complete a course of 10 to 14 days of antibiotics, then have a follow up examination
-after manifestations completely resolve, patient is recommended to have a colonoscopy to assess extent of the diverticular disease
When is surgical Management needed?
failure of medial management
Indications for surgery
perforation, obstruction, abscess formation which is not responding to antibiotic treatment, or fistula formation between the colon and another pelvic organ
-if patients develop complications, they may require surgery to remove the diseased portion of the colon; may have a temporary colostomy because re-anastomosis 3 to 6 months later is usually successful
Complications of Diverticulitis
perforation, microperforation, abscess and fistula formation, bowel obstruction, and bleeding
-inflammation can also result in fistulas to other organs
Nursing Management: Assessment and Analysis (what the patient presents with)
- Fever ranging from low-grade (101 F) due to inflammation
- tachycardia often accompanies increased temperature
- pain in LLQ or midabdomen depending on what area of colon is involved; if abdominal pain is generalized, the diverticula may have ruptured, and peritonitis should be suspected
- altered bowel habits (constipation, diarrhea, or both)
- increased flatus and anorexia
- elevated WBC
Peritonitis
Peritonitis is inflammation of the peritoneum — a silk-like membrane that lines your inner abdominal wall and covers the organs within your abdomen — that is usually due to a bacterial or fungal infection.
Nursing Diagnoses
- acute pain r/t inflammation and distension of the colon
- knowledge deficit r/t the need to consume adequate fiber in the diet
Nursing Interventions: Assessment
- vital signs
- serum potassium levels
- intake and output
- pain
- mental status in older adults
Assessment: Vital Signs
- fever accompanies diverticulitis, ranging from a low-grade fever (101 F) because of inflammation
- Tachycardia accompanies increased temperature secondary to an increase in insensible fluid loss due to fever
Assessment: Serum Potassium levels
if the patient has intermittent NG suction, potassium loss increases and requires monitoring and replacement if levels are below 3.5 mEq/L
Assessment: Intake and Output
fluid volume status may be impacted by NG suction and decreased intake
-important to monitor urine output to determine renal perfusion
Assessment: Pain
pain accompanies diverticulitis, usually in the LLQ or midabdomen depending on what area of the colon is involved
- if abdominal pain is generalized, the diverticula may have ruptured, and peritonitis should be suspected
- opioid analgesics are frequently required but should be used with caution in older adults because of the mental status change that may occur
Assessment: Mental Status in Older Adults
older adults do not always show classic signs of infection
-the first changes observed may be changes in mental status
Nursing Actions
- administer IV fluids
- administer ordered antibiotics
- nasogastric tube to low intermittent suction
- provide oral care
Actions: administer IV fluids
patients are often NPO during the acute phase to allow the bowel to rest, and fluid balance must be maintained
Actions: administer ordered antibiotics
diverticulitis is a localized infection
-antibiotics are administered until pain, inflammation, infection, and fever subside
Action: Nasogastric tube to low intermittent suction
gastric decompression decreases gastric motility and allows the bowel to rest until inflammation decreases
Action: provide oral care
oral cavity may be dry due to insensible fluid loss, as well as increased mouth breathing in a patient with an NG tube
-apply lip balm to dry cracked lips
Nursing Teachings
- dietary recommendation
- avoid straining, bending, and lifting
- weight reduction
- complete antibiotic therapy as prescribed
Teaching: Dietary recommendation
increase fiber from raw fruits and vegetables in their diet; without adequate fiber intake, more water is absorbed from the stool; this slows transit time and makes it more difficult for the stool to pass through the colon; this then causes increased intraluminal pressure from constipation and straining, which is thought to lead to the formation of diverticula
-important to note that patients should not increase their fiber during acute phases, and the diverticulitis should be resolved
Teaching: Avoid straining, bending, and lifting
increase intra-abdominal pressure, which can lead to further outpouching of the diverticula
Teaching: weight reduction
obesity has been linked to increase intra-abdominal pressure, which is a risk factor for diverticulitis
Teaching: Complete antibiotic therapy as prescribed
adherence to antibiotic therapy is crucial, and the nurse should stress to the patient who is being treated in an outpatient setting about the importance of taking all the medication as prescribed
-rebound infection can occur when the prescribed dose of antibiotics is not taken
Evaluating Care Outcomes
- may be hospitalized for antibiotic therapy and bowel rest
- 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
Intervention appropriate for the patient admitted to the hospital with Diverticulitis?
antibiotics, IV fluids, NPO, NG tube, pain medications
