Unit 3: Diverticulitis

Question 1

Diverticulum

Answer 1

small, pouchlike protrusion or herniation

-most often in GI tracts, particularly the colon

Question 2

What is Diverticulitis related to?

Answer 2

• lack of fiber in the diet
• obesity
• lack of physical activity

Question 3

Risk Factors For Diverticulitis

Answer 3

• increasing age
• obesity
• smoking
• low-fiber diet
• heredity
• mediations (NSAIDs, acetaminophen. oral corticosteroids, and opiates)
• association w/ eating red meat and high-fat diets

Question 4

Diverticulitis and Whole Fiber

Answer 4

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

Question 5

Pathophysiology of Diverticulitis

Answer 5

• 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

Question 6

Diverticulitis

Answer 6

an inflammation and/or infected diverticula

-often occurs in sigmoid colon

Question 7

Chronic Diverticulitis

Answer 7

the bowel can become scarred, leading to narrowing of the lumen, which may result in intestinal obstruction

Question 8

Diverticulosis

Answer 8

presence of diverticula that are not inflamed

• asymptomatic
• patients may not even know they have the condition

Question 9

Clinical Manifestations

Answer 9

• 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

Question 10

Clinical Manifestations in the Older patient

Answer 10

• 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

Question 11

Diagnosis

Answer 11

• 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

Question 12

What Diagnostic Test is contraindicated with Diverticulitis

Answer 12

Barium Enema

-risk of rupturing diverticula

Question 13

Treatment for Uncomplicated Diverticulitis

Answer 13

• 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

Question 14

When should the patient be admitted to the hospital?

Answer 14

• 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

Question 15

Common Antibiotics used

Answer 15

• Ciprofloxacin and metronidazole
• Amoxicillin-clavulanate
• Augmentin or Moxifloxacin

Question 16

Treatment if the patient is admitted to the hospital

Answer 16

• IV fluids started
• NPO to allow bowel rest
• Nasogastric (NG) tube for bowel decompression and parenteral antibiotics
• Pain medications PRN; opiates needed

Question 17

What should be avoided in the treatment of diverticulitis?

Answer 17

laxatives and enemas

-they increase intestinal mobility

Question 18

Discharge upon hospital

Answer 18

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

Question 19

Surgical Management

Answer 19

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

Question 20

Complications of Diverticulitis

Answer 20

• perforation
• microperforation
• abscess and fistula formation
• bowel obstruction
• bleeding
• inflammation can result in fistulas to other organs

Question 21

Nursing Management: Assessment and Analysis

Answer 21

• 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

Question 22

Nursing Diagnoses

Answer 22

• acute pain r/t inflammation and distention of the colon

- knowledge deficit r/t the need to consume adequate fiber in the diet

Question 23

Nursing Assessments

Answer 23

• Vital Signs
• Serum Potassium Levels
• Intake and Output
• Pain
• Mental status in older adults

Question 24

Assessments: Vital Signs

Answer 24

• fever; ranging from low grade to 101 b/c of inflammation

- tachycardia accompanies increased temperature

Question 25

Assessment: Serum Potassium levels

Answer 25

if patient has intermittent NG suction, potassium loss increases and requires monitoring and replacement if levels are below 3.5 mEq/L

Question 26

Assessments: Intake and Output

Answer 26

- fluid volume status may be impacted by NG suction and decreased intake - monitor urine output to determine renal perfusion

Question 27

Nursing Actions

Answer 27

- Administer IV fluids - Administer ordered Antibiotics - Nasogastric Tube (NG) to low intermittent suction - Provide oral care

Question 28

Actions: Administer IV fluids

Answer 28

often NPO during the acute phase to allow the bowel to rest, and fluid balance must be maintained

Question 29

Actions: Nasogastric Tube to low intermittent suction

Answer 29

gastric decompression decreases gastric motility and allows the bowel to rest until inflammation decreases

Question 30

Actions: Provide Oral Care

Answer 30

- 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

Question 31

Patient Teaching

Answer 31

- Dietary Recommendations - Avoid Straining, bending and lifting - Weight reduction - Complete antibiotic therapy as prescribed; avoid rebound infection

Question 32

Teaching: Dietary Recommendations

Answer 32

- 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

Question 33

Teaching: Avoid straining, bending, and lifting

Answer 33

these activities increase intra-abdominal pressure, which can lead to further outpouching of the diverticula

Question 34

Teaching: Weight reduction

Answer 34

obesity is linked to increased intra-abdominal pressure, which is a risk factor for diverticulitis

Question 35

Evaluating Care Outcome for Diverticulitis

Answer 35

- 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

Question 36

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

Answer 36

B. Antibiotics, IV fluids, NPO, NG tube, pain medications

Question 37

What is the Nasogastric Tube Used for?

Answer 37

for bowel decompression and parenteral antibiotics