Week 12: Chp 58: Diverticulitis

Question 1

Diverticulum

Answer 1

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

Question 2

A diverticulum is thought to be related to what?

Answer 2

a lack of fiber in the diet, obesity, and lack of physical acitivity

Question 3

Risk Factors

Answer 3

• increasing age
• obesity
• smoking
• low-fiber diet
• heredity
• some medications (NSAIDs, acetaminophen, oral corticosteroids, and opiates)

Question 4

Patients with diverticulitis should not comsume what?

Answer 4

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

Question 5

Where is Diverticulitis generally located?

Answer 5

extraluminal, occurring on the outside of the colon (outpouching)

Question 6

Diverticulosis

Answer 6

the presence of diverticula that are not inflamed

-are asymptomatic and may not even know they have this condition

Question 7

What is diverticulitis

Answer 7

inflammation and/or infection of diverticula

• most often occurs in the colon, most commonly sigmoid colon
• acute or chronic

Question 8

Pathophysiology of Diverticulitis

Answer 8

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

Question 9

What does dietary fiber do?

Answer 9

thought to act by producing a larger, bulkier stool that results in a wider-bore colon, which is less likely to develop diverticula

Question 10

Diverticula seem to occur at points of what in the intestinal wall?

Answer 10

points of weakness in the intestinal wall

Question 11

Fecalith

Answer 11

mass or dried, hard, concrete-like stool

Question 12

How does Fecalith develop?

Answer 12

food can become entrapped in the diverticula, and when it mixes with normal bacterial flora, this leads to decreased blood supply forming fecalith

Question 13

What happens to the diverticular wall from fecalith?

Answer 13

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

Question 14

Why is the sigmoid colon more frequent to herniation?

Answer 14

because it is the segment with the smallest diameter, and increased intraluminal pressure may predispose the area to more frequent herniation

Question 15

Chronic Diverticulitis

Answer 15

the bowel can become scarred, leading to narrowing of the lumen, and the patient may develop an intestinal obstruction

Question 16

Clinical Manifestations

Answer 16

• 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

Question 17

Why would you have bloody stool?

Answer 17

bleeding occurs because of inflammation near areas of blood vessels and may range from minor to severe

Question 18

Older adult patients and clinical manifestations

Answer 18

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

Question 19

If perforation has occurred, the patient may present with?

Answer 19

clinical manifestations of sepsis

Question 20

If peritonitis (inflammation of the peritoneum) has occurred, what will the patient display?

Answer 20

profound guarding with widespread rebound tenderness

Question 21

Most Common diagnostic Tests

Answer 21

• 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

Question 22

Uncomplicated Diverticulitis Treatment

Answer 22

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

Question 23

Common antibiotics used to treat diverticulitis

Answer 23

• Ciprofloxacin and metronidazole
• trimethoprim-sulfamethoxazole and metronidazole
• amoxicillin-clavulanate
• Augmentin
• Moxifloxacin

Question 24

When should the patient be admitted to the hospital?

Answer 24

• 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

Question 25

Dietary restrictions for acute uncomplicated diverticulitis?

Answer 25

no restrictions | -although, limiting to clear liquid diet for 2 to 3 days is common

Question 26

What happens when a person is being admitted to the hospital with diverticulitis?

Answer 26

- 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

Question 27

What should be avoided in a patient with diverticulitis?

Answer 27

laxatives and enemas because they increase intestinal motility

Question 28

When is an inpatient discharged?

Answer 28

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

Question 29

When is surgical Management needed?

Answer 29

failure of medial management

Question 30

Indications for surgery

Answer 30

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

Question 31

Complications of Diverticulitis

Answer 31

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

Question 32

Nursing Management: Assessment and Analysis (what the patient presents with)

Answer 32

- 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

Question 33

Peritonitis

Answer 33

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.

Question 34

Nursing Diagnoses

Answer 34

- acute pain r/t inflammation and distension of the colon | - knowledge deficit r/t the need to consume adequate fiber in the diet

Question 35

Nursing Interventions: Assessment

Answer 35

- vital signs - serum potassium levels - intake and output - pain - mental status in older adults

Question 36

Assessment: Vital Signs

Answer 36

- 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

Question 37

Assessment: Serum Potassium levels

Answer 37

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

Question 38

Assessment: Intake and Output

Answer 38

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

Question 39

Assessment: Pain

Answer 39

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

Question 40

Assessment: Mental Status in Older Adults

Answer 40

older adults do not always show classic signs of infection | -the first changes observed may be changes in mental status

Question 41

Nursing Actions

Answer 41

- administer IV fluids - administer ordered antibiotics - nasogastric tube to low intermittent suction - provide oral care

Question 42

Actions: administer IV fluids

Answer 42

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

Question 43

Actions: administer ordered antibiotics

Answer 43

diverticulitis is a localized infection | -antibiotics are administered until pain, inflammation, infection, and fever subside

Question 44

Action: Nasogastric tube to low intermittent suction

Answer 44

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

Question 45

Action: provide oral care

Answer 45

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

Question 46

Nursing Teachings

Answer 46

- dietary recommendation - avoid straining, bending, and lifting - weight reduction - complete antibiotic therapy as prescribed

Question 47

Teaching: Dietary recommendation

Answer 47

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

Question 48

Teaching: Avoid straining, bending, and lifting

Answer 48

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

Question 49

Teaching: weight reduction

Answer 49

obesity has been linked to increase intra-abdominal pressure, which is a risk factor for diverticulitis

Question 50

Teaching: Complete antibiotic therapy as prescribed

Answer 50

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

Question 51

Evaluating Care Outcomes

Answer 51

- 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

Question 52

Intervention appropriate for the patient admitted to the hospital with Diverticulitis?

Answer 52

antibiotics, IV fluids, NPO, NG tube, pain medications