CACAPIT, Lovely 20/3/2020
NCB2 SURGERY WARD
DIVERTICULITIS
is a type of disease that affects your digestive tract. It's a serious medical
condition that causes inflamed pouches in the lining of your intestine. These
pouches are called diverticula. They develop when weak spots in your intestinal
wall give way under pressure, causing sections to bulge out
May occur as an acute attack or may persist as a continuing, smoldering
infection.
PATHOPHYSIOLOGY
Diverticula form when the mucosa and submucosal layers of the colon herniate
through the muscular wall because of high intraluminal pressure, low volume in
the colon (i.e., fiber-deficient contents), and decreased muscle strength in the
colon wall (i.e., muscular hypertrophy from hardened fecal masses).
Bowel contents can accumulate in the diverticulum and decompose, causing
inflammation and infection.
The diverticulum can also become obstructed and then inflamed if the obstruction
continues.
The inflammation of the weakened colonic wall of the diverticulum can cause it to
perforate, giving rise to irritability and spasticity of the colon (i.e., diverticulitis)
In addition, abscesses develop and may eventually perforate, leading to
peritonitis and erosion of the arterial blood vessels, resulting in bleeding.
When a patient develops symptoms of diverticulitis, MICROPERFORATION of
the colon has occurred
CLINICAL MANIFESTATION
MILD TO SEVERE PAIN IN THE LEFT LOWER QUADRANT
NAUSEA
VOMITING
FEVER CHILLS
LEUKOCYTOSIS
If untreated, can lead to
PERIRONITIS
SEPTICEMIA
ASSESSMENT & DIAGNOSTIC FINDINGS
CT with contrast agents – is the diagnostic test of choice for diverticulitis; it
could also reveal abscesses.
ABDOMINAL X-RAYS – may demonstrate free air under the diaphragm if the
perforation has occurred from diverticulitis.
Laboratory tests:
COMPLETE BLOOD COUNT – revealing an elevated WBC count & Erythrocyte
sedimentation rate (ESR)
COLONOSCOPY is contraindicated because the risk of perforation in the
presence of local infection may result in sepsis.
COMPLICATIONS
PERITONITIS
ABSCESS FORMATION
FISTULAS
BLEEDING
MEDICAL MANAGEMENT
DIETARY MANAGEMENT
Clear liquid diet- until inflammation subsides
High-fiber, low fat diet- helps increase stool volume, decrease colonic transit time
and reduce intraluminal pressure.
PHARMACOLOGIC MANAGEMENT
For Outpatients:
REST
ANALGESIC MEDICATION
ANTISPASMODIC AGENTS
ANTIBIOTICS are prescribed for 7-10 days
A BULK-FORMING LAXATIVE
In acute cases with significant symptoms, hospitalization is required. Often indicated for
those who are older, immunocompromised, or taking corticosteroids.
Withholding oral intake
Administering IV fluids
Instituting nasogastric suctioning if vomiting or distention occurs are used to rest
the bowel movement.
BROAD-SPECTRUM ANTIBIOTICS: Ampicillin/Sulbactam,
Ticarcillin/Clavulanate, Ertapenem are prescribed for 7-10 days.
Opioid or other analgesic agents may be prescribed for pain relief
Oral intake is increased as symptoms subside.
Low-fiber diet may be necessary until signs of infection decreases.
ANTISPASMODIC AGENTS: Propantheline bromide and Oxyphencyclimine may
be prescribed
Probiotics have been suggested as a way to promote prevention of relapse in
that the healthy bacteria may promote a better balance of microbes in the
intestine and augment immune competence.
SURGICAL MANAGEMENT
If complications (perforation, peritonitis, haemorrhage, obstruction) occur, immediate
surgical intervention is necessary
CT-guided percutaneous drainage may be performed to drain the abscess, and
IV antibiotics are administered.
One-stage resection, in which the inflamed area is removed and a primary end-
to-end anastomosis is completed
Multiple-stage procedures for complications such as obstruction or perforation.
NURSING PROCESS/ MANAGEMENT
ASSESSMENT
During health history, ask about the onset and duration of pain and about past
and present elimination patterns.
Review dietary habits to determine fiber intake and ask about straining at stool,
history of constipation with periods of diarrhea, tenesmus, abdominal bloating
and distention.
Auscultate for the presence and character of bowel sounds and palpation for left
lower quadrant pain, tenderness, or firm mass.
The stool is inspected for pus, mucus, or blood.
Temperature, pulse, and blood pressure are monitored for abnormal variations
NURSING DIAGNOSIS ( may include the following)
Constipation related to narrowing of the colon from thickened muscular segments
and strictures.
Acute pain related to inflammation and infection
Collaborative problems/potential complications
Peritonitis
Abscess formation
Bleeding
PLANNING AND GOALS
Attainment and maintenance of normal elimination patterns
Pain Relief
Absence of complications
NURSING INTERVENTION
Maintaining Normal Elimination patterns
Fluid intake of 2L/day (within limits of the patient’s cardiac and renal reserve)
Suggest foods that are soft but have increased fiber, such as prepared cereals or
soft-cooked vegetables, to increase the bulk of stool and facilitate peristalsis,
thereby promoting defecation.
Individualized exercise program is encouraged to improve abdominal muscle
tone.
Review his/her daily routine to establish a schedule for meals and a set time for
defecation,
Assist in identifying habits that may have suppressed the urge to defecate.
Encourage daily intake of bulk laxatives as prescribed
RELIEVING PAIN
Opioid analgesics to relieve the pain
Antispasmodic agents to decrease intestinal spasm are administered as
prescribed
Record the intensity, duration and location of pain to determine whether the
inflammatory process worsens or subsides.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Assess for the following signs and symptoms of perforation: increased abdominal
pain and tenderness accompanied by abdominal rigidity, elevated WBC count,
elevated ESR, increased temp, tachycardia, and hypotension.
Perforation is a surgical emergency. Monitor vital signs and urine output and
administers IV fluids to replace volume loss as needed.
PROMOTING HOME AND COMMUNITY-BASED CARE
Remind the patient and family about the importance of continuing health
promotion and screening practices.
Educate pt who have not been involved in these practices in the past about their
importance and refers the patients to appropriate health care providers.
EVALUATION
Expected patient outcomes may include:
1. Attains a normal pattern of elimination
a. reports less abdominal cramping and pain
b. reports the passage of soft, formed stool without pain
c. drinks at least 10 glasses of fluid each day
d. exercise daily
2. Reports decreased pain
a. requests analgesic agent as needed
b. adheres to a low-fiber diet during acute episodes
3. Recovers without complications
a. is afebrile
b. has normal BP
c. has a soft, nontender abdomen with normal bowel sounds
d. maintains adequate urine output
e. has no blood in the stool
Reference:
BRUNNER & SUDDARTH’S
Textbook of Medical-Surgical Nursing
13th Edition
