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02.03 Nursing Care and Pathophysiology for Diverticulosis – Diverticulitis

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Pathophysiology:

Diverticulosis is pouches form along the intestinal wall. Diverticulitis involves small abscesses or infection in one or more diverticula or a perforation in the bowel.

 

Overview

  1. Diverticulosis
    1. Outpouching of intestinal mucosa → pockets inside the colon
  2. Diverticulitis
    1. Inflammation of diverticula due to trapped bacteria

Nursing Points

General

  1. Severe inflammation can lead to perforation
    1. Peritonitis → sepsis

Assessment

  1. LLQ pain worsening with straining
  2. Abdominal distention
  3. N/V
  4. Melena
  5. ↑ WBC, fever

Therapeutic Management

  1. NPO – bowel rest
  2. Bedrest
  3. Introduce fiber slowly, promote high fiber foods
  4. ↑ Fluid intake
  5. Avoid gas forming foods
  6. Bulk forming laxatives
  7. Partial or Total Colectomy with or without Colostomy
    1. Remove part of colon
    2. Pull bowel through abdominal wall for elimination of fecal matter
    3. Stoma Care
      1. Empty bag ⅓ full
      2. Secure wafer with stoma adhesive
      3. Assess stoma color (should be pink or beefy red)
      4. Assess output (quality and quantity)

Nursing Concepts

  1. Nutrition
    1. Past recommendations involved avoiding nuts, seeds, etc. – recent evidence shows these have no impact
    2. Promote high-fiber diet
    3. Avoid gas-forming foods
  2. Infection Control
    1. IV antibiotics
    2. Hand-washing
  3. Comfort
    1. Administer analgesics as ordered
    2. Administer anti-inflammatory medications as ordered

Patient Education

  1. Avoid low-fiber foods
  2. Increase fluid and fiber intake
  3. Report any severe pain or bloody stools

Reference Links

Study Tools

Video Transcript

In this lesson, we’re going to talk about Diverticulosis and Diverticulitis. We keep these together because one is basically just an exacerbation of the other.

Diverticulosis occurs when the intestinal mucosa, usually in the large intestine, develop these outpouchings. When that happens, it creates these pockets on the inside of the colon. You can see the pockets here on this colonoscopy image. The cause isn’t entirely unknown, but we believe a low-fiber diet contributes to developing diverticulosis, as well as genetics. It’s very possible that patients could be entirely asymptomatic with diverticulosis, or they might just have nonspecific symptoms like bloating or cramping. We’ll diagnose with a colonoscopy like you see here, where they insert a camera through the rectum and look into the colon. Or we could see the outpouchings on a CT scan as well. The problem with diverticulosis comes when bacteria get trapped in these little pockets and start to inflame and infect the mucosa. It’s like the stuff that falls between the couch cushions, eventually something’s gonna get stuck.

So when that happens, the little outpouchings called diverticula get inflamed and infected. These bigger outpouchings here are the diverticula. As they get more and more inflamed, it’s possible that they could perforate the bowel, which could lead to peritonitis and sepsis because of the fecal content spilling into the peritoneum. Patients will present with left lower quadrant pain that gets worse if they are straining, like if they cough or are bearing down. They’ll likely have abdominal distention, where their abdomen is bloated and firm. They’ll probably have some nausea and diarrhea, possibly even vomiting, and they’ll likely have bloody stools, also called melena. And, of course, because this is an infectious process, we could see an elevated white blood cell count and a fever. If the bowel perforates or if this becomes a chronic, recurrent issue, patients might need a partial or total colectomy, which is where they remove part of the bowel, and possibly even a colostomy, which we’ll look at in just a second.

So as far as nursing care for diverticulitis, we want to make them NPO so we can rest their bowel – the last thing they need is to try to digest food when their bowels are inflamed. And they’ll likely be on IV antibiotics. We’ll slowly introduce fiber and ensure they’re on a high fiber diet as well as increase their fluid intake. This will help form up the stools and keep them moving. If they need more help, we can give bulk-forming laxatives like Metamucil. Now – if they do require a colostomy, we will need to perform stoma care. So what is a colostomy? What they do is remove the diseased portion of the colon, then they’ll seal up the remaining portion to the rectum. Then they pull the end of the colon through the abdominal wall to create a stoma. That is where the fecal matter will exit, typically into a bag.

So as nurses, we are responsible not only to care for the stoma, but to teach the patients how to care for it as well. These days, we have Wound-Ostomy-Continence Nurses who do a lot of this, so there are a lot of nurses who aren’t comfortable with it – so we just want to give you the basics and make sure you know what to do. So this is the stoma, you’ll notice it’s a beefy red color, that’s what we want. If it’s pale or dark purple or black it could mean that blood supply is cut off or it’s being strangulated. When we do stoma care, we’ll clean the stoma and around it with warm water and a mild soap and pat it dry. We’ll measure and cut this wafer so that it sits about ⅛ of an inch around the stoma. This tan part is like a flexible gel that you can just use scissors to cut wider if you need to. Then you’ll use a stoma paste or stoma adhesive around the stoma and possibly even skin protectant wipes around here. Then you’ll peel off the paper backing and stick the wafer down around the stoma. Then the bag attaches here on this plastic part. We want to make sure to empty the bag when it’s ⅓ full to prevent leakage or explosions. We want to make sure patients avoid gas-forming foods like brussel sprouts, broccoli, or beans because if that bag fills up with gas, it’s NOT pretty when it bursts. And then we want to regularly assess the color of the stoma and the output. The farther along it is in the colon, the more formed it will be. If it’s closer to the small intestine, it may be more liquid than formed, and that’s expected. Quick Tip – Left lower quadrant should be more formed, but not hard. Right lower quadrant should be liquid. If it’s up here in the transverse colon, it will be kind of in between – soft and mushy.

So our priority nursing concepts for a patient with diverticulosis or diverticulitis are pretty self-explanatory: comfort, infection control, and nutrition and elimination. Make sure you check out the care plan attached to this lesson for more detailed nursing interventions and rationales.

So let’s recap. Diverticulosis is when the outpouching of the mucosal lining of the intestines causes little pockets to form inside. If these pockets get inflamed and infection, it can cause perforation of the bowels, which could lead to peritonitis and possible sepsis. Diverticulitis causes pain, usually in the left lower quadrant, and can cause bleeding into stools. A common thought is that it’s caused by a low-fiber diet, so we make sure to put patients on a high fiber diet and increase fluids to make sure their bowels are moving easily. In severe cases, patients may require for part of their colon to be removed and may require a colostomy – in which case we will focus on stoma care and teaching the patient how to manage it.

That’s it for diverticulosis and diverticulitis. Make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!

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