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Contents: Overview of Diverticlar disease Nursing diagnoses for diverticulosis and diverticulaitis 5 Nursing Care plans for diverticulosis and diverticulitis Terms: Diverticular disease: umbrella term for diverticulosis and diverticulitis Diverticulosis: a gastrointestinal disorder of having diverticula Diverticulitis: acute inflammation of diverticula Diverticulum(a): outpouching(s) of the large intestine or colon Pathophysiology: Diverticular disease is an outpouching of the intestinal mucosa through the colon wall. This clinical manifestation can occur in any part of the intestine but most commonly occurs in the Sigmoid colon - the descending part of the colon. These herniations occur at weak spots of the intestinal wall where blood vessels interrupt the muscle layer. If the pressure builds up in the intestinal lumen, an outpouching forms only the mucosal layers and not the muscle wall. Diverticulitis occurs when fecal matter blocks the diverticula and causes ischemia, initiating inflammation. Also, gut bacteria may cause an inflammatory process. Risk Factors/ Causes Age Male Obesity Low-fiber diet Medications such as NSAIDs and corticosteroids Smoking Sedentary lifestyle Signs & Symptoms: Majority is asymptomatic Symptomatic diverticulosis Constant abdominal pain in the left lower quadrant (in western countries); may be right lower quadrant in Asian countries because diverticulosis occurs more frequently in the ascending part of the colon. Rebound tenderness Cramp-like pain Blood in the stool from rupture of submucosal blood vessel surrounding an area of outpouching Changes in bowel habits: Diarrhea or Constipation Hyperactive bowel sounds Abdominal distention Urinary symptoms that are consistent with those of UTI Diverticulitis (inflammation of diverticula)Nausea Fever Tachycardia Loose stool Acute left iliac fossa pain (in western countries) Diagnosis: Abdominal x-ray - may help visualize possible perforation CT scan - may reveal abscess or thickening of the intestinal wallBarium enema - x-ray films with radiocontrast; may not be used during acute diverticulitis Colonoscopy - visualization of the colon; may find other malignancies Laboratory studies: WBC Hematocrit and Hemoglobin Occult stool sample C-reactive protein (CRP) Urinalysis Treatment: Medical treatment IV fluids if not contraindicated IV antibioticspain control Surgical treatment (Indication for surgery: perforation, inflammation unresponsive to medical therapy, an abscess that cannot be drained, fistula) Colon resection with primary anastomosis Temporary or permanent colostomy Possible Complications: Diverticulitis Local abscess formation Perforation > SepsisPeritonitis Fistula (Colovesicular fistula) may cause UTI Obstruction (rare) Hemorrhage from diverticulum rupture Nursing Diagnoses for Diverticulosis and Diverticulitis Acute Pain r/t bowel inflammation Deficient Knowledge r/t diet regimen and medication regimen Imbalanced Nutrition: Less than body requirements r/t loss of appetite Ineffective tissue perfusion r/t blockage of diverticula Risk for Deficient Fluid Volume Constipation r/t insufficient fiber Diarrhea r/t inflammation of intestine Disturbed Body Image r/t ostomy; incision Anemia r/t acute blood loss due to disease process 5 Nursing Care Plans for Diverticulosis and Diverticulitis Acute Pain r/t bowel inflammation Expected Outcome: The patient reports an acceptable pain level of less than 3 on a pain scale of 0 to 10. The patient's comfort level is improved, as evidenced by stable vital signs within normal limits and a relaxed posture and affect. The patient will use a combination of pharmacological and non-pharmacological treatment for pain. Assess the patient's pain level using a universal pain assessment tool such as a numeric pain scale, the Wong-Baker grimace tool, or the activity tolerance scale. Patients with diverticulosis may be completely pain-free. However, exacerbations of this condition may be painful.Note the following characteristics of pain. Onset Location Duration Characteristics Aggravating factors Alleviating factors Treatments Detailed documentation about different aspects of pain helps guide diagnosis and treatment.Perform a comprehensive abdominal assessment palpating the most painful area last. In western countries, the left lower quadrant is the most common area of pain associated with diverticulosis, whereas, in Asian countries, patients may report pain in the right lower quadrant. As mentioned previously, in Asian countries, diverticula may form in the cecum area of the intestine. Assess for changes in bowel habits. Patients with diverticular disease may have a history of constipation and diarrhea. Obtain a complete set of vital signs. Blood pressure, heart rate, and respirations reveal information about the patient's physiological condition, stress level, and pain. For example, elevated blood pressure, tachycardia, and tachypnea may be the reason for an acute change in health status or uncontrolled pain. Obtain information about the strategies the patient has tried for pain control. This information provides a baseline for adequate pain management.Provide analgesia medication as ordered. Acetaminophen (Tylenol) and antispasmodics are the first-line analgesic treatment. The use of NSAIDs and narcotic agents should be avoided, for there is an increased risk of complications associated with Diverticulitis. However, narcotic agents are still being used in cases of severe pain. Administer broad-spectrum antibiotics as ordered. The pain the patient experiences derives from an inflammatory response triggered by an infectious process. Antimicrobials help treat the infection that can occur from Diverticulitis. Offer non-pharmacological pain management techniques. Frequent position changes, meditation, and warm compresses may help alleviate pain in addition to analgesic medication.Monitor for sudden changes in severity and nature of abdominal pain. A sudden increase in pain sensations may indicate a gastrointestinal perforation, which is a life-threatening condition. Deficient Knowledge r/t diet regimen and medication regimen Expected Outcome: The patient will verbalize an understanding of the disease process and the importance of complying with diet and medication regimen. Assess the patient's knowledge base about the disease and evaluate the diet and medication regimens compliance history. This gives a baseline and offers a starting point for developing a teaching plan. For example, newly diagnosed patients need further education than patients living with the disease for years undergoing surgery. During non-acute phases (diverticulosis), encourage a high-fiber diet. A high-fiber diet is high in cellulose, such as wheat bread, whole-grain bread, and cereal. In addition, fresh fruits and vegetables with high fiber content are encouraged to add bulk to stool and ensure consistency. Encourage fluid intake of at least 2500 to 3000 ml per day, if not contraindicated. High fluid intake prevents bloating that can occur with a high-fiber diet.Tell the patient to avoid alcohol. Alcohol may irritate the gastrointestinal tract. During acute phases (diverticulitis), teach the patient to avoid fiber. Foods high in fiber stimulate bowel motility and only irritate the gastrointestinal mucosa further. Once the exacerbation subsides, the patient may gradually add fiber back into the diet. Encourage clear liquids as tolerated. Clear liquids may help maintain adequate fluid balance if the patient is stable enough to recover at home. During hospitalizations, the patient may even be kept NPO or have a nasogastric tube inserted to promote gut rest. Encourage rest during acute phases and teach the patient to avoid lifting, straining, coughing, or bending. Activities such as above may increase intraabdominal pressure and may result in the perforation of a diverticulum. Teach about medications and their indications. Antibiotics such as metronidazole (Flagyl) or ciprofloxacin (Cipro).It is important for the patient to take antibiotics on time even if he or she feels better. Each course of antibiotics should be finished to ensure all bacteria are killed and prevented from multiplying. Analgesics such as acetaminophen (Tylenol) or opiate narcotics for severe/complicated cases.Opioid analgesics may affect gut motility and can contribute to constipation. Antispasmodics/ anticholinergics These medications help to control diarrhea and cramping.Teach the patient and family to avoid laxatives and enemas. Bowel stimulating medications may irritate the intestines and exacerbate symptoms. Discuss possible surgical interventions with the patient and family. Diverticular disease may require surgical intervention. Colon resection may be indicated in some cases. For the patient that had surgical intervention, teach incision care and ostomy care if needed. Proper care will keep the site clean and reduce the risk of infection. Imbalanced Nutrition: Less than body requirements r/t loss of appetite, nausea, vomiting Expected Outcome: The patient will exhibit an improved nutritional status as evidenced by weight maintenance, absence of nausea and vomiting, and stable electrolytes. Obtain the patient's weight. Use a standing scale if possible. Compared to weighing the patient in the bed, a weight obtained from a standing scale may be more accurate. Collaborate with a dietitian to assist with appropriate food selection for each phase of diverticular disease.Diet for diverticulitis: During acute exacerbations, patients should avoid sources of fiber and eat light meals. No fiber foods: WaterBroth Jell-O Popsicles Clear juices such as apple, cranberry, or grape Diet for recovery phase: While the patient is recovering, slowly introduce low-fiber foods to the diet. Low-fiber foods: Canned and well-cooked vegetables without seeds such as apple sauce Dairy products such as cheese, milk, and yogurt Eggs Pasta, white bread, and white rice Ground meat or well-cooked meat Low-fiber cereal Diet for maintenance phase: While the patient does not experience any symptoms, a high-fiber diet is recommended. Fiber helps keep the digestive system active and prevents constipation. Constipation can contribute to building up pressure in the colon and lead to flare-ups. High fiber foods: Beans and legumes Bran and whole wheat bread Brown and wild rice instead of white rice Fresh fruit and vegetables instead of juices - fiber gets lost during the juicing processFruits and vegetables with peels and skinEliminate offending odors and other factors in the environment that might affect appetite. A pleasant environment may help make food more appetizing and increase food intake. Monitor electrolyte, vitamin, and mineral profile closely and replete as ordered. Decreased food intake, vomiting, and diarrhea can lead to deficiencies. Anticipate the need for total parenteral nutrition (TPN) as ordered. Some patients may not tolerate oral intake during exacerbations. Anticipate the need for a nasogastric tube (NGT) if the patient experiences severe nausea, vomiting, or abdominal distention.A nasogastric tube helps with decompression and promotes gut rest. Ineffective Tissue Perfusion r/t fecal blockage of diverticula Expected Outcome: The patient will exhibit adequate tissue perfusion of the gastrointestinal tract as evidenced by the absence of compilations of diverticular disease, absence of pain, and containment of acute phases of diverticular disease through necessary and appropriate interventions. Perform an abdominal assessment considering pain location, characteristics, and intensity level.Abdominal pain usually presents as cramp-like discomfort during an acute episode of diverticular disease. However, a sudden increase in pain may be an indication of rupture or perforation. This would be a medical emergency and require surgical intervention.Monitor lab studies pertinent to diverticulosis. Hemoglobin and HematocritThe blood vessels that supply the diverticula may rupture and cause bleeding. WBC Patients with acute diverticulitis often present with an elevated white blood cell count.BMP A basic metabolic panel should be obtained to assess electrolytes and renal function. Sometimes diverticular disease may cause nausea, vomiting, and diarrhea. This can cause electrolyte imbalances. UrinalysisUrine sample to rule out urinary tract infection (UTI)Occult stool sample A stool sample should be obtained to rule out occult bleeding. Anticipate the need for surgical intervention. Several options include a colon resection with primary anastomosis or a temporary or permanent colostomy. Risk for Deficient Fluid Volume Risk factors: Diarrhea Vomiting Bleeding from diverticula Expected Outcome: The patient will remain euvolemic as evidenced by good skin turgor, moist mucous membranes, and adequate urine output of at least 30 mL/hr. Assess the patient's hydration status. Note Skin turgor Mucous membranes Fluid intake output Weight Blood pressure Heart rate Signs of dehydration are tenting skin turgor, dry mucous membranes, decreased urine output, tachycardia, decreased blood pressure, and weight loss. Monitor stools for the presence of frank blood and obtain an occult stool sample as ordered. Blood loss may contribute to low circulatory volume, which may lead to low blood pressure.Monitor hemoglobin and hematocrit. These values decrease with bleeding. Encourage oral fluid intake of at least 8 to 10 glasses of fluid per day if not contraindicated. Oral fluid is the primary way to maintain an adequate fluid status. Anticipate the need for IV fluids. If the patient cannot maintain an adequate fluid status via oral intake, IV fluids may be necessary. Anticipate the need for blood transfusions as ordered. If the patient has decreased hematocrit and hemoglobin levels during an exacerbation, blood transfusions may be needed. More Care Plans: GastritisGI bleedDeficient Fluid VolumeAcute PainIneffective Tissue Perfusion References: Swanson, S. M. (2018, March 1). In the Clinic: Acute Colonic Diverticulitis. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430566/. Diagnosis and Management of Acute Diverticulitis. (n.d.). Retrieved from https://www.aafp.org/afp/2013/0501/p612.html. What Is Diverticulitis? (n.d.). Retrieved from https://www.healthline.com/health/diverticulitis Discharge Instructions for Diverticulitis. (n.d.). Retrieved from https://www.fairview.org/Patient-Education/Articles/English/d/i/s/c/h/Discharge_Instructions_for_Diverticulitis_86329. Diverticular Disease and Diet. (n.d.). Retrieved from https://www.ucsfhealth.org/Education/Diverticular%20Disease%20and%20Diet. Diverticulitis. (2019, June 3). Retrieved from https://www.eatright.org/health/wellness/digestive-health/diverticulitis. Matrana, M. R. (2009, June 5). Epidemiology and Pathophysiology of Diverticular Disease. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780269/. Gulanick, M., & Myers, J. L. (2013). Nursing Care Plans (8th ed.). Elsevier Health Sciences. Ignatavicius, D. D., & Workman, M. L. (2012). Medical-surgical Nursing (8th ed.). Elsevier Health Sciences.

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