Diverticular disease, encompassing both diverticulosis and diverticulitis, centers around diverticula, which are small, bulging sacs that can develop in the lining of the colon. Diverticulosis refers to the mere presence of these pouches and often remains asymptomatic. However, when these diverticula become inflamed or infected, the condition progresses to diverticulitis, marked by a range of distressing symptoms. While diverticula can manifest anywhere in the digestive tract, their prevalence is highest in the descending sigmoid colon, a region known for inherent weaknesses in its intestinal walls.
This detailed guide is designed for nurses and healthcare professionals to provide an in-depth understanding of diverticulitis from a nursing perspective. We will explore the essential nursing processes involved in managing patients with diverticulitis, focusing particularly on relevant nursing diagnoses, assessments, interventions, and care plans to optimize patient outcomes.
Nursing Process in Diverticulitis Management
The primary objective in diverticulitis treatment is to facilitate colon rest, allowing inflammation to subside. While some patients with mild symptoms can be effectively managed at home with oral antibiotics, pain relievers, rest, and a clear liquid diet, more severe cases necessitate hospitalization.
Surgical intervention becomes a consideration for patients experiencing recurrent diverticulitis or complications. This often involves surgical resection of the affected colon segment followed by primary anastomosis. In situations where primary anastomosis is not feasible, a temporary diverting colostomy might be necessary. Once the colon heals adequately, the colostomy can be reversed, and bowel continuity restored.
Crucially, patient education plays a pivotal role in diverticulitis management. Nurses are instrumental in equipping patients with accurate knowledge about their condition, dietary guidelines, and fluid requirements. A thorough understanding of the disease process and diligent adherence to the treatment plan are essential for preventing complications and disease exacerbations.
Nursing Assessment for Diverticulitis
The initial phase of nursing care involves a comprehensive nursing assessment to gather pertinent physical, psychosocial, emotional, and diagnostic data. This section focuses on both subjective and objective data collection relevant to diverticulitis.
Review of Health History
1. Inquire about General Symptoms:
While diverticulosis is often silent, some individuals may report vague gastrointestinal symptoms similar to other GI disorders:
- Abdominal cramps
- Tenderness in the affected area
- Abdominal swelling or bloating
- Difficulty with bowel movements (constipation)
Diverticulitis symptoms are more pronounced and include:
- Acute abdominal pain
- Abdominal distention
- Reduced or absent bowel sounds
- Nausea and vomiting
- Chills
- Constipation or diarrhea
- Rectal bleeding
2. Investigate Changes in Bowel Habits:
Note any alterations in bowel habits, such as changes in frequency or consistency, accompanying abdominal pain. Nausea and vomiting may also indicate potential bowel obstruction.
3. Identify Risk Factors:
- Non-modifiable Risk Factors:
- Ethnicity: Diverticulosis is highly prevalent in Western populations.
- Age: Prevalence increases significantly after age 40.
- Modifiable Risk Factors:
- Smoking: Smoking reduces mucus production in the colon, increasing diverticulitis risk.
- Physical Inactivity: Active individuals have a lower incidence of diverticular complications. Regular exercise is associated with reduced diverticulitis and bleeding risk.
- Diet: A low-fiber, high-fat diet contributes to constipation and bowel strain, increasing risk.
- Obesity: Obesity promotes inflammation and alters gut microbiota.
4. Determine NSAID Use:
Regular aspirin or NSAID use is linked to a higher risk of diverticulitis and diverticular bleeding.
Physical Assessment
1. Monitor Temperature:
Fever (100.4°F/38.0°C or higher) is common in diverticulitis due to infection.
2. Abdominal Palpation:
Peritoneal irritation causes tenderness, particularly in the left lower quadrant. Palpable mass may indicate abscess formation. Bowel wall perforation may present with rigidity, guarding, and rebound tenderness.
3. Auscultate Bowel Sounds:
Bowel sounds may be normal or hypoactive.
4. Rectal Examination:
Assess rectal mucosa and check for rectal bleeding.
Diagnostic Procedures
1. Incidental Diverticulosis Discovery:
Diverticulosis is often found incidentally during routine colonoscopy or abdominal scans.
2. Stool Sample Analysis:
Rule out bacterial or parasitic infections as causes of symptoms.
3. Laboratory Tests Review:
- Complete Blood Count (CBC): Assess for leukocytosis (elevated WBC indicating infection) or low hemoglobin (indicating bleeding).
- C-Reactive Protein (CRP): Elevated CRP indicates inflammation.
4. Imaging Procedures:
- Computed Tomography (CT) Scans: Visualize inflamed or infected diverticula and assess severity.
- Barium Enema: Uses barium contrast to enhance X-ray visualization of the colon.
- Ultrasonography: Less sensitive than CT but can detect diverticulitis, though may miss large abscesses.
5. Colon Visualization:
- Colonoscopy: Confirms diagnosis and identifies inflammation extent. Recommended 6-8 weeks post-symptoms to rule out other conditions like cancer or inflammatory bowel disease.
- Sigmoidoscopy: Visualizes sigmoid colon and rectum.
Alt text: CT scan image illustrating diverticulitis, highlighting inflamed diverticula in the colon.
Nursing Interventions for Diverticulitis
Effective nursing interventions are crucial for patient recovery. The following outlines key nursing interventions for diverticulitis management.
Managing Inflammation
1. No Specific Treatment for Diverticulosis:
Asymptomatic diverticulosis typically requires no active treatment. Mild diverticulitis may be managed at home with bowel rest.
2. Inflammation Prevention:
Promote a high-fiber diet to prevent diverticulitis development. Encourage increased intake of fruits, vegetables, and whole grains to prevent constipation and bloating.
3. Bowel Rest:
Uncomplicated diverticulitis is often managed with bowel rest as an outpatient. Clear liquid diet for several days, gradually transitioning to solid foods as symptoms improve.
Assisting with Treatment
1. NPO Status:
Complicated diverticulitis necessitates complete bowel rest (NPO). Total Parenteral Nutrition (TPN) may be required for nutritional support.
2. Antibiotic Administration:
Oral antibiotics target gram-negative and anaerobic bacteria. Common regimens include quinolones (ciprofloxacin) or sulfa drugs (trimethoprim/sulfamethoxazole) combined with metronidazole or amoxicillin-clavulanate for 7-10 days. IV antibiotics are required for complicated cases like bowel perforation requiring hospitalization.
3. Surgical Preparation:
Complicated diverticulitis may lead to peritonitis, fistulas, or bowel perforation requiring surgery. Bowel resection is often laparoscopic, but severe cases may require colostomy creation.
4. Abscess Drainage Assistance:
Percutaneous drainage may be necessary for diverticulitis-related abscesses. This involves abdominal incision and catheter insertion to drain pus.
Preventing Recurrent Episodes
1. Dietary Modifications:
High-fiber diet to maintain soft stools. Emphasize fresh fruits, vegetables, whole grains, and beans. Reduce red meat intake.
2. Fluid Intake Encouragement:
Adequate water intake is crucial for fiber to soften stools.
3. Exercise and Weight Loss Education:
Overweight/obese patients are at higher risk of recurrence. Encourage exercise regimens to reduce BMI.
4. Smoking Cessation:
Smoking increases complicated diverticulitis risk and worsens outcomes.
5. Re-evaluation of Nut and Seed Avoidance:
Current research suggests avoiding nuts, seeds, and popcorn is not necessary for recurrence prevention.
6. Supplement Advice:
Fiber supplements (psyllium, Metamucil) can aid fiber intake. Probiotics may also be beneficial in preventing recurrences.
Alt text: Image depicting a high-fiber diet recommended for managing diverticulitis, featuring fruits, vegetables, and whole grains.
Nursing Care Plans and Nursing Diagnoses for Diverticulitis
Identifying appropriate nursing diagnoses is fundamental to developing effective nursing care plans for diverticulitis. These plans prioritize assessments and interventions for both short-term and long-term care goals. Here are examples of key nursing diagnoses for diverticulitis:
Acute Pain
Acute pain is a hallmark symptom of diverticulitis, often severe and sudden, though it can also be milder and gradually worsen. Typically located in the lower left abdomen, it’s described as sharp, constant, and may radiate to the back, side, groin, and legs.
Nursing Diagnosis: Acute Pain
Related to:
- Disease process
- Inflammatory process
As evidenced by:
- Diaphoresis
- Distraction behavior
- Reports of abdominal pain/tenderness
- Facial grimacing
- Guarding behavior
- Positioning to ease pain
- Protective behavior
Expected outcomes:
- Patient will report a significant reduction in pain, demonstrated by stable vital signs and absence of restlessness and guarding.
Assessment:
1. Pain Characteristics: Assess pain intensity, location, quality (sharp, constant), and radiation. Use pain scales. Identify aggravating and relieving factors.
2. Diagnostic Results: Review WBC count, ESR, CRP (elevated in diverticulitis). Assess CT scan findings confirming diverticulitis.
Interventions:
1. Medication Administration: Administer prescribed antibiotics for infection and analgesics for pain management.
2. Dietary Modifications: Provide clear liquid or soft diet as ordered to reduce bowel stimulation and inflammation.
3. Bed Rest: Encourage bed rest to minimize intra-abdominal pressure and pain. Advise against activities increasing intra-abdominal pressure (straining, heavy lifting).
4. Non-pharmacological Pain Relief: Implement distraction, music therapy, guided imagery, and relaxation techniques as adjuncts to medication.
5. Surgical Preparation: Prepare patient for potential surgical intervention and provide preoperative education.
Constipation
Constipation can be both a risk factor and symptom of diverticulitis. Low fiber intake leads to stool buildup, straining the colon and potentially contributing to diverticula formation and subsequent inflammation.
Nursing Diagnosis: Constipation
Related to:
- Blockage of the colon
- Insufficient fiber intake
- Insufficient fluid intake
- Inadequate toileting habits
- Altered routine
- Decreased physical activity
- Habitually suppresses the urge to defecate
As evidenced by:
- Straining with defecation
- Sensation of anorectal obstruction
- Sensation of incomplete evacuation
- Hard stools
- Need for manual stool evacuation
- Inability to defecate
- Rectal bleeding
Expected outcomes:
- Patient will report comfortable bowel movements without straining.
- Patient will achieve bowel movements at least every 3 days.
Assessment:
1. Dietary Intake: Assess fiber and fluid intake patterns.
2. Bowel Habits: Detailed assessment of defecation patterns, frequency, consistency, and associated symptoms.
Interventions:
1. Bowel Habit Diary: Encourage patient to maintain a bowel habit diary to track progress and identify patterns.
2. High-Fiber Diet Promotion: Educate on and provide high-fiber foods (fruits, vegetables, whole grains, beans).
3. Fluid Intake Optimization: Encourage at least 1.5 liters of fluid daily (unless contraindicated).
4. Physical Activity Encouragement: Promote physical activity as tolerated to stimulate peristalsis.
5. Bowel Training Education: Address proper bathroom habits, urge to defecate response, adequate time and privacy.
6. Stool Softeners/Laxatives: Consider use of stool softeners or laxatives as needed for chronic constipation.
Diarrhea
Paradoxically, diarrhea can also occur in diverticulitis due to inflammation and infection altering bowel motility.
Nursing Diagnosis: Diarrhea
Related to:
- Disease process
- Infectious process
- Inflammatory process
As evidenced by:
- Abdominal pain
- Abdominal cramping
- Bowel urgency
- Hyperactive bowel sounds
- Dehydration
Expected outcomes:
- Patient will achieve formed stools without urgency.
- Patient will verbalize strategies to prevent dehydration with diarrhea.
Assessment:
1. Defecation Pattern and Stool Characteristics: Detail onset, frequency, consistency, and associated symptoms (pain, bleeding).
2. Stool Tests: Evaluate stool for infection, parasites, toxins, and blood.
3. CT Scan Review: Confirm diagnosis, severity, and guide treatment.
4. Dehydration Monitoring: Assess for tachycardia, hypotension, dry mucous membranes, poor skin turgor.
Interventions:
1. Medication Administration: Administer antidiarrheals and antibiotics as prescribed.
2. Liquid Diet: Initiate liquid diet to rest the bowel. Gradually reintroduce solids as symptoms improve.
3. Dietary Education (High/Low Fiber): During diarrhea, reduce fiber. Reintroduce high-fiber diet post-diarrhea resolution.
4. Fluid and Electrolyte Monitoring: Strictly monitor intake, output, and electrolyte levels.
5. Fluid Replacement: Encourage oral or administer IV fluids to prevent dehydration.
Imbalanced Nutrition: Less Than Body Requirements
Nutritional imbalances are common in diverticulitis due to symptoms and dietary restrictions. Low fiber intake is a contributing factor to the disease itself.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Inability to absorb nutrients due to inflammatory response
- Inability to digest food
- Abdominal cramping
- Abdominal pain
- Constipation
- Diarrhea
- Food intake less than recommended daily allowance (RDA)
As evidenced by:
- Difficulty swallowing
- Insufficient dietary intake
- Inadequate fluid intake
- Poor appetite
- Inadequate knowledge of nutrient requirements
Expected outcomes:
- Patient will maintain stable weight and identify appropriate food choices for diverticulitis management.
Assessment:
1. Nutritional Habits: Detailed dietary history to identify deficiencies and contributing factors.
2. Laboratory Values: Monitor prealbumin and albumin levels for malnutrition and inflammation indicators.
3. Barriers to Nutrition: Assess financial, knowledge-based, or appetite-related barriers.
Interventions:
1. Parenteral Nutrition: Provide TPN for patients on NPO status with severe diverticulitis.
2. Symptom Management: Administer antiemetics and analgesics before meals to improve appetite.
3. Food Preference Identification: Identify patient food preferences to improve dietary adherence.
4. Nutritional Education: Educate on high-fiber diets and appropriate food choices.
5. Fiber Supplements: Consider fiber supplements (Metamucil) for dietary supplementation, but avoid during acute flares.
Ineffective Tissue Perfusion
Inflammation and potential complications like obstruction or perforation in diverticulitis can compromise tissue perfusion in the affected bowel segment.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Inflammatory process
- Fecal obstruction
- Abscess formation
- Fistula formation
As evidenced by:
- Abdominal tenderness
- Abdominal cramping
- Abdominal distension or bloating
- Constipation
- Decreased or absent bowel sounds
- Nausea and vomiting
Expected outcomes:
- Patient will experience reduced abdominal pain and swelling.
- Patient will remain free from gastrointestinal tissue perfusion complications (perforation, obstruction, peritonitis).
Assessment:
1. Elimination Patterns and Bowel Sounds: Monitor for constipation and hypoactive/absent bowel sounds.
2. Symptom Monitoring: Closely monitor for worsening symptoms (chills, fever, nausea, vomiting) indicating complications.
3. Abdominal Assessment: Assess for distension, tenderness, rebound tenderness, guarding, and signs of peritonitis.
Interventions:
1. Laboratory Monitoring: Monitor WBC count, CRP, hemoglobin, and hematocrit.
2. Vital Signs Monitoring: Frequent vital sign assessment for signs of shock or instability.
3. Medication Administration: Administer antibiotics, analgesics, and IV fluids as prescribed.
4. Bowel Rest Education: Reinforce importance of bowel rest to reduce inflammation.
5. Surgical Preparation: Prepare for emergency surgery if complications arise (peritonitis, perforation, obstruction).
Alt text: Image illustrating a nurse reviewing a nursing care plan document, representing the planning and management of diverticulitis care.
