Case of Diverticulitis:

In the emergency room, Mrs. Mary is with fever of 39.2 8C and dehydrated. Mrs. Mary is
admitted and started on intravenous (IV) fluid of D51/2 normal saline (NS) with 20 mEq of
potassium chloride (KCl) at 50 mL per hour. Vital signs are (BP) 110/60, PR 90 and RR of 24.
Her potassium level is 2.8 mEq/L, erythrocyte sedimentation rate (ESR) is 37 mm/hr, and white
blood cell (WBC) count is 17,000 cells/ mm3. Two IV antibiotics (cefoxitin sodium and
metronidazole) are prescribed. Urinalysis showed a positive urinary tract infection (UTI) and an
abdominal/pelvic computed tomography (CT) scan revealed diverticulitis with a question of an
ileus. Antibiotics (cefoxitin sodium and metronidazole) are prescribed. She is on nothing by
mouth (NPO), bed rest & IV morphine sulfate for pain management. Stools are still to be
checked for occult blood, strict intake and output (I & O), and repeat blood work in the morning
to monitor her K+. Her height and weight on admission are 5 feet 8 inches and 170 lbs (77.3 kg).
She is prescribed diphenoxylate hydrochloride with atropine sulphate and propantheline
bromide.

Questions
1. Differentiate diverticulitis differ from diverticulosis?
 Diverticulosis is the condition of having small pouches protruding from the wall of
the colon.
 If infection occurs, the condition is called diverticulitis. Diverticulitis is more serious
because infection can lead to other problems.
2. Describe the predisposing risk factors for diverticulitis. Identify any contributing
factors for the development of diverticulitis in Mrs. Mary’s case.
 Aging. The incidence of diverticulitis increases with age.
 Obesity. Being seriously overweight increases your odds of developing diverticulitis.
Morbid obesity may increase your risk of needing more-invasive treatments for
diverticulitis.
 Smoking. People who smoke cigarettes are more likely than nonsmokers to
experience diverticulitis.
 Lack of exercise. Vigorous exercise appears to lower your risk of diverticulitis.
 Diet high in animal fat and low in fiber, although the role of low fiber alone isn't
clear.
 Certain medications. Several drugs are associated with an increased risk of
diverticulitis, including steroids, opiates and nonsteroidal anti-inflammatory drugs,
such as ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve).
3. The emergency department health care provider also considered that Mrs. Mary’s
symptoms could be indicative of a diagnosis of gastroenteritis. Briefly describe the
clinical features of gastroenteritis and diverticulitis.
Gastroenteritis, on the other hand, attacks your intestines, causing signs and symptoms, such as:
 Watery, usually nonbloody diarrhea — bloody diarrhea usually means you have a
different, more severe infection
  Abdominal cramps and pain
 Nausea, vomiting or both
 Occasional muscle aches or headache
 Low-grade fever
The signs and symptoms of diverticulitis include:
 Pain, which may be constant and persist for several days. Pain is usually felt in the lower
left side of the abdomen, but may occur on the right, especially in people of Asian
descent.
 Nausea and vomiting.
 Fever.
 Abdominal tenderness.
 Constipation or, less commonly, diarrhea.
4. Explain how Mrs. Marys symptoms might be related to her urinary tract infection.
Urinary tract infections don't always cause signs and symptoms, but when they do they may
include:
 A strong, persistent urge to urinate
 A burning sensation when urinating
 Passing frequent, small amounts of urine
 Urine that appears cloudy
 Urine that appears red, bright pink or cola-colored — a sign of blood in the urine
 Strong-smelling urine
 Pelvic pain, in women — especially in the center of the pelvis and around the area of the
pubic bone
5. The emergency department health care provider considered several differential
diagnoses for Mrs. Mary and a diagnosis of diverticulitis was determined. What
diagnostic test confirmed Mrs. Mary’s diagnosis of acute diverticulitis?
After that, your doctor will likely recommend:
 Blood and urine tests, to check for signs of infection.
 Pregnancy test for women of childbearing age, to rule out pregnancy as a cause of
abdominal pain.
 Liver function tests, to rule out other causes of abdominal pain.
 Stool test, to rule out infection in people who have diarrhea.
 CT scan, which can indicate inflamed or infected pouches and confirm a diagnosis of
diverticulitis. CT can also indicate the severity of diverticulitis and guide treatment.
6. Mrs. Mary’s abdominal/pelvic CT scan revealed diverticulitis with a question of an
ileus. What is an ileus? What are the symptoms associated with ileus?
 Ileus is the medical term for this lack of movement somewhere in the intestines that leads
to a buildup and potential blockage of food material. An ileus can lead to an intestinal
obstruction. This means no food material, gas, or liquids can get through. It can occur as
a side effect after surgery. However, there are other causes of this condition.
  An ileus can cause extreme abdominal discomfort. Symptoms associated with ileus
include:
o abdominal cramping
o appetite loss
o feeling of fullness
o constipation
o inability to pass gas
o stomach swelling
o nausea
o vomiting, especially vomiting stool-like contents
7. Briefly explain why a barium enema, sigmoidoscopy, and colonoscopy are not
considered appropriate diagnostic tests for a client with suspected acute diverticulitis.
 barium enema is not performed in the acute setting due to the risk of perforation and
peritonitis, even though several studies have shown it is safe if there are no clinical signs
of perforation
 Colonoscopy and Sigmoidoscopy makes it possible to determine the cause of abdominal
complaints and is the suitable method for lower gastrointestinal bleeding or to rule out a
tumor. Colonoscopy is not required to diagnose acute diverticulitis.
8. Discuss the medical management for a client with acute diverticulitis.
 One typical oral antibiotic regimen is a combination of ciprofloxacin (or trimethoprim-
sulfamethoxazole) and metronidazole. Moxifloxacin is appropriate monotherapy for
outpatient treatment of uncomplicated diverticulitis. Amoxicillin/clavulanic acid
monotherapy is acceptable as well.
 Patients should be instructed to be on a clear liquid diet only and can advance the diet
slowly as tolerated after clinical improvement, which usually occurs within 2-3 days.
9. The admitting health care provider explains to Mr. and Mrs. Mary that some clients
require surgery. If conservative treatment does not resolve the acute episode of
diverticulitis. What are the indications for surgical intervention?
The classic surgical indications include some features characteristic of Hinchey stage III or IV
disease and are as follows:
 Free-air perforation with fecal peritonitis
 Suppurative peritonitis secondary to a ruptured abscess
 Uncontrolled sepsis
 Abdominal or pelvic abscess (unless CT-guided aspiration is possible)
 Fistula formation
 Inability to rule out carcinoma
 Intestinal obstruction
 Failing medical therapy
 Immunocompromised status
 Extremes of age
10. Discuss the rationale for including prn orders for diphenoxylate hydrochloride with
atropine sulphate & propantheline bromide in Mrs. Mary’s treatment plan.
  Atropine/diphenoxylate is an antidiarrheal and anticholinergic combination. It works by
decreasing the motion of muscles in the intestines and prolonging the time it takes to
move the contents through the body.
11. When collaborating with Mrs. Mary to develop at least (3) plan of care, outcome
goals including nursing intervention?
Acute Pain related to inflamed bowel as evidenced by patient rates pain at 8/10 on pain
scale and states abdominal cramping and tenderness in abdomen.
Desired outcomes:
Patient will report a decrease in pain from 8 to 0 on the pain scale by discharge.

Interventions Rationals
Assess level of pain using appropriate pain Using an appropriate age pain rating scale will
scale. Assess pain 30 minutes before and after help the healthcare providers monitor the level
pain medication is given. of pain and adjust pain medications as needed.
Administer pain medications as prescribed and Analgesics are helpful in relieving pain and
indicated. helping in the recovery process.
Check for number of bowel movements at least Immobility caused by pain may decrease the
once per shift. parasympathetic stimulation to the bowel.
Incorporate nonpharmacologic measures to Ideally, the use of comfort measures will
assist with control of pain. distract the patient from pain and may increase
the effectiveness of pharmacological measures.

Risk for infection

Desired outcomes:
By discharge, the patient will remain free signs and symptoms of infection.

Interventions
Assess vital signs including temperature every
4 hours and as needed. Report any abnormal
findings to the healthcare provider.
Assess mental status and level of
consciousnesses every 4-6 hours.
Report and note any abnormal laboratory
values (i.e. elevated WBC count) to the
healthcare provider.
Rationals
Fever is often one of the first signs of
infection.
Mental status changes, confusion, or any
deterioration from baseline can signify
infection.
Certain abnormal laboratory results could be
an indicator of infection

Risk for deficient fluid volume related to inflammation

The nurses plan and implement the following nursing interventions for Mrs. Ukoha.

• Assess comfort status frequently, providing analgesics as needed.

• Maintain intravenous infusion as prescribed.

• Measure intake and output; weigh daily.

• Provide mouth care every 2 to 4 hours until oral intake resumes, then every 4 hours until client
assumes self-care.

• Measure temperature every 4 hours.

• Advance diet from clear liquids to low-residue diet when allowed.

• Provide instruction and dietary consultation for high-fiber diet