Diverticular disease (diverticulosis and diverticulitis) is a group of conditions associated with diverticula (bulging pouches) in the colon. Diverticulosis is the presence of multiple pouches in the colon and is often asymptomatic.
Diverticulitis is when these diverticula become inflamed or infected, causing symptoms. While diverticula may occur anywhere in the gastrointestinal tract, it is most common in the descending sigmoid colon, where there are weak points in the intestinal walls.
In this article:
Nursing Process
The goal of treatment in diverticulitis is to let the colon rest until the inflammation resolves. While some patients can be managed at home with oral antibiotics, analgesics, bed rest, and a clear liquid diet, hospitalization is required for those with severe symptoms.
Surgery may be indicated for those patients with recurring diverticulitis or complications. Surgical intervention often involves the resection of the involved colon with a primary anastomosis. If this is not possible, the patient will have a temporary diverting colostomy. Once the colon heals, the colostomy will be removed and the colons will be reconnected.
Patient education is important for the management of diverticulitis. Nurses should provide patients with accurate information about their condition as well as dietary and fluid requirements. Proper understanding of the disease process and adherence to the treatment plan will prevent complications and exacerbation.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to diverticulitis.
Review of Health History
1. Ask about the patient’s general symptoms.
Diverticulosis typically has no bothersome symptoms. However, some patients report the following signs that are common with other gastrointestinal (GI) disorders:
- Abdominal cramps
- Tenderness over the affected site
- Swelling or bloating
- Difficulty passing stool (constipation)
Symptoms of diverticulitis include the following:
- Acute abdominal pain
- Distention
- Decreased or absent bowel sounds
- Nausea and vomiting
- Chills
- Constipation
- Rectal bleeding
2. Investigate any changes in bowel habits.
A change in bowel habits (such as a change in frequency) may accompany abdominal pain. Patients may also have nausea and vomiting, which could be caused by bowel obstruction.
3. Determine the risk factors.
- Non-modifiable risk factors
- Ethnicity: In Western populations, diverticulosis is highly prevalent.
- Age: Diverticular disease is common in people over age 40, and the rate increases with age.
- Modifiable risk factors
- Smoking: Smoking increases the risk for diverticulitis due to decreased mucus production in the colon caused by tobacco use.
- Physical inactivity: Diverticular disease complications are not prevalent in physically active people. Regular exercise is also linked to a significantly lower risk of diverticulitis and diverticular bleeding.
- Diet: Diverticulosis and diverticulitis can result from a low-fiber, high-fat diet that causes bowel strain and constipation.
- Obesity: Obesity triggers the inflammatory response and is associated with alterations in gut microbiota.
4. Determine the use of NSAIDs.
A higher risk of diverticulitis and diverticular bleeding was linked to regular use of aspirin or NSAIDs.
Physical Assessment
1. Monitor the temperature.
Diverticulitis causes a fever of 100.4 F (38.0 C) or above due to the infectious process.
2. Palpate the abdomen.
The irritation of the peritoneum usually results in sensitivity to palpation over the area of inflammation. Diverticulitis manifests as more intense abdominal pain, particularly in the left lower quadrant. Patients may feel a mass if an abscess is present. With bowel wall perforation, patients may have symptoms such as rigidity, guarding, and rebound pain.
3. Auscultate the bowel sounds.
Normal or hypoactive bowel sounds are both possible upon auscultation.
4. Perform a rectal examination.
A rectal examination can determine abnormalities of the rectal mucosa. Check for any rectal bleeding in diverticulitis.
Diagnostic Procedures
1. Diverticulosis may be discovered randomly.
Diverticulosis may be diagnosed through a routine colonoscopy or abdominal scan, as it usually does not cause symptoms on its own.
2. Obtain stool samples for testing.
A stool sample is examined to rule out abnormal bacteria or parasites as potential sources of the infection, abdominal pain, blood in the stool, diarrhea, or other symptoms.
3. Review laboratory tests.
Blood tests include:
- Complete blood count to assess for signs of infection, such as leukocytosis (an elevated WBC) or bleeding causing a low hemoglobin level.
- C-reactive protein (CRP) may reveal an increased inflammatory response.
4. Assist the patient in imaging procedures.
Imaging scans visualize the bowel for inflammation or complications.
- Computed tomography (CT) scans reflect inflamed or infected diverticula and their severity.
- Barium enema requires injecting barium that makes the colon visible on X-rays.
- Ultrasonography is inferior to CT scans, though it can still diagnose diverticulitis but may not visualize large abscesses.
5. Visualize the colon.
- Colonoscopy confirms the diagnosis by exposing the locations of inflammation throughout the colon. A colonoscopy is advised six to eight weeks after the symptoms have subsided to rule out cancer, inflammatory bowel disease, or colitis.
- Sigmoidoscopy visualizes the sigmoid colon (common site for diverticula) and rectum.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with diverticulitis.
Manage the Inflammation
1. Expect no specific treatment for diverticulosis.
Diverticulosis is usually asymptomatic and does not call for treatment. New guidelines state that mild cases of diverticulitis may only require bowel rest at home.
2. Prevent inflammation.
Patients should consume a fiber-rich diet as a preventative precaution since diverticulosis may result in diverticulitis. Consuming more fruits, vegetables, and grains will help prevent constipation and bloating.
3. Rest the bowel.
Uncomplicated diverticulitis can often be treated on an outpatient basis with bowel rest. Patients are placed on a clear liquid diet for several days and can gradually transition back to solid foods once symptoms improve.
Assist With Treatment
1. Keep the patient NPO.
Complicated diverticulitis requires complete bowel rest. The patient may need total parenteral nutrition (TPN) to support nutrition while they are NPO.
2. Administer antibiotics as prescribed.
Gram-negative and anaerobic bacteria are treated by oral antibiotic therapy. Quinolones (ciprofloxacin) or sulfa medications (trimethoprim/sulfamethoxazole) are frequently combined with metronidazole or amoxicillin-clavulanate as a single agent for 7 to 10 days. For patients with complications such as bowel perforation, admission to the hospital is needed to receive intravenous antibiotics.
3. Prepare for surgery.
Complicated diverticulitis may cause peritonitis, fistulas, or bowel perforation that require immediate surgery. Bowel resections are commonly performed laparoscopically, but severe cases of inflammation may result in the creation of a stoma with a colostomy.
4. Assist with draining abscesses.
Diverticulitis may cause pockets of pus (abscesses) in the intestines. These are drained through percutaneous drainage, where an incision is made in the abdomen, and a catheter is tunneled into the abscess to drain the infectious pus.
Prevent Recurrent Episodes
1. Diet modifications.
A high-fiber diet is recommended to keep the stool soft so it passes easily through the intestines. High-fiber foods include fresh fruits and vegetables, whole grain pasta and bread, and beans. The patient should reduce their intake of red meat.
2. Encourage water and fluids.
Fiber absorbs water as it passes through the colon and helps the stool stay soft.
3. Educate on exercise and weight loss.
Overweight and obese patients are at higher risk of recurrent and complicated diverticulitis. Help the patient plan an exercise regimen to reduce their body mass index.
4. Do not smoke.
Smoking is associated with higher rates of complicated diverticulitis with worse outcomes.
5. Avoiding nuts and seeds is no longer advised.
Recent research shows that avoiding nuts, seeds, or popcorn is not useful as previously thought to reduce the risk of recurrent diverticulitis.
6. Advise on supplements.
Fiber supplements like psyllium or Metamucil can aid patients who struggle with getting enough fiber from their diet. Probiotic supplements may also prove beneficial in preventing recurrences.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for diverticulitis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for diverticulitis.
Acute Pain
Acute pain in diverticulitis is typically severe and occurs suddenly. However, it may be mild and worsen over several days. It usually occurs on the lower left side of the abdomen and is described as sharp and constant, radiating 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 verbalize a significant reduction of pain as evidenced by stable vital signs and absence of restlessness and guarding behavior.
Assessment:
1. Assess pain characteristics, intensity, and location.
Pain in diverticulitis is described as sharp, constant, and sudden, usually to the lower left quadrant of the abdomen. Ask the patient to rate their pain and identify any precipitating or relieving factors.
2. Assess results of diagnostic imaging and laboratory studies.
Patients with diverticulitis will have elevated white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) in their laboratory results. CT scan of the abdomen and pelvis with oral contrast will identify diverticulitis.
Interventions:
1. Administer medications as needed.
Antibiotics are prescribed for an infectious process while pain medications will treat the acute pain symptoms.
2. Provide a clear liquid or soft diet as indicated.
If the patient is not NPO, provide a clear liquid diet or soft diet to enable the bowels to rest and reduce inflammation.
3. Encourage bed rest.
Increased intraabdominal pressure can aggravate pain. Avoid activities that can increase intraabdominal pressure like vomiting, bending, wearing tight clothing, heavy lifting, and straining with bowel movements.
4. Provide nonpharmacological pain relief.
Nonpharmacologic pain relief includes distraction, music therapy, imagery, and relaxation. Such techniques can be used to complement the pharmacological treatment of pain.
5. Prepare for surgical intervention as indicated.
Surgical intervention may be indicated to improve the symptoms of diverticulitis. Prepare the patient preoperatively by providing patient education.
Constipation
Constipation is one of the symptoms of diverticulitis. Low fiber intake causes the buildup of waste in the colon leading to constipation. Constipation places extra strain and pressure on the colon, creating small pouches, or diverticula, in weakened areas. Infection and inflammation in these small pockets occur when stool or bacteria gets caught in these diverticula.
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
- A sensation of anorectal obstruction
- A sensation of incomplete evacuation
- Hard stools
- Need for manual stool evacuation
- Inability to defecate
- Rectal bleeding
Expected outcomes:
- Patient will report passing stool without straining.
- Patient will report at least one bowel movement every 3 days.
Assessment:
1. Assess the patient’s fiber and fluid intake.
Inadequate nutritional intake can contribute to the development of constipation. Understanding the patient’s normal nutritional intake can help address the patient’s nutritional needs.
2. Assess the patient’s bowel habits.
Assessing the patient’s defecation patterns will help determine the extent of the problem. This will help the nurse plan appropriate interventions and monitor outcomes.
Interventions:
1. Encourage the patient to keep a diary of their bowel habits.
A diary of bowel habits should include time, length of time in the toilet, consistency, amount and frequency of stool, and straining. This information can help the patient and healthcare team monitor progress.
2. Encourage the patient to eat a high-fiber diet.
Provide patients with high-fiber foods to prevent constipation: apples, pears, peas, beans, potatoes, whole grains, bran cereal, and nuts.
3. Encourage adequate fluid intake.
Encourage the patient to drink at least 1.5 liters per day (unless contraindicated). Water intake promotes the formation of soft stools and makes them easier to pass.
4. Encourage physical activity as tolerated.
Physical activity stimulates peristalsis in the colon and encourages the movement of feces for elimination.
5. Educate on bowel training.
Poor bathroom habits can cause constipation. Ensure the patient is not suppressing the urge to defecate. The patient should be provided with adequate time and privacy to complete defecation.
6. Consider stool softeners or laxatives.
Chronic constipation may require the use of stool softeners or laxatives to prevent worsening diverticulitis.
Diarrhea
The inflammatory and infectious process in diverticulitis may cause a change in bowel movements, like diarrhea, along with fever, abdominal pain, and tenderness.
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 exhibit formed stools without experiencing bowel urgency.
- Patient will verbalize two strategies to prevent dehydration with diarrhea.
Assessment:
1. Assess the patient’s pattern of defecation and stool characteristics.
Diverticulitis can be associated with constipation and diarrhea. Changes in bowel habits, rectal bleeding, and abdominal pain or cramping should be investigated further.
2. Evaluate stool tests.
Diarrhea should be assessed for the presence of parasites, infection, toxins, and blood to guide treatment.
3. Assess CT scan results.
A CT scan is often indicated to help identify inflamed and infected diverticula and confirm the diagnosis, determine the severity of the condition, and help guide treatment.
4. Monitor for symptoms of dehydration.
Diarrhea can quickly cause dehydration if lost fluids are not replaced. Assess for tachycardia, hypotension, dry mucous membranes, and poor skin turgor.
Interventions:
1. Administer medications as ordered.
Antidiarrheals and antibiotics are indicated to help treat patients with signs of infection and symptoms of diarrhea related to diverticulitis.
2. Place the patient on a liquid diet.
A liquid diet is often prescribed for a few days to help the bowel rest, recover, and heal. Once the signs and symptoms of diverticulitis have improved, solid foods may be gradually added to the patient’s diet.
3. Instruct on high-fiber and low-fiber diets.
When experiencing diarrhea, fiber should be decreased so stools don’t pass as quickly through the GI tract. Once diarrhea resolves, the patient can resume a high-fiber diet to prevent constipation and inflammation common with diverticulitis.
4. Monitor the patient’s fluid and electrolytes.
Since diarrhea can cause dehydration and electrolyte imbalances, strict monitoring of the patient’s intake and output, fluid status, and electrolyte levels is essential.
5. Encourage PO or IV fluid intake.
The patient with diverticulitis may be on strict NPO status. If so, administer IV fluids to support hydration.
Imbalanced Nutrition: Less Than Body Requirements
Nutrition is a priority consideration in the treatment and prevention of diverticulitis. Diverticulitis is associated with low fiber intake. Addressing poor nutritional intake in patients with diverticulosis will improve outcomes.
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 an average weight and identify food choices appropriate for diverticulitis.
Assessment:
1. Assess the patient’s nutritional habits.
Assessing the patient’s nutritional intake can help to identify causative factors and develop an appropriate approach to the management of the condition.
2. Assess laboratory values.
A decrease in prealbumin and albumin may indicate an inflammatory response and acute malnutrition.
3. Assess for barriers to acquiring adequate nutrition.
Barriers to acquiring adequate nutrition may include financial barriers, lack of interest, or inadequate knowledge. Assessing these factors can help determine the best approach to provide adequate nutrition to the patient.
Interventions:
1. Provide parenteral nutrition as indicated.
Patients with severe diverticulitis are often placed on NPO status. To ensure adequate nutrition, parenteral nutrition is provided.
2. Administer antiemetics and pain medications as indicated.
Diverticulitis occurs with pain and nausea resulting in a decrease in appetite. Providing medications before meals can help improve the patient’s appetite.
3. Identify food preferences.
It’s important when educating on dietary changes to first discuss which foods the patient prefers and will eat to increase adherence.
4. Educate the patient about proper nutrition.
Diverticulitis is associated with low fiber intake. It is important to educate the patient about the importance of following a high-fiber diet by including foods the patient has identified they will eat.
5. Consider fiber supplements.
Fiber supplements such as metamucil can supplement diets. Fiber supplements should not be consumed during a flare of diverticulitis as it could worsen symptoms.
Ineffective Tissue Perfusion
Diverticulitis occurs when diverticula in the gastrointestinal tract become inflamed or infected. Inflammation can cause obstruction or bowel perforation, compromising perfusion.
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 not experience severe abdominal pain or swelling.
- Patient will remain free from gastrointestinal tissue perfusion complications like intestinal perforation, obstruction, and peritonitis.
Assessment:
1. Assess the patient’s elimination patterns and bowel sounds.
Diverticulitis often causes decreased or absent bowel sounds and constipation due to intestinal inflammation.
2. Closely monitor signs and symptoms.
Changes in symptoms, particularly chills, fever, nausea, and vomiting, may signal a worsening condition and the progression of complications like peritonitis.
3. Assess the patient’s abdomen.
Diverticulitis is associated with abdominal distension, where the patient often reports tenderness over the affected area. If complications like peritoneal irritation or peritonitis are present, additional symptoms like localized muscle spasm, rebound tenderness, guarded movement, sepsis, and hypotension can occur.
Interventions:
1. Monitor laboratory studies.
The WBC count is often elevated in patients with diverticulitis due to intestinal infection. C-reactive protein levels will be elevated with inflammation. If bleeding is present, there is decreased hemoglobin and hematocrit.
2. Monitor the patient’s vital signs.
Vital signs must be monitored as this can indicate developing perfusion complications like bleeding, perforation, peritonitis, and shock. Hypovolemia and hypotension are present in patients experiencing diverticulitis complications that may result in shock.
3. Administer antibiotics, analgesics, and IV fluids.
A combination of drug therapy can help decrease infection and inflammation associated with diverticulitis, preserve hemodynamic stability, and provide pain relief.
4. Educate on bowel rest.
Complicated diverticulitis requires complete bowel rest. The nurse can increase adherence by explaining that bowel rest will reduce intestinal inflammation.
5. Prepare for surgery.
Serious complications like peritonitis, perforation, or obstruction require immediate intervention to prevent sepsis and preserve intestinal perfusion and function.
References
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