Diverticular disease: Nursing

Diverticular disease is a condition characterized by the formation of diverticula, which are small pouch-like protrusions that form along the walls of a hollow structure, most commonly, the large intestine.

Having multiple diverticula in the colon is called diverticulosis. And if one or more of these diverticula become inflamed, that’s called diverticulitis.Now, let’s zoom into the wall of the intestine, which is made up of four layers.

The outermost layer is called serosa or adventitia. Next is the muscular layer, which contracts to move food through the bowel.

After that is the submucosa, which consists of a dense layer of tissue that contains blood vessels, lymphatics, and nerves.

And finally, there’s the inner lining of the intestine called the mucosa; which surrounds the lumen of the gastrointestinal tract and comes into direct contact with digested food.Now, there isn’t a single cause of diverticular disease, but rather it’s a multifactorial disease, meaning that there’s a combination of genetic predisposition and environmental risk factors.

These include age over 40 years old, consuming a diet low in fiber and high in fatty foods or red meat, being obese, and having a sedentary lifestyle.

Other risk factors include smoking, alcohol use, and taking certain medications, like NSAIDs.All right, now, regardless of the cause, there’s an increase in the pressure inside the colon.

This pressure pushes on the mucosa and submucosa until they bubble out through weak spots along the wall, like where a blood vessel penetrates the muscle layer of the intestine.

These blood vessels can get weaker and rupture, leading to gastrointestinal bleeding. In addition, bacteria and undigested food may get stuck inside these protrusions, and cause infection within the intestinal wall.

Diverticulitis can in turn lead to serious complications, including bowel obstruction, as well as the formation of an abscess, which is a pocket of infected pus.

Some clients may develop fistulae, which are abnormal connections with an adjacent organ or structure. In other cases, if the diverticula becomes distended enough, it may rupture and cause peritonitis.Now, the clinical manifestations of diverticular disease will depend on the severity of the disease.

Most of the time, clients won’t even know they have diverticulosis until the diverticula become inflamed, leading to an acute episode of diverticulitis.

At this point, they may present with abdominal pain, which typically localizes in the lower left quadrant of the abdomen; fever, along with nausea and vomiting; a change in bowel habits, like alternating constipation and diarrhea; as well as painless hematochezia, which means bright red or maroon blood passing from the rectum.

Moreover, if the acute episode of diverticulitis does not completely resolve, it may become chronic.Diagnosis of diverticulosis is typically made incidentally during a routine colonoscopy or a CT scan that might be done for another reason entirely.

On the other hand, the diagnosis of diverticulitis starts with history and physical assessment, followed by a CT scan of the abdomen and pelvis.

A complete blood count might also be performed, typically showing leukocytosis, along with elevated inflammatory markers like CRP.

Although there’s no cure for diverticular disease, certain treatment options can be used to help mitigate some of the symptoms, improve the client’s quality of life, and prevent complications.

This involves lifestyle modifications, like maintaining a balanced, high fiber diet, and increasing fluid intake. In severe cases of gastrointestinal bleeding, surgical intervention might be required, like coagulation therapy and surgical clips, which are applied to the bleeding artery in order to seal it.

Now, clients with mild diverticulitis that isn't associated with systemic signs like fever, are typically managed with analgesics, or oral antibiotics.

On the other hand, for severe diverticulitis with systemic signs like fever, as well as for clients that are immunocompromised, intravenous fluids and intravenous antibiotics might be administered.

Finally, surgical intervention is required for clients who develop serious complications.All right, now let’s look at the nursing care you’ll be providing for a client with diverticular disease.

Priority goals of care are to improve gastrointestinal function, monitor for complications, and provide supportive care.

Begin by placing your client on bed rest, instituting NPO status, and administering the ordered IV fluids, antibiotics, and analgesics.

If your client has nausea and vomiting and is diagnosed with a bowel obstruction, insert a nasogastric tube attached to low suction.

Next, review their most recent laboratory test results and assess their vital signs. Immediately report signs of severe diverticular bleeding to the healthcare provider, such as decreased hematocrit or hemoglobin, or tachycardia, or hypotension.

Then, send blood to the lab for type and crossmatch in the event their hemoglobin drops below 7g/dL and they need a blood transfusion; and prepare your client for a diagnostic colonoscopy, as ordered.

Additionally, auscultate your client’s bowel sounds and then gently palpate their abdomen. Immediately report to the healthcare provider if you assess signs of peritonitis, including diminished or absent bowel sounds, distension, and rebound tenderness, and prepare your client for emergent surgical intervention, as ordered.Now, if your client is diagnosed with an abscess, administer the prescribed antibiotics, and prepare your client for percutaneous drainage, as ordered.

On the other hand, if a fistula is diagnosed, prepare your client for surgical resection of the bowel. Finally, as you care for a client with diverticular disease, continue to provide supportive care by advancing their diet to clear liquids and soft food, as tolerated, as well as providing comfort measures and analgesics as needed, and closely monitoring for complications.

All right, let’s move on to client and family teaching. First, provide an explanation of the disorder and how it causes the symptoms they are experiencing.

Let them know that they can manage their disease by increasing the amount of fiber in their diet, by including foods like apples, bananas, prunes, green leafy vegetables, legumes, and whole grains; as well as choosing foods low in fat; decreasing their meat consumption; increasing their fluid intake to at least 2 liters daily, and avoiding alcohol.

Let them know that nuts and seeds are good sources of fiber, and are safe to eat with their condition. Also instruct them to take the prescribed fiber supplement as directed, but to avoid the use of laxatives or enemas.

Recommend regular physical activity, as tolerated, as well as maintenance of a healthy weight. Lastly, remind them to avoid heavy lifting, straining or bending, as these are activities that increase intra-abdominal pressure, which can worsen the condition.Now, if your client experiences mild abdominal pain, instruct them to contact their healthcare provider right away; as well as to use a heating pad set low on their belly for comfort; and to switch to a clear liquid diet that includes broth, fruit juices without pulp, carbonated drinks, and gelatin.

Lastly, instruct them to immediately seek medical attention if they develop symptoms like severe abdominal pain, fever, blood in their stool, and an inability to tolerate fluids.All right, as a quick recap… Diverticular disease is a condition in which multiple pouch-like protrusions called diverticula develop along the colon.

Having multiple diverticula in the colon is called diverticulosis; and if one or more of these diverticula become inflamed, that’s called diverticulitis.

Risk factors include low fiber diet, obesity, alcohol use, smoking, being over age 40, and having a sedentary lifestyle.

Symptoms include abdominal pain, usually in the lower left quadrant of the abdomen; fever, along with nausea, vomiting; a change in bowel habits, as well as painless hematochezia.

Complications include diverticular bleeding, abscess formation, obstruction, peritonitis, and fistula formation. Diagnosis is based on history and physical assessment; followed by an abdominal CT scan; and laboratory test results that may show leukocytosis and elevated CRP.

Treatment depends on the severity of the disease, and can include bowel rest, fluids, antibiotics, and surgical intervention.

The priority goals of nursing care are to improve gastrointestinal function, monitor for complications, and provide supportive care.

Client and family teaching is focused on lifestyle modifications to manage the disease and when to contact their healthcare provider.

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