Diverticulitis is a common condition in the United States, though its prevalence is growing worldwide. In the developed world, greater than 65% of adults over the age of 65 have some form of diverticular disease (McGarry, 2011). Although the condition is extremely common, severe complications requiring surgery occur in approximately 1% of patients overall (McGarry, 2011). Diverticulitis is a condition that can be acute or chronic with many different treatment and management methods as well as different considerations with each treatment option.
The traditional treatments available are surgery (in extreme cases), antibiotic therapy (in most cases, in addition to other treatments), and lifestyle changes (mostly surrounding diet). The following will discuss the etiology, pathophysiology, signs, symptoms, and treatments of Diverticulitis. Diverticulitis is typically seen in white adults over the age of 65. Certain considerations must be taken into account when adapting a plan of care for aged patients; thus the responsibilities of care and education for a diverticulitis patient from a nursing standpoint will also be included.
There are many organizations and agencies to assist with patient education, treatment, and management. Discussion Diverticulitis is a condition in which diverticula found in the colon become inflamed. Diverticula are small pockets that form along the inside of the colon; when asymptomatic, this is referred to as diverticulosis (Venes, 2005). Although diverticulosis is present in approximately two thirds of the elderly population, the majority of patients will remain completely asymptomatic (McGarry, 2011).
Pain, anorexia, vomiting, constipation or diarrhea, urge to void or defecate more than normal, bloody bowel movements, bloating, gas, and fever are all characteristic of diverticulitis (Truven, 2012); in severe cases patients will present with intestinal perforation, hemorrhage, abscess formation, peritonitis, and fistula formation. In extreme cases, death can occur. The pathogenesis of diverticulitis is uncertain, though it is widely agreed that a stasis or obstruction in the narrow neck of the diverticulum leads to overgrowth of the pathogens and local tissue ischemia (McGarry, 2011).
The overgrowth of these pathogens commonly results in infection and inflammation resulting in Diverticulitis. A problem that occurs when trying to discern the pathophysiology or etiology of diverticulitis is the number of factors effecting the progression of the disease. While all illnesses should be viewed on a patient by patient case, it is traditional that the cause is one of a few common factors or a combination of these.
“The pathophysiology of diverticular disease is extremely complicated because of the multifactorial contributing factors, including diet, colonic wall structure, intestinal motility, and possible genetic predispositions” (Tursi, 2012). “The etiology of diverticulosis is poorly understood, but it is probably a multi-factorial process involving dietary habits (specifically low fiber intake) as well as changes in colonic pressure, motility, and wall structure that are associated with ageing” (McGarry, 2011).
Acute Diverticulitis presents much like appendicitis, though the symptoms are usually located in the lower left quadrant rather than the lower right quadrant; inflammation of the peritoneum, formation of an abscess. In untreated patients, intestinal gangrene accompanied by perforation can occur. Chronic Diverticulitis can cause thickening of the bowel walls which may produce stricture formation and chronic intestinal obstruction. It is marked by mucous in the stool and intermittent lower left quadrant pain. Cases of diverticulitis are further broken down into complicated and uncomplicated.
Complicated is characterized by patients with abscesses, perforation, fistula formation, or obstruction. In cases of complicated diverticulitis surgery is the most common treatment recommendation, though aggressive intravenous antibiotic therapy can ease the attack. Uncomplicated diverticulitis responds well to antibiotic treatment, usually oral, though occasionally intravenous in extreme cases (McCafferty, Roth, & Jorden 2008). Surgery is not typically necessary in the case of uncomplicated diverticulitis, though it is typically recommended after the second attack.
With continued attacks over long periods of time, the disease could become complicated. A computer tomography (CT) scan, is the typical procedure done to look for the presence of diverticulitis (Tursi, 2012), though a patient with diverticulosis found during a routine colonoscopy will be monitored as high risk for developing diverticulitis. In the case of early risk detection, the patient education should begin. Primary prevention techniques including lifestyle change education and symptom detection, though this will be further discussed later.
There are three major treatments that are employed based on the individual patient and the severity of the condition. The first and least invasive is the promotion of lifestyle changes, in regards to diet. The effectiveness of this common suggestion is currently under study with inconclusive results. Despite this, a high fiber diet is still often recommended, and avoiding the ingestion of nuts and seeds (Tursi, 2012). Antibiotic therapy is typically employed in both cases of diverticulitis.
Because of the potential involvement of microbial imbalance due to contaminants stuck in the diverticulum, a single broad-spectrum antibiotic is typically given. Rifaximin, a poorly absorbed, broad-spectrum, oral antibiotic that has activity against gram-positive, gram-negative, aerobic, and anaerobic bacteria, is typically administered to treat uncomplicated diverticulitis (Tursi, 2012). “According to guidelines by the American Society of Colon and Rectal Surgeons and others, elective resection should be considered after 1 or 2 well-documented episodes of diverticulitis” (Tursi 2012).
This recommendation of course varies patient to patient based on the severity of the attack, age, and medical fitness of the patient. The majority of patients with diverticulitis are over the age of 65. The dangers of anesthesia at that age and older only grows. The patient may not be a suitable candidate for surgery because of this complication. Surgery is not always a permanent solution. Diverticulitis recurs in many patients despite surgical treatments. Symptoms persist in 25% of patients following sigmoid resection (Tursi, 2012). New therapeutic approaches are being investigated,
including mesalamine and probiotics. Probiotics show promise in treating the disease, though there is not yet enough data to gather definitive conclusions (Tursi, 2012. ) Education Needs of Client from a Nursing Perspective There are many things the patient will need to learn to successfully manage their diverticulitis. The first would be the signs and symptoms of infection. In patients with diverticulosis, the easiest way to tell something is wrong is by recognizing the signs, abdominal pain, anorexia, and fever. Diet control is a good point to educate on as a preventative measure.
A high fiber diet will help things pass through the bowels and prevent stasis or obstructions from occurring. After an attack solid foods should be avoided to rest the bowels. The patient will also need to know about the chronicity of their condition and the progression of the disease (complicated or uncomplicated). They should be educated on the different tests that may need to be performed to confirm a diagnosis as well as the treatment options available to them. It is important to discuss the risks of anesthesia with elderly patients.
The importance of taking antibiotics exactly as prescribed and that feeling better does not mean that they can be discontinued taking the prescription (Truven, 2012). Contact a primary caregiver if any of the following occur: pain upon urination, symptoms worsen or persist; or questions arise about the condition, treatment, or care. Contact emergency services if any of the following occur: severe diarrhea that does not improve, constipation or urinary retention, cramps or abdominal pain in conjunction with fever, new or increased blood in stool, and foul-smelling discharge from the vagina during defecation (women only)(Truven, 2012).
Age is primary consideration when it comes to education of diverticulitis in any area. Certain options may not be available to patients based on their age, such as surgery under anesthesia. Is the patient familiar with technology? What is their transportation situation? What is their level of consciousness? What are their home life and their family situation like? Do they work? What is their culture and spirituality? Are they able to care for themselves? Allergies, comorbidities, chronic health conditions or disease processes.
Anything that can have an effect on the current condition is a potential road block or teaching necessity. The patient’s compliance with treatment should also be gauged to evaluate the necessity for continued teaching. The best way to test a patient’s understanding and education level is to ask them questions and have them redemonstrate information. Community Agency There are many community centers and colleges that offer free, short classes on nutrition and health maintenance across the US. One such local is the organization is the Nutrition & Dining – Stay Fit Dining program.
This is a program thought the Erie County Department of Senior Servicers. Their goal is to provide healthy and nutritious meals to senior citizens while offering a sense of community, a safe place for socialization, and free wellness counseling and education. This service is open only to those of 60 years or older. There is a recommended donation of $3. 50, though they will never deny a meal to someone unable to contribute. The wellness counseling includes free nutrition education and free nutrition counseling.
The latter specifically beneficial in that it is a private individualized consultation with registered dieticians. They also offer a senior fitness exercise program, stressing the importance of staying active though within reason to one’s limits. The meals are at noon Monday through Friday at over forty locations, advance reservations are required. For more information about locations or to make reservations, please visit http://www2. erie. gov/seniorservices/index. php? q=nutrition-amp-dining-stay-fit-dining-program. They also offer home meal delivery programs and grocery services.
Nursing Journal and Journal Articles “Diverticulitis, from Truven Analytics Inc. at CareNotes is a short and concise article geared to the Diverticulitis patient. It is devoid of medical jargon and lays out all of the necessities for a basic understanding of the disease process. The etiology, pathophysiology, signs, symptoms, tests they may undergo, medication or treatments they may be give, risks, and emergency conditions. The best part is it gives the why of each, something that makes it more relatable to the reader.
“Advances in the management of colonic diverticulitis,” by Antonio Tursi is a great article for reading up on treatments and the risk factors, benefits, and downsides of those treatments. It is very informative and requires a mid-level of medical knowledge to understand. Published in September of 2012, the article provides the most current information giving an up-to-date understanding of the disease process. “Latest diagnosis and management of diverticulitis,” by Phillip McGarry et al. is useful in understanding the disease process of diverticulitis itself.
It requires a solid grasp of medical understand as it is peppered with jargon and demands an understanding of underlying concepts. It also contains and interesting section on outpatient versus inpatient treatment. It stresses that, though inpatient treatment is sometimes necessary and highly effective, outpatient treatment has huge merits and should be utilized whenever possible. This will keep the patient independent and return them to their comfortable home rather than have them holed up in a hospital.
“Current Management of Diverticulitis”, by Michael McCafferty et al. is over all a well-rounded view of diverticulitis, though it is not for a novice reader. An entry from the journal, The American Surgeon, it is written with the surgeon in mind and the jargon reflects that. Conclusion Diverticulitis, with the right education, support, and health maintenance, is a manageable disease.
The simplest way to control diverticulitis is to control one’s diet. A high fiber diet will increase bowel motility, reducing the risk of stasis and blockage. In the event of an attack, antibiotics are a suitable treatment and an alternative to invasive surgery.
The most interesting lesson to be taken away from this discussion on diverticulitis is how specific each illness is to the patient that has it. Unlike in the case of many other disease processes that share many of the causes and effects, diverticulitis is heavily influenced by the patient. Their age, genetics, culture, lifestyle choices, comorbidities, acute or chronic disease processes, body type, activity level, and diet all have a profound effect on the development of diverticulitis and the progression of it.
Diverticulosis is a process that occurs over a long period, a lifetime of wear and tear on the body. That life and genetic predispositions will change each experience for each individual patient, an important factor to remember in the healthcare field. The existence of an organization such as the Nutrition & Dining – Stay Fit Dining Program is a gift to be cherished. Many people do not seek out healthcare because of the cost and stress of what that cost will incur. Offering a safe place for seniors to gather, enjoy a meal, and gain much needed health information is a phenomenal achievement.
Clients can speak to volunteers who know about health issues specific to their age group. This is a service that should be kept near to the heart of the city and never be allowed to die. References McCafferty, M. H. , Roth, L. , & Jorden, J. (2008). Current management of diverticulitis. The American Surgeon, 74(11), 1041-1049. Retrieved from http://search. proquest. com/docview/212820430? accountid=10753 McGarry, P. , et al. (2011). Latest diagnosis and management of diverticulitis.
British Journal of Medical Practitioners, 4(4), 26. Retrieved from http://go. galegroup.com/ps/i. do? id=GALE%7CA277875462&v=2. 1&u=erieccn_main&it=r&p=HIRCA&sw=w Truven Health Analytics Inc. (2012).
Diverticulitis. CareNotes. Retrieved from http://go. galegroup. com/ps/i. do? id=GALE%7CA294901796&v=2. 1&u=erieccn_main&it =r&p=HRCA&sw=w Tursi, A. (2012). Advances in the management of colonic diverticulitis. Canadian Medical Association, 184(13), 1470-1476. Retrieved from htps://search. porquest. com/docviw/1069228258? accountid-10753 Venes, D. (2005). Taber’s cyclopedic medical dictionary. (21 ed. , pp. 676-677). Philadelphia: F. A. Davis Company.