Adult Medical- Surgical Nursing

1. Adult Medical- Surgical Nursing Gastro-intestinal Module: Diverticular Disease: (Diverticulosis/ Diverticulitis)

2. Diverticular Disease: Incidence and Aetiology • A condition of the colon, often affecting the sigmoid • Mostly found in the elderly • Associated with a low fibre diet, dehydration, constipation and straining to defaecate • The elderly often present with diverticulitis, inflammation and infection of the colon

3. Diverticular Disease: Pathophysiology • With straining to defaecate, the submucosal and mucosal layers of the colon herniate through the muscle forming pockets (diverticulosis) • The pockets can trap faecal matter and become inflamed (diverticulitis) • Local inflammation → bowel irritability/ spasticity • Abscesses may form, which may: • Perforate → peritonitis (acute abdomen) or • Erode a blood vessel (haemorrhage and malaena) • Healing causes fibrosis and strictures, increasing constipation and risk of sub-acute or acute obstruction

4. Diverticulosis: Clinical Manifestations • Left-sided lower abdominal pain • Nausea/ anorexia • Low grade fever • Abdominal distension • Constipation • Weight loss/ malnutrition

5. Diverticulitis: Clinical Manifestations • Acute, severe pain in the left lower abdomen • Fever (may lead to septicaemia: hyperpyrexia and rigors) • Constipation (may be silent bowel: no bowel sounds) • If perforation, symptoms of peritonitis (shock) • Rectal bleeding and malaena

6. Diverticular Disease: Medical Treatment • Rest the bowel while inflamed (clear fluids) • → once settled, a high fibre, low fat diet • Antibiotic course • Bulk-forming laxative (Fybogel) • Anti-spasmodic (Probanthin, Buscopan) • Pain relief (avoid codeine as constipating) • Stool-softening agent when hard, or glycerin suppositories

7. Diverticulitis: Emergency Treatment • 25% of patients with diverticulitis require immediate surgical intervention for an “acute abdomen”: perforation, abscess, peritonitis, haemorrhage, obstruction • Antibiotic cover • Surgical resection with end-to-end anastamosis • Resection with double-barrel colostomy and later anastamosis • If sub-acute, antibiotics and elective “cold” surgery may be required later

8. Diverticular Disease: Nursing Considerations • Patient teaching about diet, exercise and bowel habit • If surgery required: pre- and post-operative nursing of a patient undergoing bowel resection • Colostomy care and patient education: • Observe stoma is healthy (active, red & shiny) • Care of colostomy and surrounding skin • Management of diet with colostomy

9. Diverticular Disease: Bowel Resection Pre-operative Care • Emergency operation: • General physical check-up, chest Xray, ECG • Blood profile, IVI, group and cross-match (GXM) • Breathing exercises to prepare for post-op • Thrombo-embolism stockings/ prophylactic heparin • Explanation of operation and possible stoma, consent and emotional support • Nil orally pre-op

10. Bowel Resection: Post-operative Care • Regular pain relief • Monitor vital signs, pulse oximetry, IV fluids, urine output and fluid balance • Semi-sitting position once recovered • Breathing and leg exercises. Early ambulation • Low molecular dose heparin. IV antibiotics • Nil by mouth (NPO) initially→ graduated intake (mouth care) • Nasogastric tube aspirations, wound, drain care, stoma care