1. Diverticulosis: a diverticulum is a small pouch or sac composed of mucous membrane that has protruded through the muscular wall of the intestine. The presence of several of these is called diverticulosis. Inflammation of the diverticula is called diverticulosis.
    1. Pathophysiology: weakening in a localized area of muscular wall of the colon (especially the sigmoid colon), accompanied by increased intraluminal pressure.
    2. Risk factors:
      1. Diverticulosis:
        1. Age: seldom before 35 yr; 60% incidence in older adults.
        2. History of constipation.
        3. Diet history: low in vegetable fiber, high in carbohydrate.
      2. Diverticulitis: highest incidence between ages 50 and 60 yr.
    3. Assessment:
      1. Subjective data: pain: cramplike; left lower quadrant of abdomen.
      2. Objective data:
        1. Constipation or diarrhea, flatulence.
        2. Fever.
        3. Rectal bleeding.
        4. Diagnostic procedures:
          1. Palpation reveals tender colonic mass.
          2. Barium enema (done only in absence of inflammation) reveals presence of diverticula.
          3. Sigmoidoscopy/colonoscopy.
    4. Analysis/nursing diagnosis:
      1. Constipation related to dietary intake.
      2. Pain related to inflammatory process of intestines.
      3. Risk for fluid volume deficit related to episodes of diarrhea or bleeding.
      4. Risk for injury related to bleeding.
      5. Knowledge deficit related to prevention of constipation.
    5. Nursing care plan/implementation:
      1. Goal: bowel rest during acute episodes.
        1. Diet: soft, liquid.
          1. Antibiotics: ciprofloxacin (Cipro), metronidazole (Flagyl), cephalexin (Keflex), doxycycline (Vibramycin).
          2. Antispasmodics: chlordiazepoxide (Librax), dicyclomine (Bentyl), Donnatal, hyoscyamine (Levsin).
        2. Fluids, IVs if oral intake not adequate.
        3. Medications:
        4. Monitor stools for signs of bleeding.
      2. Goal: promote normal bowel elimination.
        1. Diet: bland, high in vegetable fiber if no inflammation.
          1. Include: fruits, vegetables, wholegrain cereal, unprocessed bran.
          2. Avoid: foods difficult to digest (corn, nuts).
        2. Bulk-forming agents as ordered: methylcellulose, psyllium.
        3. Monitor: abdominal distention, acute bowel symptoms.
      3. Goal: health teaching.
        1. Methods to avoid constipation.
        2. Foods to include/avoid in diet.
        3. Relaxation techniques.
        4. Signs and symptoms of complications of chronic inflammation: abscess, obstruction, fistulas, perforation, or hemorrhage.
    6. Evaluation/outcome criteria:
      1. Inflammation decreases.
      2. Bowel movements return to normal.
      3. Pain decreases.
      4. No perforation, fistulas, or abscesses noted.

  2. Ulcerative colitis: inflammation of mucosa and submucosa of the large intestine. Inflammation leads to ulceration with bleeding. Involved areas are continuous. Disease is characterized by remissions and exacerbations.
    1. Pathophysiology: Currently believed to be an autoimmune disease. The body’s immune system is called on to attack the inner lining of the large intestine, causing inflammation and ulceration. Edema and hyperemia of colonic mucous membrane superficial bleeding with increased peristalsis, shallow ulcerations, abscesses; bowel wall thins and shortens and becomes at risk for perforation. Increased rate of flow of liquid ileal contents —» decreased water absorption and diarrhea.
    2. Risk factors:
      1. Highest occurrence in young adults (age 20-40 yr).
      2. Genetic predisposition: higher in Caucasians, Jews.
      3. Autoimmune response.
      4. Infections.
      5. More common in urban areas (upper-middle incomes and higher educational levels).
      6. Nonsmokers/ex-smokers.
      7. Genetic, inherited, or familial tendencies.
      8. Chronic ulcerative colitis is a risk factor for colon cancer.
    3. Assessment:
      1. Subjective data:
        1. Urgency to defecate, particularly when standing.
        2. Loss of appetite, nausea.
        3. Colic-like abdominal pain.
        4. History of intolerance to dairy products,
        5. Emotional depression.
      2. Objective data:
        1. Diarrhea: 10-20 stools/day; can be chronic or intermittent, episodic or continual; stools contain blood, mucus, and pus.
        2. Weight loss and malnutrition, dehydration,
        3. Fever.
        4. Rectal bleeding.
        5. Lab data: decreased: RBC, potassium, sodium, calcium, bicarbonate related to excessive diarrhea.
        6. Lymphadenitis.
        7. Diagnostic tests:
          1. Sigmoidoscopy/colonoscopy for visualization of lesions.
          2. Barium enema.
    4. Analysis/nursing diagnosis:
      1. Diarrhea related to increased flow rate of ileal contents.
      2. Self-esteem disturbance related to progression of disease and increased number and odor of stools.
      3. Pain related to inflammatory process.
      4. Fluid volume deficit related to frequent episodes of diarrhea.
      5. Knowledge deficit related to methods to control symptoms.
      6. Social isolation related to continual diarrhea episodes.
    5. Nursing care plan/implementation:
      1. Goal: prevent disease progression and complications.
        1. Administer medications:
          1. Salicylates: sulfasalazine (Azulfidine), olsalazine (Dipentum), mesalamine (Asacol, Pentasa). All given PO in high doses. Mesalamine (Rowasa) is given in enema or suppository form.
          2. Corticosteroids: prednisone, PO or IV. Hydrocortisone (Cortenema) is given by enema.
          3. Immunosuppressants: azathioprine (Imuran), and 6-mercaptopurone (Purinethol), cyclosporine (Sandimmune), and methotrexate (Rheumatrex).
          4. Nicotine.
          5. Sedatives and tranquilizers to produce rest and comfort.
          6. Absorbents: kaolin/pectin (Koapectate).
          7. Anticholinergics and antispasmotics to relieve cramping and diarrhea: atropine sulfate, phenobarbital, diphenoxylate/atropine sulfate (Lomotil).
          8. Anti-infective agents to relieve bacterial overgrowth in bowel and limit secondary infections: metronidazole (Flagyl).
          9. Potassium supplements to relieve deficiencies related to excessive diarrhea.
          10. Calcium folate and vitamin Bl2 when malabsorption is present.
      2. Goal: reduce psychological stress.
        1. Provide quiet environment.
        2. Encourage verbalization of concerns.
      3. Goal: health teaching.
        1. Diet:
          1. Avoid: coarse-residue, high-fiber foods, e.g., raw fruits and vegetables, whole milk, cold beverages (because of inflammation).
          2. Include: bland, /iig/i-protein, highvitamin, hig/i-mineral, /ííg/i-calorie foods.
          3. Parenteral hyperalimentation for severely ill.
          4. Force fluids by mouth.
        2. Monitor for colon cancer, especially 8-10 years after incidence.
      4. Goal: prepare for surgery if medical regimen unsuccessful.
        1. Possible surgical procedures:
          1. Permanent ileostomy.
          2. Continent ileostomy (Kock pouch).
          3. Total colectomy, anastomosis with rectum.
          4. Total colectomy, anastomosis with anal sphincter.
    6. Evaluation/outcome criteria:
      1. Fluid balance is obtained and maintained.
      2. Alterations in lifestyle are managed.
      3. Stress-management techniques are successful.
      4. Complications such as fistulas, obstruction, perforation, and peritonitis are avoided.
      5. Patient is prepared for surgery if medical regimen is unsuccessful or complications develop.