On Thursday night February 25, 2010, DC, a 64 year old female Caucasian came to the emergency room complaining of chills, abdominal pain, vomiting x 2days and diarrhea x3days. DC is 5’6″ and weighs 239 pounds. She stated that after eating dinner on Tuesday night she began to feel abdominal pain that worsened and then developed vomiting and diarrhea. DC’s pain ranged from 5/10-10/10 and complained of tenderness over her entire abdomen, that was worse midline. DC has a left brachial cephalic A/V fistula that has a palpable thrill and a good bruit. Upon being admitted to the Emergency Department DC’s vital signs were BP 136/79, T 97.9, HR 101, R16 and O2 sat 95% on room air. DC’s lung sounds were clear to auscultation and she denied being short of breath. Blood urea nitrogen (BUN) and creatinine were both elevated. An x-ray and a CT scan both showed evidence of a small bowel obstruction with perforation with evidence of diverticular disease of the colon (see medical management for details). It was at this time that DC was transferred to E300.
Primary Diagnosis and Priority Secondary Diagnosis
The primary medical diagnosis is diverticulosis/diverticulitis, with a small bowel obstruction. The secondary diagnosis is chronic renal failure (CRF).
Patient History
DC has a history of hypertension, atrial fibrillation (AFib), end stage renal disease (ESRD), past peritoneal dialysis (2.5 years), and peritonitis. She has been on a Monday, Wednesday, Friday hemodialysis schedule for the past 2 years.
PATHOPHYSIOLOGY OF THE PRIMARY DIAGNOSIS AND PRIORITY SECONDARY DIAGNOSIS
Diverticula are pouch-like herniations of the mucosa through the muscular wall of the small intestine or colon. Diverticulosis is the presence of many diverticula in the wall of the intestine. Most people with diverticulosis have no symptoms and remain symptom free for a lifetime. Diverticulitis is used to describe when one or more of the diverticula become inflamed. Diverticula occur most commonly in the sigmoid colon, although they may occur in any part of the small or large intestine. The musculature of the colon hpertrophies, thicken and becomes rigid, and herniation occurs through the colon wall. Diverticula occur at points of weakness in the intestinal wall, where blood vessels interrupt muscular continuity. The muscle weakness develops as part of the aging process (Ignatavicius & Workman, 2006).
Diverticula usually cause few problems. If undigested food or bacteria become trapped in the diverticulum blood supply will diminish and bacteria invade the diverticulum. Diverticulitis occurs when the diverticulum perforates and a local absess forms (Ignatavicius & Workman, 2006).
Diets with small amounts of fiber have been linked to the development of diverticula due to the fact that they cause less bulky stool and constipation. However fiber is not proven to be a preventative measure (uptodate.com). Only one of five people with diverticulitis will actually display symptoms (Ignatavicius & Workman, 2006). Exactly how diverticula become inflamed is not clear. One theory is that increased pressure in the colon can lead to breakdown of the wall of the diverticula leading to infection. Another theory is the openings of the diverticula may trap fecal matter, which can lead to infection. Or, an obstruction in the narrow opening of the diverticulum may reduce blood flow to the area which may lead to inflammation. In the past, medical professionals thought that nuts, seeds, popcorn and corn played a role in causing diverticulitis. However, recent research has found that these foods aren’t associated with an increased risk of diverticulitis (mayoclinic.com).
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On physical examination of a client with diverticultis they have abdominal pain, most often in the lower left quadrant. The pain becomes progressively worse and steadier. Nausea and vomiting are also common. The abdomen may be distended and tenderness on palpation may be noted over the area involved (Ignatavicius & Workman, 2006). Complications associated with diverticulitis may include: an absess (collection of pus), fistula, obstruction (blockage of the colon), peritonitis, or sepsis (uptodate.com).
Intestinal obstructions can be partial or complete and are classified as mechanical or nonmechanical. A small bowel obstruction falls under mechanical obstruction. In mechanical obstruction the bowel is physically obstructed by a disorder outside of the intestine or by blockages in the lumen of the intestine (diverticulitis). The intestinal contents accumulate at or above the area of obstruction. The intestines cannot absorb and move the contents down the intestinal tract, resulting in intestinal distension. Peristalsis increases in an effort to move the intestinal contents forward. With the increase in peristalsis more secretions are stimulated leading to additional distention. This causes the bowel to swell with increased capillary permeability. Plasma leaking into the peritoneal cavity and fluid trapped in the intestinal lumen markedly decrease the absorption of fluid and electrolytes into the vascular space. Reduced circulatory blood volume and electrolyte imbalances typically occur. Hypovolemia may range from mild to extreme. Specific fluid and electrolyte problems result depending upon the location of the blockage (Ignatavicius & Workman, 2006).
Intestinal obstruction is a common and serious disorder caused by a variety of conditions. It can occur anywhere in the intestinal tract, although the ileum in the small intestine is the most common site. Mechanical obstruction can result from: adhesions, tumors, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis, or vascular disorders. In individuals age 65 or older, diverticulitis and tumors are the most common cause (Ignatavicius & Workman, 2006).
A client with a mechanical obstruction may present with mid-abdominal pain or cramping. Vomiting often accompanies obstruction and is often more profuse with obstructions in the small intestine. Diarrhea may be present in partial obstruction. Stool may be positive for blood. Bowel sounds may sound high pitched or be absent in later stages (Ignatavicius & Workman, 2006).
Chronic renal failure is a progressive, irreversible kidney injury. Kidney function will never recover. When kidney function is too poor to sustain life, chronic renal failure is termed end-stage renal disease. Excessive amounts of metabolic wastes such as urea and creatinine accumulate in the blood. The kidneys are unable to maintain homeostasis. Hypervolemia can occur owing to the inability of the kidneys to excrete sodium and water, or hypovolemia can occur owing to the inability of the kidneys to conserve sodium and water (Ignatavicius & Workman, 2006).
The causes of chronic renal failure are many and complex. Three main causes of ESRD are diabetes mellitus, hypertension, and glomerulonephritis (Ignatavicius & Workman, 2006).
Chronic renal failure cause changes in many body systems. Most manifestations are related to changes in fluid volume, electrolyte and acid-base imbalances, and buildup of nitrogenous wastes. Neurologic symptoms may include lethargy, decreased attention span, seizures, coma, slurred speech, asterixis, tremors, myoclonus, ataxia and parasthesias. Cardiovascular symptoms may include cardiomyopathy, hypertension, peripheral edema, heart failure, uremic pericarditis, pericardial effusion, pericardial friction rub and cardiac tamponade. Respiratory symptoms may include uremic halitosis, tachypnea, yawning, Kussmaul respirations, uremic pneumonitis, shortness of breath, pulmonary edema, pleural effusion, depresses cough reflex and crackles. Hematologic symptoms may include anemia, abnormal bleeding or bruising. Gastrointestinal symptoms may include anorexia, nausea, vomiting, metallic taste in mouth, changes in taste acuity and sensation, diarrhea, constipation, uremic gastritis, uremic fetor and stomatitis. Urinary symptoms may include polyuria, oliguria, anuria, proteinuria, hematuria, diluted and strawlike appearance. Integumentary symptoms may include decreased skin turgor, yellow-gray pallor, dry skin, pruritus, ecchymosis, purpura, soft-tissue calcifications and uremic frost. Musculoskeletal symptoms may include muscle weakness and cramping, bone pain, pathologic fractures and renal osteodystrophy.
Reproductive symptoms may include decreased fertility, infrequent or absent menses, decreased libido and impotence (Ignatavicius & Workman, 2006).
DC’s history of past peritoneal dialysis with a complication of peritonitis may have lead to the diverticula to become more susceptible to inflammation and infection. DC has had chronic renal failure for five years. The association of colonic diverticulitis with chronic renal failure is well known. Diverticulitis with chronic renal failure is common (1). With DC’s inability to get rid of waste products on her own, the accumulation of fluid and waste that build up before she has dialysis may lead to an increase in infection.
ACTUAL OR POTENTIAL IMPACT OF RELEVENT MEDICAL/SURGICAL HISTORY ON THE PRIMARY DIAGNOSIS AND PRIORITY SECONDAY DIAGNOSIS
DC’s history of hypertension is what leads to her chronic renal failure and atrial fibrillation. High blood pressure makes the heart work harder and over time can damage blood vessels throughout the body. If the blood vessels in the kidneys are damaged, they may stop removing wastes and extra fluid from the body (Ignatavicius & Workman, 2006). In most cases atrial fibrillation is secondary to other medical problems, i.e. her hypertension. Atrial fibrillation is an irregular heart rhythm that starts in the upper parts of the heart. The quivering upsets the normal rhythm between the atria and the ventricles of the heart. If afib is left uncontrolled it increases the risk of stroke. DC was on peritoneal dialysis for 2.5 years in which she developed peritonitis as a complication, twice. With a history or peritonitis she could have experienced some scarring in her intestine. When this happens the colon is unable to move the bowel contents out normally and a blockage may occur. With the blockage she experienced inflammation of the diverticula leading to her diverticulitis. The last time she recovered from peritonitis she under went the switch to hemodialysis.
MEDICAL MANAGEMENT: Diverticulitis
The books recommendation for non-surgical interventions for moderate to severe diverticulitis may require hospitalization. Clinical manifestations that require hospitalization are a temperature of >101 ‘F, persistent abdominal pain >3 days, or evidence of a lower GI bleed. A combination of drug and diet therapy with rest is recommended to reduce inflammation and improve tissue perfusion. In clients with mild diverticulitis antibiotics are given. Mild analgesics are given for pain. Do not give laxatives or enemas. Encourage bed rest and tell client to refrain from lifting, bending, straining, coughing, to avoid perforation of the diverticulum. Clients with more severe symptoms are kept nothing by mouth (NPO) and a nasogastic tube (NG) may be placed if persistent nausea, vomiting, or abdominal distension is severe. Administer IV fluids for hydration. When inflammation has stopped and bowel function returns to normal, fiber is introduced into the diet gradually (Ignatavicious & Workman, 2006).
The client with diverticulitis has an elevated white blood cell (WBC) count. Decreased hematocrit and hemoglobin values are found if chronic or severe bleeding is present. A flat plate film of the abdomen may reveal free air and fluid in the left lower quadrant, suggesting an abscess or free air under the diaphragm, indicating perforation. The health care provider may also order a computed tomography (CT) scan to diagnose an abscess or thickening of the bowel related to diverticulitis (Ignatavicious & Workman, 2006).
Actual medical management for DC included an x-ray of the abdomen. The x-ray findings were consistent with a small bowel obstruction. There were small amounts of free air found near the liver and a CT scan was ordered. The CT revealed evidence of an abscess that seemed in close association with one of the dilated small bowel loops and evidence of diverticular disease of the colon. A complete blood count (CBC) with BUN and creatinine was ordered. WBC of 9.0(N=4.8-10.8), RBC of 3.45 (N=3.6-5.4), hemoglobin of 11.5 (N=12-16), hematocrit of 32.7 (N=34-45), platelets of 164 (N=150-450), protime of 15 (N=9-12), BUN of 30 (N=7-18), and creatinine 7.8 (N=0.6-1.0). The elevation in the BUN and creatinine levels is consistent with DC’s history of chronic renal failure. Upon discharge her BUN was 21 and her creatinine was 7.4. All other labs were within normal limits. DC was scheduled for surgery, put on strict bed rest; her diet was nothing by mouth (NPO), vital signs every 4 hours, no blood pressures to the left arm, and normal saline at 100 cc per hour. Upon DC’s return from surgery her orders changed to up with assist post op day 1, remain NPO, D51/2 at 100cc/hr, morphine PCA to manage pain. DC’s pain ranged from 4-6/10 in her abdominal area after returning from surgery for 3 days. At which time her PCA was discontinued and she was managing pain with oral pain medication. By the end of DC’s stay her diet had advanced to a renal diet, she was up independently, vital signs every shift, pain level of 1/10 with no IV fluids running.
NURSING MANAGEMENT: Diverticulitis
The text book recommends nursing management for the patient with diverticulitis as: encourage bed rest, provide antibiotics and analgesics, do not give laxatives or enemas, teach to avoid straining and bending to avoid pressure in the abdomen, provide and teach about a low fiber diet, perform frequent abdominal assessments, and to check stools for occult or frank bleeding. If a colostomy has been performed, give the patient the opportunity to express their feelings about the ostomy. When the patient is ready encourage them to look at the ostomy and to begin learning how to care for it. Teach the patient about the importance of eating and preparing high fiber foods when they are at home. Teach incision and colostomy care and the importance of temporary limitations to activity (Ignatavicious & Workman, 2006).
DC’s abdomen and bowel sounds were inspected every shift and as needed. DC’s vital signs were monitored every 4 hours until the day before discharge. Her input and output was monitored closely. Since she had chronic renal failure and was on dialysis 3 times a week she rarely put out more than 20 cc of urine per day. DC’s activity was closely monitored and ranged from strict bed rest to being up independently. Her diet was strict NPO and then advanced to clears and finally to a renal diet. The colostomy nurse was in to teach DC about colostomy care and her stoma. She was taught about the importance of splintering her abdominal incision site when moving about or coughing. She was administered antibiotics and analgesics. Staples to her midline incision were covered with dry gauze and paper tape. Upon discharge she was taught about the importance of notifying her doctor if she had an increase in temperature, new onset of abdominal pain, any abnormal bleeding, or a change in colostomy drainage/color. DC was taught about the importance of increasing fiber in her diet and following a renal diet, although she stated that she “eats what she wants.”
PHARMACOLOGICAL MANAGEMENT: Diverticulitis
The text book recommends antibiotics such as metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (Bactrim, Septra) or ciprofloxacin (Cipro). An opiod analgesic may be given for pain such as morphine sulfate or meperdidine hydrochloride (Demerol). IV fluids are given to correct dehydration and to maintain proper hydration, while the patient remains NPO, and recovering from surgery (Ignatavicious & Workman, 2006).
Actual pharmacological interventions for DC included metronidazole (Flagyl) 500mg/100ml IV to be administered 3 times a day. Flagyl is an antibiotic. It is used as a perioperative prophylactic agent in colorectal surgery. She was also on morphine PCA. Morphine is a schedule II opiod analgesic. The PCA helped to control her pain but by post-op day 2 she was trying not to rely on it as much.
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SURGICAL MANAGEMENT: Diverticulitis
According to the book the patient with diverticulitis may need to undergo surgical management for any of the following complications: rupture of the diverticulum with subsequent peritonitis, pelvic absess, bowel obstruction, fistula, persistent fever or pain after 4 days of medical treatment, or uncontrolled bleeding. Colon resection with or without colostomy is the most common surgical procedure for patients with diverticular disease. Select patients may be candidates for colostomy closure and anastomosis after the bowel has had time to rest for 3 to 6 months. If a colostomy has been performed, a colostomy bag may be placed over the stoma. The stoma should be monitored for color and integrity. The stoma should be pink to cherry red without prolapse or retraction into the abdomen. If a colostomy is in place it should start to function within 2-4 days. Most patients who undergo surgery and colostomy formation for diverticulitis have a sigmoid colostomy because the sigmoid colon is the most common site for diverticulitis. A tight seal around the stoma is essential to avoid contact of feces with the skin. Discharge instructions vary according to the treatment provided (Ignatavicious & Workman, 2006).
Actual surgical intervention for CD was a laparatomy, sigmoid colectomy with end colostomy and Hartmann pouch. Indications for the operation were a 2 day history of abdominal pain, diffuse significant tenderness and the results of the CT scan. DC had expressed her feelings of sadness/anger of having the colostomy to the colostomy nurse. The colostomy nurse gave her a lot of education both verbally and written for her and her husband to review. By discharge DC’s stoma to the left abdomen was 1½ inches round, pink with edematous sutures intact to the mucocutanious junction. Peristernal skin intact with large formed soft brown stool in pouch.
PROVIDER AND MANAGER ROLE: NURSING CARE PLAN
Priority Nursing Diagnosis
“P” Acute pain
“R” Pain from inflammation of bowel/surgery
“C” 1. unrelieved pain > patient tolerance, pain ranging from 4-6/10
2. tender over entire abdominal area
3. need for PCA to administer pain relief
Priority Patient Goal
The patient will demonstrate lack of pain by discharge as evidenced by:
pt verbalized lack of pain.
abdominal pain and tenderness minimized
lack of parenteral medication for 24 hours before discharge
Three Priority Nursing Interventions
The nurse will administer pain medication
The nurse will help patient to reposition for comfort and teach patient how to splint incision site.
The nurse will teach the patient how to maintain pain levels before pain becomes unmanaged.
PROVIDER AND MANAGER ROLE
As a provider of care I administered antibiotic therapy as prescribed. I followed physician’s orders accordingly to ensure safe care of DC by frequently checking and implementing orders. I frequently assessed DC and made provisions according to her needs for rest. I changed DC’s abdominal bandages according to doctor’s orders once per shift.
Member of the Discipline and the Role of the Multi-Disciplinary Team
The primary physician and other consulting physicians were responsible for all medications. They ordered labs and diagnostic tests for DC. She had a surgeon, renal doctor and a colostomy nurse on consult during her stay. Her surgeon performed her sigmoid colectomy with end colostomy. The renal doctor was responsible for providing dialysis orders. The colostomy nurse gave DC and her husband patient education on colostomy care, what type of supplies they needed and even personal information regarding how to deal with new feelings associated with having a new colostomy. Pharmacy was responsible for the delivery of ordered medications. Food service was in charge of following through with the different diets that she had ordered. Runners provided her transportation to and from diagnostic testing and hemodialysis. The RN’s responsibilities included assessment, administering medications, implementing orders, teaching, notifying the Dr. of abnormal findings, and collaborating with other health care professionals to ensure safe care of the patient.
Manager of Care Role
As a Manager of Care, I reviewed the patients chart, Kardex, medication sheets and took written and oral report regarding my patient. I oversaw another student and was sure that not only had she performed her duties but they were done appropriately with the correct documentation made.
Growth in the Manager of Care Role
I have learned to look at the whole patient picture, not just what they are diagnosed with. History and predisposing conditions play a big part in why the patient is in the hospital. If I do not have a good understanding of my patient I really have the opportunity to miss something important. I have also realized how important it is to follow through with other members of the team regarding patient care. Even though I am only a student I have found that I need to speak up when I think something is wrong or has been missed. The worse I could be is wrong, but patient safety comes first. I have also learned to help others out and they are more likely to help you when you are in need.
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