I. INTRODUCTION Diverticulitis is a common digestive disease particularly found in the large intestine.

Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed. Patients often present with the classic triad of left lower quadrant pain, fever, and leukocytosis (an elevation of the white cell count in blood tests). Patients may also complain of nausea or diarrhea; others may be constipated.Less commonly, an individual with diverticulitis may present with right-sided abdominal pain. This may be due to the less prevalent right-sided diverticula or a very redundant sigmoid colon. The most common symptom of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, then nausea, vomiting, fever, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications. Diverticulitis may worsen throughout the first day, as it starts as small pains and/or diarrhea, and may slowly turn into vomiting and sharp pains. The researchers chose this case to understand the disease because it is quiet rare and new to our hearing. Therefore, it is researchers goal to increase their knowledge and awareness of this disease, so that the researchers will be better equipped with clinical 1

competencies in dealing with patients afflicted with the aforementioned disease condition.

Statistics Frequency United States Asymptomatic diverticulosis is a common condition. The incidence of diverticulosis increases with age, from less than 5% before age 40 years to greater than 65% by age 85 years. Diverticulitis appears to be more common in patients with the largest number of diverticula; 15-20% of those with diverticulosis develop diverticulitis. While diverticulitis is generally considered a disease of the elderly population, as many as 20% of patients with diverticulitis are younger than 50 years. International Diverticulosis occurs more frequently in Western countries and industrialized societies. As it is less common in underdeveloped countries, diverticulitis is also less common. The reason is unclear but presumably secondary to lifestyle and dietary factors. In fact, after adopting a more Western lifestyle, the prevalence of diverticulosis has increased in Japan. For unclear reasons, right-sided disease is more common in Asian people, accounting for as many as 75% of cases of diverticulitis in that group.

Mortality/Morbidity Of patients with diverticulosis, 80-85% remain asymptomatic. Approximately 5% develop diverticulitis; 15-25% of those with diverticulitis develop complications leading to surgery. These complications include abscess formation, intestinal rupture, peritonitis, and fistula formation.

Diverticulitis may be a more severe illness in patients who are immunocompromised, in patients with significant comorbid conditions, and in those taking anti-inflammatory medications.

Patients with diverticulitis who are managed conservatively (ie, do not receive surgery) have a recurrence rate of 20-35%.

In one study of 252 patients, a recurrence rate of 50% was reported after 7 years. The rate of surgery in these patients was 8% at 7 years and rose to 14% by 13 years. Recurrence rates after surgical resection range from 1-3%. The mortality rate from complications in patients with recurrent disease in this small study was 1%.

Another study of 337 patients hospitalized for complicated diverticulitis revealed an association of perforation and mortality in those with no prior history of diverticulitis. Of these patients with complicated diverticulitis, 53% presented on a first event.

These morbidity and mortality data, as well as recurrence rates, are based on a retrospective review of relatively short-term data. Race Genetics are believed to play a role, in addition to dietary factors. Left-sided diverticula predominate in the United States. Asians, including Asian Americans, have a predominance of right-sided diverticula. Sex Prevalence is similar in men and women. Age Diverticular disease increases in incidence with age, reaching a prevalence of greater than 65% in those older than 85 years. The mean age at presentation with diverticulitis appears to be about 60 years. Nurse-Centered Objectives At the end of the study, student nurses shall have: COGNITIVE Identified possible causes and risk factors that may have contributed to the occurrence of the disease process. 3

 Described the signs and symptoms of Diverticulosis, and its short-term and long-term complications. Recognized the nursing diagnoses and laboratory procedures in accordance to the synthesis of the disease process. PSYCHOMOTOR Performed review of patients chart to gather pertinent information, necessary for individualized care. Conducted nursing history taking and assessment to aid in the comprehension of the disease condition. Formulated significant nursing diagnoses and SOAPIEs to assist client for treatment and recuperation. Implemented nursing interventions and evaluated the outcomes of the said actions Applied therapeutic techniques of communication with the client and significant others. AFFECTIVE Displayed proper knowledge, skills, and attitude in the provision of effective and efficient nursing care. Exhibited proper ethics and positive attitude towards patients condition, needs, and demands.

II. NURSING ASSESSMENT 1. Personal History a. Demographic Data Mrs. Colon, a 65-year old female was born on January 1, 1946. She is a pure Filipino and a Catholic by religion. Married and was blessed with three kids, 2 boys and a girl. Their family is currently residing at Angeles City, Pampanga.

b. Socio-Economic and Cultural Factors Mrs. Colons family is composed of five members. She had her college degree in education in the year 1967. She works as a teacher in Kuwait. She speaks Tagalog and Kapampangan since she is a native of Pampanga.

Mrs. Colon loves to eat fruits, vegetables and fruits. But because she is currently working Kuwait her appetite was lessened and she would rather do some work or sleep than to eat. When it comes to his health practices, she said that she often self medicate. When she had severe abdominal pain and blood in the stool that was the time that her coteachers in Kuwait brought her to the hospital last 2009. She also doesnt believe in quack doctors or albularyo. Upon waking up at around 5:00 in the morning in Kuwait, she would prepare for going to school. According to her she usually neglect eating lunch especially when there is a lot of work to do like checking papers and would only drink coffee. After 5

work she would directly go home to her apartment. After resting refreshing for a while she would start doing her lesson plans for the next day. Then at around 7:00 in the evening she would only preheat her left-over food from the last evening. After eating she usually watches TV until 10:00.

b. Existing Diseases in the Family Mrs. Colon has a family history of her grandmother on the maternal side had an operation on the intestine and her grandfather on the same side was an alcoholic and both grandparents from the paternal side died out of old age. Her fathers youngest brother has hypertension. While the youngest sibling of her mother has asthma and the eldest sibling died of heart attack. Her father died in a heart attack and her mother died of old age.

3. History of Past Illness WHAT TX WAS GIVEN TO THE PT WHEN SHE WAS IN KUWAIT According to Mrs. Colon, she was admitted in a hospital in Kuwait due to abdominal pain and blood in the stool, and she acquired German measles, chicken fox, cough, colds during her childhood. 4. History of Present Illness HYPERTENSION? Few hours prior to admission Mrs. Colon complained of severe pain on the left side of her abdomen. She was admitted on August 21, 2011, at 12:46PM. According to her there was also blood in her stool whenever she goes to the CR.

KUWAIT LIFE- DISCUSS HER DIET, ACTIVITIES, AND LIFESTYLE, HEALTH PRACTICES *CHECK YOUR GRAMMAR!!!!

a. Hereditary Diseases in the Family Paternal Side Maternal Side

GRANDPA

GRANDMA

GRANDPA

GRANDMA

Alcoholic

ELDEST CHILD
rd

2nd CHILD

ELDEST CHILD

ND

CHILD (MOTHER)

4th CHILD

3 CHILD (FATHER)

3 CHILD

RD

Female Male
Mrs. Colon

Asthma Heart Attack/ heart problem Hypertension Complications Brought by Old Age GI operation BE SPECIFIC 8

f. Physical Examination (IPPA-Cephalocaudal Approach)

Initial Assessment by the student nurses on August 26, 2011 Vital signs taken as follows: Blood pressure: 120/70 mmHg Temperature: 37.2 C Pulse rate: 79 bpm Respiratory rate: 20pm

General Appearance: Upon initial contact, the student nurses received the patient on bed. The patient was wearing a blue cotton sun dress. When she was asked with questions, the patient was quite restless and irritable due to pain, however she is oriented with the place, time and date. HOW SHE ANSWER YOUR QUESTIONS IF SHE IS NOT FEELING WELL! ANY OTHER SOURCES ASIDE FROM THE PT??? Skin Pale complexion Dry skin but not scaly Cold and clammy Short and clean nails

Hair and Scalp Black short hair with streaks of white Evenly hair distributed No infestations, lesions and inflammation noted Fine in texture No masses or tenderness noted Fine hair and slightly oily

Nails Pinkish nail bed No brittleness or cracking Capillary refill of >3 seconds No lesions

Head and Face Rounded skull shape Smooth skull contour Symmetrical eyebrows Symmetrical nasolabial folds No mass, swelling or tenderness noted

Eyes General- symmetrical; absence of discharges Eyebrows- hair growth evenly distributed Eyelashes- equally distributed Sclera- anicteric sclerae Pupils- black in color; equal in size; PERRLA *HEAD AND FACE

Ears Symmetrical No lesions, masses and tenderness noted

Nose and Sinuses No deformities and tenderness noted Aligned nasal septum

Mouth and Throat Lips- slightly pale in color Gums- pink in color; no discharge or swelling 10

Tongue- in midline; pink in color; moist; tongue have thin white coating Palates and uvula- pink in color; absence of swelling; uvula positioned at the midline of soft palate Throat- no soreness or inflammation

Neck No stiffness, tenderness or lumps noted

Breast and axillae No pain, tenderness, swelling noted No nipple discharge No masses or lumps noted

Chest No lumps or masses noted (-) crackles (-) wheezes

Abdomen Protuberant in contour Auscultated 6 BS per min (Active)

Extremities Even color of skin in all extremities Palpable and equal pulses

g. Diagnostic and Laboratory Procedures

11

Diagnostic and Laboratory Procedure Procedure Date Indication (Hematology) ordered and purpose

Results and date

Normal values

Analysis and interpretation The result is within normal range

Hemoglobin

August 21, 2011

August 22, 2011

To determine 13.0 the amount of hemoglobin in a person's 12.5 red blood cells (RBCs) Refers to the 'percentage' of one's red blood cells.

(12.0 - 16.0 g/dL)

Hematocrit August 21, 2011

August 22, 2011

To determine 40.7 how much oxygen your body tissues get depends on how many 38.7 RBCs you have and how well they work. 4.45

(36.0 47.0%)

The result is within normal range

RBC August 21, 2011

To help monitor the bodys response to various treatments and to monitor bone marrow function.

( 4.20 - 5.40 X 10 12/L)

The result is within the normal range

12

WBC August 21, 2011

To diagnose allergy, drug reactions, Parasitic infections, collagen disease, Hodgkins disease, Myeloproliferative diseases.

5.83

( 4.6 -10.6 X 10 9/L)

The result is within normal range

Eosinophils August 21, 2011 2.0

(0 - 7%)

The result is within normal range

Neutrophils August 21, 2011

63.7

(40 - 74%)

The result is within normal range

Basophils August 21, 2011 Lymphocyte August 21, 2011 Platelet ct August 21, 2011 0.3 (0-2%)

The result is within normal range The result is within normal range The result is within normal range

29.3

(19 - 48%)

To determine 223 the number of platelets in a given volume of blood.

(150 - 400 X 10 9/L)

13

Mean Corpuscular Volume (MCV) Mean Corpuscular Hemoglobin (MCH)

August 21, 2011

To measure the average size of RBC.

90.8 (82 - 98 FL)

The result is within normal range

August 21, 2011

To calculate the average amount of oxygencarrying hemoglobin inside a red blood cell.

29.0 (28 - 33 PG) The result is within normal range

Mean Corpuscular August 21, Hemoglobin 2011 Concentration (MCHC)

To calculate 32.0 the average concentration of hemoglobin inside a red cell.

(32 - 38%)

The result is within normal range

**Hematology BEFORE: Explain the procedure for obtaining the specimen. Secure patient consent for procedure. Provide client comfort, privacy, and safety. DURING: Provide patient comfort.

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 Use the correct procedure for obtaining a specimen or ensure that the client or staff followed the correct procedure. Obtain the amount of blood needed Instruct patient to avoid opening & closing of the hand after the tourniquet is applied If the patient is receiving IV infusion obtain the blood from the opposite site. AFTER: Provide patient comfort. Transport the specimen to the laboratory promptly. Label specimen properly.

III. ANATOMY AND PHYSIOLOGY 15

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in thedigestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.

The primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in

16

reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces). In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.

Basic structure The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The contents of the tube are considered external to the body and are in continuity with the outside world at the mouth and the anus. Although each section of the tract has specialised functions, the entire tract has a similar basic structure with regional variations.

The wall is divided into four layers as follows:

Mucosa 17

The innermost layer of the digestive tract has specialised epithelial cells supported by an underlying connective tissue layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple layers). Areas such as the mouth and oesophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of smooth muscle which can contract to change the shape of the lumen.

Submucosa The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and submucosa.

Muscularis externa This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen.

Serosa/mesentery The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium.

Individual components of the gastrointestinal system

Lower Gastrointestinal Tract

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The lower gastrointestinal tract includes most of the small intestine and all of the large intestine. According to some sources, it also includes theanus present in human body. Bowel or intestine

Small intestine, which has three parts:

Duodenum - Here the digestive juices from pancreas (digestive enzymes) and gallbladder (bile) mix together. The digestive enzymes break down proteins and bile emulsifies fats into micelles. Duodenum contains Brunner's glands which produce bicarbonate and pancreatic juice contains bicarbonate to neutralize hydrochloric acid of stomach Jejunum - It is the midsection of the intestine, connecting duodenum to ileum. Contain plicae circulates, and villi to increase surface area. Ileum - It has villi, where all soluble molecules are absorbed into the blood (capillaries and lacteals). Cecum (the vermiform appendix is attached to the cecum). Colon (ascending colon, transverse colon, descending colon and sigmoid flexure). The main function of colon is to absorb water, but it also contains bacteria that produce beneficial vitamins like Vitamin K. Rectum in human body

Large intestine, which has three parts:

Anus The ligament of Treitz is sometimes used to divide the upper and lower GI tracts.

Small intestine The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines digestive secretions from the pancreas and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and empties into the caecum at the ileocaecal junction.

19

The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream. The lining of the small intestine is made up of numerous permanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions.

Large intestine The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli). 20

The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters, control the passage of faeces.

The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete mucous to lubricate faecal matter as it solidifies. The functions of the large intestine can be summarised as: 1. The accumulation of unabsorbed material to form faeces. 2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas. 3. Reabsorption of water, salts, sugar and vitamins.

21

IV. PATHOPHYSIOLOGY a. book based i. Schematic Diagram Predisposing Factor: Develop and Industrialized AGE Precipitating Factor: Low fiber Diet Stress constipation high intake of meat and red meat Lack of Exercise Constipation

Increase in production of adrenalin

Hypertension

Increase in stomach acid production

Increased intraluminal 22 pressure Erosion of the diverticular wall

Erosion of stomach lining Mucosal damage Signs and symptoms: Bloating Abdominal cramps Constipation

Development of Ulcer Sign and symptoms: Pain in the belly Bloating Constipation Cramping

Ingestion

Upper Abdomin al burning pain

Hunger Pain Signs and symptoms: Severe abdominal pain Nausea Vomiting Fever Chills

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ii. Synthesis of the Disease 1. Definition of the disease Diverticulosis/Diverticulitis A gut diverticulum (singular) is an outpouching of the wall of the gut to form a sac. Diverticula (plural) may occur at any level from esophagus to colon. In Western societies, half the population will develop at least one, usually a few dozen diverticula, by age 60. Most diverticula occur in the left colon, but they also occur elsewhere, but not the rectum. Uncomplicated diverticular disease is called diverticulosis and most individuals who possess colonic diverticula have no symptoms and are unaware of them. They may coexist with other colonic disorders, such as irritable bowel syndrome. Nevertheless, colonic diverticula (one of many) can occasionally become the source of serious illness. These few may bleed or perforate thus becoming complicated diverticular disease. The resulting infection, diverticulitis, is usually confined to the surface of the adjacent colon producing an acute, sometimes devastating illness characterized by severe abdominal pain in the left lower part of the abdomen, fever, and prostration. A change in diet is a treatment during a mild attack of diverticulitis; a doctor will usually recommend a clear liquid diet or a low-fiber diet while the infected area heals.

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2. Predisposing and precipitating

Predisposing:
1. Develop and Industrialized Country where diets are high in fiber and rich in grains, fruits and vegetables, most doctors believe this condition is due in part to a diet low in fiber. 2. AGE- As the body ages, the outer layer of the intestinal wall thickens. This causes the open space inside the intestine to narrow. Stool (feces) moves more slowly through the colon, increasing the pressure.

Predisposing: 1. Low fiber Diet-. If a diet is low in fiber, the colon must exert more pressure than usual to move
small, hard stool. A low-fiber diet also can increase the time stool remains in the bowel, adding to the high pressure.

2. Stress 3. Constipation 4. high intake of meat and red meat 5. Lack of Exercise

3. Signs and Symptoms Bloating Abdominal cramps Pain in the belly Constipation Cramping

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b. Client- based i. Schematic Diagram *PRECIPITATING SHOULD APPEAR IN YOUR PT DESCRIPTION ON SOCIO ECONOMIC FACTOR

Predisposing Factor: 1. Kuwait 2. 65 years old

Precipitating Factor: Low fiber Diet Stress constipation high intake of meat and red meat Lack of Exercise Constipation

Increase in production of adrenalin

Hypertension IT SHOULD BE REVEAL IN PT NSG HX

Increase in stomach acid production Erosion of stomach lining Mucosal damage Signs and symptoms: Bloating Abdominal cramps Constipation

Increased intraluminal pressure Erosion of the diverticular wall Development of diverticulosis Inflammation of diverticula Sign and symptoms: Pain in the belly Bloating Constipation Cramping 26 Development of diverticulitis

Development of Ulcer

Upper Abdomin al burning pain DATES?

Signs and symptoms: Severe abdominal pain Nausea Vomiting Fever Chills

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ii. Predisposing Factor 1. Kuwait 2. Age- As the body ages, the outer layer of the intestinal wall thickens. This causes the open space inside the intestine to narrow Precipitating Factor:

1. Low fiber Diet-. If a diet is low in fiber, the colon must exert more pressure than usual to move
small, hard stool. A low-fiber diet also can increase the time stool remains in the bowel, adding to the high pressure.

2. Stress 3. Constipation Hard stools, such as those produced by a diet low in fiber or slower stool "transit time" through the colon can further increase the pressure. 4. high intake of meat and red meat 5. Lack of Exercise iii. signs and symptoms Hematochecia Hypertension Severe Abdominal pain Constipation

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V. THE PATIENT AND HIS CARE i. IVF Date Ordered, Date Medical Management General Description Indications/ Purpose Performed, Date Changed or D/C Isotonic solutions have the same salt concentration as the surrounding blood cells. So a isotonic PNSS 1L q 8 solution will have no effect on the surrounding cells. The cells will not gain or lose water if place in isotonic solution. For Hypertonic solutions D5NSS contain a high concentrati on of solute replaceme nt or maintenan ce of fluid and electrolyte s. D.O.: 08/22/11 D.P.:08/22/11 The patient did not manifest any sign of dehydration due to the IVF given to him. 29 NS can be used to replace fluids in dehydration, go with blood transfusions, hyponatremia, and burn victims, it is isotonic The patient did not manifest any sign of dehydration due to the IVF given to him. Clients Response to Treatment

D.O.: 08/21/11 D.P: 08/21/11

relative to another solution ( e.g. the cells cytoplasm ) when a cell is placed in a hypertonic solution, the water

Nursing Responsibilities a.1. IVF before: 1. 2. 3. Verify the doctors order. Explain the procedure to the patient. Obtain the necessary materials. Acquaint the SO & patient the

requirements needed for IV infusion. During: 1. 2. 3. 4. 5. After: 1. 2. Adjust rate of flow of fluids appropriate to needs of patient as prescribed. Monitor IVF flow and patients response. Check IV level. Check for the patency of the tubing. Check if the IVF is infusing well. Select a suitable vein for vernipuncture. Practice aseptic technique.

30

3.

Monitor patient for evidence of local IV R/T complications, such as pain, swelling & tenderness.

4. 5.

Check for the presence of air in tubing. If there is, remove it immediately. Isotonic solutions expand the intravascular compartment, monitor patients fluid overload.

6.

Record all procedures done.

a.2. IVF before: 4. 5. 6. Verify the doctors order. Explain the procedure to the patient. Obtain the necessary materials. Acquaint the SO & patient the

requirements needed for IV infusion. During: 6. 7. 8. 9. Check IV level. Check for the patency of the tubing. Check if the IVF is infusing well. Select a suitable vein for vernipuncture.

10. Practice aseptic technique. After: 7. 8. 9. Adjust rate of flow of fluids appropriate to needs of patient as prescribed. Monitor IVF flow and patients response. Monitor patient for evidence of local IV R/T complications, such as pain, swelling & tenderness. 10. Check for the presence of air in tubing. If there is, remove it immediately. 11. Record all procedures done.

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ii. Pharmacotherapy

Drug Name

Date Ordered Date Performed Date Changed or Discontinued

Route, Dosage, Frequency

Indication/Purpose

Client Response to the Treatment

Omeprazole

DATE ORDERED. WALANG DATES

40mg 1 cap OD

Decreases the amount of acid produced in the stomach. Prevents enzymes in the body from breaking down blood clots.

RESPONSE!!!

Tranexamic acid

500mg IV

20 mg q 8 Buscopan

5 mg tab OD Amlodipine

used to relieve cramps in the muscles of your:Stomach,Gut (intestine),Bladder and the tubes that lead to the outside of your body (urinary system)

Used to treat high blood pressure (hypertension) or chest pain (angina)

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33

iii. Diet

Typ e of Diet

General Description

Indications/Purpos e

Date ordered . Date started, date

Clients Respons e and Reaction to the

Nursing Responsibilities Prior to, During, and Initiation of the diet

changed diet or D/C High It acts by changing To provide a diet with 20 to 35 grams of appropriate fiber to promote regular elimination andincreases fecal excretion.Use: This diet can be used for the management of diverticulosis. 08/22/11 Patient followed the dietary regimen. Prior > Verify doctors order. Discuss importance of the diet. Cite examples of food under diet ordered. Ask patients SO of the food preference that may be included in their list. 34

Fiber the nature of the Diet contents of the gastrointestinal tract and by changing how other nutrients and chemicals are absorbed.[2] Soluble fiber absorbs water to become a gelatinous, viscous substance and is fermented by bacteria in the digestive tract. Insoluble fiber has bulking action and is not

fermented.[3] Lignin , a major dietary insoluble fiber source, may alter the fate and metabolism of soluble fibers

During > Assist px for comfortable position. >Identify the patient. Verify the meal served in the tray. After > Monitor how much meal and fluids were taken. Monitor pxs reaction and compliance with diet. Instruct SO to increase fruit juices and milk in diet for nourishmen t

35

36

37

VI. NURSING CARE PLAN (PATIENT- BASED) Priority # 1: Acute Pain Cues Nursing Diagnosis S > masakit Acute pain yung tiyan ko r/t: nerve endings O > with facial grimace With guarding behaviour Moaning With pain scale of 9/10 irritation AEB: a pain scale of 9/10.

Scientific Explanation Increase in stomach acid production causing erosion of stomach lining that leads to mucosal damage and will develop ulcer that causes the pain in the left lower abdomen.

Objectives After 1 hr of nursing interventions pt will be able to verbalize nonpharmacological method that provide relief and scale will reduce from 9/10 to 4/10.

Interventions Monitor and record VS

Rationale To obtain baseline data.

Evaluation Pts pain scale was decreased from 9/10 to

Provide comfort measures

To promote nonpharmacological pain management

5/10

Encourage use of relaxation technique

To distract attention and reduce tension

Encourage rest periods

To avoid fatigue

Provide diversional activities such as reading, listening to radio.

To divert attention and lessen pain

Administer

For faster relief of 38

buscopan as prescribe by the physician

pain

39

Priority # 02 : Activity Intolerance Cues Nursing Diagnosis S > nanghihina Activity ako intolerance O > body r/t: imbalance weakness between With limited oxygen supply and range of demand motion AEB: pt HGB appears HCT weak.

Scientific Explanation The inner lining of the colon hypertrophies and thickens thus blood supply to that area diminishes causes accumulation of blood in GI tract that leads hematochezia, therefore massive loss of blood causes dysfunctional organs.

Objectives After 2 hrs of nursing interventions pt will be able to participate willingly in necessary or desired activities.

Interventions Monitor and record VS Assist pt with ADL

Rationale To obtain baseline data. To protect from injury To enhance ability to participate in activities To promote safety to the pt.

Evaluation Pt. Was able to verbalize ways to increase activity tolerance.

Provide comfort measures

Raise side rails

Advise pt to eat To gain enough nutritious foods such energy as fruits and vegetables. Advise to increase fluid intake Administer tranexamic acid as prescribed. To rehydrate the pt.

To lessen the bleeding.

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Priority # 03: Impaired Tissue Integrity Cues Nursing Scientific Diagnosis Explanation S>O Impaired There is a decrease O > appears pale Appears weak Appears irritable tissue integrity r/t: altered circulation AEB: pt appears pale intraluminal pressure and decrease muscle contraction thus retained undigested food in the divierticula compromises the blood supply to that area and facilities bacterial invasion, causing herniation of the mucosa through the sigmoid colon forming prforated local abcess.

Objectives After 2 hrs of nursing interventions pt will able to verbalize

Interventions Monitor and record VS

Rationale To obtain baseline data.

Evaluation Pt was able to verbalize understanding of

Promote optimum nutrition with high-

To facilitate fast healing

condition and causative factors.

understanding quality protein. of condition and causative factors. Encourage adequate rest and sleep To prevent fatigue

Provide/assist with oral care

To prevent damage to mucosa membranes

Promote early mobility

To promote circulation and prevent excessive

Monitor laboratory studies

tissue pressure for change indicative and healing or 41

infection/ complication.

42

VII. PATIENTS DAILY PROGRESS (FROM ADMISSION TO DISCHARGE) CRITERIA NURSING PROBLEMS 1. Acute pain r/t: break in continuity of nerve endings AEB: a pain scale of 9/10. ADMISSION (08-21-11) 08/26 /11 DISCHARGE (08-26-11 )

2. Activity intolerance r/t: imbalance between oxygen supply and demand AEB: pt appears weak. 3. Impaired tissue integrity r/t: altered circulation AEB: pt appears pale VITAL SIGNS Temperature(C)

Pulse rate

Respiratory rate

Blood pressure

9-12 9 10 11 12 9-12 9 10 11 12 9-12 9 10 11 12 9-12 9 10 11 12

37.2

36

36.3C

79

60

71

20

22

23

120/70

70/40

90/60

DIAGNOSTIC PROCEDURES / LABORATORY EXAMS 1. ABG 2. Hemoglobin A1C 43

3. CK-MB 6. CBC 7. Chest xray 8. BUN 9. CREA 10. HBAIC MEDICAL MGMT. IVFS PNSS 1L q 8 D5NSS 1L q 10

DRUGS 1. Omeprazole 40mg 2. tranexamic acid 500mg iv 3. Buscopan 20mg 4. Amlodipine 5mg 5. faktu supp/ rectum 6. xtenda 1gm iv in D5W 7.Therabloc 25mg tab 8.Dolcet 1 cap 9.Biogesic 500mg tab 10. Mucosta 100 mg 1 tab DIET High Fiber diet SURGICAL MANAGEMENT

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VIII. DISCHARGE PLANNING a. General condition of the patient upon discharge

Upon discharge the patient is not that well enough. There are still symptoms she is complaining about. But when she heard that she is going home already, she felt a sudden joy. It was like the symptom she is feeling has disappeared all of a sudden. She is feeling anxious of staying in the hospital.

b. METHOD M MEDICATION Advised patient to continue his prescribed medicines like: >mucosta 100 mg /tab three times a day >risek 40mg/cap twice a day >tergecet 20mg/cap twice a day >dagomet 500mg/tab three times a day E EXERCISE Avoid strenuous and forceful activity Advised not work on full stomach Advised patient to take a leisurely stroll

T TREATMENT Comply with the treatment provided

H HEALTH TEACHING Provided written and oral instructions, diet recommendations, medications, and follow-up visits. Instructed patient to report immediately to her attending physician if symptoms persist.

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Emphasized importance of keeping follow-up appointments.

O- OUT PATIENT DEVELOPMENT Patient follow up will be on September 01, 2011

D- DIET Low salt low fat Advised patient to eat higher fiber diet because it increases stool bulk and prevent constipation Advised patient to avoid nuts, corn, and seeds Advised patient not to drink to much coffee, tea, or alcohol. They can make constipation worse.

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IX. CONCLUSION AND RECOMMENDATION

Diverticulosis, (which, when symptomatic, is known as "diverticular disease") is the condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. These are more common in the sigmoid colon, which is a common place for increased pressure. All of the things we learned in the case study must be shared and be given an importance. Proper education should be imparted in clients with diverticulosis. They should be educated on what are the things that they should be aware of. This includes the diet, the activities of daily living and the medications the patient must take. We should also include that they should abide the orders of the physician in order for them to be treated in this condition. As nurses, we should also take in consideration the financial stability and the degree of knowledge our client has so that we can come out with nursing interventions that is appropriate to their level of understanding. As a future nurses, this case study is aimed to promote an awareness over the disease process of diverticulosis with its components including the signs and symptoms, diagnosis and prognosis, pathophysiology and other significant details related to the disease condition which is an extremely important in the nursing field. This will also help in providing current and accurate information concerning the latest approaches for the treatment of diverticulosis and its complications. Moreover, it will initiate participation of client and family members in the therapy for the disease. This will also help in ensuring that the client understand treatment options and provide clarification when necessary. Another purpose of this study is that to promote health consciousness in high risk individual and aid in preventive measures.

Health care providers should be aware of the risk and complications of the disease to patients. We should be careful of what we are eating and doing. We can avoid having this disease by following a healthy diet and regular exercise. As a famous saying from the medical field, Prevention is better than cure. There are certain diseases in which we do not have control of having or acquiring. And if we already have the disease, what we need to do is to fight against it. How? We have to understand the disease process, know the contributing factors which contribute to its development, identify its transmission, signs and symptoms, how it can be 47

treated and most importantly how we can prevent acquiring such disease. Upon knowing all the important facts regarding the disease, the next thing to do is comply with the treatment and its management. Compliance is necessary if the patient is really determined to be free from illness or disease.

In the end, it is still the individual who decides for himself. It is his/her choice whether to promote wellness in himself/herself and prevent the occurrence of diseases or create the disease in himself and suffer in the end.

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X. BIBLIOGRAPHY AND REFERENCES http://www.virtualmedicalcentre.com/anatomy.asp?sid=7&title=Gastrointestinal-System http://www.ece.ncsu.edu/imaging/MedImg/SIMS/GE1_2.html http://www.asge.org/PatientInfoIndex.aspx?id=6818 http://www.iffgd.org/site/gi-disorders/other/diverticulosis http://www.emedicinehealth.com/diverticulosis_and_diverticulitis/article_em.htm http://www.webmd.com/digestive-disorders/tc/diverticulosis-topic-overview http://en.wikipedia.org/wiki/Diverticulosis http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/ http://www.medicinenet.com/diverticulosis/page5.htm http://www.medicinenet.com/peptic_ulcer/page5.htm

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