Download Situation: Mr. Lopez, a 57yo Hispanic male, has been admitted to

Situation:
Mr. Lopez, a 57yo Hispanic male, has been admitted to the hospital directly from the gastroenterologists
office for diagnostic testing and treatment. His chief complaint is been recurrent mild to severe
abdominal cramping with blood streaked stool this past week.
Background:
PMH: hypertension, obesity
Social History: Works as a stockbroker and describes is job as “sedentary & stressful ”. He lives alone.
Family History: Father and brother died of colon cancer at a young age.
Assessment
Subjective
Smokes: 1 pack/x 30 years.
Drinks: He admits to drinking 2-3 per day but has not had a drink in 2 months.
Pain: stabbing, intermittent with a scale of 6/10 up to 10/10 when severe.
It has been happening on and off for the past 2 months but is getting worse.
He occasionally feels feverish.
Appetite: Haven’t been eating much lately, no appetite.
3 day recall: 3 day diet recall: white bread, steak, potatoes, ice cream, cheeseburger & fries, breakfast
burrito, potato chips, healthy choice entrée for dinner salad.
Nauseated 2nd to pain?
Obj GI assessment:
Abdomen rounded, non distended, no visible pulsations or change in venous pattern, no jaundice.
Bowel sounds hyperactive x 4 quadrants
Moderate guarding with increased tenderness in the left lower quadrant.
VS: T100.6⁰F (O), BP168/98, P 126, RR24 O2 sat 98% RA Full Code NKDA
Collaborative Assessment
Orders: NPO, CT Abd. r/o abcess
IV: D5 0.45 NS 1L to infuse over 8 hours
I/O
Weight daily
1. Identify four general health risk problems that Mr. Lopez exhibits.
Smoker, sedentary, obesity, sedentary, poor diet.high stressful job, bad eating habits and family
history of colon CA.
2. Identify 3 key findings in his physical exam and discuss their significance.
Blood pressure tachycardic, febrile and tachypnic 2nd to pain, infection, anxiety
LLQ abdominal pain tenderness, guarding due to possible infection
blood streaked stool possible due to intestinal disorder diverticulitis, cancer, constipation with
hemorrhoids.
The HCP orders an KUB (xray of the kidneys, ureters, bladder), CT scan of the abdomen with
contrast, CBC, and a complete metabolic profile (CMP).
Recommendation:
Mr. Lopez is diagnosed with acute diverticulitis with the following treatment plan.
NPO
IV D5 and lactated ringers 1 liter to infuse at a rate of 150 ml/hr
Metronidazole 1gram IVPB every 8 hours.
Ceftriaxone 1 gram IVPB every 12 hours.
Bedrest
Urecholine
Morphine sulfate 2 mg IV push every 4 hours prn pain
3. Describe the pathophysiology of diverticulosis?
Diverticula are small, protruding sacs that develop because of abnormally high pressure against the colon
wall, which causes small pouches to form bulging outward through small defects in the wall that surround
blood vessels. They are most common in the colon, especially the sigmoid colon, the lowest part of the
colon.
Diverticulitis is an infection of the diverticular sacs which is thought to be caused by an obstruction with
fecal matter.
Inadequate dietary fiber slows transit time, and more water is absorbed from the stool, making it more
difficult to pass through the lumen. Decreased stool size raises intraluminal pressure, thus promoting
diverticula formation.
4. What are the complications if diverticulitis is untreated?
Complications associated with diverticulitis are perforation with peritonitis, abscess and fistula formation,
bowel obstruction, ureteral obstruction, and bleeding, and is the most frequent cause of lower GI
hemorrhage. Inflammation if the diverticula can result in perforation of one or more diverticula which are
found throughout the GI tract but most commonly in the sigmoid colon.
5. What is the rationale for the HCP ordering bedrest and and NPO.
Bed rest and NPO is ordered to allow the intestines to rest,
Anticholinergic it may be necessary to slow gastric secretions and motility.
TABLE 43-32
COLLABORATIVE CARE Diverticulosis
Diagnostic:
History and physical examination
Testing of stool for occult blood
Barium enema,Sigmoidoscopy, Colonoscopy
CBC
Urinalysis
Blood culture
CT scan with oral contrast, Abdominal x-ray, Chest x-ray
Conservative Therapy:
High-fiber diet, Dietary fiber supplements, Stool softeners, Anticholinergics, Mineral oil, Bed rest,
Clear liquid diet
Oral antibiotics
Bulk laxatives
Weight reduction (if overweight)
Acute Care: Diverticulitis
Antibiotic therapy
NPO status
IV fluids
Possible resection of involved colon for obstruction or hemorrhage
Possible temporary colostomy
Bed rest
NG suction
The patient is kept on NPO status and bed rest, and fluids and IV antibiotics are given. Observe for signs of
abscess, bleeding, and peritonitis, and monitor the WBC count. When the acute attack subsides, give oral fluids
first and then progress the diet to semisolids. Ambulation is allowed.
A high-fiber diet, mainly from fruits and vegetables, and decreased intake of fat and red meat are
recommended for preventing diverticular disease. High levels of physical activity also seem to decrease the
risk.67 A high-fiber diet (see Table 43-6) is also recommended once diverticular disease is present, although its
benefits are unclear. Currently there is no evidence to support the theory that diverticulitis can be prevented by
avoiding nuts and seeds. In fact, nuts and popcorn may have a protective effect against diverticulitis. (Lewis
1047)
Mr. Lopez recovers for this acute episode and is ready for discharge.
6.
Discuss the type of diet he should have and what lifestyle changes he should make.
7. Given his history, what questions must you ask Mr. Lopez before he takes his initial dose of
metronidazole?
Drinking: Patients must avoid alcohol for 24 hours before initiation of therapy and for at least 36 hours after the
last dose of metronidazole. Metronidazole may also increase the toxicity of lithium, benzodiazepines, cyclosporine,
calcium channel blockers, various antidepressants
Contraindications:It is "common knowledge" that alcohol and metronidazole interact in a severe or even dangerous
way. Patients should avoid the
use of alcohol during therapy or within 3 days of discontinuing therapy.
8. To prevent further episodes of constipation that could result in diverticulitis what would be the
focus or your discharge teaching?
Weight reduction is important for the obese person. Increased intraabdominal pressure should be avoided because
it may precipitate an attack. Factors that increase intraabdominal pressure are straining at stool, vomiting,
bending, lifting, and tight, restrictive clothing.
Dietary fiber is found in plant foods: fruits, vegetables, and grains (Table 43-6). Wheat bran and prunes are
especially effective for preventing and treating constipation.
Insoluble fiber is found in higher concentrations in whole wheat and bran. Dietary fiber adds to the stool bulk
directly and by attracting water. Large, bulky stools decrease pressure within the lumen of the colon and move
through the colon much more quickly than small stools. As a result stool frequency increases and constipation is
prevented. Fluid intake of approximately 2000 mL daily is important. However, the recommended fluid intake may
be contraindicated in the patient with cardiac disease or renal insufficiency or failure. The patient's understanding
of the diet and the role of dietary fiber are important to ensure compliance. Tell the patient that increasing fiber
intake may initially increase gas production because of fermentation in the colon, but that this effect decreases with
use.