diverticulosis is the condition of having diverticula or outpouchings many patients are asymptomatic and have no idea they have the condition the out pouching can be compared to a protrusion or herniation the incident increases with age with diverticulite is found in 30 to 50% of adults over the age of 60 and increasing to 65 % by age 85 men are more affected than women in younger patients whereas females are more affected in older patients it is also important to note that younger people can get this condition as well risk factors for diverticulosis include increasing age obesity smoking low fiber diet heredi and some medications such as nids acetominophen oral corticosteroids and opiates there has also been an association between eating red meat and high fat diets with the risk of diverticular complications when diverticular become inflamed the condition becomes diverticulitis it often occurs in the sigmoid Colin when a patient has diverticula the colon wall thickens and becomes rigid without adequate fiber intake more water is absorbed from the stool this slows Transit time and makes it more difficult for the stool to to pass through the colon this then causes increased inter luminal pressure from constipation and straining which is thought to lead to the formation of diverticulum dietary fiber is thought to act by producing a larger bulkier stool that results in a wider bore colon Which is less likely to develop diverticula food can become entrapped in the diverticula and when it mixes with normal bacterial Flora this leads to decreased blood supply forming a mass called a falth or dried hard concrete light stool the dive verticular wall is eroded by increased intraluminal pressure or hard dry food particles this process leads to inflammation and or infection the inflammation can spread to other areas of the intestine and because the sigmoid colon is a segment with the smallest diameter increased intraluminal pressure may predispose this area to more frequent herniation diverticulitis may be acute or chronic in chronic diverticulitis the bowel can become scarred leading to narrowing of the Lumen and the patient may develop an intestinal obstruction in a small number of patients with diverticulitis it is difficult to distinguish from carcinoma because both may show focal thickening of the bowel wall or it may even resemble inflammatory bow disease diverticulite may lead to stricture formation that also has the appearance of cancer so biopsy is required to make the differential diagnosis for this picture just note that the outpouchings are in the descending colon and the sigmoid colon both which reside on the left side of the body if you look at the picture on the right it's showing you some that are inflamed and once it's inflamed it becomes diverticulitis this picture is someone's cold and look where the two arrows are and you can see it kind of looks like a little tunnel but that's the actual out pouching patients with diverticulitis complain of abdominal pain over the area that is involved usually the sigmoid colon and remember that's the left lower quadrant they may experience fever or [Music] lucyisanerd dominal bloating or distension and diarrhea or constipation stools may contain mucus and blood bleeding occurs because of inflammation near areas of blood vessels and may range from minor to severe now older patients are going to be different they may present a febr and have a normal white blood cell count they might also have minimal abdominal tenderness the first sign that may appear in the older patient is a change in mental status so just like if they had a UTI that might be the only sign that we have Baseline temperature is often decreased from normal in the older patient as well therefore one of the most common signs of infection may not be apparent in the older adult and the patient may present with increased confusion falling and anorexia if perforation has occurred the patient may present with clinical manifestations of sepsis if the pain is more eniz over the abdomen peritonitis may have developed and if peritonitis has occurred the patient displays profound guarding with a widespread rebound tenderness symptoms we can think of the acronym what's up where is the pain usually is going to be the left lower quadrant how does it feel we want to know the quality of it it's usually tender and crampy are there any aggravating or alleviating factors constipation and a low fiber diet May aggravate it treatment of constipation May alleviate it for timing was it a gradual onset intermittent severity is usually between 5 and 7 other useful data could be intermittent rectal bleeding straining at stool constipation alternated with diarrhea they might even have pus in the um stool or blood in the stool and then the patient's perception they usually fear a diagnosis of cancer now we want to know how it's diagnosed many times an abdominal x-ray is performed but the diagnosis is usually confirmed with the CT scan the CT scan also helps differentiate from other sources of abdominal pain and complicated cases of diverticulitis white blood cells are monitored for elevations initially associated with inflammation and possible infection but should decrease with treatment a urinal may show a few red blood cells if the urer is near a perforated diverticulum the patient with suspected diverticulitis should not have a barium enema because of the risk of rupturing the diverticula during testing uncomplicated diverticulitis may be treated on an outpatient basis with broadspectrum antibiotics for 7 10 days but should be reassessed after 2 to 3 days of therapy the patient is advised to consume a clear liquid diet until symptoms suside and then they can advance slowly as tolerated common antibiotics could be ciprofloxin and metronidazol Baum Augmentin or moxifloxacin the patient should be admitted to the hospital for fever over 102.5 microperforation immunosuppression significant lucyisanerd Advanced age significant comorbidities intolerance of oral intake non-compliance or they retreated outpatient and it failed there are no dietary restrictions in acute uncomplicated diverticulitis although limiting to a clear liquid diet for 2 to 3 days is common while advancing is tolerated if the patient is admitted to the hospital IV fluids are started and nothing is given by mouth to allow the bow to rest the patient may have a nasogastric tube for bowel decompression and will receive pereral antibiotics laxatives and anas should be avoided because they increase intestinal motility pain medications may be given as needed and opiates are frequently needed inpatients may be discharged as clinical manifestations resolve and should complete a course of 10 to 14 days of antibiotics and then have a follow-up exam after clinical manifestations completely resolved the patient is recommended to have a colonoscopy to assess the extent of the dive verticular disease for colonoscopy there are a few options for the bow prep but the patient is usually placed on clear liquids the day before and begin bow prep the evening before they will be NPO after midnight and must have someone drive them home after the procedure due to Anesthesia given failure of medical management May necessitate the need for surgical intervention indications for surgery may include perforation obstruction abscess formation which is not responding to antibiotic treatment or fistula formation between the colon and another pelvic organ if the patient develops complications they may require surgery to remove the diseased portion of the colon they may have a temporary colostomy because reanastomosis 3 to 6 months later is usually successful complications include perforation micro perforation AB ESS and fistula formation bile obstruction and bleeding inflammation can also result in fistulas to other organs fever often accompanies diverticulitis ranging from a low grade fever to 101° F due to inflammation tacac cardia often accompanies increased temperature pain accompanies diverticulitis usually in the left lower quadrant or mid abdomen depending on what area of the colon is involved if abdominal pain is generalized the diverticulum may have ruptured and peritonitis should be suspected altered bow habits often accompany diverticulitis with constipation diarrhea or both the patient may also complain of increased flatus and anorexia elevated white blood cells are indicative of infection however it is not unusual for the patient with diverticulitis to initially present with a normal white blood cell count diagnoses include acute pain related to inflammation and distension of the colon and knowledge deficit related to the need to consume adequate fiber in the diet for Vital Signs we're looking at fever which could be low grade and then teoc cardium serum potassium we want to monitor that because the patient may be on intermittent NG suction and they may require replenishment fluid volume status can be impacted by NG suction and decrease intake so we need to monitor the urinary output to make sure that renal profusion is intact pain we know is going to be the left lower quadrant it could also be mid abdomen depending on the area that's involved or if we're concerned about peritonitis and then mental status changes in older adults we know this already okay that's usually the symptom that's prevalent administer IV fluids because patients are often NPO during the acute phase to allow for bowel rest administer ordered antibiotics because diverticulitis is a localized infection antibiotics are administered until pain inflammation infection and fever subside if a naso gastric tube is present it's usually to low intermittent suction for gastric decompression it also decreases gastric motility and allow allows the bowel to rest until inflammation decreases and then don't forget about providing Oral Care the oral cavity might be dry to due to insensible fluid loss but the patient might also be mouth breathing due to the NG tube so don't be afraid to apply lip balm to any dry cracked lips the patient needs to be on low fiber diet in the acute phase but once the diverticulitis has resolved then they need to have a high fiber diet because remember one of the risk factors was not having enough fiber in their diet beforehand avoid straining bending and lifting because those activities increase intraabdominal pressure which can lead to further outpouching of the DI reticulum obesity is one of the risk factors so we want the patient to try to lose weight because obes obesity also increases the intraabdominal pressure and then adherence to antibiotic therapy is important so the nurse should stress to the patient that they need to finish the medication as prescribed okay for evaluation we want the patient to be free from abdominal pain and free from fever but we also need to make sure that they understand that they need to have adequate fiber intake from here on out BPH stands for benign prostatic hyperplasia another name that you might see is hypertrophy which just means enlargement of the prostate gland the prostate gland is a normal part of the male anatomy and is about the size of a walnut it also surrounds the ureum its primary function is to assist in controlling urine flow it also mixes sperm with prostatic and seminal fluid to be ejaculated during orgasm for reasons unknown the prostate begins to grow around age 25 but there's increased incidence as the person ages usually over 50 there are theories that include a balanced change between estrogen and testosterone an accumulation of the male hormone DHT or a high intake of calories protein calcium and polyunsaturated fats a patient can have BPH and prostate cancer simultaneously or independently of each other the clinical manifestations of BPH are related to lower urinary tract symptoms that include difficulty starting the flow of urine even with straining a weak stream of urine multiple interruptions during urination and dribbling once urination is complete symptoms related to changes in the bladder include urgency frequency the feeling that the bladder has not completely emptied after urination and frequent Awakening at night to urinate as the bladder becomes more sensitive to the retention of urine incontinence may result the patient may experience bed weding and the inability to respond quickly enough to the need to urinate a urethal obstruction or enlarged prostate that is left untreated may result in blad or Outlet obstruction which includes accute urinary retention bladder infection bladder stones and increasing pressure in the kidney which could possibly result in hydron nephrosis or postrenal acute kidney injury or Pyon nefritis diagnosis is made on the basis of symptoms and is confirmed with a digital rectal exam because the enlarged prostate can be palpated on examination a UR analysis is also done to rule out the presence of an infection causing any of the symptoms in addition the prostate specific antigen level is checked this is a protein produced by the prostate gland and may be considered a tumor marker because an elevated PSA May be indicative of prostate cancer but it's important to note that raised PSA levels might be due to infection so it does not mean that the patient has cancer the least invasive treatment for BPH is watchful waiting or active surveillance this approach is used in patients who have minimal symptoms and minimal enlargement of the prostate patients who opt for this treatment plan receive yearly provider examinations with evalu ation using a drv it is advised during this watchful waiting period that the patient avoid tranquilizers and over-the-counter medications that contain decongestion because these medications can worsen obstructive symptoms in addition patients should avoid excess fluids in the evening to decrease the chances of noctua looking at this chart you can see that the patient can have mild all the way to severe symptoms but as long as it's not interfering with daily life then watchful waiting is okay as soon as symptoms interfere with daily life then the patient needs to discuss with the doctor maybe starting some medication or looking into surgery options if they have um obstructive symptoms then that patient usually is going to need surgery there are a few options of medications that'll work I'll alpha aeric blockers act on the alpha receptors in the prostate causing the smooth muscles of the prostate to relax relaxation of the muscles decreases the constriction of the urethal it may take two to two weeks to four months to notice symptom Improvement the patient needs to be aware of adverse effects such as headache nasal congestion dizziness drowsiness postural hypertension reflex tacac cardia and retrograde or delayed ejaculation an example of this type of medication would be Flomax or tamuin another medication classification is the five Alpha reductase Inhibitors which act as anti-androgens testosterone affects prostate growth and development five Alpha reductases converts testosterone into DHT or dihydro testosterone dihydrotestosterone stimulates the growth factors that encourage prostate hyperplasia while concurrently reducing the rate of cell death in the prostate this imbalance results in enlargement of the prostate the five Alpha reductase inhibitors prevent testosterone from being converted to DHT which causes enlarg tissues to shrink thus reducing obstruction of the ureum another um positive of this medicine is that it doesn't affect circulating testosterone so it decreases the chance of erectile dysfunction it can take 3 to 6 months for these meds to take effect it has been reported that some men may experience a reduction in male pattern baldness possible adverse effects include rash breast enlargment breast tenderness reduce volume of ejaculate decreased libido Ned some men experience better results with a combination of the alpha blockers and the five Alpha reductive Inhibitors the combination has been shown to delay clinical progression as much as 67% an example of a five Alpha reductase inhibitor is the medication prar or feride if the patient with BPH has an overactive bladder and anticholinergic to relaxed bladder smooth muscle such as oxybutinin may be added if pharmacological treatment was not effective and the patient is a surgical candidate then one of the most common surgeries for BPH is a transurethral resection of the prostate or turp it is usually used to treat smaller prostates in the procedure a lighted scope known as a rectoscope is passed into the ureum a small cutting tool is used to remove the entire inner prostate leaving the outer layer symptoms are usually relieved quickly resulting in a stronger flow of urine a catheter May remain in place after surgery for 3 to 5 days to drain the bladder recovery from a turp may include a risk of bleeding and infection the patient is permitted only light activity immediately postoperatively another procedure is the transurethral incision of the prostate and is used for a patient with small to moderately enlarged prostates during this procedure instruments are inserted through the urethra just like the turp but the prostate is not removed the surgeon makes two small incisions into the prostate which relieves compression of the urethra and opens up the channel the result is an easier passage of urine for a patient with a very large prostate who is experiencing complications such as bladder stones or bladder damage their surgeon May perform an open prostatectomy this procedure is performed approximately 200 100,000 times a year in the US during this procedure an incision is made in the patient's lower abdomen to access and remove the prostate gland it carries a higher risk of complications such as incontinence impotance and retrograde ejaculation another option is laser surgery for men with smaller or moderately large prostate glands this therapy uses high energy lasers to annihilate and or remove overgrown prostate tissue several laser procedures include ablan procedures that burn away prostate tissue and an nucleation procedures that remove the prostate tissue that is restricting the flow of urine and prevent tissue regrowth laser surgery usually results in immediate symptom relief and has a lower risk of adverse effects than a turp this may be used for men who are taking anti-coagulant because there's usually less bleeding I mentioned that a patient may have a catheter in place for a couple of days um one reason is the doctor May order continuous bladder irrigation and the goal is to maintain the flow rate of the irrigant to keep the output light pink or colorless we need to assess urinary output every 1 to 2 hours for color consistency of amount and presence of any blood clots also assess for bladder spasms pain and bladder distension bladder distension may result from output obstruction which increases the risk for bleeding make sure to calculate the difference between irrigation fluid and the patient's actual output when calculating iOS there's something else that we need to watch for called TP syndrome so we need to assess for fluid volume excess and high hyponatremia in addition to decreased hematocrite hypertension Broc cardia nausea and confusion if any of these occur notify the healthc care provider turp syndrome results from the absorption of irrigating fluids during and after surgery if untreated it may result in dymas and or seizures this chart shows you complications of BPH um it could be as simple as urinary retention UTI or bladder stones but I mentioned a couple other things such as hydron nephrosis and pylon nephritis hydron nephrosis is when the urine back flows instead of going from the urer down to the bladder some of it will backflow towards the kidney and can cause infection pylon nephritis is a UTI that migrated from the bladder to the kidney urinary symptoms are of concern if it's affecting their daily life um we should still document information about it temperature we're looking at to see if it's elevated they might have a UTI a distended abdomen May signify blad distension so the patient might not be able to empty the bladder all the way and would be at a risk for UTI a bladder scanner could be used to see if there's any postvoid residual indicating that the patient has urinary stasis that could lead to infection and then a UR analysis can be checked to see if there's infection intermittent catheterization can be used to relieve the bladder of any postvoid residual that's left over um to relieve that distended bladder and then decrease risk of bladder damage and then we would in administer any medications if they're ordered it is important to teach about each of these however I would say stress the importance of followup with the provider to report any worsening symptoms and need for possible further intervention if they discuss any surgical options then printed information may be helpful for that and then if there are any surgical or treatment sites then teach the patient about aseptic technique to decrease the risk of infection