PLANNING/ IMPLEMENTING/EVALUATION (see grading rubric for NCP

criteria)
Med/Surg Nursing Diagnosis: Risk for Infection related to Inflammation of diverticulum in the intestinal tract and peripheral IV
site.___________
Long Term Goal: Pt will be free of infection________________________________________________________________________________________

OUTCOME
CRITERIA

INTERVENTIONS

1.) PTs vital signs will

be with in normal
parameters as
assessed Q4H &
PRN
a. BP: 100/50
to 140/90
b. HR:60 to
100
c. R: 12 to 20
d. T: 96.8 to
100.4
e. O2: 95% to
100%

Independent: Monitor
Vital signs Q4H & PRN

2.) Pts abdomen will

be soft, nondistended, with
present bowel
sounds in all

Independent: Assess
Abdomen Q4H & PRN

RATIONALE
Monitoring Vital signs every 4 hours
and as needed is important in order to
assess for signs of infection. The Pt
was admitted with acute sigmoid
diverticulitis that puts him at an
increased risk for intestinal
perforation and peritonitis. He is at an
increased risk due the inflammation of
the mucous membrane in the
intestinal tract. The inflammation
makes the MM delicate and prone to
tearing. With an intestinal perforation
you may see an increase in HR and
Temp and a decrease in BP. This
happens because loss of body fluid
into the abdominal cavity causes a
decrease in BP, which causes the
Heart rate to increase in order to
perfuse the body with blood. Keeping
a close eye on the trends of Vital signs
can help identify an intestinal
perforation early on to reduce risk and
prevent peritonitis.
The Pt was admitted with acute
sigmoid diverticulitis this puts him at
an increased risk for perforation that
can lead to peritonitis. Peritonitis is
the inflammation of mucous

EVALUATION
Outcome met
Will continue
to monitor
until
discharge

Outcome met
Bowel sounds
present x4,
abd soft,
obese and

quads as
assessed Q4H &
PRN

3.) Pt will have soft

formed stool that
is free of blood
and mucus as
assessed per BM.

Independent: Monitor /
Assess Bowel
movements per BM.

4.) Pts will report no

acute increase of
pain from baseline

Independent: Assess
Pain level Q4H & PRN.

membranes of the peritoneal cavity.

He is at an increased risk for this due
the inflammation of the mucous
membrane in him intestinal tract
caused by his acute diverticulitis. The
inflammation makes the MM delicate
and prone to tearing. Signs of
peritonitis present as intense,
constant abdominal pain that worsens
on movement. With an abdomen that
is rigid and board like, distended and
typically has decreased bowel sounds.
Abdominal assessment in one of the
best ways to identify such a problem
and helps increase early intervention
which is key to treatment.
Pt was admitted with acute sigmoid
diverticulitis. Due to the inflammation
this causes in the mucous membrane
it is extremely delicate and at an
increased risk for perforation.
Monitoring frequency, consistency,
and if blood or mucus is present is
very important. If Pt had decreased
frequency or the stool is hard it could
mean he is constipated. Constipation
puts him at an increased risk for a
bowel perforation which could lead to
peritonitis due to the delicate mucous
membranes of the intestinal tract
related to diverticulitis. Stools should
be soft, formed and free of blood. If
stool is hard and/or Pt is constipated
medical intervention should be taken,
stool softeners can be used as
treatment.
Pt was admitted with acute
diverticulitis and has a base line pain

nondistended
Will continue
to monitor
until
discharge

Outcome Met
Pt had Soft
formed BM on
3/27
Will continue to
monitor until
discharge

Outcome Met
Pt pain 5 out

of 5 on pain scale
as assessed Q4h
& PRN.

5.) Pt will intake at

least 2L of fluid
QD as assessed
Qshift

6.) Pt will be free of

Signs and
symptoms of
systematic
infection as
assessed Q4H &
PRN.

Independent:
Encourage increased
fluid intake QShift

Independent: Assess
for S&S of systematic
infection Q4H & PRN

scale rating or 5 out of 10. An acute

onset of increased pain could indicate
a bowel perforation. Generally the
pain will be localized to the site of
perforation early on and will spread to
rest of abdominal area later on.
Abdominal pain that is intense,
constant and worsens on movement
could indicate peritonitis. Using the
pain scale and watching trends in the
Pts pain level can be an early warning
sign that infection is worsening.
Pt was admitted with acute
diverticulitis. A complication of
diverticulitis is perforation of the
bowel leading to peritonitis.
Constipation and hard packed stool
can damage and cause perforation of
the bowel due to the delicate state of
the intestinal mucous membrane.
Increasing fluid intake to at least 2L or
3L of fluid helps to keep the Pts stool
soft and formed and decreased the
risk of constipation there for
decreasing the risk for perforation and
peritonitis.
Pt was admitted with acute sigmoid
diverticulitis. This puts him at risk for
developing sepsis. Sepsis is the
bodys systematic inflammatory
response to infection. Signs and
symptoms of early sepsis are
deviation in Temp (fever or
hypothermia), tachycardia, tachypnea
and evidence of inadequate blood flow
to organs such as decreased urinary
output decreased LOC. This happens
due to the overwhelming infection

of 10 during
whole shift.
Denied any
pain
medication
Will continue
to monitor
until
discharge

Outcome Met
Pt fluid intake
2,700ml
Will continue
to monitor
until
discharge

Outcome Met
Will continue
to monitor
until
discharge

increasing the oxygen demand on the

body. To compensate for this
increased demand the respiratory rate
increases and so does the HR.
Assessing for these signs and
symptoms allows for early
intervention to treat and prevent
worsening systematic infection from
occurring.

7.) Pt will tolerate

regular diet with
no c/o of pain or
nausea as
assessed QMeal

8.) Pts WBC count will

trend down to be
WNL of 4.8 to
10.8 as assessed
when ordered by
MD.

Collaborative:
Advance diet slowly as
tolerated per MD order
as assessed QMeal.

Dependent: Monitor
WBCs when ordered
per MD.

Pt was admitted with acute sigmoid

diverticulitis. During acute
intervention NPO status is needed to
allow the bowel to rest and decrease
further irritation to the mucous
membrane. Advancing the diet slowly
from NPO, clear liquids, full liquids and
then regular can allow the nurse to
observe how the Pt tolerates the
reintroduction of food back into the
bowel. Due to the inflammation in the
bowel from the diverticulitis the MM is
delicate and reintroducing food to fast
can cause complications such as
perforation and peritonitis as well as
recurrent diverticulitis. Pt should be
assessed for pain and or nausea
before, during and after meals to
assess how they tolerated diet and be
advanced when tolerating said diet
with no c/o pain or nausea.
Pt was admitted with acute sigmoid
diverticulitis. His WBC count on admit
was 17.2 and is trending down in
response to treatment to 11.1.
Monitoring the trends in the WBC
count can help monitor the course of

Outcome Met
Advanced
from NPO to
regular diet
Will continue
to monitor
until
discharge

Outcome Met
Pt WBC
trending
down from
17. 2 to 11.1
Will continue

infection. An Increase in the WBCs can

indicate worsening infection. Also
Leukopenia (lower than normal WBC
count) can be an indicator of sepsis.

9.) Pt will have Lactic

acid level WNL of
0.5 to 2.2 mmol/L
as assessed when
ordered by MD.

10.)
Pt
Abdominal CT
scan will show no
evidence of
intestinal
perforation as
assessed when
ordered per MD.

Dependent: Monitor
Lactic acid when
ordered per MD.

Dependent: Monitor
Abdomen CT scan
when resulted per MD
order.

Pt was admitted with acute sigmoid

diverticulitis. This puts him at an
increased risk of developing sepsis. A
way to monitor of such systematic
infection is to monitor Lactic acid
levels. Lactic acid levels increase
when the body must break down
carbohydrates to use for energy
during times of low O2 levels. Sepsis
can be a cause for the lactic acid level
to rise because in sepsis the blood
perfusion to the body is compromised
resulting in a decrease of 02 to the
tissue. Normal lactic acid levels are
0.5 to 2.2 mmol/L. An increase from
this range may indicate sepsis there
for monitoring it should be done when
at risk for sepsis.
Pt was admitted with acute sigmoid
diverticulitis. Due to the inflammation
this causes in the mucous membrane
it is extremely delicate and at an
increased risk for perforation and
peritonitis. Monitoring the intestines
by assessing abdominal CT scan can
help identify if the inflammation from
the diverticulitis is improving there for
reducing the Pts risk, or if it is
worsening which could indicate an
increase rick for complications. The
Abdominal CT scan can also help

to monitor
until
discharge

Outcome Met
Pt lactic acid
level is 0.9
Will continue
to monitor
until
discharge

Outcome Met
Will continue
to monitor
until
discharge

11.)
Pts WBC
count will trend
down to be WNL
of 4.8 to 10.8 as
assessed when
ordered by MD.

12.)
Pts WBC
count will trend
down to be WNL
of 4.8 to 10.8 as
assessed when
ordered by MD.

Dependent:
Administer Cipro
400mg in 20ml of
D5W Q12H per MD
order

Dependent:
Administer Flagyl
500mg/100ml Q8H
per MD order

detect a perforation or peritonitis

there from close monitoring by CT
scan is recommended to for early
detection and treatment.
Pt was admitted with acute sigmoid
diverticulitis. Diverticulitis is an
inflammation and infection of
diverticulum in the intestines. This
infection and inflammation causes the
mucous membranes of the intestinal
tract to be delicate and at risk to be
damaged. This increased risk for
trauma increased the Pts risk for other
infections such as Peritonitis and
sepsis. Cipro is a Fluoroquinolone antiinfective that is used commonly to
treat complicated intra-abdominal
infections because it inhibits bacterial
DNA synthesis by inhibiting DNA
gyrase enzyme. By treating the
original infection you are reducing
inflammation that has occurred in the
intestines, there for decreasing the
fragility of the mucous and in turn
decreasing risk for other infections.

Pt was admitted with acute sigmoid

diverticulitis. Diverticulitis is an
inflammation and infection of
diverticulum in the intestines. This
infection and inflammation causes the
mucous membranes of the intestinal
tract to be delicate and at risk to be
damaged. This increased risk for
trauma increased the Pts risk for other
infections such as Peritonitis and
sepsis. Flagyl is an anti-infective that
is used congruently with Cipro to treat
complicated intra-abdominal

Outcome Met
Pt WBC trending
down from 17. 2
to 11.1
Will continue to
monitor until
discharge

Outcome Met
Pt WBC
trending
down from
17. 2 to 11.1
Will continue
to monitor
until
discharge

13.)
Pt will have
soft formed stool
that is free of
blood and mucus
as assessed per
BM.

14.)
Pt will
consult
Gastroenterologist
about
diverticulosis as
assessed QShift.

Dependent:
Administer Bisacodyl
10mg QD PRN for
constipation per MD
order

Collaborative: Obtain
order for
Gastroenterologist
consult

infections because it disrupts DNA and

protein synthesis in susceptible
organisms cause bacteria death. By
treating the original infection you are
reducing inflammation that has
occurred in the intestines, there for
decreasing the fragility of the mucous
and in turn decreasing risk for other
infections.
Pt was admitted with acute sigmoid
diverticulitis. Due to the inflammation
this causes in the mucous membrane
it is extremely delicate and at an
increased risk for perforation.
Constipation puts him at an increased
risk for a bowel perforation which
could lead to peritonitis due to the
delicate mucous membranes of the
intestinal tract related to diverticulitis.
Bisacodyl can be use PRN to help
prevent constipation and/or straining
to have bowel movement. Bisacodyl is
a stimulating laxative alters F&E
transport, producing accumulation of
fluid in the colon. This helps the stool
to be softer and easier to evacuate. In
turn this decrease the trauma done to
the inflamed intestinal tract and
reduces the risk of perforation and
peritonitis.
This Pt has history of recurrent
diverticulitis, hepatomegaly and fatty
liver. These conditions should be
monitored closely. The best doctor to
follow up care of such conditions
would be a Gastroenterologist. A
Gastroenterologist is a physician with
dedicated training and unique

Outcome Met
Pt had Soft
formed BM on
3/27
Will continue
to monitor
until
discharge

Outcome not
met
Will consult
with MD for
order

15.)
Pt will
verbalize
understanding for
following High
fiber & well
balanced diet as
assessed QShift.

Teaching: Teach Pt to
follow High fiber well
balance diet Qshift.

experience in the management of

diseases of the gastrointestinal tract
and liver.
The Pt has a Hx of Diverticulitis due to
having diverticulum in his intestines.
A Diverticula is an out pouching in the
walls of the intestinal tract. These out
pouchings are prone to getting foods
trapped in them. This trapping of food
is what can cause the Diverticulitis.
Pts diet should be well balanced with
food that provide dietary roughage in
the form of fruits, vegetables and
cereal fibers but is non-irritating to the
bowel is recommended. Also foods
such a corn, nuts and seeds should be
avoided to prevent future infections.

Outcome not
met
Pt needed to
be taught
about proper
diet to follow
Will teach and
reevaluate
prior to
discharge