Scenario:T

Scenario:T.H., a 57-year-old stockbroker, has come to the gastroenterologist for treatment ofrecurrent mild to severe cramping in his abdomen and blood-streaked stool. You are theregistered nurse doing his initial workup. Your findings include a mildly obese man who demonstrates moderate guarding of his abdomen with both direct and rebound tenderness,especially in the left lower quadrant (LLQ). His vital signs are 168/98, 110, 24, 100.4° F (38° C), and he is slightly diaphoretic. T.H. reports that he has periodic constipation. He has had

previous episodes of abdominal cramping, but this time the pain is getting worse.

Past medical history reveals that T.H. has a "sedentary job with lots of emotional

moments," he has smoked a pack of cigarettes a day for 30 years, and he has had "2 or 3

mixed drinks in the evening" until 2 months ago. He states, "I haven't had anything to drink in

two months." He denies having regular exercise: "just no time." His diet consists mostly of

"white bread, meat, potatoes, and ice cream with fruit and nuts over it." He denies having a

history of cardiac or pulmonary problems and no personal history of cancer, although his

father and older brother died of colon cancer. He takes no medications and denies the use of

any other drugs or herbal products.

1. Identify four general health risk problems that T.H. exhibits.

2. Identify a key factor in his family history that might have profound implications for his

health and present state of mind.

3. Identify three key findings on his physical exam, and indicate their significance. The

physician ordered a KUB (x-ray of the kidneys, ureters, and bladder), CBC, and

complete metabolic profile. Based on x-ray and lab findings, physical examination,

and history, the physician diagnoses T.H. as having acute diverticulitis and discusses

an outpatient treatment plan with him.

4. What is diverticulitis? What are the consequences of untreated diverticulitis?

5. While the patient is experiencing the severe crampy pain of acute diverticulitis, what

interventions would you perform to help him feel more comfortable?

6. What is the rationale for ordering bed rest?

Case study progress

T.H. is being sent home with prescriptions for metronidazole (Flagyl) 500 mg PO q6h,

ciprofloxacin (Cipro) 500 mg PO q12h, and dicyclomine (Bentyl) 20 mg qid PO x 5 days.

7. For each medication, state the drug class and the purpose for T.H.

8. Given his history, what questions must you ask T.H. before he takes the initial dose of

metronidazole? State your rationale.

9. What is a disulfiram reaction?

10. When teaching T.H. about the metronidazole prescription, which instructions need to

be included? (Select all that apply.)

a. Avoid all alcohol-containing products while on this medication.

b. If his urine turns reddish brown, notify his doctor immediately.

c. Take the medication exactly as scheduled, without skipping doses.

d. He might feel some tingling or numbness in his hands, which is an expected effect.

e. Take the medication with or after meals.

f. This medication might cause a metallic taste.

11. What specific information would you want to know before T.H. starts the antibiotics?

12. What are the signs and symptoms of an allergic reaction?

13. T.H. asks you if he can take a laxative for his occasional constipation. What is your

answer?

14. T.H. asks you about his diet. "I'm confused. I was always told that I needed to be

eating a high-fiber diet, which is difficult for me. But the doctor just told me that I need

to be on a low-fiber diet for now, so now I'm confused. Which is it supposed to be?"

How will you answer his question?

Case study progress

To help T.H. work through his dietary concerns, you obtain a referral to a registered

dietitian.

15. What measures do you think the dietitian will discuss with T.H. to avoid recurrent

diverticulitis once his acute symptoms are resolved?

Activity

1. What are the possible complications of diverticular disease?

2. Present the medical management of diverticular disease by highlighting:

a. Nutritional therapy

b. Surgical therapy

c. Pharmacological therapy in MNEMONIC form

3. Present nursing management of patient with diverticular disease by making a nursing

care plan

4. Make your own pathophysiology of diverticular disease