UNIVERSITY OF THE EAST

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER INC.

#64 Barangay Dona Imelda Aurora Boulevard Quezon City 1113

SURGERY WARD – NURSING PROCESS:

Colovesical Fistula secondary to Ruptured Diverticulitis
(s/p Enbloc Sigmoidectomcy with Partial Cystectomy)

Submitted by:
Caragan, Chantal
To:
Sir Gaudymer Lopez
(Clinical Instructor)
I. Introduction
A Colovesical fistula is an uncommon condition. It is an open connection between the
colon (large intestine) and the bladder. This can allow fecal mayter from the colon to
enter the bladder, causing painful infections and other complications.
Diverticula is thought that pressure within the colon causes bulging pockets of tissue
(sacs) that push out from the colonic walls as a person ages. A small bulging sac pushing
outward from the colon wall is called a diverticulum. More than one bulging sac is
referred to in the plural as diverticula. Diverticula can occur throughout the colon but
are most common near the end of the left colon, referred to as the sigmoid colon, in
Western countries. In Asia, the diverticula occur mostly on the right side of the colon.
The condition of having these diverticula in the colon is called diverticulosis.
 Demographic Profile
- Patient N.DLR, 62 years old, married, Roman Catholic, Female, residing at Little
Baguio, San Juan City. Patient was advised admission at UERM Hospital on July 17,
2019 at 8:42 PM with an admitting diagnosis of Colovesical fistula secondary to
diverticulosis, rule out malignancy.

II. Nursing Health History

 Chief Complaint
- Fecaluria of 2 weeks duration.
 Present Health History
- 2 weeks prior to admission patient started to experience urine in frequency
and urine was tea-colored, foul-smelling with associated Dysuria. Patient
sought consult at a public hospital wherein she underwent the following
tests: Papsmear, speculum examination and ultrasound. Patient’s fecaluria
persisted. She underwent the following tests at Our Lady of Lourdes
Hospital: Urinalysis and Abdominal CT Scan wherein an incidental finding of
colonic diverticulosis was revealed. Patient was advised admission at UERM
Hospital with a final diagnosis of Colovesical fistula secondary to ruptured
diverticulitis.
 Past Health History
- s/p Open Choloecystectomy (1992)
- s/p Excision of Baker’s Cyst (2018)
- developed Type 2 Diabetes Mellitus (2019)
- allergy with Alaxan and Mefenamic acid
 OB and Gynecological History
- G4P0A0L4M0, Patient had no crisis during pregnancy.
 Developmental History
- Patient is 65 years old – Ego integrity vs Despair
It is in this final stage of development that involves reflecting on one’s life and
either moving into feeling satisfied and happy with one’s life or feeling a deep
sense of regret.
Upon interview and assessment, according to the patient she is at the point
of her life wherein she is very glad with what she has right now. She is happily
contented with her family and grandchildren being around their house
because this fills up their house with joy. She never complained about taking
care of her grandchildren because for the patient this means that she is
accepting her responsibilities and achieving satisfaction with herself is
essential to one’s life.
 ADLs/IADLs
- Patient bathes, dresses up, and feeds herself and can use the comfort room
alone.
- Patient can cook, go shopping, can use smart phones and can go to the
hospital by commuting.
  Family Health History
- Patient’s grandparents and parents are already deceased and all three siblings
are living, with one husband and four children, three boys and one girl.
GENOGRAM:

Paternal Maternal

/ / / /

F-/ M-/

P-DM

Legend:
Circle – Female / – Deceased
Square – Male P – Patient
Triangle – Patient DM – Diabetus Mellitus
F – Father M – Mother
III. Gordon’s Functional Health Pattern and Physical Assessment
Health Pattern Before Hospitalization During Hospitalization Nursing Diagnosis
1. Health S: “Okay naman ako nung S: “Inoperahan ata ako sa No alterations
Perception - una kaso napansin ko pantog.” As verbalized by needed in this
Health noong kama kalian lang the patient pattern.
Management may ibang amoy yung ihi O:
ko tapos iba rin ang kulay Vital signs at 8AM:
kahit madalas naman ako BP: 120/80
uminom ng tubig.” As HR: 69 BPM
verbalized by the patient. RR: 18 BPM
Temp: 36.3 C
 Patient has JP drain with
Foley Catheter to leg
bag.
 CN V: Good temporalis
and masseter tone.
 Lungs clear to
auscultation to
inspiration and
expiration.
2. Nutrition – S: “4 times a day ako S: “Hindi ako mahilig sa No alterations
Metabolic kumakain sa isang araw. gulay pero ngayon yun ang needed in this
Mahilig ako sa baboy, pinapakain sa akin ng pattern.
manok, kanin, matamis at doctor.” As verbalized by
malakas ako sa patient.
softdrinks.” As verbalized O:
by the patient.  Intake – 150 mL of Fresh
Milk
 Patient is alert, awake,
oriented and in lying
position in bed.
 Patient has good Gag
reflex.
3. Elimination S: “Mga tatlong beses o S: “Nakakaihi naman ako No alterations
A. Urine kaya apat na beses sa mga tatlong beses pa rin needed in this
isang araw ako umiihi.” naman tsaka naka catheter pattern.
As verbalized by the ako.” As verbalized by the
patient. patient.
O:
 (+) Foley Catheter
 Total urinary output:
150 mL
 Urine is light yellow
in color.

B. Elimination S: “ Normal naman pag S: “Kakadumi ko lang No alterations

dumi ko minsan mga 1-2 ngayong umaga.” As needed in this
times sa isang araw ako.” verbalized by the patient. pattern.
As verbalized by the O:
patient.  Few bruits in the
Left Lower
Quadrant.
Abdominal Sounds:
 RUQ – 6
 LUQ – 7
 RLQ – 10
 LLQ - 6
4. Sleep – Rest S: “Maaga ako natutulog S: “Putol putol and tulog ko Disturbed Sleeping
sa amin, mga 8 ng gabi dito. Minsan kulang ako sa Pattern due to
natutulog na ako at tulog. Baka kasi namamahay unfamiliar
nagigising ako 6 ng ako pero minsan naman may surroundings and
umaga. Hindi na ako maiingay na pasyente pero hospital
natutulog sa hapon para madalas talaga nahihirapan interruptions as
di ako mahirapan lang ako kaya di ako manifested by
matulog sa gabi.” As makatulog.” As verbalized restlessness and lack
verbalized by the patient. by the patient. of interest in
O: activities
 Patient is alert, awake
and oriented and was in
a lying position in bed.
 Patient seems restless
and lacks interest in
patient interview.
5. Activity – S: “Wala naman akong S: “Wala naman akong Activity Intolerance
Exercise exercise siguro yung pag magawang exercise dito. related to physical
aalaga ko lang sa mga apo Hinihingal pa rin naman ako deconditioning –
ko yun na tsaka pag pag naglalakad ako aging as manifested
lalakad lakad sa umaga papuntang banyo tapos by wheezing and
yun ang exercise ko. pabalik dito sa kama ko.” As shortness of
Madalas na rin ako verbalized by the patient. breathe.
hingalin.” As verbalized O:
by the patient.  Patient is rested in bed,
awake, alert and
oriented.
 Patient spends majority
of her time in a lying
position in bed and
asleep.
 (-) Murmurs
 (-) Crackles
 (+) Wheezing
  (-) nasal flaring
 HR: 69 bpm
 RR: 18 bpm
6. Cognitive – S “May salamin ako ang S: “May salamin pa rin No alterations
Perceptual grado 150-175.” As naman ako ganon pa rin ang needed in this
verbalized by the patient. grado 150-175.” As pattern.
verbalized by the patient.
O:
 Patient moves eyes
when awake.
 Patient’s eye are
equally round,
reactive and light
accommodating.
7. Self S: “Okay naman ako sa S: “Okay pa rin naman ang No alterations
Perception – sarili ko masaya at pakiramdam ko sa sarili ko, needed in this
Self Concept komportable naman ako masaya pa rin ako sa buhay pattern.
sa buhay ko.” As ko, lagi andito mga anak ko
verbalized by patient. at asawa ko.” As verbalized
by the patient.
O:
 Patient was relaxed and
rested in bed.

8. Role – S: “Masaya ako sa buhay S: “Ganoon pa rin naman. No alterations

Relationship ko, buhay asawa at buhay Bumibisita sila dito araw- needed in this
pamilya. Close kami lahat araw para lang siguraduhin pattern.
ng mga anak ko lagi lagi na okay ako.” As verbalized
kami mag kakasama para by the patient
mapatibay yung pamilya O:
namin.” As verbalized by  The patient has visitors.
the patient.
9. Sexuality – S: “Isa lang naman ang S: “Asawa ko lang pa rin ang No alterations
Reproductive partner ko ang asawa ko. partner ko, syempre di kami needed in this
Dalawa o kaya tatlong nakakapag talik dito lalo na’t pattern.
beses sa isang linggo kami bagong opera pa ako.” As
nag tatalik. Unang regla verbalized by the patient.
ko ay 17 years old ako,
hindi ko na gaano maalala O:
ilang taon ako nag  Breast is symmetrical in
menopause. Apat ang size, shape, no
anak ko, lahat buhay.” As prominent pores and
verbalized by the patient. areolas are dark pink to
brown color and no
discharges were
present.
10. Coping – S: “Sa edad kong ito wala S: “Wala namang naka stress No alterations
Stress na akong stress. Kung sa akin dito sa buong stay ko needed In this
Tolerance meron man pinag dadasal sa ospital.” As verbalized by pattern.
ko ito.” As verbalized by the patient.
the patient. O:
 Behavior and thought
process appropriate to
age and intellectual
capability.
11. Value – Belief S: “Catholic kami at nag S: “Nag dadasal kami dito No alterations
sisimba tuwing linggo. kami ng anak ko at ng asawa needed in this
Nagpapray kami lagi bago ko, nako lalo na ako.” As pattern.
kumain at may altar din verbalized by the patient.
kami sa bahay. Maka – O:
diyos kami ng pamilya  Presence of religious
ko.” As verbalized by the articles by bed side.
patient.
 IV. Diagnostic Tests and Laboratory Data
REFERENCE
TEST RESULT UNIT INDICATION
RANGE
Hemoglobin 115 g/L 120-140 Studies revealed
that the
Hemoglobin
levels were lower
in patient with
diverticula than
in those
individuals
without; lower
Hemoglobin
levels were likely
associated with
the presence of
diverticula as this
is a major cause
of lower
gastrointestinal
bleeding.
Hematocrit 36 % 37-47 Normal
RBC 3.8 x10^12/L 4.5-5.5 Low red blood
cells is known as
Anemia and may
indicate bleeding
in the GI tract.
MCHC 32 % 32-37 Normal
MCH 30.2 pg 27.5-33.2 Normal
MCV 94 fL 80-94 Normal
RDW 13.9 % 11.0-15.0 Normal

WBC 115.7 x10^9/L 5.0-10.0 Elevated levels of

White blood cells
 may indicate
11infection.

DIFFERENTIAL COUNT
Neutrophils 17 % 37-72 Neutropenia
refers to a low
level of white
blood cells.
Lymphocytes 50 % 20-50 Normal
n. Monocytes 2 % 0-14 Normal
Eosinophils 0 % 0-6 Normal
Basophils 1 % 0-1 Normal

Platelet 414 x10^9/L 150-440 Normal

MPV 10.0 fL 7.5-11.5 Normal
RBC Morphology Normochromic Normocytic
V. Review of Anatomy and Physiology
The large intestine is the terminal portion of the GI tract. The overall functions of the
large intestine are the completion of absorption, the production of certain vitamins, the
formation of feces, and the expulsion of feces from the body.
The large intestine, which is about 1.5cm (5 ft) long and 6.5 cm (2.5 inches) in diameter,
extends from the ileum to the anus. It is attached to the posterior abdominal wall by its
mesocolon, which is a double layer of peritoneum, Structually, the four smooth muscle.
Unlike the other parts of the GI tract, portions of the longitudinal muscles are thickened,
forming three conspicuous longitudinal bands called the teniae coil, that run most of the
length of the large intestine.
The urinary bladder is a hollow, distensible muscular organ situated in the pelvic cavity posterior to
the pubic symphysis. In males, it is directly anterior to the rectum; in females, it is anterior to the
vagina and inferior to the uterus. Folds of the peritoneum hold the urinary bladder in position.
When slightly distorted due to the accumulation of urine, the urinary bladder is spherical. When it is
empty, it collapses. As urine volume increases, it becomes pear-shaped and rises into the
abdominal cavity. Urinary bladder capacity averages 700-800 mL. It is smaller in females because
the uterus occupies the space just superior to the urinary bladder.
 VII. Pathophysiology

Non – Modifiable
Modifiable Factors:
Factors:
- Low fiber diet
- > 65 years old
- NSAID drugs
- Gender
- Corticosteroi
- Hereditary
ds

(Lumen) Mesenteric
artery supplying the colon

Penetrates inside the colon wall to

supply the mucosa and submucosa

When pressure builds up within the Lumen,

since the area of penetration is a weak spot
a diverticulum forms – involving only the
mucosa and submucosa layers

Diverticulum/Outpouching

Fecal can just lodge in there and blocks the site

Causing some form of ischemia

Damaged cells release Histamine, Bradykinin, and Prostaglandins

(Inflammatory response)

Blood vessels to leak fluid

into the tissues
Signs & Symptoms:

Swelling and rupture of  Fecaluria

peridiverticular submucosal  Blood in stool
blood vessels
 Tea-colored urine
 Dysuria
VIII. Drug Analysis
DRUG MECHANISM OF ACTION DOSAGE INDICATION ADVERSE SIDE EFFECTS NURSING MANAGEMENT
EFFECTS
1. Celecoxib Thought to inhibit Adults: 400 Is a nonsteroidal anti- Dark urine, Stomach pain, - Advise patient to promptly report
200mg prostaglandin synthesis, mg P.O., inflammatory drug. It persistent gas, constipation, signs of GI bleeding, such as blood
Generic impeding initially, works by reducing nausea/vom dizziness, nausea, in vomit, urine, or stool.
name: cyclooxygenase-2, to followed by hormones that cause iting/loss of headache - Advise patient to take drug with
Celebrex produce anti- another 200 inflammation and appetite, food because stomach upset
inflammatory, analgesic, mg dose if pain in the body. severe occurs.
antipyretic needed. Celebrex (Celecoxib) stomach/ab
is used to treat pain dominal
or inflammation. pain, and GI
reflux.

2. Vitamin C Necessary for Adults: 500 Supplemental therapy Cramps, Cramps, diarrhea. - Advise patient to take medication
500mg collagen formation mg/day for in some GI diseases diarrhea. Heartburn, as prescribed by the physician.
Generic and tissue repair. at least 14 during long-term Heartburn, nausea and Excess doses may lead to diarrhea.
Name: Involved in days. parenteral nutrition. nausea and vomiting - Advise patient to eat foods high in
Ascorbic oxidation reduction reactions; vomiting ascorbic acid. Foods high in
acid cellular respiration ascorbic acid include citrus fruits,
and resistance tomatoes, and orange juices.
to infection.
3. Vitamin B Vitamins and Vit B1 - This product is a High blood Vomiting, nausea, - Obtain a sensitivity test
Complex Minerals 100mg combination of B sugar levels, increased history before
Vit B6 - 5mg vitamins used to treat hemorrhage urination, administration.
Vit B12 - or prevent vitamin , heartburn diarrhea, An intradermal test dose
50mcg deficiency due to abdominal is recommended in
poor diet or certain cramps, and patients with
illnesses. B vitamins blurry vision. possible sensitivity.
include thiamine, - Monitor patient for
riboflavin, niacin, hypokalemia for first
vitamin B6, vitamin 48 hours.
B12, folic acid and
pantothenic.
4. Tramadol Unknown. Thought to Adults age Is indicated for the Anorexia, Mouth, dyspepsia - Monitor patient’s
+ bind to opioid receptors 17 and management of dizziness, and flatulence. bowel and
Paraceta and inhibit reuptake of older: 25mg moderate to headache, bladder function.
mol norepinephrine and P.O. in the moderately severe urinary - Explain assessment and monitoring
(Algesia) serotonin. morning. pain in adults. frequency. process to patient and family.
Adjust by 25 Instruct them to immediately
mg every 3 Aged 65 to 75 years report difficulty of breathing.
days to 100 old administered - Caution ambulatory patient to be
mg/day. tramadol have plasma careful when rising and walking.
Thereafter, concentrations and
adjust by elimination half-lives
50mg every comparable to those
3 days to observed in health
reach 200 subjects less than 65
mg/day. years of age.
IX. Nursing Care Plan
Assessment Diagnosis Planning Intervention Theory of Framework Evaluation
S: “Wala naman Activity Independent: After 6 hours of
At the end of 6
akong magawang Intolerance hours of 1. Ascertain the patient’s 1. Helping Art of successful nursing
exercise dito. related to physical successful ability to stand and Clinical interventions the
Hinihingal pa rin deconditioning – nursing move about and the Nursing patient was able to
naman ako pag aging as interventions degree assistance attain and verbalize
naglalakad ako manifested by patient will be necessary to determine methods to reduce
papuntang banyo wheezing and able to attain current status and activity intolerance.
tapos pabalik dito shortness of and verbalize needs associated with
sa kama ko.” As breathe methods to participation in desired
verbalized by the reduce activity activities.
patient. intolerance. 2. Determine the patient’s 2. Human-to-
O: current activity level Human
 Patient is and physical condition Relationship
rested in bed, with observation and Model
awake, alert use of a functional-level
and oriented. classification system
(Gordon’s). This
 Patient provides a baseline for
spends comparison and an
majority of opportunity to track
her time in a changes.
lying position 3. Increase activity levels
in bed and gradually; Teach patient 3. Theory of Goal
asleep. methods to conserve Attainment
 (-) Murmurs energy such as stopping
 (-) Crackles to rest for 3 minutes

 (+) Wheezing during a 10-minute

 (-) nasal walk.

flaring 4. Provide safe and

 HR: 69 bpm positive atmosphere. 4. Environmental

 RR: 18 bpm This protects patient Theory

from injury and
rechannel energy.
5. Encourage patient to
verbalize feelings. To 5. Helping Art of
establish individual Clinical
goals. Nursing
6. Discuss with patient
and SOs the ability to
perform desired
 activities to understand 6. Health as
that this relationship Expanding
can help with Consciousness
acceptance of
limitations.
7. Encourage patient to
attain and maintain a
positive attitude;
7. Self-care
suggest use of
Deficit Theory
relaxation techniques
of Nursing
such as visualization,
listening to music and
deep breathing
exercises to enhance
sense of well – being.
Dependent:
1. Provide supplemental
oxygen if prescribed by
the physician.
 Collaborative:
1. Refer patient to leisure
specialists to develop
individually appropriate
therapeutic regimens.

Assessment Diagnosis Planning Intervention Theory of Framework Evaluation

S: “Putol putol Disturbed Independent: After 6 hours of
At the end of 6
and tulog ko dito. Sleeping Pattern hours of 1. Asses patient’s usual 1. Helping Art of successful nursing
Minsan kulang due to unfamiliar successful sleep patterns and Clinical interventions the
ako sa tulog. Baka surroundings and nursing compare with current Nursing patient was able to
kasi namamahay hospital interventions sleep disturbance to attain and verbalize
ako pero minsan interruptions as patient will be ascertain intensity and comfort measures
naman may manifested by able to attain duration of problems that improve her
maiingay na restlessness and and verbalize and to identify useful sleeping pattern.
pasyente pero lack of interest in comfort treatment options.
madalas talaga activities measures that 2. Adjust ambient 2. Environmental
nahihirapan lang will improve lightning to maintain Theory
ako kaya di ako sleeping daytime light and
makatulog.” As pattern. nighttime dark.
verbalized by the 3. Encourage usual 3. Self-care
patient. bedtime routines such Deficit Theory
O: as washing face, hands of Nursing
 Patient is and brushing teeth.
alert, awake 4. Turn on soft music to 4. Environmental
and oriented enhance relaxation. Theory
and was in a 5. Teach patient and 5. Environmental
lying position patient’s SOs to Theory
in bed. minimize sleep-
disrupting factors such
Patient seems as reduce talking and
restless and other disturbing noises
lacks interest such as phones to
in patient promote readiness for
interview. sleep and improve
sleep duration and
quality.
6. Encourage patient to be 6. Theory of Goal
more active during day Attainment
and more passive in the
evening to help in
prometon of normal
sleep-wake patterns.
7. Assure patient that 7. Health as
occasional Expanding
sleeplessness should Consciousness
not threaten health and
that resolving time-
limited situation can
restore healthful sleep.
Dependent:
1. Administer herbal
supplements to provide
 assistance in falling and
staying asleep as
prescribed by the
physician.

Collaborative:
1. Refer patient to sleep
specialists for specific
interventions.