INDIRECT INGUINAL LEFT HERNIA

HERNIA A protrusion of an organ through a weak area in the

muscles or tissue that surround and contain it. Most commonly, the word hernia is used to refer to an abdominal hernia. An inguinal hernia occurs when a loop of intestine enters the inguinal canal in the groin area, between the pubis and the top of the leg. The intestine goes through the lower layers of the weakened abdominal wall and creates a lump.

Causes of Inguinal Hernia -Heavy lifting

-Straining during bowel movements and urinating -Constipation -Excessive coughing or sneezing -Vigorous exercise or sex can be contributory factors -Family history of hernia -Obesity

Signs and Symptoms of Inguinal HerniaTenderness or sharp pain in the groin often aggravated by lifting or bending. A tender lump in the groin or scrotum it usually disappears when you lie down and enlarges when you cough, sneeze or strain.

CONTENTSI. Objectives of the StudyII. Patient’s Profile Personal Data History of Present Illness Past Medical History Familial History Social/Lifestyle History Physical ExaminationIII. Anatomy and PhysiologyIV. PathophysiologyV. Diagnostic Test/Special Procedure Laboratory Test Special ProceduresVI. Course in the WardVII. Treatment Drug StudyVIII. Nursing Care PlanIX. Health Education/Patient’s Education

Objectives of the study

General Objectives:

The purpose of this study is to prevent further complications brought by inguinal hernia.

SPECIFIC OBJECTIVES:

• To inform and update the knowledge of patient about inguinal hernia self-care and prevention of complications during hospitalization.

• To plan management strategies to a inguinal hernia patient.

 • To use the nursing process as a framework for

care in patients with hernia.

• To improve status of the patient

• To correct defect and prevent strangulation.

• To include adequate nutritional intake.

PATIENT’S PROFILE

PERSONAL DATA

Name : Mr. ZAge : 24 years oldDOB : November 4, 1985 Place of Birth : Quezon CitySex : Male Religion : R. CatholicOccupation : none Nationality : Filipino Weight: 120 lbsHeight : 5 ft 9 inch

History of present illness Date of Admission : July 4, 2010Time of Admission : 9:45a.mChief Complaint : Inguinal mass to leftAdmitting Diagnosis : Indirect Inguinal Left

Hernia Vital Signs:

Temp: 36.5C BP: 120/70 mmHg Pulse Rate: 81 bpm RR : 20 cycle/min

PAST MEDICAL HISTORY  (-) Allergy (+) Asthma- Last attack during childhood    FAMILY HISTORY  (+) Hypertension – Parent’s Side

 

SOCIAL/LIFESTYLE  -Non smoker  -Alcoholic Beverage Drinker  -His diet consist of nutritional intakeaccording to his satisfaction  -Helping his brother making hallow blocks and collecting heavy steel  -Heavy lifting comes usually to his work 

Physical Examination

•General Survey: Conscious and Coherent

•Vital Signs: Temp=36.8º c PR: 98 bpm RR: 20 cycles/min BP: 100/70 mmHg

•Integumentary –Black Contour

-Skin: Warm, Moist skin -Hair: Hair evenly distributed Smooth texture Absence of dandruff Absence of infestation Thick hair-Nails: Oval in shape with slight thickness At end part of nail, smooth texture Normal Capillary refill (1-2 secs.)

•Head and Neck-Head: Normocephalic Symmetric-Eyes: Normal visual acuity Both eyes coordinated movement with parallel alignment Symmetric evenly distributed Eyebrow/Eyelashes Eyelids color matches the skin with coordinated movement Pink partial conjunctiva-Ears: Symmetric , Smooth auricle with light brown color, Small in shape No discharge, No wounds, Presence of cerumen

-Nose: Located at the midline of the face and there is no swelling or lesions noted-Mouth: Pale lips, smooth and not scaly. Absence of tooth decay Pinkish and reddish gums. Pink pharynx Normal flow of saliva Tongue is pinkish in color, both palate is still and normal position

-Neck: Client was able to turn his neck from left to right motion Head position is equal on both sides-Thorax and lungs: Spine vertically aligned No tenderness or masses Breathing is normal-Abdomen: Unblemished skin and uniform in color Dullness at the lower right quadrant

-Musculoskeletal: Irregular movements Weak in appearance-Lower Extremities: Symmetrical on both sides of the body with no contractures Muscles are firm with smooth coordinated movements No deformities, no tenderness, or swelling with joints moving smoothly-Neurologic: Full consciousness, response to verbal stimuli, organized speech noted-Genitourinary System: Client refuse

Diagnosis

An inguinal hernia occurs when a loop of intestine enters the inguinal canal in the groin area, between the pubis and the top of the leg. The intestine goes through the lower layers of the weakened abdominal wall and creates a lump. Indirect inguinal hernia- a hernias are much more common in males than females because of the way males develop in the womb. In a male fetus, the spermatic cord and both testicles, starting from an intra-abdominal location. Normally descend through the inguinal canal into the scrotum, the sac that holds the testicles. Sometimes the entrance of the inguinal canal at the inguinal ring does not close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the small intestine slides through the weakness into the inguinal canal, causing a hernia. In females, an indirect inguinal hernia is caused by the female organs or the small intestine sliding into the groin through a weakness in the abdominal wall.

• Causes:Any condition that increases the pressure in the intra-abdominal cavity may contribute to the formation of a hernia, including the following: -Heavy lifting -Straining during bowel movements and urinating -Constipation -Excessive coughing or sneezing -Vigorous exercise or sex can be contributory factors -Family history of hernia -Obesity

Anatomy and Physiology•An indirect inguinal hernia

follows the tract through the inguinal canal. This results from a persistent process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine.

The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac.

Types of Hernia - Location

Hernias may occur commonly in such areas as the lower abdomen or groin areas (Inguinal Hernia), at the region around the navel (Umbilical Hernia), or even through a prior surgical incision (Incisional Hernia). Hernias can re-occur in an area of a previous hernia repair (Recurrent Hernia).

Anatomic locations for various hernias

But Hernias can and do occur anywhere on the abdominal wall, and are given other various names such Femoral, Epigastric, Spigelian or Sports Hernia. The basic problem remains the same, the muscle container of the abdominal wall no longer holds the contents safely and securely in place. As pressure inside the abdomen pushes the abdominal contents through this defect, a bulge is created, and pain, burning or aching are experienced. These symptoms gradually increase in intensity with time as the hernia gradually enlarges, stretching surrounding tissue and irritating local nerve pain fibers

PATHOPHYSIOLOGY

Increased pressure in the compartment of the abdomen is develop

Intra-abdominal wall (containing membranes or muscle) of inguinal canal

into the scrotum becomes weakened

Causing the inguinal ring not to close

Evolves into a hole or defect

Fat or part of the small intestine slide trough the inguinal canal

Feeling of weakness or pressure In the

groin

Pain or Discomfort

Swollen or enlarged of scrotum

DIAGNOSTIC TEST&

SPECIAL PROCEDURE

URINALYSIS

Physical Examination

Reference Values

Microscopic Examination

Reference Values

Color Yellow Yellow RBC: 0-1/hpf 0-1 / hpf

Transparency Slightly Hazy Clear WBC: 0-1/hpf 0-3 / hpf

Reaction 6.5 4.8 – 7.8 Bacteria: occasional

Few

Specific Gravity 1.015 1.015- 10.25 Epithelial Cells: occasional

Few

Chemical Examination:•Sugar: Negative•Albumin: Negative

CBC- Complete Blood Count

Examination Result Normal ValueHemoglobin 14.1 13.5- 18.5 g/dLHematocrit 41.8 40-54%Red Blood cells 5.08 4.0- 6.0 : 10ˆ6 /υLMean Corpuscular Hemoglobin

27.8 26- 34 pg

Mean Corpuscular Volume 82.3 80- 100 fLMean Corpuscular Hemoglobin

33.7 31- 37 g/dL

WBC 9.06 4.5- 11.0 : 10ˆ3/υLNeutrophils 57.0 50- 70%Lympocyte 33.2 20-40%Monocyte 6.5 0- 7%Eosinophils 2.9 0.0- 5.0%Basophils 0.4 0.0- 1.0%Platelet Count 223 150- 400ˆ6/υL•Remarks: Platelet Adequate

Fecalysis Report

Gross Examination

Result Microscopic Examination

Result

Color Dark Brown RBC None

Consistency Formed Pus Cells None

Mucus None

Ova or Parasites

None Seen

Cysts of Trophozoite

None Seen

Radiology/X-Ray Section

-INTERPRETATION-

*Chest ( PA OR AP) Adult

Lungs are clear. Hila and Pulmonary vessels are within normal limit

Heart is normal in size and configuration

Diaphragm and Sulci are intact

The visualized bony and soft tissue structures are normal

COURSE IN THE WARD

On admission, nursing diagnostics done and therapeutics started on, 7/05/10.

Patient underwent herniorrhaphy , left, Post- operative condition was stable.

He was discharged, improved and stable.

Treatment for Inguinal Hernia

Treatment is important to avoid a potentially serious condition called a strangulated hernia. This is when the bulging through the muscle wall obstructs the flow of blood to the intestine or stops the flow of intestinal contents, leading to tissue death.

An inguinal hernia can often be reduced (pushed back into place). If this doesn't work, then surgery is required under a general anesthetic. The segment of bowel is put back in the abdominal cavity and the muscle is closed. A piece of plastic mesh is sometimes used to reinforce the weakened muscle area. A dry dressing protects the incision area for a few days.

DRUG STUDY

Cloxacillin-500mg 1cap 4x/day for 7days C: Penicillin I: Infections due to staph resistant to benzyl penicillin including infections of the skin and soft tissue, bones and joints, resp. tract and urinary tract; otitis media

A: Take empty stomach 1hr. Before or 2hrs. After meals

Ci: Hypersensitivity to penicillins SE: History of significant allergies or asthma

AR: G.I. disturbances and skin rashes

• Mefenamic Acid-500mg 1cap 3x/day C: Non-steroidal Anti-inflammatory drug I: For Acute and chronic relieving pain A: Take immediately after meals Ci: Ulceration ir inflammation of GIT SE: Pregnancy; Renal and hepatic impairment. Patients suffering from dehydration. May exacerbate asthma AR: GI disturbances, drowsiness, skin rash DI: Coumarin Anticoagulants

• Cefuroxime-750mg IV q8º C: Cephalosporin (Anti-biotic) I: Infections of urinary and lower resp. tract. Peri-operative prevention : Inhibits cell-wall synthesis, promoting osmotic instability usually bacteria. A: Should be taken with food AR: G.I. disturbances and skin rashes Ci: Hypersensitivity to penicillin

• Ranitidine-50mg I.V q8º C: Antacids, Antireflux agent, Antiulcerants I: Management of peptic ulcer disease, persistent dyspepsia, patient at risk of acid aspiration during gen. anesthesia or child birth. D: Active duodenal ulcer A: Before and after meals SE: Rule out gastric malignancy prior to therapy. AR: Constipation, Diarrhea, Nausea/Vomitting, abdominal pain.rash

• Diclofenac-35mg. I.M 2x/day

C:Anti-Inflammatory I:Relief of mild to moderate pain of dysmenorrhea : Inhibits Prostaglandin A: Should be taken with food (Take immediately after meals. Swallow whole, do not chew/crush.) SE: Abnormal pain dyspepsia heartburn diarrhea hepatotoxicity AR: Active G.I. bleeding/ ulcer disease

Nursing Care Plan

Long Term goal: The patient will verbalize recognition of Intrapersonal/family dynamics and reactions that affect the pain problem.Short Term goal: The patient will verbalize and demonstrate relief and/or control of pain/discomfort.

Assessment Nursing Diagnosis Scientific Rationale Intervention Rationale Expected Outcome

S>>Patient verbalized, “Nahihirapan ako magkikilos dahil kumikirot pag tumatayo ako”

O>> V/S: Temp: 36.5ºc BP:120/70mmHg PR : 81 bpm RR : 20cycle/min.

-(+)discomfort-8/10 pain scale-Facial Grimacing-(+)Tenderness-(+)Swelling

-Acute pain related to his present condition of indirect inguinal left hernia

-Unpleasant sensory and emotional experience arising from actual or potential tissue damaged or described in terms of such damage

1. Note sex and age of patient.

2. Evaluate pain behavior

3. Assist client to learn diaphragmatic breathing.

4. Monitor vital signs

5. Provide comfort measures

1. Suggests there may be differences between women and men as to how they perceive and/or respond to pain.

2. May exaggerated because client’s perception of pain is not believed or because client believes caregivers are discounting reports of pain

3. To assist in muscle and generalized relaxation.

4. Usually altered in acute pain

5. To provide nonpharmacological pain management.

The patient will verbalized relief/absence of pain

SHORT TERM GOAL: PATIENT WILL PARTICIPATE WILLINGLY IN DESIRED ACTIVITIES LONG TERM GOAL: PATIENT WILL USE IDENTIFIED TECHNIQUES TO ENHANCE WOUND HEALING

Assessment Nursing Diagnosis Scientific Rationale Intervention Rationale Expected Outcome

S>>Patient verbalized, “Hindi ko naman alam kung pano linisan ang opera ko”

O>> V/S: Temp: 36.5ºc BP:120/70mmHg PR : 81 bpm RR : 20cycle/min.

-Worries about his condition

-(+)Oozing-(+)Redness-(+)Tenderness-Poor wound healing-(+)Swelling-Poor wound healing

-Risk for infectionrelated to surgicalincisionsecondary toHerniorrhaphy

-Because of thebroken skin,traumatized tissueon the injured sitehas occurred.This could lead tothe invasion ofpathogenicmicroorganismthereforeincreasing therisk of infectionand may result tofurthercomplications ifnot prevented

1. Establish rapport

2. Monitor Vital Signs

3. Encourage therelative to changedressings of thepatient as needed

4. Encourage the patient or relative to cleansewith solution thesites of wound ofthe patient daily

5. Instruct thepatient thetechniques toprotect integrityof skin, care oflesions andprevention ofspread ofinfection.

1. To gain trust to patient

2. To determine any abnormalities

3. To reduce existing factors

4. To prevent any pathogenic infections

5. To promote wellness

- The patient will be able to identify reducing infections

Health Education/Patient’s Education

Patient teaching home health guide 

Explain what an inguinal hernia is and how it's usually treated.

Explain that elective surgery is the treatment of choice and is safer than waiting until hernia complications develop, necessitating emergency surgery.

Warn the patient that a strangulated hernia can require extensive bowel resection, involving a protracted hospital stay and, possibly, a colostomy.

Tell the patient that immediate surgery is needed if complications occur.

If the patient uses a truss, instruct him to bathe daily and apply liberal amounts of cornstarch or baby powder to prevent skin irritation.

• Warn against applying the truss over clothing, which reduces its effectiveness and may cause slippage.

• Point out that wearing a truss doesn't cure a hernia and may be uncomfortable.

• Tell the postoperative patient that he'll probably be able to return to work and resume all normal activities within 2 to 4 weeks.

• Explain that he or she can resume normal activities 2 to 4 weeks after surgery.

• Remind him to obtain his physician's permission before returning to work or completely resuming his normal activities.

• Before discharge, Instruct him to watch for signs of infection (oozing, tenderness, warmth, redness) at the incision site. Tell him to keep the incision clean and covered until the sutures are removed.

• Inform the postoperative patient that the risk of recurrence depends on the success of the surgery, his general health, and his lifestyle.

• Teach the patient signs and symptoms of infection: poor wound healing, wound drainage, continued incision pain, incision swelling and redness, cough, fever, and mucus production.

• Explain the importance of completion of all antibiotics.

• Explain the mechanism of action, side effects, and dosage recommendations of all analgesics.Caution the patient against lifting and straining