Hernias

Dr. Ibrahim Bashayreh RN, PhD

Objectives of case presentationTo share experience and knowledge gained from

case study to friends and supervisors.

To get feedback from the friends and supervisors for further improvement.

To develop confidence in facing the mass and presenting skills.

Objectives of case presentation At the end of this session, participants will be

able to explain about Obstructed Inguinal Hernia in terms of its clinical presentation, diagnosis, treatment and nursing management.

To share experience and knowledge gained from case study to friends and supervisors

To get feedback from the friends and supervisors for further improvement

To develop confidence in facing the mass and presenting skills

Rational for selection of the caseObstructed inguinal hernia is most common

health problem in worldwideI selected this case as to learn more about

the disease conditionProviding nursing care by applying nursing

process

Bio-data of my patient Patient’s Name :- Bhadra Bahadur Kunwar Age/ sex :- 62y/Male Marital status :- Married Education :- Illiterate Occupation :- Religion :- Hindu Address :- Bharatpur -13 ,chitwan Diagnosis :- Obsturcted Inguinal Hernia Operative diagnosis :- Ward :- Male Surgical ward Bed No. :- 31 IP No. :- 42159 Date of admission :- 2068/03/32 Date or operation :- 2068/04/02 Date of discharge :- 2068/04/04 Attending physician :- Dr. Kishor Kumar Tamrakar Informants :- Patient (self) & his son (Gopal Kunwar) Phone number :- 9849238655

Chief Complain

discomfort or sharp pain -especially when straining, lifting, or

exercising -improves when resting a feeling of weakness or pressure in the

groin

History of present illnessPatient was having complain of scrotal mass

and pain since 5 daysThan patient came to CMC OPD and had

consultation with physician where he diagnosed to have obstructed Inguinal Hernia

History of present illness Cont… Onset of symptoms- Characteristics- Duration- Associated symptoms- Aggravating factors- -sudden twists, pulls, or muscle strains -lifting heavy objects -straining on the toilet because of constipation -chronic coughing Alleviating factors- Allergy-No allergies noted Any health problem- Type of illness- Duration of illness- Placement of treatment-

History of past illnessAllergy-Any health problem-Types of illness-Duration of illness-Place of treatment-

Family HistoryHe belongs to extended familyThere are 6 members in his familyMedical history of family memberGood relation among family membersHas 5 room well ventilated and separate

kitchen. Environmental sanitation well maintained.

Personal HistoryDietary pattern-Non-vegHas good appetiteBathing habits-Regular everydayBladder and bowel habits-Regular bladder

habits but he has complain of constipation on and off

Smoking-NoAlcohal-No

Personal History Cont..Housing pattern-Fuel using-Purpose of kitchen

Health beliefsPatient including his family members has a

complete belief in modern science and visit doctor and hospital during health problems

Finding from physical examinationPatient look anxious, well balanced gait, well

nourished and average body built

Head to toe physical examination : During head to toe examination , scrotal

mass and pain . No any other abnormal findings detected.

Introduction of Disease Condition

HerniaA hernia is the abnormal protrusion of an

organ,tissue or part of an organ through the structure that normally contains it.Hernia most commonly occurs in the abdominal cavity as a result of a congenital or acquired wakness of abdominal musculature.Hernias can occurs at any age and in either sex.Indirect hernias are most common type and typically occurs in men.Direct hernias found more commonly in elder people.

There are several types of hernia : -Inguinal hernia -Femoral hernia -Incisional hernia -umbilical hernia -Hiatus hernia -Epigastric hernia -Spigelian hernia -Muscles hernia

Obstructed Inguinal HerniaProtrusion of abdominal cavity contents

through the inguinal canal. They are very common and their repair is one of the most frequently performed operations.

There are two types of Inguinal herniao Direct inguinal herniao Indirect inguinal hernia

Indirect Inguinal HerniaThe abnormal passage of an internal abdominal

organ or structure trough the inguinal canal.In males this will result in a unilateral bulge in the scrotum,in female there will be unilateral swelling in ths region of the labia majora.

Many hernias reduce (go away) on their own but returns at times of straining of lifting

A hernia that does not go away and cause pain is a surgical emergency

EpidemiologyIt is estimated that over 20 million surgical

procedures for inguinal hernia are performed each year

the disorder predominantly affects men (male:female ratio is 7:1

Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct

Courtsy-BMJ Group

Incidence RateAbout 25% of males and 2% of females

develop inguinal hernias; this is the most common hernia in males and females.

EtiologyAccording to bookAlthough abdominal hernias can be present at birth,

others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness

Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia

For example- ObesityHeavy liftingCoughingStraining during bowel movement or urination

Chronic lungs diseaseFluid in abdominal cavityA family history of hernias

PathophysiologyIndirect inguinal hernias usually occur because of a

persistent process vaginalis. As the hernia emerges through the deep internal ring

it carries with it fascial linings of the tissue it transverses

The hernia courses along the inguinal canal lateral to the epigastric arteries and emerges through the external ring slightly lateral to the pubic tubercle.

Contents of this hernia then follow the tract of the spermatic cord down into the scrotal sac in men

or follows the round ligament in females

Clinical Manifestation According to BookA bulge in the area on

either side of your pubic bone

A burning, gurgling or aching sensation at the bulge

Pain or discomfort in your groin, especially when bending over, coughing or lifting

A heavy or dragging sensation in your groin

According to PatientSwelling left inguinalscrotal regionPain in left inguinal

region

Fever

Occasionally, in men, pain and swelling in the scrotum around the testicles when the protruding intestine descends into the scrotum

Smoking Undesended testicles

On Physical examination-Cough impulse + non

reducible

Diagnostic Evaluation According to BookHistory takingPhysical examination -Examine the patient in

standing and supine position

Blood countHerniographyUltrasonographyMRICT Scan

According to patientHistory TakingPhysical ExaminationChest X-rayLab test-Serology test .HIV I and II Antibody.HBsAG.HCVPlatelet countSodium Potasium

Finding on Diagnostic Tests on PatientChest X-ray showsHaematologyWBC-6,600HB-13.8Neutrophil-69%Lymphocytes-28Monocytes-02Esinophil-01Basophil-00Bleeding time-2’00’Cloting time-12’00’Platelet counts 170000

BiochemistryUrea – 27.5SodiumPotasiumBlood sugar (R)-101mg/dl SerologyHIV I & II Antibody – Non ReactiveHBsAG- Non Reactive HCV – Non Reactive

TreatmentTreatment can be Non operative and OperativeNon-OperativeObservationIf there are compelling co-morbid medical

conditions that preclude surgery, then a truss, or support hernia belt may be employed. A truss does not repair the hernia defect, but will afford some relief of symptoms

Trusses can provide symptomatic relief -Hernia control in 30% of patient

Operative or Surgical ManagementThe Surgical procedure for Inguinal Hernia• Bassini• Shouldice• Mc vay• Lichtenstein• Pre-erotoneal• Laproscopic

Treatment According to My PatientPre-operativeTab.Alprox 0.5mg HSPost-OperativeInj.Megapen 1gm iv 6 hourlyInj.Aciloc 50mg iv BDInj.Tramadol 50mg I/M SOSInj.Phenargan 25mg SOS

On DischargeCap Megapen 1gm po qid x 3 daysTab nise 100mg po bd x 2 daysTab Aciloc 150mg po bd x 2 days

ComplicationsRecurrenceInfectionNeuralgiaBladder InjuryTesticular InjuryVas Deference Injury

Prognosis of My PatientMy patient stayed hospital for 2 days after surgery.

During post operative periods no any complication arises and discharged on 068/04/04 so, the prognosis of my patient is good.

Theory application during case study While caring the patient I applied Orem’s theory. There

are three component in Orem’s theory:1. Theory of self care2. Theory of self care deficit3. Theory of nursing system Wholly compensatory Partially compensatory Supportive educative system

Nursing ManagementPre-operative

Closely monitor vital signs and provide routine preoperative preparation. If necessary, When surgery is scheduled

Administer I.V. fluids and analgesics for pain as ordered.

Place the patient in Trendelenburg's position to reduce pressure on the hernia site.

Pain related to swelling and pressure

Post operativeProvide routine postoperative care. Don't allow the patient to cough, but do

encourage deep breathing and frequent turning.

Apply ice bags to the scrotum to reduce swelling and relieve pain; elevating the scrotum on rolled towels also reduces swelling.

Administer analgesics as necessary. In males, suspensory bandage may be used to

provide support

Nursing DiagnosisAssessmentSubjective data-I have pain and swelling on

my scrotumObjective Data-Inspection reveal swelling

and pain as evidence by restlessness, pallor, elevated pulse and facial expression

Vital signs-Tempreture-98 Pulse-94/m Respiration-20/m Blood pressure-130/80mmofhg

Nursing Diagnosis-Pain related to swelling and pressureDesire outcome-Control of pain within 2

hoursPlanning- - Perform comprehensive assessment of pain - Teach the use of non-pharmacological technique- Proper position the patient- Administer analgesics as prescribed

Nursing Intervention- Performed comprehensive pain assessment

including location ,characteristics ,onset,frequency ,quality, intensity and severity

- Tought the patient the use of non-pharmacological technique e.g. Relaxation guided imaginary

- Place the patient in Trendelenburg's position to reduce pressure on the hernia site.

- Administered Prescribed Analgesic

Evaluation-The disired outcome met as patient verbalized the relief of pain ,request analgesic on onset of pain

Nursing assessmentSubjective Data-Objective Data-

Nursing Diagnosis-Fear and anxiety related to outcomes of surgery Desire outcome- Reduction in fear and anxiety- The patient will demonstrate the knowledge of psychological

response to invasive procedure

Planning Assess patient’s anxiety and fear before surgery Assess patient’s knowledg about procedure and expected

outcome preoperatively Encourage patient to verbalize reactions, feelings and

fears Encourage family members to be with the patient and

share feelings Evaluate the meaning of alterations resulting

from surgical procedure for the patient and family

Nursing interventionAssessed patient’s anxiety and fear before surgery

Assessed patient’s knowledge about procedure and expected outcome preoperatively

Encouraged patient to verbalize reactions,feelings and fear

Encouraged family members to be with the patient and share feelings

Evaluate the meaning of alterations resulting from surgical procedure for the patient and family

Evaluation The patient participates in decision affecting his plan

of careThe patient demonstrate the knowledge of

psychological response to invasive procedure

Nursing assessment Subjective Data-I have discomfort due to Foleys

catheterObjective Data-

Nursing Diagnosis-impaired urinary elimination related to surgery Desire outcome-Absence of urinary bladder

distention

Planning - Monitor urine output and characteristics

Monitor for evidence of catheter blockage,change the catheter as needed

prevent excessive tension on the catheter. Encourage high fluid intake (2500-3000ml/day)

Nursing interventionMonitored urine output and characteristicsMonitored for evidence of catheter blockage,change the catheter as

neededMaintained patency of indwelling urinary catheterEncouraged high fluid intake (2500-3000ml/day)

EvaluationExpected desire was met as there was no

evidence of impaired on urinary elimination

Nursing assessmentSubjective dataObjective Data

Nursing Diagnosis-Disturbed sleep pattern due to hospitalization

Risk for injury related to surgery

Nursing Diagnosis-Risk for chest infection related to previous disease condition(Asthma) and anaesthetic medication

Discharge TeachingTell the postoperative patient that he'll probably be able

to return to work or school 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.

Follow up visit in OPD for stich removal

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.

THANK YOU FOR YOUR KIND ATTENTION

Treatment Options

All hernias should be surgically corrected to remove the risk of incarceration and strangulation.

If there are compelling co-morbid medical conditions that preclude surgery, then a truss, or support hernia belt may be employed. A truss does not repair the hernia defect, but will afford some relief of symptoms.

Modern methods of repair include open primary closure of the defect with sutures (Shouldice or "Canadian" Repair, Bassini Repair); patch closure with prosthetic materials (Polypropylene or Gortex) tension-free (Lichtenstein-type) and laparoscopic repair.

Primary Nursing Diagnosis: Pain related to swelling and pressurePrimary nursing Outcomes: Pain, disruptive effects; pain levelPrimary nursing Interventions: Analgesic administration; pain management

Common Nursing diagnoses found on Nursing care plan for Inguinal HerniaActivity intolerance Acute painIneffective tissue perfusion: GIRisk for infectionRisk for injury