Catanduanes State Colleges COLLEGE OF HEALTH SCIENCES NURSING DEPARTMENT Virac,Catanduanes

CASE STUDY
(Indirect Inguinal Hernia)
Submitted by: LANON, EMLYN JOSEPHINE M. BSN4A/G3

Submitted to: MR. JOEL T.OLFINDO, RN, MAN Clinical Instructor

I. INTRODUCTION
An inguinal hernia is a common condition in infancy and childhood, and is the most common surgical operation in childhood. An inguinal hernia occurs when tissue or part of the intestine pushes through a weak spot in the abdominal wall in the groin area, causing a bulge in the groin or scrotum. It occurs usually in boys (9:1). An (indirect) inguinal hernia is caused by an opening in the inguinal canal that does not close as it should before birth. This allows abdominal tissue to push through the lower abdominal muscles. The occurrence of inguinal hernia and undescended testes is related to the developmental events that result in the formation of the processus vaginalis and the descent of the testicles into the scrotum. The most common type of abdominal hernia is an inguinal or groin hernia. Patients usually bring these hernias to the attention of their physicians when they either feel a lump in their groin or develop pain or soreness with certain activities. The activities that tend to exacerbate hernia pain include prolonged standing, lifting, and straining to have a bowel movement. Hernias are essentially holes in the abdominal wall through which abdominal organs can protrude through causing a bulge or lump when looking at the skin.

II. STATEMENT OF THE OBJECTIVES A. SPECIFIC

To be familiar with the etiology of the disease To know the pathophysiology of the disease To be aware of the signs and symptoms To know its complications To be knowledgeable on how to prevent the disease To know the treatment and how to apply it To know the diagnostic exam To be aware of appropriate nursing interventions

B. GENERAL
To be knowledgeable about the nature of Indirect Inguinal Hernia; its management and treatment to be able to render effective nursing care to the client.

III. PATIENTS PROFILE

A. GENERAL DATA
NAME AGE : Justin Lee Rdulfo : 7 y/o : June 27, 2012 @ 9:00 PM : Dr. Badong : Scrotal Mass L : Indirect Inguinal Hernia L : Indirect Inguinal Hernia L BIRTHDATE: January 12, 2005 ADDRESS : Cabugao, Bato

DATE OF ADMISSION ATTENDING PHYSICIAN CHIEF COMPLAINT TENTATIVE DIAGNOSIS FINAL DIAGNOSIS

B. HISTORY 1. Past Health History Justin was full-term; born via NSD. He obtained all imperative immunizations during his childhood. Justins mother revealed that he was born with hernia (congenital). It became prominent when Justin was 3 months old. It also became bigger while hes growing, yet it has never been a source of health problem for Justin. The patient did not feel pain in the affected part ever since. Furthermore, he did not experience abdominal pain, nausea and vomiting before due to hernia. Occasionally, he suffers from mild cough and colds with slight fever. He has no known allergies to any food or medications.

2. Present Health History Justin, a seven-year-old child, was rushed to the emergency department with complaints of scrotal mass. It was not associated with pain or swelling. The parents just noticed that the hernia has increased in size. 3. Family-socio-economic-environmental Status A familial history of inguinal hernia was ruled out. Justins father and grandfather have it. Justin, as told by the mother, is an active boy playing outside their house. Justin jumps, lifts, and plays. He is picky with foods and eats vegetables in minimal amount. A caring and supportive family surrounds him and provides him whatever he needed of. The Rodulfo family belongs in the middle class status and they are sociable. C. INITIAL PHYSICAL EXAMINATION 1. Actual Vital Signs BP: 80/50 mm Hg P : 82 bpm R : 16 bpm Wt. 11.5 kg. 2. Physical Examination General Survey: Normothermic; Has a swelling left scrotum; without complaints of pain Child appears malnourished, doesnt have eye contact Child doesnt talk much, seems fearful and uncomfortable Developmental Assessment: Uncooperative, nods and shakes head when asked.

IV. COURSE IN THE WARD

Doctors order
6/27/12
Please admit at pedia surgery ward under my service Secure consent for admission and management NPO advised Monitor VS q shifting Requests for CBC, urinalysis, blood typing IVF: D5 0.3% NaCl 500 cc @ 20 ugtts/min Medications: Cefuroxime 500 mg q 8 TIVT ANST Kindly refer to surgery for further evaluation STAT Please refer accordingly Thank you. 10 PM For E herniotomy For pediatric evaluation pls For CXR APL Pls. give Nalbuphine 5 mg IV stat

Nurses notes
6/27/12
(9:20 P.M.) F - Admission: D a 7 y/o male, child accompanied by relative with chief complaint taken as scrotal mass L A seen and examined by Dr. Romano; VS taken and recorded; consent to care signed; IVF inserted aseptically; lab exam prescribed by Dr. Badong; informed

A - seen and examined by Dr. Badong; Nalbuphine 5 mg IV is given @ 10:20 pm; for pedia clearance tom as ordered by Dr. Badong; CXR done;advised for E herniotomytomorrorow AM as verbalized by Dr. Badong

10:45 P.M. F- Postward Transfer Assessment D- in from ER @ 10:45 PM cuddled by father accompanied by relatives

with ongoing IVF of D5 0.3% NaCl 500 cc patent and infusing well; with scrotal mass L; for urinalysis A- V/S taken and recorded; oriented to ward set-up; NPO advised; for E herniotomy, for pedia clearance tom. AM once lab results are in

11-7 D with patent IVF, afebrile, with scrotal mass L for urinalysis, for E herniotomy, for pedia clearance tom. AM once lab results are in A urine specimen sent to lab; NPO maintained; meds started 6/28/12 7-3 F Imbalanced Nutrition: Less than Body Requirements D poor skin turgor; dry crack lips; weak-looking; thin and with ongoing IVF; patent and infusing well A advised watcher to OFI; encouraged to eat nutritious food; kept safe and comfortable R watcher verbalized understanding F- E Herniotomy

D with order to E herniotomy; seen by Dr. Badong with order for DAT; pediatric clearance performed by Dr. Barceta @ 10;45 AM with order to proceed with contemplated procedure; with scrotal mass L A advised to have DAT; assessed for dysuria; encouraged verbalization R verbalized pagadakulaangsugokniyagahapdosangbitukanyabudanasakitansya mag-ihi; kept safe and comfortable 3-11 F- For E Herniotomy 6/28/12 6:30 PM NPO post midnight For elective herniotomy in AM Secure consent Refer to AOD/OR staff 7:50 PM Pre-op Orders Patient seen and examined Secure consent for anesthesia and procedure Secure good IV line: D5 0.3 NaCl 500 cc @ 50 ugtts/min Secure materials: Bupiracaine 1 amp # 1 D- seen by Dr. Badong @ 6:30 PM with order for elective herniotomy tomorrow AM (6/29/12) A- informed watcher for operation tomorrow AM; consent for anesthesia and surgery secured; referred to AOD; NPO to solid foods @ least 6 and NPO to clear fluids @ least 2 prior to OR advised; materials and medications presrfibed; advised for oral/body hygiene prior to OR R- watcher expressed understanding and willingness to comply with given instructions

Spinalneedle g. 25 # 1 Midazolam 5 mg amp # 1 Atropine 1 mg cap # 1 Nalbuphine 100 mg amp # 1 Premed: Nalbuphine 50 mg TIV to be given 30 mins. PTOR NPO to solid foods @ least 6 PTOR NPO to clear liquids @ least 2 PTOR Advise oral/body hygiene To OR on-call

DIAGNOSTIC EXAMS: HEMATOLOGY NAME OF Lab. Test RESULT NORMAL RANGE SIGNIFICANCE

Hematocrit

0.42

0.40-0.54

Normal.

Hemoglobin

126 g/L

140- 160 g/L (F)

DecreasedAnemia, hyperthyroidism, cirrhosis of the liver, and severe hemorrhage

WBC Count

20.5 x 10 g/L

5.0 x 10 g/L

Increased- Leukemia, bacterial infection, severe sepsis Increased- Acute bacterial infection, tumor, inflammation, stress, drug reaction

Neutrophils

0.82

0.58-0.66

Platelet

206 X 10^ 9/L

150-350 X 10^9/L

Normal.

PURPOSE: The CBC provides valuable information about the blood and to some extent the bone marrow, which is the bloodforming tissue. The CBC is used for the following purposes: as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis to identify persons who may have an infection to diagnose anemia to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia to monitor treatment for anemia and other blood diseases to determine the effects of chemotherapy and radiation therapy on blood cell production NURSING IMPLICATIONS: PatientTeaching: Inform the patient this test can assist in evaluating the amount of hemoglobin in the blood to assist in diagnosis and monitor therapy. Obtain a history of the patient's complaints, including a list of known allergens, especially allergies or sensitivities to latex.

Obtain a history of the patient's cardiovascular, gastrointestinal, hematopoietic, hepatobiliary, immune, and respiratory systems; symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures. Note any recent procedures that can interfere with test results. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture. Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. There are no food, fluid, or medication restrictions unless by medical direction.

Intratest: If the patient has a history of allergic reaction to latex, avoid the use of equipment containing latex. Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Observe standard precautions, and follow the general guidelines. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. Perform a venipuncture; collect the specimen in a 5-mL lavender-top (EDTA) tube. An EDTA Microtainer sample may be obtained from infants, children, and adults for whom venipuncture may not be feasible. The specimen should be mixed gently by inverting the tube 10 times. The specimen should be analyzed within 24 hr when stored at room temperature or within 48 hr if stored at refrigerated temperature. If it is anticipated the specimen will not be analyzed within 24 hr, two blood smears should be made immediately after the venipuncture and submitted with the blood sample. Smears made from specimens older than 24 hr may contain an unacceptable number of misleading artifactual abnormalities of the RBCs, such as echinocytes and spherocytes, as well as necrobiotic white blood cells. Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. Promptly transport the specimen to the laboratory for processing and analysis.

Post-test:

A report of the results will be sent to the requesting HCP, who will discuss the results with the patient. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient's symptoms and other tests performed. URINALYSIS Macroscopic: Color -yellow Transparency - clear Specific Gravity - 1.010 Reaction - acidic Albumin Microscopic: Epith. Cells Red cells Pus cells Cast Others - few - 0-1 hpf - 0-1 hpf

Nursing Considerations for Routine Urinalysis 1. Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. Women should always have a clean-catch specimen if a microscopic examination is ordered. Feces, discharges, vaginal secretions and menstrual blood will contaminate the urine specimen. 2. Collect specimens form infants and young children into a disposable collection apparatus consisting of a plastic bag with an adhesive backing around the opening that can be fastened to the perineal area or around the penis to permit voiding directly to the bag. Depending on hospital policy, the collected urine can be transferred to an appropriate specimen container. 3. Cover all specimens tightly, label properly and send immediately to the laboratory. 4. If a urine sample is obtained from an indwelling catheter, it may be necessary to clamp the catheter for about 15-30 minutes before obtaining the sample. Clean the specimen port with antiseptic before aspirating the urine sample with a needle and a syringe. 5. Observe standard precautions when handling urine specimens.

If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated or have an appropriate preservative added.

MEDICATIONS:

Name of the Drug

Dosage, Route, Frequency

Action

Contraindications

Side Effects/ Adverse Effects

Nursing Responsibility

Use IV route for severe life Cefuroxime (antiinfective; antibi otic; secondgeneration cephalosporin) 500 mg TIVT q 8 ANST Infections of the bone and joint, upper and lower respiratory tract, skin and soft tissue, surgical infections, UTI Hypersensitivity, GI absorption difficulties, children < 5 yr Diarrhea/loose stool, threatening infections. N&V, abdominal pain Slowly inject drug over 3 to 5 min, or give in tubing of other IV solutions. Do not add cefuroxime to solutions of aminoglycosides Protect drug from light

V. ANATOMY AND PHYSIOLOGY

During uterine development, the testes descend out of the abdomen into the scrotum. They pass out of the abdominal cavity into the inguinal canal via the deep (internal) ring and then into the scrotum via the superficial (external) ring. In females, the same tract develops as well. The descent of the the testes occurs during the 7 th or 8th month of fetal development, or in some cases, shortly after birth. After the testes descend, the inguinal canals narrow permanently, but they remain as weak spots in the abdominal wall. If an inguinal canal enlarges or ruptures, this can result in inguinal hernia.

VI. PATHOPHYSIOLOGY (DIAGRAMMATIC PATHOPHYSIOLOGY)

Inguinal site In utero, failure of upper portion of processus vaginalis to close Development of hernia sac along inguinal canal Increased intra-abdominal pressure Opening of hernial sac
[

Abdominal fluid and structures forced into sac Inguinal swelling; palpable mass during straining Reducible Irreducible

Obstruction of intestinal loop Incarceration of loop of bowel when forced into sac Surgical repair Complete obstruction

An (indirect) inguinal hernia is caused by an opening in the inguinal canal that does not close as it should before birth. This allows abdominal tissue to push through the lower abdominal muscles. The occurrence of inguinal hernia and undescended testes is related to the developmental events that result in the formation of the processus vaginalis and the descent of the testicles into the scrotum. These events occur at 3 months gestational age related to hormonal influences that allow the testis to descend into the scrotum. The testicles are attached to a structure called the gubernaculum. This structure is responsible for passing through the internal ring and inguinal canal of the abdominal wall and extending into the scrotum. As this developmental process takes place the testicles come through the internal inguinal ring, a portion of the peritoneum (this portion is the processus vaginalis) and through the ring of the inguinal canal. When this formation takes place the processus vaginalis is pulled with the testis and forms the sacs. In most children this sac closes on its own, when these structures fail to close this can lead to either: (1) An inguinal of scrotal hernia- this occurs when the sac is open to wide and allows the intestine to enter, and/or (2) fluid can pass down into the groin and scrotum in boys to form a hydrocele- or if the sac is wide enough it can allow abdominal contents such as intestine or fat to travel down (or in girls an ovary or tube). Most families notice a bulge in boys in the groin or scrotal sac. The bulge may be more noticeable during crying or straining and can come and go. The bulge may also reduce back into the groin or scrotal area Most inguinal hernias enlarge over time if they're not repaired surgically. Large hernias can put pressure on surrounding tissues in men they may extend into the scrotum, causing pain and swelling. But the most serious complication of an inguinal hernia occurs when a loop of intestine becomes trapped in the weak point in the abdominal wall (incarcerated hernia). This may obstruct the bowel, leading to severe pain, nausea, vomiting and the inability to have a bowel movement or pass gas. It can also diminish blood flow to the trapped portion of the intestine a condition called strangulation that may lead to the death of the affected bowel tissues. A strangulated hernia is life-threatening and requires immediate surgery.

Normal scrotum: the processus vaginalis and tunica vaginalis are closed and contain no fluid or abdominal contents

Inguinal hernia: the processus vaginalis has remained open allowing abdominal contents (fluid and loops of bowel) to enter into the scrotum

VII. NURSING CARE PLAN

Assessment

Diagnosis

Inference

Goal/Objective

Intervention

Rationale

Evaluation

Bako talaga syang makinaon. Lalo na gulay. Mapili kaya sa pagkaon. Gusto niya sana karne buda mga junk foods, mother

Imbalanced Nutrition: Less than Body Requirements related to poor dietary habits

After 2 hours of nursing interventions, the patient/ parents will verbalize or demonstrate selection of foods/meals that will achieve an

1.

Monitor/explore attitudes toward eating/food.

Many factors determine the type, amount, and appropriateness of food consumed. HOB elevated for 30 aids in swallowing and reduces risk of aspiration.

Assist patient with meals as needed. Ensure a pleasant environment, a facilitative

2.

After 2 hours of nursing interventions, the patient/ parents verbalized and demonstrated selection of foods/meals that will achieve an

verbalized. Objective: has dysfunctional eating patters inadequate caloric intake noted

optimum nutrition. position and good oral hygiene.

3.

Encourage exercise.

Metabolism and utilization of nutrients are enhanced by activity. May decrease appetite and may lead to early satiety. Gain optimum wellness/ promotes health status.

optimum nutrition.

4.

Discourage caffeinated/ carbonated beverages.

5.

Reinforce importance of maintaining caloric intake (at least 2,400 cal/day), highly nutritious food (vegetables and fruits); foods high in protein that will promote weight gain and nitrogen balance. Instruct parents in use of special devices or utensils for feeding. Inform parents of need for food supplements and the quality of food is more important that the quantity of food ingested.

Promotes food intake.

6.

7.

Ensures nutritional status and provides parents realistic information about food intake. Provides support for the childs dietary needs.

8.

Refer/consult to nutritionist/dietician.

Promotes effective plan of instruction to ensure compliance.

Ano ang mangayayri sainya pakatapos ng operasyon?Ano ang mga bawal at pede nyang gibuon? mother verbalized. Objective: Frequent questioning noted

Deficient knowledge related to lack of knowledge about postoperative care

After 2 hours of nursing interventions, the parents will obtain knowledge about postoperative care

1. Assess knowledge of causes of hernia; surgical procedure performed, willingness and interest to implement treatment regimen. 2. Provide parents and child as appropriate with information and clear explanations in understandable language, include teaching aids and encourage questions 3. Inform to maintain incision dressing until it peels off and to apply diaper so that it does not cover incision. 4. Teach to give sponge batch until incision heals. 5. Encourage to refrain from lifting, pushing or engaging in strenuous play.

Ensures understanding based n learning ability and age.

After 2 hours of nursing interventions, the parents obtained knowledge about postoperative care and showed willingness to comply with given instructions.

Maintains dry and clean incision site.

Maintains incision integrity. Reduces strain on incision and possible recurrence of hernia. Promotes healing.

6. Advise parents to increase diet and fluids as ordered. 7. Reassure parents that there is high survival rate during the operation and it is one of the most common surgeries performed during childhood.

Provides assurance and comfort to parents in giving care.

VIII. DISCHARGE CARE PLAN

Medication Environment Treatment Hygiene Observation Diet Spirituality