Dr.

Ibrahim Bashayreh RN, PhD

Objectives of case presentation

y To share experience and knowledge gained from

case study to friends and supervisors.

y To get feedback from the friends and supervisors

for further improvement.

y 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.

y To share experience and knowledge gained from

case study to friends and supervisors

y To get feedback from the friends and supervisors

for further improvement

y To develop confidence in facing the mass and

presenting skills

Rational for selection of the case

y Obstructed inguinal hernia is most common health

problem in worldwide y I selected this case as to learn more about the disease condition y Providing nursing care by applying nursing process

Bio-data of my patient
y y y y y y y y y y y y y y y y y y

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
y discomfort or sharp pain

-especially when straining, lifting, or exercising -improves when resting y a feeling of weakness or pressure in the groin

History of present illness

y Patient was having complain of scrotal mass and pain

since 5 days y Than patient came to CMC OPD and had consultation with physician where he diagnosed to have obstructed Inguinal Hernia

History of present illness Cont

y y y y y

y y y y y y

Onset of symptomsCharacteristicsDurationAssociated symptomsAggravating factors-sudden twists, pulls, or muscle strains -lifting heavy objects -straining on the toilet because of constipation -chronic coughing Alleviating factorsAllergy-No allergies noted Any health problemType of illnessDuration of illnessPlacement of treatment-

History of past illness

y Allergyy Any health problemy Types of illnessy Duration of illnessy Place of treatment-

Family History
y He belongs to extended family y There are 6 members in his family y Medical history of family member y Good relation among family members  Has 5 room well ventilated and separate kitchen.

Environmental sanitation well maintained.

Personal History
y Dietary pattern-Non-veg y Has good appetite y Bathing habits-Regular everyday y Bladder and bowel habits-Regular bladder habits but

he has complain of constipation on and off y Smoking-No y Alcohal-No

Personal History Cont..

y Housing patterny Fuel usingy Purpose of kitchen

Health beliefs
y Patient including his family members has a complete

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

Finding from physical examination

y Patient 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

Hernia
y A 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.

y There are several types of hernia :

-Inguinal hernia -Femoral hernia -Incisional hernia -umbilical hernia -Hiatus hernia -Epigastric hernia -Spigelian hernia -Muscles hernia

Obstructed Inguinal Hernia

y Protrusion of abdominal cavity contents through the

inguinal canal. They are very common and their repair is one of the most frequently performed operations. y There are two types of Inguinal hernia o Direct inguinal hernia o Indirect inguinal hernia

Indirect Inguinal Hernia

y The 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. y Many hernias reduce (go away) on their own but returns at times of straining of lifting y A hernia that does not go away and cause pain is a surgical emergency

Epidemiology
y It is estimated that over 20 million surgical procedures

for inguinal hernia are performed each year y the disorder predominantly affects men (male:female ratio is 7:1 y Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct
y

Courtsy-BMJ Group

Incidence Rate
y About 25% of males and 2% of females develop

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

Etiology According to book

y Although 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 y Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia For exampley Obesity y Heavy lifting y Coughing y Straining during bowel movement or urination

y Chronic lungs disease y Fluid in abdominal cavity y A family history of hernias

Pathophysiology
y Indirect inguinal hernias usually occur because of a persistent

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

y it carries with it fascial linings of the tissue it transverses y The hernia courses along the inguinal canal lateral to the

epigastric arteries and emerges through the external ring slightly lateral to the pubic tubercle. cord down into the scrotal sac in men

y Contents of this hernia then follow the tract of the spermatic

y or follows the round ligament in females

Clinical Manifestation
According to Book y A bulge in the area on either side of your pubic bone y A burning, gurgling or aching sensation at the bulge y Pain or discomfort in your groin, especially when bending over, coughing or lifting y A heavy or dragging sensation in your groin According to Patient y Swelling left inguinalscrotal region y Pain in left inguinal region

y Fever

w Occasionally, in men, pain and

y On Physical examination

swelling in the scrotum around the testicles when the protruding intestine descends into the scrotum w Smoking w Undesended testicles

-Cough impulse + non reducible

Diagnostic Evaluation
According to Book y History taking y Physical examination -Examine the patient in standing and supine position y Blood count y Herniography y Ultrasonography y MRI y CT Scan According to patient y History Taking y Physical Examination y Chest X-ray y Lab test -Serology test .HIV I and II Antibody .HBsAG .HCV y Platelet count y Sodium Potasium

Finding on Diagnostic Tests on Patient

y Chest X-ray shows

Haematology y WBC-6,600 y HB-13.8 y Neutrophil-69% y Lymphocytes-28 y Monocytes-02 y Esinophil-01 y Basophil-00 y Bleeding time-2 00 y Cloting time-12 00 y Platelet counts 170000

Biochemistry y Urea 27.5 y Sodium y Potasium y Blood sugar (R)-101mg/dl Serology y HIV I & II Antibody Non Reactive y HBsAG- Non Reactive y HCV Non Reactive

Treatment
Treatment can be Non operative and Operative Non-Operative y Observation
y 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

y Trusses can provide symptomatic relief

-Hernia control in 30% of patient

Operative or Surgical Management

The Surgical procedure for Inguinal Hernia Bassini Shouldice Mc vay Lichtenstein Pre-erotoneal Laproscopic

Treatment According to My Patient

Pre-operative Tab.Alprox 0.5mg HS Post-Operative Inj.Megapen 1gm iv 6 hourly Inj.Aciloc 50mg iv BD Inj.Tramadol 50mg I/M SOS Inj.Phenargan 25mg SOS

On Discharge
y Cap Megapen 1gm po qid x 3 days y Tab nise 100mg po bd x 2 days y Tab Aciloc 150mg po bd x 2 days

Complications
y Recurrence y Infection y Neuralgia y Bladder Injury y Testicular Injury y Vas Deference Injury

Prognosis of My Patient
y My 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 care 2. Theory of self care deficit 3. Theory of nursing system y Wholly compensatory y Partially compensatory y Supportive educative system

Nursing Management Pre-operative

y Closely monitor vital signs and provide routine

preoperative preparation. If necessary, When surgery is scheduled y Administer I.V. fluids and analgesics for pain as ordered. y Place the patient in Trendelenburg's position to reduce pressure on the hernia site. Pain related to swelling and pressure

Post operative
y Provide routine postoperative care. y Don't allow the patient to cough, but do encourage

deep breathing and frequent turning. y Apply ice bags to the scrotum to reduce swelling and relieve pain; elevating the scrotum on rolled towels also reduces swelling. y Administer analgesics as necessary. y In males, suspensory bandage may be used to provide support

Nursing Diagnosis Assessment

y Subjective data-I have pain and swelling on my

scrotum y Objective Data-Inspection reveal swelling and pain as evidence by restlessness, pallor, elevated pulse and facial expression y Vital signs-Tempreture-98 Pulse-94/m Respiration-20/m Blood pressure-130/80mmofhg

Nursing Diagnosis-Pain related to swelling and pressure

y Desire outcome-Control of pain within 2 hours y Planning- 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

y Evaluation-The disired outcome met as patient

verbalized the relief of pain ,request analgesic on onset of pain

Nursing assessment
y Subjective Datay 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 intervention
y Assessed patient s anxiety and fear before surgery y Assessed patient s knowledge about procedure and expected outcome preoperatively y Encouraged patient to verbalize reactions,feelings and fear y Encouraged family members to be with the patient and share feelings y Evaluate the meaning of alterations resulting from surgical procedure for the patient and family

Evaluation
y The patient participates in decision affecting his plan of care y The patient demonstrate the knowledge of psychological response

to invasive procedure

Nursing assessment
y Subjective Data-I have discomfort due to Foleys catheter y Objective Data-

Nursing Diagnosis-impaired urinary elimination related to surgery

y Desire outcome-Absence of urinary bladder distention y 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 intervention
y Monitored urine output and characteristics y Monitored for evidence of catheter blockage,change the catheter as

needed y Maintained patency of indwelling urinary catheter y Encouraged high fluid intake (2500-3000ml/day)

Evaluation
y Expected desire was met as there was no evidence of

impaired on urinary elimination

Nursing assessment
y Subjective data y Objective 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 Teaching
y Tell the postoperative patient that he'll probably be able to y y y

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

y Inform the postoperative patient that the risk of

recurrence depends on the success of the surgery, his general health, and his lifestyle.

y 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.

y Explain the importance of completion of all

antibiotics. Explain the mechanism of action, side effects, and dosage recommendations of all analgesics.

y Caution the patient against lifting and straining.

THANK YOU FOR YOUR KIND ATTENTION

Treatment Options
y All hernias should be surgically corrected to remove the risk of incarceration and strangulation. y 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. y 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 pressure Primary nursing Outcomes: Pain, disruptive effects; pain level Primary nursing Interventions: Analgesic administration; pain management Common Nursing diagnoses found on Nursing care plan for Inguinal Hernia Activity intolerance Acute pain Ineffective tissue perfusion: GI Risk for infection Risk for injury