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Foundation University

COLLEGE OF NURSING
Dumaguete City

Central Objective:

At the end of the presentation, through the use of a variety of learning approaches, the learners will be able to understand concepts related to the
disease condition, expand knowledge on such, and acquire positive attitudes and values towards the care of a patient having Inguinal Hernia.

Specific Objectives:

This case study is conducted for students to be able to:

1. Recognize different factors that contributed to the patients condition.


2. Identify different manifestations of the patient, and how they are managed.
3. Understand the treatment regimen of the patient.
4. Know the appropriate nursing interventions during the nursing care of the patient.
5. Discuss and discover the nature and progression of the condition.
6. Identify possible nursing diagnosis and its corresponding management.
7. Trace the pathophysiology of the disease process.
8. Enhance knowledge about the condition and other concepts related to it.

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INTRODUCTION

As a student nurse, our main responsibility is to take in as much knowledge and information possible to better equip ourselves in giving
individuals quality health care. The analysis of medical cases may seem unfamiliar but with the proper guidance from our teachers, be it clinical
instructors, doctors in the hospitals, or to the books that we face on a daily basis, growth as a health care personnel will be achieved.
A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall. In many people, the
abdominal wall weakness that leads to an inguinal hernia occurs at birth when the abdominal lining (peritoneum) doesn't close properly. Other
inguinal hernias develop later in life when muscles weaken or deteriorate due to aging, strenuous physical activity or coughing that accompanies
smoking. A hernia usually develops between your chest and hips. In many cases, it causes no or very few symptoms, although you may notice a
swelling or lump in your tummy (abdomen) or groin. The lump can often be pushed back in or disappears when you lie down. Coughing or
straining may make the lump appear.
Inguinal hernias occur when fatty tissue or a part of your bowel pokes through into your groin at the top of your inner thigh. This is the most
common type of hernia and it mainly affects men. It's often associated with aging and repeated strain on the abdomen. Some inguinal hernias
have no apparent cause. Others might occur as a result of: Increased pressure within the abdomen, A pre-existing weak spot in the abdominal
wall, A combination of increased pressure within the abdomen and a pre-existing weak spot in the abdominal wall, Straining during bowel
movements or urination, Strenuous activity, Pregnancy, Chronic coughing or sneezing.
Weaknesses can also occur in the abdominal wall later in life, especially after an injury or abdominal surgery. In men, the weak spot usually
occurs in the inguinal canal, where the spermatic cord enters the scrotum. In women, the inguinal canal carries a ligament that helps hold the
uterus in place, and hernias sometimes occur where connective tissue from the uterus attaches to tissue surrounding the pubic bone. Inguinal
hernias can be repaired using surgery to push the bulge back into place and strengthen the weakness in the abdominal wall.

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DEMOGRAPHIC PROFILE

NAME OF PATIENT: Patient Junior A

AGE: 25 years old

SEX: Male

STATUS: Married

EDUCATIONAL BACKGROUND: College level

BIRTHDATE: November 22, 1979

OCCUPATION: Construction worker

RELIGION: Roman Catholic

ADDRESS: Palinpinon, Valencia

NATIONALITY: Filipino

DATE OF ADMISSION: June 5, 2017

ADMISSION TYPE: Emergency

ATTENDING PHYSICIAN: Nervez, Erwin Jay G., MD

POST-OP DIAGNOSIS: Indirect Inguinal Hernia (Right)

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CHIEF COMPLAINTS:
Patient claimed for pain around scrotum area, enlargement of right scrotum prior to admission

GENERAL IMPRESSION:
Received patient on stretcher at OR, awake and aware of surroundings, speech coherent. PNSS IVF 1L infusing well at the right metacarpal
vein, no signs of inflammation noted. FBC in place attached to urobag- drained. Transferred to OR table on supine position, O2 administered at
2L/min via nasal cannula. Vital signs: BP= 120/80 mmHg, T= 36.3 C, P= 103 bpm, R= 18 cpm.

HISTORY OF PRESENT ILLNESS:


Noted mass at right testicles during childhood years. 2 months PTA, mass grew bigger with associated pain. Pain characterized as tearing,
constant rated as 8/10 in pain scale. Patient sought consult and diagnosed with inguinal hernia. Patient was advised for surgery but did not
comply. For past few weeks pain persisted and mass was characterized as reducible. Thus, patient sought another consult and was scheduled for
surgery. Mass usually noted during exertion or whenever there is increase in abdominal pressure like when coughing, exercising, and standing
position.

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NURSING HISTORY

A. CHIEF COMPLAINTS:
Patient claimed for pain around scrotum area, enlargement of right scrotum prior to admission

B. ADMITTING IMPRESSION/DIAGNOSIS:
Indirect Inguinal Hernia (Right)

C. HISTORY OF PRESENT ILLNESS:


Noted mass at right testicles during childhood years. 2 months PTA, mass grew bigger with associated pain. Pain characterized as tearing,
constant rated as 8/10 in pain scale. Patient sought consult and diagnosed with inguinal hernia. Patient was advised for surgery but did not
comply. For past few weeks pain persisted and mass was characterized as reducible. Thus, patient sought another consult and was scheduled for
surgery. Mass usually noted during exertion or whenever there is increase in abdominal pressure like when coughing, exercising, and standing
position.

D. PAST HEALTH HISTORY:


Childhood Illnesses:
Fever
Cough
Colds
Tooth decay
Immunization:
Fully immunized
Medical:
No previous hospitalizations
Takes OTC drugs when sick
Allergies
No food and drug allergies
Habits and lifestyle
Patient does not smoke but drinks alcoholic beverages rarely
Plays basketball sometimes

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E. Family History with Genogram

Enusensio Felipa
75 yrs.o.
Ferolito 75 yrs.o. Maria
76 y.o. 74 y.o.
75 y.o. 84 y.o.
Senior citizen Senior citizen
COD: Stroke COD: old
age Food allergy Hypertensive

A&W A&W

Antonio
Margarita Anghela Patricia Mannela
Teresita
Pablito 47 y.o.
Pedrita Pedro Paulita 56 y.o. 54 y.o. 45 y.o.
58 y.o. 52 y.o.
56 y.o. Married
54 y.o. 53 y.o 50 y.o.
Married
Married Married Married
Married
Married Housewife Housewife Sari-sari Panday
Married Married Helper
Housewife store owner Housewife
Farmer A&W A&W A&W
LEGEND: Panday Labandera A&W
A&W A&W A&W
A&W A&W
Patient = A&W

Female =

Male =
Josephine Mikaela
Angel
Deceased = Joseph
26 y.o.
23 y.o. 21 y.o.
A&W = Alive & Well Married
25 y.o.
Single Single
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House helper Married
Jobless Jobless
A&W Construction
Worker A&W A&W
F. PSYCHOSOCIAL HISTORY
Patient was friendly, responsive, and optimistic. Listens and responds attentively during interview. He is working as a construction worker
by contractual. His relationship with his wife is doing good. Patient claimed that he has a lot of friends and that he never had been to any trouble.
He got married a year ago and decided to move to a new house with his wife. He claimed that he has no difficulties in relating with his parents as
well as his in-laws.

G. ENVIRONMENTAL HISTORY
Patient lives in a rural environment where there is plenty of trees, abundant with water, and the air is fresh.

H. SPIRITUAL HISTORY
Patients religion is Roman Catholic and goes to church with his wife every Sunday. He believes in God, where he seeks strength from. He
prays every day.

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DEVELOPMENTAL TASKS

Intimacy Versus Isolation: 20 to 30 Years

The objective during this stage is to form an intense, lasting relationship or a commitment to another person, a cause, an institution, or a creative
effort. (Townsend M. C., 2014)
Achievement of the task results in the capacity for mutual love and respect between two people and the ability of an individual to pledge total
commitment to another. The intimacy goes far beyond the sexual contact between two people. It describes a commitment in which personal
sacrifices are made for another, whether it be another person, a career, or other type of cause or endeavor to which an individual elects to devote
his or her life. Intimacy is achieved when an individual has developed the capacity for giving of oneself to another. This is learned when one has
been the recipient of this type of giving within the family unit. (Townsend M. C., 2014)
Non-achievement results in withdrawal, social isolation, and aloneness. The individual is unable to form lasting, intimate relationships, often
seeking intimacy through numerous superficial sexual contacts. No career is established; he or she may have a history of occupational changes (or
may fear change and thus remain in an undesirable job situation). The task remains unresolved when love in the home has been absent or
distorted through the individuals younger years (Murray et al, 2009). One fails to achieve the ability to give of the self without having been the
recipient early on from primary caregivers. (Townsend M. C., 2014)
Correlation: Our patient is currently 25 years old. He is married but has no children. He has formed a relationship with another person, which is
his wife and has pledged to stay honest and committed to her. He verbalized that he loves his wife and that he would like to have kids as well in the
future. He supports his wife and other members of his family when they are in need, he has made a good relationship with other members of his
and his wifes family. He was able to achieve his stage of development task, which is intimacy, and thus, he is not alone and isolated.

Physical Development (Erikson)


The musculoskeletal system is well developed and coordinated. All other system of the body (cardiovascular, visual auditory and reproductive)
are functioning at peak efficiency. Although physical change is minimal during this stage weight and muscle mass may change as a result of diet
and exercise.

Correlation: The clients musculoskeletal system has developed and coordinated at the age of 25 with the height of approximately 57 and
weight of 56kg. The cardiovascular system functions well as manifested with the heart rate of 76 bpm and the S1 (lub) heard loud at the apex of the
heart. The visual auditory is functioning at peak efficiency. The reproductive system is probably malfunctioning as client claimed that he never had
a chance to impregnate a woman during his previous relationship. Therefore, the task was partially met.

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ANATOMY AND PHYSIOLOGY OF THE SYSTEM/S INVOLVED
The Integumentary System
The Integumentary system is an organ that consist of the skin, its derivatives (sweat and oil glands), nails and hair. The basic function of the skin is
protection. The skin consists of epidermis and dermis.

Epidermis
Cells of the Epidermis
Cells: consists of keratinocytes, melanocytes, Merkel cells and
Langerhans cells
Keratinocytes: tightly packed and connected to desmosomes;
originate from stratum basale; produce keratin
Melanocytes: spider-like cells that produce melanin (forms a pigment
shield that protects the nucleus from the UV rays).
Langerhans cells: star-shaped cells from bone marrow. Function to
activate the immune system as macrophages.
Merkel cells: function as sensory receptors

Layers of the Epidermis

Stratum basale: consist of predominantly single row of keratinocytes; some melanocytes (10-25%) and Merkel cells;
Stratum spinosum: several layers thick; Contains flattened irregularly-shaped keratinocytes, pre-keratin intermediate filaments.
Stratum granulasum: consist of flattened keratinocytes which accumulate keratohyaline granules (granules form keratin) and lamellated granules
(produce water-resistant chemical).
Stratum lucidum: present only in thick skin and made up of a few rows of clear, flat, dead keratinocytes.
Stratum corneum: outermost layer, conts many layers of cells (cornified or horny cells). Dead skins slough off.

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Dermis
Richly supplied with nerves (sensory receptors), blood vessels, lymphatic vessels, sweat and sebaceous glands derived from the epidermis.
Contains two layers: papillary and reticular
Papillary layer: Consists of areolar connective tissue made up of loose collagen and elastic fibers, projections called papillae which contain touch and
pain receptors (Messsners corpusles). The papillae also form epidermal ridges found on the surfaces of palms, fingers and feet. On the palm and
fingers they form the fingerprints (genetic markers of individuality).
Reticular layer: account for about 80% of thickness of dermis; consist of dense irregular connective tissue. The ECM of this layer consist of bundles
of collagenous fibers which run in parallel and opposite directions. The fibers give strength and resilience (toughness) and recoil, while collagen
absorbs water and keep the skin hydrated. Stretch marks found on the buttocks, thighs, abdomen and breast are due to these fibers.
Skin Coloration
Skin color is due to a combination of three pigments: melanin, carotene and hemoglobin.
Melanin is a brown-black pigmentation formed in cells called melanocytes. Cells are found in the stratum basale and spinosum. The amount of
melanin produced by an individuals is based on inheritance. Freckles are small patches of Melanin on the skin due to uneven distribution.
Hemoglobin is the molecules found in RBC that gives blood its red coloration. It is made of non-protein (heme which contains iron) and the protein
(globin).
Carotene is the yellowish pigment found in the corneum and the dermis.
Skin color of human races occur as a result of the relative abundance of melanin and carotene. Dark-skin coloration is due to melanin.
Caucacians produce more carotene than melanin.
Melanin protects the skin and cells of the skin by shielding the UV light of the sun against the nucleus.
Accesory Structures
Accessory structures include hair, nail, and glands.
a. Hair: formed of keratinized cells and consist of two parts: a shaft and root. The shaft is above the skin and root embedded in the dermis, in a
hair follicle connected to blood supplies and arrector muscle.
b. Nail: they are formed of keratinized epidermal cells and occur on the finger and toes. Consist of a visible area (body) and the root (embedded
in the dermis).
c. Glands: There are there exocrine (conts ducts) glands: sebaceous, sudoriferous and ceruminous glands. These glands secrete their contents
to the exterior unlike endocrine which secrete their contents directly into blood.
d. Sebaceous glands: produce oil (sebaum) which keeps the skin oily. The glands are branched and attached to the hair follicle. Blockage of the
gland causes acne.
e. Sudoriferous (sweat) gland: produce sweat or perspiration composed of water, salt, urea and uric acid. They are coiled and tubular shaped
and of two types: Eccrine (found on forehead, back of palm and soles), and Apocrine (larger that eccrine, found in pubic regions and secrete
into hair follicles). Mammary glands: are specialized form of sudoriferous gland secrete milk.

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f. Ceruminous glands: found only in the external auditory canal where they secrete cerumen (earwax). Cerumen is an insect repellant and also
keep the eardrum (tympanic membrane) from drying out. Excess amount may block.

Temperature Regulation
The regulation of body temperature is carried out by the hypothalamus in conjunction with the skeletal muscle. The system works similar to the
thermostat in buildings. Normal body temperature is 37C(98.6F). This temperature is produced as a result of metabolic activities which produce heat
in the body. During the cold when heat loss is excessive, the blood vessel constrict (therefore less blood to the surface) the muscle contract
frequently (shivering) to produce heat. In the summer, the vessels dilate (more blood to the skin surface, more heat loss), sweat pores open and
produce perspiration that cool the surface as heat is lost.
Skin Aging
After 50 years, wrinkles and sagging of the skin become more noticeable. Effects of aging are a result of deterioration of collagen, elastic
fibers; decrease in sebaum production, decrease in melanin production, decrease in content and decomposition of cutaneous fat.
Disorders of the skin
There are several types of skin disorders associated with the skin. Some of them are infectious (contagious) or non-infectious. These
disorders include acne, athletes foot, boils, fever blisters, impetigo, warts, alopecia, burns, calluses (corns), cancers, dandruff, eczema, moles
psoriasis and others.
Skin disorders
Contagious disorders are caused by bacteria or virus or fungus
Acne: characterized by plugged hair follicles that form pimples. Caused by bacteria, prevalent in teenage years.
Boils: painful infection of hair follicles and sebaceous glands by Staphylococcus bacteria.
Fever blisters: cold soresfluid filled blisters on the lips or oral membrane caused by Herpes simplex virus and transmitted by oral and
respiratory exposure. Genital Herpes are painful blisters on the genitals and transmitted by sexual contact.
Impetigo: highly contagious skin infection caused by bacteria, occurs in children and characterized by fluid-filled pustules forming yellow crust
over infected area.
Warts: small skin tumors caused by viral infection that stimulate excessive growth of epithelial cells
Non-contagious skin disorders
Alopecia: loss of hair (pattern baldness) is most prevalent in males and inherited. May also be caused by factors such as poor nutrition,
sensitivity to drugs, and eczema.
Eczema: inflammation producing redness, itching, scalding and cracking of skin. Seborrheic eczema is produced by hyperactivity of the
sebaceous glands.

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Male Reproductive System

Scrotum

The scrotum is a sac-like organ made of skin and muscles


that houses the testes. It is located inferior to the penis in the pubic
region. The scrotum is made up of 2 side-by-side pouches with a
testes located in each pouch. The smooth muscles that make up
the scrotum allow it to regulate the distance between the testes
and the rest of the body. When the testes become too warm to
support spermatogenesis, the scrotum relaxes to move the testes
away from the bodys heat. Conversely, the scrotum contracts to
move the testes closer to the bodys core heat when temperatures
drop below the ideal range for spermatogenesis.

Testes
The 2 testes, also known as testicles, are the male gonads responsible for the production of sperm and testosterone. The testes are ellipsoid
glandular organs around 1.5 to 2 inches long and an inch in diameter. Each testis is found inside its own pouch on one side of the scrotum and is
connected to the abdomen by a spermatic cord and cremaster muscle. The cremaster muscles contract and relax along with the scrotum to regulate
the temperature of the testes. The inside of the testes is divided into small compartments known as lobules. Each lobule contains a section of
seminiferous tubule lined with epithelial cells. These epithelial cells contain many stem cells that divide and form sperm cells through the process of
spermatogenesis.

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Epididymis
The epididymis is a sperm storage area that wraps around the superior and posterior edge of the testes. The epididymis is made up of several
feet of long, thin tubules that are tightly coiled into a small mass. Sperm produced in the testes moves into the epididymis to mature before being
passed on through the male reproductive organs. The length of the epididymis delays the release of the sperm and allows them time to mature.
Spermatic Cords and Ductus Deferens
Within the scrotum, a pair of spermatic cords connects the testes to the abdominal cavity. The spermatic cords contain the ductus deferens
along with nerves, veins, arteries, and lymphatic vessels that support the function of the testes.
The ductus deferens, also known as the vas deferens, is a muscular tube that carries sperm superiorly from the epididymis into the abdominal
cavity to the ejaculatory duct. The ductus deferens is wider in diameter than the epididymis and uses its internal space to store mature sperm. The
smooth muscles of the walls of the ductus deferens are used to move sperm towards the ejaculatory duct through peristalsis.
Seminal Vesicles
The seminal vesicles are a pair of lumpy exocrine glands that store and produce some of the liquid portion of semen. The seminal vesicles are
about 2 inches in length and located posterior to the urinary bladder and anterior to the rectum. The liquid produced by the seminal vesicles contains
proteins and mucus and has an alkaline pH to help sperm survive in the acidic environment of the vagina. The liquid also contains fructose to feed
sperm cells so that they survive long enough to fertilize the oocyte.
Ejaculatory Duct
The ductus deferens passes through the prostate and joins with the urethra at a structure known as the ejaculatory duct. The ejaculatory duct
contains the ducts from the seminal vesicles as well. During ejaculation, the ejaculatory duct opens and expels sperm and the secretions from the
seminal vesicles into the urethra.
Urethra
Semen passes from the ejaculatory duct to the exterior of the body via the urethra, an 8 to 10 inch long muscular tube. The urethra passes
through the prostate and ends at the external urethral orifice located at the tip of the penis. Urine exiting the body from the urinary bladder also
passes through the urethra.

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Prostate
The prostate is a walnut-sized exocrine gland that borders the inferior end of the urinary bladder and surrounds the urethra. The prostate
produces a large portion of the fluid that makes up semen. This fluid is milky white in color and contains enzymes, proteins, and other chemicals to
support and protect sperm during ejaculation. The prostate also contains smooth muscle tissue that can constrict to prevent the flow of urine or
semen.

Cowpers Glands
The Cowpers glands, also known as the bulbourethral glands, are a pair of pea-sized exocrine glands located inferior to the prostate and
anterior to the anus. The Cowpers glands secrete a thin alkaline fluid into the urethra that lubricates the urethra and neutralizes acid from urine
remaining in the urethra after urination. This fluid enters the urethra during sexual arousal prior to ejaculation to prepare the urethra for the flow of
semen.
Penis
The penis is the male external sexual organ located superior to the scrotum and inferior to the umbilicus. The penis is roughly cylindrical in
shape and contains the urethra and the external opening of the urethra. Large pockets of erectile tissue in the penis allow it to fill with blood and
become erect. The erection of the penis causes it to increase in size and become turgid. The function of the penis is to deliver semen into the vagina
during sexual intercourse. In addition to its reproductive function, the penis also allows for the excretion of urine through the urethra to the exterior of
the body.
Semen
Semen is the fluid produced by males for sexual reproduction and is ejaculated out of the body during sexual intercourse. Semen contains
sperm, the male reproductive gametes, along with a number of chemicals suspended in a liquid medium. The chemical composition of semen gives it
a thick, sticky consistency and a slightly alkaline pH. These traits help semen to support reproduction by helping sperm to remain within the vagina
after intercourse and to neutralize the acidic environment of the vagina. In healthy adult males, semen contains around 100 million sperm cells per
milliliter. These sperm cells fertilize oocytes inside the female fallopian tubes.
Spermatogenesis
Spermatogenesis is the process of producing sperm and takes place in the testes and epididymis of adult males. Prior to puberty, there is no
spermatogenesis due to the lack of hormonal triggers. At puberty, spermatogenesis begins when luteinizing hormone (LH) and follicle stimulating

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hormone (FSH) are produced. LH triggers the production of testosterone by the testes while FSH triggers the maturation of germ cells. Testosterone
stimulates stem cells in the testes known as spermatogonium to undergo the process of developing into spermatocytes. Each diploid spermatocyte
goes through the process of meiosis I and splits into 2 haploid secondary spermatocytes. The secondary spermatocytes go through meiosis II to form
4 haploid spermatid cells. The spermatid cells then go through a process known as spermiogenesis where they grow a flagellum and develop the
structures of the sperm head. After spermiogenesis, the cell is finally a sperm cell, or spermatozoa. The spermatozoa are released into the
epididymis where they complete their maturation and become able to move on their own.
Fertilization
Fertilization is the process by which a sperm combines with an oocyte, or egg cell, to produce a fertilized zygote. The sperm released during
ejaculation must first swim through the vagina and uterus and into the fallopian tubes where they may find an oocyte. After encountering the oocyte,
sperm next have to penetrate the outer corona radiata and zona pellucida layers of the oocyte. Sperm contain enzymes in the acrosome region of the
head that allow them to penetrate these layers. After penetrating the interior of the oocyte, the nuclei of these haploid cells fuse to form a diploid cell
known as a zygote. The zygote cell begins cell division to form an embryo.

Gastrointestinal System

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing
through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that
assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall
bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular
walls.

The primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide
energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach
and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then
absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing
excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of feces).
In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop
symptoms of nausea, vomiting, diarrhea, mal-absorption, constipation or obstruction. Gastrointestinal problems are very common and most people
will have experienced some of the above symptoms several times throughout their lives.

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Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages
approximately 6m in length, extending from the pyloric sphincter of the stomach to the
ileocecal valve separating the ileum from the cecum. The small intestine is compressed
into numerous folds and occupies a large proportion of the abdominal cavity.
The duodenum is the proximal C-shaped section that curves around the head of the
pancreas. The duodenum serves a mixing function as it combines digestive secretions
from the pancreas and liver with the contents expelled from the stomach. The start of the
jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where
the majority of digestion and absorption occurs. The final portion, the ileum, is the longest
segment and empties into the caecum at the ileocecal junction.
The small intestine performs the majority of digestion and absorption of nutrients. Partly
digested food from the stomach is further broken down by enzymes from the pancreas
and bile salts from the liver and gallbladder. These secretions enter the duodenum at the
Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and
carbohydrates are broken down to small building blocks and absorbed into the bodys
blood stream.
The lining of the small intestine is made up of numerous permanent folds called
plicaecirculares. Each plica has numerous villi (folds of mucosa) and each villus is
covered by epithelium with projecting microvilli (brush border). This increases the surface
area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialized cells. Some are responsible for
absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions.

Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum,
ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm.
The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into fecal material. Food then
travels along the colon. The wall of the colon is made up of several pouches (hastra) that are held under tension by three thick bands of muscle
(taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold fecal matter before it passes through the anorectal canal to the anus.
Thick bands of muscle, known as sphincters, control the passage of feces.
The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is flat with several deep intestinal glands. Numerous
goblet cells line the glands that secrete mucous to lubricate fecal matter as it solidifies. The functions of the large intestine can be summarized as:

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1. The accumulation of unabsorbed material to form feces.
2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas.
3. Reabsorption of water, salts, sugar and vitamins.

Liver
The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen. It is surrounded by a strong capsule and
divided into four lobes namely the right, left, caudate and quadrate lobes. The liver has several important functions. It acts as a mechanical filter by
filtering blood that travels from the intestinal system. It detoxifies several metabolites including the breakdown of bilirubin and estrogen. In addition,
the liver has synthetic functions, producing albumin and blood clotting factors. However, its main roles in digestion are in the production of bile and
metabolism of nutrients. All nutrients absorbed by the intestines pass through the liver and are processed before traveling to the rest of the body.
The bile produced by cells of the liver, enters the intestines at the duodenum. Here, bile salts break down lipids into smaller particles so there is a
greater surface area for digestive enzymes to act.

Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the livers right lobe. It consists of a
fundus, body and neck. It empties via the cystic duct into the biliary duct system. The main functions of the gall bladder are storage and
concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored in the
gallbladder until it is needed. Bile is released from the gall bladder by contraction of its muscular walls in response to hormone signals from the
duodenum in the presence of food.

Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail
extends to the spleen. The organ is approximately 15cm in length with a long, slender body connecting the head and tail segments. The pancreas
has both exocrine and endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The Islets
produce insulin, glucagon and other substances and these are the areas damaged in diabetes mellitus. The exocrine (secretory) portion makes up
80-85% of the pancreas and is the area relevant to the gastrointestinal tract.
It is made up of numerous acini (small glands) that secrete contents into ducts which eventually lead to the duodenum. The pancreas
secretes fluid rich in carbohydrates and inactive enzymes. Secretion is triggered by the hormones released by the duodenum in the presence of
food. Pancreatic enzymes include carbohydrases, lipases, nucleases and proteolytic enzymes that can break down different components of food.
These are secreted in an inactive form to prevent digestion of the pancreas itself. The enzymes become active once they reach the duodenum.

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REVIEW OF RELATED LITERATURE
Inguinal Hernia

This is the most common hernia (about 70% of all hernias are inguinal hernias). They occur in the groin, the small area of the lower abdomen
on each side just above the line separating the abdomen and the legs, and around the pubic bone. They occur through the inguinal canal, a conduit
where the testicle comes through on its way to the scrotum during the development of males. Men and women develop from the same basic pattern
so there are anatomical similarities between men and women, meaning that women also have the inguinal canal. But in women the inguinal canal is
much much smaller, and as a result inguinal hernias are much more uncommon than in men (Anonymous, Hernia).

Considering that surgery is the main elective treatment for repairing inguinal hernia, surgical audit data can be considered a reasonable
indicator of incidence/prevalence rates. In England, from 2001 to 2002, approximately 70,000 surgical interventions were performed for inguinal
hernias (62,969 primary hernias against 4939 recurrent hernias), equivalent to 0.14% of the overall population; requiring over 100,000 NHS hospital-
bed days. Audit data from 2014 to 2015 shows 69,637 primary inguinal hernia repair finished consultant episodes (not including recurrent hernia
repairs), of which 92% were male (Anonymous, Inguinal Henria, 2016).

In the US, approximately 4.5 million people have an inguinal hernia, with around 500,000 new inguinal hernias diagnosed annually, though
recent data are not available. About 750,000 procedures were performed in 2003 across the US for inguinal hernia. Although the incidence and
prevalence worldwide is unknown, it is estimated that over 20 million surgical procedures for inguinal hernia are performed each year. Operation
rates vary between countries, but range from 100 to 300 procedures per 100,000 people per year. Although inguinal hernia can occur in both sexes,
the disorder predominantly affects men (male to female ratio is 7-9:1). In general, inguinal hernia affects all ages, but the incidence increases with
age. The lifetime risk of inguinal herniation is approximately 27% for men and 3% for women. Inguinal hernia is bilateral in up to 20% of affected
adults. Family history of inguinal hernia is associated with increased risk (Anonymous, Inguinal Hernia, 2016).

Two types of inguinal hernias are

indirect inguinal hernias, which are caused by a defect in the abdominal wall that is congenital, or present at birth
direct inguinal hernias, which usually occur only in male adults and are caused by a weakness in the muscles of the abdominal wall that
develops over time
Inguinal hernias occur at the inguinal canal in the groin region (Sarr, 2014).

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Signs and Symptoms

The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sides of the grointhe area just above the groin crease between
the lower abdomen and the thigh. The bulge may increase in size over time and usually disappears when lying down (Sarr, 2014).
Other signs and symptoms can include:
discomfort or pain in the groinespecially when straining, lifting, coughing, or exercisingthat improves when resting

feelings such as weakness, heaviness, burning, or aching in the groin


a swollen or an enlarged scrotum in men or boys
Indirect and direct inguinal hernias may slide in and out of the abdomen into the inguinal canal. A health care provider can often move them back
into the abdomen with gentle massage (Sarr, 2014).

Causes

Inguinal and femoral hernias are due to weakened muscles that may have been present since birth, or are associated with aging and repeated
strains on the abdominal and groin areas. Such strain may come from physical exertion, obesity, pregnancy, frequent coughing, or straining on the
toilet due to constipation (Anonymous, 2015).

There isnt one cause for this type of hernia, but weak spots within the abdominal and groin muscles are thought to be a major contributor.
Extra pressure on this area of the body can eventually cause a hernia.

Risk factors

Risk factors can increase your chances of this condition. Examples of risk factors include:

heredity cystic fibrosis


personal history of hernias chronic cough
being male frequent constipation
premature birth frequently standing for long periods of time
being overweight or obese
pregnancy

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Complications

Inguinal hernias can cause the following complications:

Incarceration. An incarcerated hernia happens when part of the fat or small intestine from inside the abdomen becomes stuck in the groin or
scrotum and cannot go back into the abdomen. A health care provider is unable to massage the hernia back into the abdomen.

Strangulation. When an incarcerated hernia is not treated, the blood supply to the small intestine may become obstructed, causing
strangulation of the small intestine. This lack of blood supply is an emergency situation and can cause the section of the intestine to die.

Tests and diagnosis

A health care provider diagnoses an inguinal hernia with

a medical and family history


a physical exam
imaging tests, including x rays

Medical and family history. Taking a medical and family history may help a health care provider diagnose an inguinal hernia. Often the symptoms
that the patient describes will be signs of an inguinal hernia.

Physical exam. A physical exam may help diagnose an inguinal hernia. During a physical exam, a health care provider usually examines the
patients body. The health care provider may ask the patient to stand and cough or strain so the health care provider can feel for a bulge caused by
the hernia as it moves into the groin or scrotum. The health care provider may gently try to massage the hernia back into its proper position in the
abdomen.

Imaging tests. A health care provider does not usually use imaging tests, including x rays, to diagnose an inguinal hernia unless he or she

3
is trying to diagnose a strangulation or an incarceration

cannot feel the inguinal hernia during a physical exam, especially in patients who are overweight

is uncertain if the hernia or another condition is causing the swelling in the groin or other symptoms

Specially trained technicians perform imaging tests at a health care providers office, an outpatient center, or a hospital. A radiologista doctor
who specializes in medical imaginginterprets the images. A patient does not usually need anesthesia.

Tests may include the following:

Abdominal x ray. An x ray is a picture recorded on film or on a computer using a small amount of radiation. The patient will lie on a table or
stand during the x ray. The technician positions the x-ray machine over the abdominal area. The patient will hold his or her breath as the
technician takes the picture so that the picture will not be blurry. The technician may ask the patient to change position for additional pictures.

Computerized tomography (CT) scan. CT scans use a combination of x rays and computer technology to create images. For a CT scan, the
technician may give the patient a solution to drink and an injection of a special dye, called contrast medium. A health care provider injects the
contrast medium into a vein, and the injection will make the patient feel warm all over for a minute or two. The contrast medium allows the
health care provider to see the blood vessels and blood flow on the x rays. CT scans require the patient to lie on a table that slides into a
tunnel-shaped device where the technician takes the x rays. A health care provider may give children a sedative to help them fall asleep for
the test.

Abdominal ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an
image of their structure

Treatment

If your hernia is small and isn't bothering you, your doctor might recommend watchful waiting. In children, the doctor might try applying manual
pressure to reduce the bulge before considering surgery. Enlarging or painful hernias usually require surgery to relieve discomfort and prevent
serious complications. There are two general types of hernia operations open hernia repair and laparoscopic repair.

4
Open hernia repair - In this procedure, which might be done with local anesthesia and sedation or general anesthesia, the surgeon makes an
incision in your groin and pushes the protruding tissue back into your abdomen. The surgeon then sews the weakened area, often reinforcing
it with a synthetic mesh (hernioplasty). The opening is then closed with stitches, staples or surgical glue. After the surgery, you'll be
encouraged to move about as soon as possible, but it might be several weeks before you're able to resume normal activities.
Laparoscopy - In this minimally invasive procedure, which requires general anesthesia, the surgeon operates through several small incisions
in your abdomen. Gas is used to inflate your abdomen to make the internal organs easier to see. A small tube equipped with a tiny camera
(laparoscope) is inserted into one incision. Guided by the camera, the surgeon inserts tiny instruments through other incisions to repair the
hernia using synthetic mesh.
People who have laparoscopic repair might have less discomfort and scarring after surgery and a quicker return to normal activities. However,
some studies indicate that hernia recurrence is more likely with laparoscopic repair than with open surgery. Laparoscopy allows the surgeon to
avoid scar tissue from an earlier hernia repair, so it might be a good choice for people whose hernias recur after traditional hernia surgery. It
also might be a good choice for people with hernias on both sides of the body (bilateral). Some studies indicate that a laparoscopic repair can
increase the risk of complications and of recurrence. Having the procedure performed by a surgeon with extensive experience in laparoscopic
hernia repairs can reduce the risks.

Nursing Management
Assess the skin daily
Watch for and immediately report signs of incarceration and strangulation.
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.
Control fever with acetaminophen or tepid sponge baths as ordered.
Place the patient in Trendelenburg's position to reduce pressure on the hernia site.
Provide Heath Teaching
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.
Tell 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.

5
Explain that he or she can resume normal activities 2 to 4 weeks after surgery.
Remind him or her 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.

After surgery,
Provide 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, a jock strap or suspensory bandage may be used to provide support.

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NURSING THEORY APPLICABLE FOR THE PATIENT

Theory of Goal Attainment by Imogene King


Kings theory offers insight into nurses; interactions with individuals and groups within the environment. It highlights the importance of
clients participation in decision that influences care and focuses on both the process of nurse-client interaction and the outcomes of care. King
indicates that assessment occur during interaction. The nurse brings special knowledge and skills whereas client brings knowledge of self and
perception of problems of concern to this interaction. Communication is required to verify accuracy of perception, for interaction and transaction.
The nursing focus is the care of human being. To her the nursing goal is the health care of individuals and groups. She views human being as an
open systems interacting constantly with their environment. She views that nurse and client communicate information, set goal mutually and then
act to attain those goals, is also the basic assumption of nursing process. According to her theory Each human being perceives the world as a
total person in making transactions with individuals and things in environment.

Correlation:
As a student nurses assigned in the Operating Room caring on client with inguinal hernia, our nursing care is imbued to Imogene kings
theory which is goal attainment. We believe that establishing an interacting nurse-client relationship and building trust is important in setting
mutual goal in order to attain goal. Our patient have shown full cooperation on our initial assessment and have given us the privilege to do
physical assessment to the affected areas of inguinal hernia for our case study which in return that we can provide him basic knowledge that he
needs in order to fully understand his condition and fully recovered after the surgery.

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LABORATORY AND DIAGNOSTIC EXAM

Laboratory and Diagnostic Results Normal Values Implication


exams
Ultrasound (inguinal) The patient has inguinal hernia.
Thick echogenicities are noted
______
superior to the right testicle due to
herniated omentum. There are
dilated vascular structures at the
left testicle in the area of
pampinniform plexus due to
varicocele.

______ For possible blood transfusion.


Blood typing
O positive

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CONCEPT MAP

9
TREATMENT MODALITIES
Preoperative Rationale
July 5, 2017

Please admit under my care (Dr. NERVEZ). Dr. Nervez is the patients doctor.
NPO To be ready for the surgery.
Labs: stat CBC, UA, blood typing CBC: Results are nonspecific, but leukocytosis with left shift may
occur with strangulation.
o UA: to rule out UTI or kidney stone may cause pain in the
groin area that can be mistaken for hernia pain.
o Blood typing: to know the patients blood type in case of
severe bleeding
Vital signs every 4 hours. Baseline data
IVF= PLR to run at 30 gtss/min x3 cycles Reduces acidity, has the same tonicity as blood, used for possible
extreme bleeding
Meds:
1. Cefuroxime 750mg IVTT every 8hrs ANST () Please refer to drug study
2. Ranitidine 50 mg IVTT every 8 hours Please refer to drug study

For herniorrhaphy, Right side


Insert foley catheter French 16 with urobag For inguinal hernia repair, with suturing of abdominal wall.
AP prep To prevent distraction durig surgery, 16 french is ideal for adults.
Inform OR and anesthesia To prepare for surgery
To alert the OR team of the upcoming surgery.

Intraoperative Rationale
July 6, 2017
For surgery
To OR
Meds: Please refer to drug study
1. Bupivacaine 0.5% solution Please refer to drug study

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2. Medazolam 0.5cc 2.5 mg Please refer to drug study
3. Atracurium 0.5cc 5mg
Reduce number of microorganisms on the skin, thus prevent
Skin prep infection

Postoperative Rationale
July 7, 2017 For further monitoring and evaluation
To PACU
1. Vital signs every 15 mins for q2h, every hour for q4h, every Provides comparative data for evaluating changes on the clients
4 hours q24h condition.
2. Bedrest To achieve patient comfort and rest
3. To ward For admission purposes
4. Flat on bed turn side to side every q2h To prevent bed sores

Follow up meds:
1. Ketorolac 30g IVTT q8h prn for pain Please refer to drug study
2. Tramadol 50 mg IVTT q6h Please refer to drug study
3. Paracetamol 500mg 1 tab q4h PRN T <38 C Please refer to drug study

For further monitoring and evaluation


Please refer accordingly
MGH

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DRUG STUDY
Cefuroxime 750mg IVTT every 8hrs ANST ( )

Generic name: Cefuroxime Sodium, Ceforxime Axetil

Brand name: Zinacef, Ceftin, Kefurox

Drug classification: 3rd generation cephalosporin

Mechanism of action: Semisynthetic second-generation cephalosporin antibiotic with structure similar to that of the penicillins. Resistance against
beta-lactamase-producing strains exceeds that of first generation cephalosporins. Antimicrobial spectrum of activity resembles that of cefonicid.
Preferentially binds to one or more of the penicillin-binding proteins (PBP) located on cell walls of susceptible organisms. This inhibits third and final
stage of bacterial cell wall synthesis, thus killing the bacterium. Partial cross-allergenicity between other beta-lactam antibiotics and cephalosporins
has been reported.

Indication: Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsillitis, sinusitis, lower respiratory
tract infections, skin and soft tissue infections, urinary tract infections, and is used for surgical prophylaxis, reducing or eliminating infection.

Side effects: Thrombophlebitis (IV), diarrhea

Contraindication: Hypersensitivity, Pregnancy (cat. B), Lactation

Dosage: 750mg IVTT q8h ANST ( )

Nursing Responsibilities:

Assessment & Drug Effects

Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is
initiated.
Lab tests: Perform culture and sensitivity tests before initiation of therapy and periodically during therapy if indicated. Therapy may be
instituted pending test results. Monitor periodically BUN and creatinine clearance.
Inspect IM and IV injection sites frequently for signs of phlebitis.

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Report onset of loose stools or diarrhea. Although pseudomembranous colitis (see Signs & Symptoms) rarely occurs, this potentially life-
threatening complication should be ruled out as the cause of diarrhea during and after antibiotic therapy.
Monitor for manifestations of hypersensitivity. Discontinue drug and report their appearance promptly.
Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.

Patient & Family Education

Report loose stools or diarrhea promptly.


Report any signs or symptoms of hypersensitivity.
Do not breast feed while taking this drug.

Ranitidine 50 mg IVTT every 8 hours

Generic name: Ranitidine Hydrochloride

Brand name: Zantac, Zantac-75, GELdose

Drug classification: H2 Blocker

Mechanism of action: Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2-receptor sites on parietal cells, thus
blocking gastric acid secretion. Indirectly reduces pepsin secretion but appears to have minimal effect on fasting and postprandial serum gastrin
concentrations or secretion of gastric intrinsic factor or mucus.

Indication: Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute ulcer; treatment of
gastroesophageal reflux disease; short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (e.g.,
Zollinger-Ellison syndrome, systemic mastocytosis, and postoperative hypersecretion); heartburn.

Side effects: Headache, malaise, dizziness, constipation, nausea, diarrhea, reversible decrease in WBC count

Contraindication: Hypersensitivity to ranitidine; acute porphyria; OTC administration in children <12 y.

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Dosage: 50 mg IVTT q8h

Nursing Responsibilities:

Assessment & Drug Effects

Potential toxicity results from decreased clearance (elimination) and therefore prolonged action; greatest in the older adult patients or those
with hepatic or renal dysfunction.
Lab tests: Periodic liver functions. Monitor creatinine clearance if renal dysfunction is present or suspected. Be alert for early signs of
hepatotoxicity (though low and thought to be a hypersensitivity reaction): jaundice (dark urine, pruritus, yellow sclera and skin), elevated
transaminases (especially ALT) and LDH.
Long-term therapy may lead to vitamin B12 deficiency.
Patient & Family Education

Note: Long duration of action provides ulcer pain relief that is maintained through the night as well as the day.
Be aware that even if symptomatic relief is provided by ranitidine, this should not be interpreted as absence of gastric malignancy. Follow-up
examinations will be scheduled after therapy is discontinued.
Adhere to scheduled periodic laboratory checkups during ranitidine treatment.
Do not supplement therapy with OTC remedies for gastric distress or pain without physician's advice (e.g., Mylanta II reduces ranitidine
absorption).
Do not smoke; research shows smoking decreases ranitidine efficacy and adversely affects ulcer healing. Do not breastfeed.

Bupivacaine 0.5% solution IVTT

Generic name: Bupivacaine Hydrochloride

Brand name: Sensorcaine, Marcaine

Drug classification: Local Anesthetic (Amide-type), CNS agent

14
Mechanism of action: Anesthetic of the amide type. Decreases sodium flux into nerve cell, inhibiting initial depolarization, and prevents propagation
and conduction of the nerve impulse. Progression of anesthesia, related to diameter, myelination, and conduction velocity of affected fibers is
manifested clinically as sequential loss of nerve function. May stimulate or depress the CNS or do both.

Indication: Infiltration anesthesia; peripheral, sympathetic nerve, and epidural (including caudal) block anesthesia; 0.75% bupivacaine solution in
dextrose is used for spinal anesthesia.

Side effects: dizziness, drowsiness, nausea, vomiting, total spinal block, persistent analgesia

Contraindication: Known sensitivity to bupivacaine, local anesthetics, other amide-type anesthetics. Parabens, or metabisulfites; acidosis; heart
block; severe hemorrhage; hypotension and shock; hypertension, cerebrospinal diseases; obstetrical paracervical anesthesia or spinal anesthesia in
septicemia; topical or IV regional anesthesia; intercurrent use with chloroprocaine; history of malignant hyperthermia. Safety during pregnancy
(category C) other than during labor, lactation, or children <12 y is not established.

Dosage: 0.5% solution IVTT

Nursing Responsibilities:

Assessment & Drug Effects

Monitor for signs of inadvertent intravascular injection, which can produce a transient "epinephrine response" (increased heart rate or systolic
BP or both, circumoral pallor, palpitations, nervousness) within 45 seconds in the unsedated patient and an increase by 20 bpm or more in
heart rate for at least 15 seconds in sedated patient.
Vasoconstrictor-containing solution should be administered cautiously, if at all, to areas with end arteries (e.g., digits, penis) or to areas that
have a compromised blood supply; ischemia and gangrene can result. Inspect areas for evidence of reduced perfusion because of
vasospasm: pale, cold, sensitive skin.
Note: Systemic reactions (toxicity) are more apt to occur in children or older adults and may develop rapidly or be delayed for as long as 30
min after administration.
Monitor for toxicity: CNS stimulation (unusual anxiety, excitement, restlessness) usually occurs first, followed by CNS depression (drowsiness,
unconsciousness, respiratory arrest). However, because stimulation is apt to be transient or absent, drowsiness may be the first sign in some
patients (especially children and older adults).
After spinal anesthesia, sensation to lower extremities may not return for 2.53.5 h.

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Midazolam 0.5cc 2.5 mg

Generic name: Midozolam Hydrochloride

Brand name: Lorazepam

Drug classification: Benzodiazepine Anxiolytic, Sedative-Hypnotic, CNS agent

Mechanism of action: Short-acting parenteral benzodiazepine. Mechanism of action unclear. Intensifies activity of gamma-aminobenzoic acid
(GABA), a major inhibitory neurotransmitter of the brain, by interfering with its reuptake and promoting its accumulation at neuronal synapses. This
calms the patient, relaxes skeletal muscles, and in high doses produces sleep.

Indication: Sedation before general anesthesia, induction of general anesthesia; to impair memory of perioperative events (anterograde amnesia);
for conscious sedation prior to short diagnostic and endoscopic procedures; and as the hypnotic supplement to nitrous oxide and oxygen (balanced
anesthesia) for short surgical procedures.

Side effects: Retrograde amnesia, drowsiness, headache, Hypotension, Nausea, vomiting

Contraindication: Intolerance to benzodiazepines; acute narrow-angle glaucoma; shock, coma; acute alcohol intoxication; intraarterial injection.
Safety in pregnancy (category D), labor and delivery, or lactation is not established.

Dosage: 0.5cc 2.5 mg

Nursing Responsibilities:

Assessment & Drug Effects

Inspect insertion site for redness, pain, swelling, and other signs of extravasation during IV infusion.
Monitor for hypotension, especially if the patient is premedicated with a narcotic agonist analgesic.
Monitor vital signs for entire recovery period. In obese patient, half-life is prolonged during IV infusion; therefore, duration of effects is
prolonged (i.e., amnesia, postoperative recovery).
Be aware that overdose symptoms include somnolence, confusion, sedation, diminished reflexes, coma, and untoward effects on vital signs.

16
Patient & Family Education

Do not drive or engage in potentially hazardous activities until response to drug is known. You may feel drowsy, weak, or tired for 12 d after
drug has been given.
Be prepared for amnesia to prevent an upsetting postoperative period.
Review written instructions to assure future understanding and compliance. Patient teaching during amnestic period may not be remembered.
Even if dose is small and depth of amnesia is unclear, relearn information.

Atracurium 0.5cc 5mg

Generic name: Atracurium Besylate

Brand name: Tracrium

Drug classification: Skeletal Muscle Relaxant, ANS agent, Neuromuscular blocker, Nondepolarizing

Mechanism of action: Inhibits neuromuscular transmission by binding competitively with acetylcholine to muscle end plate receptors. Lacks
analgesic action and has no apparent effect on pain threshold, consciousness, or cerebration. Given in general anesthesia only after
unconsciousness has been induced by other drugs.

Indication: Adjunct for general anesthesia to produce skeletal muscle relaxation during surgery; to facilitate endotracheal intubation. Especially
useful for patients with severe renal or hepatic disease, limited cardiac reserve, and in patients with low or atypical pseudocholinesterase levels.

Side effects: bradycardia, tachycardia, increased salivation

Contraindication: Myasthenia gravis. Safety during pregnancy (category C), lactation, or in children <2 is not established.

Dosage: 0.5cc 5mg

Nursing Responsibilities:

17
Assessment & Drug Effects

Lab tests: Baseline serum electrolytes, acidbase balance, and renal function as part of preanesthetic assessment.
Note: Personnel and equipment required for endotracheal intubation, administration of oxygen under positive pressure, artificial respiration,
and assisted or controlled ventilation must be immediately available.
Evaluate degree of neuromuscular blockade and muscle paralysis to avoid risk of overdosage by qualified individual using peripheral nerve
stimulator.
Monitor BP, pulse, and respirations and evaluate patient's recovery from neuromuscular blocking (curare-like) effect as evidenced by ability to
breathe naturally or to take deep breaths and cough, keep eyes open, lift head keeping mouth closed, adequacy of hand-grip strength. Notify
physician if recovery is delayed.
Note: Recovery from neuromuscular blockade usually begins 3545 min after drug administration and is almost complete in about 1 h.
Recovery time may be delayed in patients with cardiovascular disease, edematous states, and in older adults.

Ketorolac 30g IVTT q8h prn for pain

Generic name: Ketorolac Tromethamine

Brand name: Toradol, Acular, Acular LS

Drug classification: NSAID, Analgesic, CNS agent, Antipyretic

Mechanism of action: It inhibits synthesis of prostaglandins and is a peripherally acting analgesic. Ketorolac does not have any known effects on
opiate receptors.

Indication: Short-term management of pain; ocular itching due to seasonal allergic conjunctivitis, reduction of post-operative pain and photophobia
after refractive surgery.

Side effects: Drowsiness, Nausea, dizziness, headache

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Contraindication: Hypersensitivity to ketorolac; individuals with complete or partial syndrome of nasal polyps, angioedema, and bronchospastic
reaction to aspirin or other NSAIDs; during labor and delivery; patients with severe renal impairment or at risk for renal failure due to volume
depletion; patients with risk of bleeding; active peptic ulcer disease; pre- or intraoperatively; intrathecal or epidural administration; in combination with
other NSAIDs; lactation.

Dosage: 30g IVTT q8h prn for pain

Nursing Responsibilities:

Assessment & Drug Effects

Correct hypovolemia prior to administration of ketorolac.


Lab tests: Periodic serum electrolytes and liver functions; urinalysis (for hematuria and proteinuria) with long-term use.
Monitor urine output in older adults and patients with a history of cardiac decompensation, renal impairment, heart failure, or liver dysfunction
as well as those taking diuretics. Discontinuation of drug will return urine output to pretreatment level.
Monitor for S&S of GI distress or bleeding including nausea, GI pain, diarrhea, melena, or hematemesis. GI ulceration with perforation can
occur anytime during treatment. Drug decreases platelet aggregation and thus may prolong bleeding time.
Monitor for fluid retention and edema in patients with a history of CHF.
Patient & Family Education

Watch for S&S of GI ulceration and bleeding (e.g., bloody emesis, black tarry stools) during long-term therapy.
Note: Possible CNS adverse effects (e.g., light-headedness, dizziness, drowsiness).
Do not drive or engage in potentially hazardous activities until response to drug is known.
Do not use other NSAIDs while taking this drug.
Do not breast feed while taking this drug.

Tramadol 50 mg IVTT q6h

Generic name: Tramadol Hydrochloride

Brand name: Ultram, Zydol

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Drug classification: Analgesic, Narcotic (Opiate) Agonist, CNS agent

Mechanism of action: Centrally acting opiate receptor agonist that inhibits the uptake of norepinephrine and serotonin, suggesting both opioid and
nonopioid mechanisms of pain relief. May produce opioid-like effects, but causes less respiratory depression than morphine.

Indication: Management of moderate to moderately severe pain.

Side effects: dizziness, vertigo, fatigue, headache, somnolence, nausea, constipation, vomiting, restlessness, anxiety

Contraindication: Hypersensitivity to tramadol or other opioid analgesics; patients on MAO inhibitors; patients acutely intoxicated with alcohol,
hypnotics, centrally acting analgesics, opioids, or psychotropic drugs; substance abuse; patients on obstetric preoperative medication; abrupt
discontinuation; alcohol intoxication; pregnancy (category C); lactation; children <16 y.

Dosage: 50 mg IVTT q6h

Nursing Responsibilities:

Assessment & Drug Effects

Assess for level of pain relief and administer prn dose as needed but not to exceed the recommended total daily dose.
Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression.
Discontinue drug and notify physician if S&S of hypersensitivity occur.
Assess bowel and bladder function; report urinary frequency or retention.
Use seizure precautions for patients who have a history of seizures or who are concurrently using drugs that lower the seizure threshold.
Monitor ambulation and take appropriate safety precautions.
Patient & Family Education

Exercise caution with potentially hazardous activities until response to drug is known.
Understand potential adverse effects and report problems with bowel and bladder function, CNS impairment, and any other bothersome
adverse effects to physician.
Do not breast feed while taking this drug.

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Paracetamol 500mg 1 tab q4h PRN T <38 C

Generic name: Paracetamol

Brand name: Abenol, Halenol, Panadol

Drug classification: Non-narcotic analgesic, Antipyretic, CNS agent

Mechanism of action: Produces analgesia by unknown mechanism, perhaps by action on peripheral nervous system. Reduces fever by direct
action on hypothalamus heat-regulating center with consequent peripheral vasodilation, sweating, and dissipation of heat. Unlike aspirin,
acetaminophen has little effect on platelet aggregation, does not affect bleeding time, and generally produces no gastric bleeding.

Indication: Fever reduction. Temporary relief of mild to moderate pain. Generally as substitute for aspirin when the latter is not tolerated or is
contraindicated.

Side effects: anorexia, nausea, vomiting, dizziness, diaphoresis, chills, rash, hepatotoxicity

Contraindication: Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Dosage: 500mg 1 tab q4h PRN T <38 C

Nursing Responsibilities:

Assessment & Drug Effects

Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have
ingested alcohol over prolonged periods; poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological
dependence (withdrawal has been associated with restless and excited responses).
Patient & Family Education

Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can
cause liver damage and other toxic effects.
Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a physician.
Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5 C (103 F), or recurrent fever.
21
Do not give children more than 5 doses in 24 h unless prescribed by physician.
Do not breast feed while taking this drug without consulting physician.

22
NURSING MANAGEMENT
A. PHYSICAL ASSESSMENT
CATEGORY FINDINGS
General Appearance The patient is well groomed and oriented to the time and place.

No difficulty in hearing.

Presence of FBC.

Complaining presence of pain in RLQ


Vital Signs T: 36.3 C
P: 103 bpm
RR: 18 cpm
BP: 120/70
Integumentary Inspection:

Uniform skin color with slightly darker exposed areas.


No unusual odor
Skin lesions in the lower extremities
Hair evenly distributed, presence of dandruff

Palpation:

Skin warm
Exposed areas are usually drier than unexposed areas
Exposed skin usually not as soft as unexposed
Good skin turgor
Good capillary refill

23
Scalp non tender

Abdomen Inspection:
Skin color consistent with patients ethnicity
Color lighter on abdomen than on other areas of body because of lack of exposure
Skin color same throughout the abdomen
Abdominal skin intact, no presence of lesions, masses
Umbilicus inverted and midline
Abdomen symmetrical bilaterally from costal margin to iliac crest, with umbilicus in center
No abdominal distension. Contour is rounded
Peristalsis and aortic pulsation are not visible
Uses abdominal muscles more with breathing
Undistended bladder
Auscultation:
RUQ: 18 clicks/min
LUQ: 17 clicks/min
RLQ: 17clicks/min
LLQ: 16 clicks/ min
No bruits, venous hum and friction rub noted
Percussion:
Tympany noted
Dullness noted (above the bladder) at the midline above the symphesis pubis
Palpation:
No organomegaly or masses
Tenderness is noted in light palpation.
Tenderness is noted in deep palpation.
Bladder is not palpable
Inguinal lymph nodes are palpable, mobile with tenderness noted
Deminish abdominal responses

24
No masses or organ is felt
No Kehrs sign, Ballance sign, Murphys sign noted
Negative McBurneys sign
Negative obturator muscle test
Negative Rovsings sign
Negative Cutaneous Hypersensitivity

Reproductive Inspection:
Pubic hair distribution triangular, sparsely distributed in scrotum and inner thigh, and
absent on penis.
Penis: no lesions or inflammation. Presence of FBC
Bulging on the right scrotum, painful when being touched

25
B. GORDONS FUNCTIONAL HEALTH PATTERN

USUAL PATTERN INITIAL APPRAISAL ON GOING APPRAISAL


(7-6-2017) (7-7-2017)
A. Health Perception /Management
- health during the past few years was - general health at this time is poor - general health at this time is not so
good - seeks hospitalization for recovery poor
- eat nutritious and variety of food as - Pre-op: sakit akong bulog, diri - seeks hospitalization for recovery
main source of nutrients dapit sa tu-o , as verbalized by the - gamay nalang ang sakit nga
- no child yet patient. akong nabati, as verbalized by the
- experience minimal weight loss for - Post-op: sakit akong bulog, diri patient.
the past dapit sa gi-operahan , as - Rated pain as 3 out of 0-10 pain scale
9 months verbalized by the patient. - Absence of facial grimacing
- pt remember of complete - Rated pain as 8 out of 0-10 pain scale - able to move extremeties
immunization during childhood - Facial grimacing noted - able to sit on bed
- perform annual testicular self-exam - Unable to move freely - absence of guarding protective
- pt. had already notice a lump on his - Lying down most of the time behavior
right scrotum since childhood but it - Guarding protective behavior - V/S as follows:
does bother him so he did not seek - V/S as follows: T= 37.0 degrees Celsius
medical advice T= 36.3 degrees Celsius P= 76 bpm
- never been hospitalized before P= 103 bpm R= 20 cpm
- had experienced cough and colds in R= 18 cpm Bp= 120/80 mmHg
the past years Bp= 120/70 mmHg
- takes OTC drugs when having fever
or slight illness Medications: Medications:
- had not taken any illegal drugs 1. Cefuroxime 750 mg IVTT q8h 1. Cefuroxime 750 mg IVTT q8h
- does not anticipate problem in caring 2. Ranitidine 50mg q12h IVTT 2. Ranitidine 50mg q12h IVTT
for himself 3. Ketorolac 30g IVTT q 8h prn for
pain
Blood type: 4. Tramadol 50mg IVTT q 6h
O positive 5. Paracetamol 500mg 1 tab q4h
PRN T <38 C

26
6. Bupivacaine 0.5% solution
7. Medazolam 0.5cc 2.5 mg
8. Atracurium 0.5cc 5mg
Diagnostic Exams:
- UTZ results:

Thick echogenicities are noted


superior to the right testicle due to herniated
omentum. There are dilated vascular structures
at the left testicle in the area of pampinniform
plexus due to varicocele.

B. Nutritional Metabolic Pattern


Breakfast - On NPO - DAT
Lunch - Drink 1000ml of water
- Rice - 1 cup rice and a boul of beef stew
- Fried chicken
- Bowl of soup
Dinner
- Rice
- Fish/meat
- Vegetables
Patient eat snacks sometimes
Patients appetite is good
Usual fluid intake
Kind Quantity
Breakfast
- Water 1 glass
- Coffee 1 cup
Snacks

27
- Juice 1 glass
Lunch
- Water 2 glasses
Snacks
- Coffee 1 cup
- Water 1 glass
Dinner
- Water 2 glasses

C. Elimination Pattern
Bladder: Bladder:
- Urine: light yellow in color; pungent - Urine: dark yellow in color - Urine: dark yellow in color
odor :with FBC attached, indwelling :with FBC attached, indwelling
- Urinates a maximum of 4 times a day Bowel:
with approximately 1800ml - Wala pako kalibang sukad ko na admit
as verbalized by the patient. - Has defecated once
Bowel:
- Defecates at least once a day Skin:
- Stool is light brown in color - Minimal perspiration noted - TSB done by the SO
- No unusual odor - No unusual odor
Skin: - Moist, good skin turgor - Moist, good skin turgor
- Slight perspirations
- No unusual odor

D. Activity-Exercise Pattern
- Working 5 days a week as - Has decreased energy in doing activities - Pt. Report of increase energy level
construction worker, communte - Pre-op: musamot sakit akong kilid - malihok-lihok na naku akong
through his work inig molihok ko , as verbalized by the lawas ug makalingkod napud qo,
- Energy is sufficient enough for doing patient. as verbalized by the patient.
his daily activities at home and at - Post-op: maglisod qo ug lihok kay - Able to participate activities relevant

28
work sakit samot akong opera, as to his recovery
verbalized by the patient. - Able to move extremities and sit on
- Not able to do activities of daily living bed
- Unable to move freely
- Lying down most of the time

Feeding: 0 Feeding: 4 Feeding: 0


Grooming: 0 Grooming: 4 Grooming: 2
Bathing: 0 Bathing: 4 General Mobility: 0
General Mobility: 0 General Mobility: 4 Dressing: 2
Cooking: 0 Cooking: 4 Toileting: 0
Dressing: 0 Dressing: 4 Bed Mobility: 0
Toileting: 0 Toileting: 4
Home Maintenance: 0 Home Maintenance: 4
Bed Mobility: 0 Bed Mobility: 4
Shopping: 0 Shopping: 4
Functional Level Codes: Functional Level Codes:
0 = full self-care 0 = full self-care
II = requires help , supervision, or teaching II = requires help , supervision, or
from another person teaching from another person
III = requires assistance or supervision from III = requires assistance or supervision
another person or device from another person
IV is dependent and does not participate or device
IV = is dependent and does not
participate

E. Sleep Rest Pattern


Onset: 10-11 pm Onset: 2am Onset: 8pm
Awakening: 5-6am Awakening: 10am Awakening: 4-5am
- Experiences nightmares; causing - Sleep is sometimes interrupted by nurses - Sleep is sometimes interrupted by nurses
sleep interruptions going on rounds going on rounds
- Hours of sleep: 6-7 hours - Hours of sleep: 8 hours - Hours of sleep: 8-9 hours

29
- No use of sleeping aids - No use of sleeping aids - No use of sleeping aids
- No sleeping problems - No sleeping problems - No sleeping problems
- Feels rested after sleep

F. Cognitive Perceptual Pattern


- Highest educational attainment: - Responsive - Responsive
College Level- 1st year 1st semester - Oriented to time and place - Oriented to time and place
- No hearing problem or hearing aids - Doing his best to talk and respond if - Doing his best to talk and respond if
used being asked being asked
- Can retain information
- No memory changes
- His easiest way to learn and
understand things is through listening

G. Self-Perception / Self-Concept Pattern


- Described self as a friendly and silent - Patient was responsive - Responsive
- Described self as silent most of the - Lying on bed and did not want to move - Turn into unaffected side or sit
time - Most concerned about his current health sometimes
- Feels good about himself status - Pt. verbalizes of accurate information
- He is worried every time he finds out - Expressing misconception - Pt. is able to deal with current health
about having an illness - miss magka-anak paba ko?, usa situation
raman ka itlog ang maapektuhan - Pt. is calm
noh?, as verbalized by the patient. - Would like to recover quickly
- gikulba.an ko sa operation miss, dili
rapod dagway ko maba.og noh? as
verbalized by the patient.
- Would like to recover quickly

H. Role Relationship Pattern


- He lives with his wife at valencia - Patient currently depend on his mother - Dependent to his mother
- Decision making is done by both of and wife - Family is supportive

30
them - Family is supportive despite his condition - Talk to SO for comfort
- Has no difficulties in relation with his - His would call his wife who are left at
family home
- Has close friends in their barangay - Speak bisaya
- Experienced having little - College level
misunderstanding and conflicts but - His wife is teacher
was solved easily
- Can speak bisaya, a little bit of
tagalong and English
- Speak clearly and relevant
- Able to understand verbally, and other
gestures
- Turn help to parents in Dumaguete
when need help

I. Sexuality Reproductive Pattern


- No history of previous operations that - Patient has no difficulty in urinating, but - No difficulty in urinating
involved the reproductive system only wasnt able to go to toilet - Pt. Said that he has previous
- Does not have history regarding - Patient does not complain of any pain girlfriends but never had a chance to
surgeries of reproductive organ while urinating impregnate woman
- Has previous girlfriends
- But has no child yet, even with the
exes
- Does not use any contraceptive
method when engaged into sex

J. Coping Stress Tolerance Pattern


- Stress is relieved by taking a nap - Patient prays before sleeping to seek for - Pray and talk to God by heart
- he prays and seeks advices and Gods healing - Talk to SO for comfort
comfort from his mother - Patient talks to his mother or call his wife - Take a nap when stressed
- SO stated he is one of the most for comfort

31
helpful family member

K. Value Belief
- Patient goes to church regularly along - Patient stated he believes that God is - Have faith in God
with his wife greater than anything else in this world - Pray to God
- Prays every day before and after bed - Patient stated that he knows God will - Does not lose his hope despite his
time heal him condition.
- Religion: Roman Catholic - Did not lose hope and faith in the Lord
- Pt. stated that in facing problems in despite his condition
life, his only solution to it is to pray
and have faith in the Lord.

32
C. LIST OF NURSING DIAGNOSIS

PRE-OPERATIVE PHASE:

1. Acute pain related to protrusion on the right scrotum


2. Activity intolerance related to pain secondary to inguinal hernia
3. Anxiety related to surgical procedure (herniorrhapy)

INTRA-OPERATIVE PHASE:

1. Impaired tissue (skin) integrity related to surgical incision secondary to inguinal hernia repair
2. Risk for injury/bleeding related to surgical procedure
3. Risk for infection related to surgical procedure manifested by surgical instruments introduced in the body

POST-OPERATIVE PHASE:

1. Pain/discomfort related to surgical incision secondary to inguinal hernia repair


2. Impaired tissue (skin) integrity related to surgical incision secondary to inguinal hernia repair
3. Impaired physical mobility related to pain/discomfort from surgical incision

33
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Acute pain related to At the end of 2 days 1. Assess V/S, noting 1. To obtain baseline At the end of 2 days
sakit akong bulog, diri protrusion of the right duty, the patient will be tachycardia, data. Changes in duty, the goal was met
dapit sa tu-o, as scrotum able to experience hypertension, and these vital signs often as manifested by:
verbalized by the minimal pain as increased respiration, indicate acute pain
patient. manifested by: even if patient denies and discomfort. Note: - Vital signs
pain. Some patients may within
-Rated pain as 8 out of - Vital signs have a slightly lowered normal
0-10 pain scale within BP, which returns to range:
normal normal range after T- 36.9
range pain relief is achieved. P- 76 bpm
- Pain rating R- 20 cpm
of 3-4 out of 2. Note presence of 2. Concern about the BP- 120/70
Objective: 0-10 pain anxiety or fear, and unknown (e.g., mmHg
- Facial scale relate with nature of outcome of a biopsy)
grimacing - Absence of and preparation for and/or inadequate - Pt. Report of
noted facial procedure. preparation (e.g., decreased
- Unable to grimace emergency perception of
move freely - able to move appendectomy) can pain
- Lying down freely heighten patients - Pain rating
most of the - able to at perception of pain. of 3 out of 0-
time least sit 10 pain
- Guarding down 3. Maintain 3. Relieves pain and scale only
protective - absence of immobilization of prevents bone upon
behavior guarding affected part by means displacement/ movement
- PR= 103 protective of bed rest or splint. extension of tissue - Absence of
bpm behaviour injury. facial
- UTZ results: grimacing
Thick 4. Reposition as 4. May relieve pain - able to move
echogeniciti indicated: semi- and enhance freely

34
es are noted Fowlers; circulation. Semi- - able to sit
superior to Fowlers position down and
the right relieves abdominal ambulate
testicle due muscle tension and - absence of
to herniated arthritic back muscle guarding
omentum. tension. protective
There are 4. Evaluate reports of behaviour
dilated pain, noting location, Monitors effectiveness
vascular characteristic and of interventions. Level
strucuresat intensity. Note of anxiety may affect
the left nonverbal pain cues. perception of pain.
testicle in
the area of
pampinnifor 5. Encourage use of 5. Relieves muscle
m plexus relaxation techniques: and emotional tension;
due to deep-breathing enhances sense of
varicocele. exercises, guided control and may
imagery, visualization, improve coping
music. abilities.

6. Identify diversional 6. Prevents boredom,


activities appropriate reduces tension, and
for patients age, may enhance self-
physical abilities and esteem and coping
personal preference. abilities.
s
7. Apply cold/icepack if 7. Reduces edema/
not contraindicated. hematoma formation,
decreases pain
sensation.

35
Collaborative:
1. Regulate IV fluids. 1. For F/E
replacement.
2. Administer
medications as
ordered.
Cefuroxime 750 Antimicrobial
mg IVTT q8h, agent
ANST
Ranitidine 50mg Reduces gastric
q12h IVTT acid production

3. Provide health 3. To educate patient


teaching regarding with measures to
measures to alleviate alleviate pain.
pain.

36
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Activity intolerance At the end of 2 days 1. Monitor V/S. 1. To obtain baseline At the end of 2 days
musamot sakit akong related to pain duty, the patient will be data. duty, the goal was met
kilid inig molihok ko, secondary to inguinal able to exhibit as manifested by:
as verbalized by the hernia tolerance in performing 2. Assess the physical 2. Provides baseline
patient. activities of daily living activity level and information for - Vital signs
as manifested by: mobility of the patient.. formulating nursing within
-Rated pain as 8 out of goals during goal normal
0-10 pain scale - Vital signs setting. range:
within T- 36.9
normal 3. Investigate the 3. Causative factors P- 76 bpm
range patients perception of may be temporary or R- 20 cpm
- Pain rating causes of activity permanent as well as BP- 120/70
Objective: of 3-4 out of intolerance. physical or mmHg
- Facial 0-10 pain psychological. - Pt. Report of
grimacing scale Determining the cause decreased
noted - Absence of can help guide perception of
- Unable to facial the nurse during pain
move freely grimace the nursing interventio - Pain rating
- Lying down - able to move n. of 3 out of 0-
most of the freely 10 pain
time - able to at 4. Evaluate reports of 4. Monitors scale only
- Guarding least sit pain, noting location, effectiveness of upon
protective down and characteristic and interventions. Level of movement
behavior ambulate intensity. Note anxiety may affect - Absence of
- PR= 103 - absence of nonverbal pain cues. perception of pain. facial
bpm guarding grimacing
- UTZ results: protective 5. Assess the patients 5. Adequate energy - able to move
Thick echogenicities behaviour nutritional status. reserves are needed freely
are noted superior to during activity. - able to sit
the right testicle due to down and
herniated omentum. ambulate

37
There are dilated 6. Perform and 6. Maintain strength/ - absence of
vascular strucuresat supervise passive mobility of the affected guarding
the left testicle in the ROM. muscles and facilitates protective
area of pampinniform resolution of behaviour
plexus due to inflammation in injured
varicocele. tissues.

7. Provide alternate 7. Improves general


comfort measures e.g circulation; reduces
position changes. area of local pressure
and muscle fatigue.

8. Encourage 8. This helps the


verbalization of patient to cope.
feelings regarding Acknowledgment that
limitations. living with activity
intolerance is both
physically and
emotionally difficult.

9. Apply cold/icepack if 9. Reduces edema/


not contraindicated. hematoma formation,
decreases pain
sensation.

Collaborative:
1. Regulate IV fluids. 1. For F/E
replacement.
2. Administer
medications as
ordered.
Cefuroxime 750 Antimicrobial
mg IVTT q8h, agent

38
ANST
Ranitidine 50mg Reduces gastric
q12h IVTT acid production

3. Provide health 3. To educate


teaching regarding patient with
measures to alleviate measures to
pain. alleviate pain.

39
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Anxiety related to At the end of 2 days 1. Monitor V/S. 1. To obtain baseline At the end of 2 days
gikulba.an ko sa surgical procedure duty, the patient will be data. duty, the goal was met
operation miss, dili (herniorrhapy) able to experience as evidenced by:
rapod dagway ko minimal anxiety as 2. Assess clients level 2. Anxiety also plays a
maba.og noh? as evidenced by: of anxiety and physical role in somatoform - Vital signs
verbalized by the reactions to anxiety. disorders, which are within
patient. - Vital signs characterized by normal
within physical symptoms range:
normal such as pain, nausea, T- 36.9
range weakness, or P- 76 bpm
- Patient dizziness that have no R- 20 cpm
Objective: describes apparent physical BP- 120/70
own anxiety cause. mmHg
PR= 103 bpm and coping - Patient
Apprehensive patterns. 3. Use presence, 3. Being supportive described
Feelings of - improved touch (with and approachable own anxiety
inadequacy concentratio permission), encourages and coping
Focus on self n verbalization, and communication. patterns.
Uneasy feeling - accuracy of demeanor to remind - improved
noted thoughts clients that they are concentratio
persistent - able to not alone and to n
increased reassure self encourage expression - accuracy of
helplessness - Patient or clarification of thoughts
Difficulty identifies needs, concerns, - able to
concentrating strategies to unknowns, and reassure self
Fear of reduce questions. - Patient had
unspecified anxiety identified
consequences - Patient 4. Allow and reinforce 4. Talking or otherwise strategies to
Facial flushing appears clients personal expressing feelings reduce
calm reaction to or sometimes reduces anxiety
expression of pain, anxiety. - Patient is

40
discomfort, or threats calm
to well-being (e.g.,
talking, and other
physical or nonverbal
expressions)

5. Help client identify 5. Gaining insight


precipitants of anxiety enables the client to
that may indicate reevaluate the threat
interventions. or identify new ways to
deal with it.

6. Encourage the client 6. Cognitive therapies


to use positive self- focus on changing
talk. behaviors and feelings
by changing thoughts.
Replacing negative
self-statements with
positive self-
statements helps to
decrease anxiety.

7. Avoid excessive 7. Reassurance is not


reassurance; this may helpful for the anxious
reinforce undue worry. individual.

8. Explain all activities, 8. With preadmission


procedures, and patient education,
issues that involve the patients experience
client; use nonmedical less anxiety and
terms and calm, slow emotional distress and
speech. Do this in have increased coping
advance of procedures skills because they

41
when possible, and know what to expect.
validate clients
understanding.

9. Explore coping skills 9. Methods of coping


previously used by with anxiety that have
client to relieve been successful in the
anxiety; reinforce past are likely to be
these skills and helpful again. Listening
explore other outlets. to clients and helping
them to sort through
their fears and
expectations
encourages them to
take charge of their
lives.

10. Use therapeutic 10. Healing touch may


touch and healing be one of the most
touch techniques. useful nursing
interventions available
to reduce anxiety.

42
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Impaired tissue (skin) At the end of 5 hours 1. Monitor V/S. 1. To obtain baseline At the end of 5 hours
karon akong schedule integrity related to nursing intervention, data. nursing intervention,
sa opera miss, g surgical incision the patient will be able the goal was partially
hernia man gud qo secondary to inguinal to demonstrate 2. Determine the 2. Prior assessment is met as evidenced by:
as verbalized by the hernia repair improve tissue (skin) extent of the incision. critical for proper
patient. integrity as evidenced identification of nursing - Vital signs
by: interventions. within
normal
- Vital signs 3. Assess site of 3. Redness, swelling, range:
within impaired tissue pain, burning, and T- 36.9
Objective: normal integrity and its itching are indication of P- 76 bpm
- Incision over range condition. inflammation and the R- 20 cpm
the inguinal - Patient bodys immune system BP- 120/70
canal demonstrate response to localized mmHg
- UTZ results: s tissue trauma. - Patient
Thick understandi demonstrate
echogeniciti ng of plan to 4. Monitor site of 4. Systematic d
es are noted heal tissue impaired tissue inspection can identify - understandin
superior to and prevent integrity at least once impending problems g of plan to
the right injury daily for color early. heal tissue
testicle due - Patients changes, redness, and prevent
to herniated wound swelling, warmth, pain, injury
omentum. decreases in or other signs of - Patients
There are size and has infection. wound has
dilated increased not yet
vascular granulation 5. Assess changes in 5. Fever is a systemic decreased in
strucuresat tissue body temperature, manifestation of size but has
the left specifically increased inflammation and may no indication
testicle in in body temperature. indicate the presence of further
the area of of infection. inflammation
pampinnifor

43
m plexus 6. Assess the patients 6. Pain is part of the
due to level of distress. normal inflammatory
varicocele. process. The extent
and depth may affect
pain sensations.

7. Assess patients 7. Inadequate


nutritional status; refer nutritional intake
for a nutritional places the patient at
consultation and/or risk for skin breakdown
institute dietary and compromises
supplements. healing.

8. Keep a sterile 8. This technique


dressing technique reduces the risk for
during wound care. infection.

9. Do not position 9. This is to avoid


patient on site of adverse effects of
impaired tissue external mechanical
integrity. If ordered, forces (pressure,
turn and position friction, and shear).
patient at least every 2
hours, and carefully
transfer patient.

Collaborative:
1. Regulate IV fluids. 1. For F/E
replacement.

44
2. Administer
medications as
ordered. Antimicrobial
Cefuroxime 750 agent
mg IVTT q8h,
ANST
Ranitidine 50mg Reduces gastric
q12h IVTT acid production

3. Anesthetic agents is 3. To ease the pain


given by the and promote relaxation
anaesthesiologist. during surgery.

45
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Risk for injury/bleeding After 5 hours 1. Monitor patients 1. Hypotension and At the end of 5 hours
Objective: related to of nursing vital signs, especially tachycardia are initial nursing intervention,
Patients vital surgical procedure intervention patient will BP and HR. Look for compensatory the goal was met as
signs is closely be free from signs of orthostatic mechanisms usually evidenced by:
monitored: injury/bleeding during hypotension. noted with bleeding.
P- 103 bpm the whole procedure - Vital signs
Patient is in a as manifested by: 2. Evaluate the 2. Drugs that interfere within
supine position, - Vital signs patients use of any with clotting normal
the abdomen is within medications that can mechanisms or values:
exposed normal affect hemostasis. platelet activity T- 36.9
Incision over values increase risk for P- 76 bpm
inguinal area - Absence of bleeding. R- 20 cpm
(close to any signs 3. Monitor hematocrit BP- 120/70
femoral artery) and (Hct) and hemoglobin 3. When bleeding is mmHg
symptoms of (Hgb). not visible, decreased - Absence of
bleeding Hgb and Hct levels any signs
may be an early and
indicator of bleeding. symptoms of
bleeding
4. When laboratory 4. Blood product
values are abnormal, transfusions replace
administer blood blood clotting factors;
products as RBCs increase
prescribed. oxygen-carrying
capacity; FFP replaces
clotting factors and
inhibitors; platelets and
cryoprecipitate provide
proteins for
coagulations.

46
5. Assess skin turgor 5. Signs of dehydration
and oral mucous may also indicate
membranes for signs decreased in blood
of dehydration. volume.

6. Auscultate and 6. Cardiac alterations


document heart like dysrhythmias may
sounds; note rate, reflect hypovolemia
rhythm or other and/or electrolyte
abnormal findings. imbalance,

7. Monitor active fluid7. Fluid loss from


loss from wound wound drainage and/or
drainage, tubes, or bleeding cause
bleeding if any. decreased fluid
volume.
8. Keep in touch with 8. This is to assure
blood transfusion the availability of blood
center. when needed.

Collaborative: 1. Parenteral fluid


1. Insert and IV replacement is
catheter to have IV indicated to prevent or
access. treat hypovolemic
complications.

2. Fluids are
2. Administer necessary to maintain
parenteral fluids as hydration status.
prescribed. Consider Determination of the
the need for an IV fluid type and amount of

47
challenge with fluid to be replaced
immediate infusion of and infusion rates will
fluids for patients with vary depending on
abnormal vital signs. clinical status.

3. Administer blood 3. Blood transfusions


products as may be required to
prescribed. correct fluid loss.

4. Administer 4. May be given


antibiotics as prophylactically for
indicated. suspected infection or
contamination.

5. Educate the patient 5. Early evaluation and


and family members treatment of bleeding
about signs of by a health care
bleeding that need to provider reduce the
be reported to a health risk for complications
care provider. from blood loss.

48
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Risk for infection After 5 hours 1. Monitor V/S. Assess 1. To obtain baseline At the end of 5 hours
Objective: related to of nursing changes in body data. Fever is a nursing intervention,
surgical procedure intervention patient will temperature, systemic manifestation the goal was met as
Patients vital manifested by surgical be free from infection specifically increased of inflammation and evidenced by:
signs is closely instruments introduced during the in body temperature. may indicate the
monitored in the body whole procedure as presence of infection. - Vital signs
Patient is in a manifested by: within
supine position, - Vital signs 2. Adhere to facility 2. Established normal
the abdomen is within infection control, mechanisms designed values:
exposed normal sterilization, and to prevent infection.. T- 36.9
Introduction of values aseptic policies and P- 76 bpm
instruments - Absence of procedures. R- 20 cpm
inside the body any signs BP- 120/70
and mmHg
symptoms of 3. Verify sterility of all 3. Prepackaged items - Absence of
infection manufacturers items. may appear to be any signs
sterile; however, each and
item must be symptoms of
scrutinized for infection
manufacturers
statement of sterility,
breaks in packaging,
environmental effect
on package, and
delivery techniques.

4. Review laboratory 4. Increased WBC


studies for possibility count may indicate
of systemic infections. ongoing infection,
which the operative
procedure will

49
alleviate.

5. Prepare operative 5. Minimizes bacterial


site according to counts at operative
specific procedures. site.

6. Contain 6. Containment of
contaminated fluids blood and body fluids,
and materials in tissue, and materials in
specific site in contact with an
operating room suite, infected wound.
and dispose of Patient will prevent
according to hospital spread of infection to
protocol. environment and/or
other patients or
personnel.

7. Apply sterile 7. Prevents


dressing. environmental
contamination of fresh
wound.

8. Provide copious 8. May be used


wound irrigation, e.g., intraoperatively to
saline, water, reduce bacterial
antibiotic, or antiseptic. counts at the site and
cleanse the wound of
debris, e.g., bone,
ischemic tissue, bowel
contaminants, toxins.

50
9. Assess nutritional 9. Promote healing
status of the patient. and aids in fighting
against infection.

Collaborative:
1. Regulate IV fluids. 1. For F/E
replacement.

2. Administer 2. May be given


antibiotics as prophylactically for
indicated. suspected infection or
contamination.

51
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Pain/discomfort related At the end of 2 days 1. Assess V/S, noting 1. To obtain baseline At the end of 2 days
sakit akong bulog, diri to surgical incision duty, the patient will be tachycardia, data. Changes in duty, the goal was met
dapit sa gi-oprahan, secondary to inguinal able to experience hypertension, and these vital signs often as manifested by:
as verbalized by the hernia repair minimal pain as increased respiration, indicate acute pain
patient. manifested by: even if patient denies and discomfort. Note: - Vital signs
pain. Some patients may within
-Rated pain as 8 out of - Vital signs have a slightly lowered normal
0-10 pain scale within BP, which returns to range:
normal normal range after T- 36.9
range pain relief is achieved. P- 76 bpm
- Pain rating R- 20 cpm
of 3-4 out of 2. Note presence of 2. Concern about the BP- 120/70
Objective: 0-10 pain anxiety or fear, and unknown (e.g., mmHg
- Facial scale relate with nature of outcome of a biopsy)
grimacing - Absence of and preparation for and/or inadequate - Pt. Report of
noted facial procedure. preparation (e.g., decreased
- Unable to grimace emergency perception of
move freely - able to move appendectomy) can pain
- Lying down freely heighten patients - Pain rating
most of the - able to at perception of pain. of 3 out of 0-
time least sit 10 pain
- Guarding down 3. Maintain 3. Relieves pain and scale only
protective - absence of immobilization of prevents bone upon
behavior guarding affected part by means displacement/ movement
- PR= 103 protective of bed rest or splint. extension of tissue - Absence of
bpm behaviour injury. facial
- UTZ results: grimacing
Thick 4. Reposition as 4. May relieve pain - able to move
echogeniciti indicated: semi- and enhance freely
es are noted Fowlers; circulation. Semi- - able to sit
superior to Fowlers position down and

52
the right relieves abdominal ambulate
testicle due muscle tension and - absence of
to herniated arthritic back muscle guarding
omentum. tension. protective
There are 4. Evaluate reports of behaviour
dilated pain, noting location, Monitors effectiveness
vascular characteristic and of interventions. Level
strucuresat intensity. Note of anxiety may affect
the left nonverbal pain cues. perception of pain.
testicle in
the area of
pampinnifor 5. Encourage use of 5. Relieves muscle
m plexus relaxation techniques: and emotional tension;
due to deep-breathing enhances sense of
varicocele. exercises, guided control and may
Ketorolac 30g imagery, visualization, improve coping
IVTT q 8h prn music. abilities.
for pain
Tramadol 50mg 6. Identify diversional 6. Prevents boredom,
IVTT q 6h activities appropriate reduces tension, and
for patients age, may enhance self-
physical abilities and esteem and coping
personal preference. abilities.

7. Apply cold/icepack if 7. Reduces edema/


not contraindicated. hematoma formation,
decreases pain
sensation.
Collaborative:
1. Regulate IV fluids. 1. For F/E
replacement.

53
2. Administer
medications as
ordered.
Cefuroxime 750 Antimicrobial
mg IVTT q8h, agent
ANST
Ranitidine 50mg Reduces gastric
q12h IVTT acid production
Ketorolac 30g Reduces pain
IVTT q 8h prn
for pain
Tramadol 50mg Reduces pain
IVTT q 6h
Paracetamol Analgesic
500mg 1 tab
q4h PRN T <38
C

3. Provide health 3. To educate patient


teaching regarding with measures to
measures to alleviate alleviate pain.
pain.

54
CUES/EVIDENCES NURSING SPECIFIS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective: Impaired tissue (skin) At the end of 2 days 1. Monitor V/S. 1. To obtain baseline At the end of 2 days
karon akong schedule integrity related to duty, the patient will be data. duty, the goal was
sa opera miss, g surgical incision able to demonstrate partially met as
hernia man gud qo secondary to inguinal improve tissue (skin) 2. Determine the 2. Prior assessment evidenced by:
as verbalized by the hernia repair integrity as evidenced extent of the incision. is critical for proper
patient. by: identification of - Vital signs
nursing interventions. within normal
- Vital signs range:
within normal 3. Assess site of 3. Redness, swelling, T- 36.9
range impaired tissue pain, burning, and P- 76 bpm
Objective: - Patient integrity and its itching are indication R- 20 cpm
- Incision over demonstrates condition. of inflammation and BP- 120/70
the inguinal understandin the bodys immune mmHg
canal g of plan to system response to
- UTZ results: heal tissue localized tissue - Patient
Thick and prevent trauma. demonstrated
echogeniciti injury - understandin
es are noted - Patient 4. Monitor site of 4. Systematic g of plan to
superior to describes impaired tissue inspection can heal tissue
the right measures to integrity at least once identify impending and prevent
testicle due protect and daily for color problems early. injury
to herniated heal the changes, redness, - Patient
omentum. tissue, swelling, warmth, pain, described
There are including or other signs of measures to
dilated wound care infection. protect and
vascular - Patients heal the
strucuresat wound 5. Assess changes in 5. Fever is a systemic tissue,
the left decreases in body temperature, manifestation of including
testicle in size and has specifically increased inflammation and wound care
the area of increased in body temperature. may indicate the - Patients
pampinnifor granulation presence of infection. wound has

55
m plexus tissue not yet
due to 6. Assess the patients 6. Pain is part of the decreased in
varicoele. level of distress. normal inflammatory size but has
process. The extent no indication
and depth may affect of further
pain sensations. inflammation

7. Assess patients 7. Inadequate


nutritional status; refer nutritional intake
for a nutritional places the patient at
consultation and/or risk for skin
institute dietary breakdown and
supplements. compromises healing.

8. Keep a sterile 8. This technique


dressing technique reduces the risk for
during wound care. infection.

9. Do not position 9. This is to avoid


patient on site of adverse effects of
impaired tissue external mechanical
integrity. If ordered, forces (pressure,
turn and position friction, and shear).
patient at least every 2
hours, and carefully
transfer patient.

10. Educate patient 10. This is to prevent


the need to notify further complications.
physician or nurse.

Collaborative:
1. Regulate IV fluids. 1. For F/E

56
replacement.

2. Administer
medications as
ordered.
Cefuroxime 750 Antimicrobial
mg IVTT q8h, agent
ANST
Ranitidine 50mg Reduces
q12h IVTT gastric acid
production
Ketorolac 30g Reduces pain
IVTT q 8h prn
for pain
Tramadol 50mg Reduces pain
IVTT q 6h
Paracetamol Analgesic
500mg 1 tab
q4h PRN T <38
C

3. Teach skin and 3. Early assessment


wound assessment and intervention
and ways to monitor help prevent the
for signs and development of
symptoms of infection, serious problems.
complications, and
healing.

4. Instruct patient, 4. Accurate


significant others, and information increases
family in proper care of the patients ability to
the wound including manage therapy

57
hand washing, wound independently and
cleansing, dressing reduce risk for
changes, and infection.
application of topical
medications).

5. Provide health 5. helps promote


teaching on proper faster healing.
nutrition.

58
CUES/EVIDENCES NURSING GOALS/ OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS

Subjective: Impaired physical At the end of 2 days - take vital signs - to obtain At the end of 2 days
maglisod qo ug lihok mobility related to duty, the patient will be baseline data duty, the goal was met
kay sakit samot akong pain/discomfort from able to maintain as manifested by:
opera, as verbalized surgical incision mobility at the highest - assist degree - patient may be
by the patient. possible level as of immobility restricted by - Pain rating of
manifested by: produced by self-perception 3-4 out of 0-
injury/ out of proportion 10 pain scale
- Pain rating of treatment and with actual - able to move
Objective: 3-4 out of 0- note patients physical freely
- Rated pain 10 pain scale perception of limitations - able to sit
as 7out of 0- - able to move immobility - absence of
10 pain freely guarding
scale - able to sit - instruct and - increases blood protective
- Unable to - absence of assist patient flow to muscle behaviour
move freely guarding with passive and bone to - able to
- Lying down protective ROM exercises improve muscle participate in
most of the behaviour with affected tone, maintain activities
time - able to and unaffected joint mobility, relevant to
- Guarding participate in area prevent recovery
protective activities contractures/atr - able to
behaviour relevant to ophy, calcium walked
- Unable to recovery resorption from through the
participate in - able to walk disuse comfort room
activities through the - report of
relevant to comfort room - assess or - improves understandin
recovery - report of encourage self- muscle strength g on
- With FBC understandin care hygiene and circulation, measures
attached g on (e.g bathing) enhances that promote
measures patient control physical
that promote and situation, mobility

59
physical and promote
mobility self-directed
wellness

- assess mobility - Early mobility


by means of reduces
wheel chair or complication of
crutches as bed rest and
soon as promotes
possible. healing and
Instruct safe normalization of
use of mobility organ function
aids

- consult with - useful in


physical creating
therapist or individualized
rehabilitation activity /
specialist program

Collaborative:
- administer - to promote
medications as healing
ordered.
- initiate bowel
program (stool - done to promote
softeners, regular bowel
laxatives as evacuation
indicated)

- do health - to educate
teaching on patient with
physical measures that

60
mobility promote and
improve
physical mobility

61
ANNOTATED READINGS

Nerve Blocks Reduce Acute and Chronic Pain After Inguinal Hernia Repair
Two types of peripheral nerve block, lateral abdominal transversus abdominis plane block (TAP block) and iliohypogastric/ilioinguinal nerve block
(IHINB), were found to be effective in reducing acute and long-term pain after inguinal herniorrhaphy. These study results were published in
the Journal of Anesthesia.
TAP block targets the branches of the T7-L1 spinal nerves within the lateral abdominal wall and is used in abdominal procedures such as
inguinal hernia repair and total abdominal hysterectomy. IHINB blocks the ilioinguinal and iliohypogastric nerves, which arise from the T12-L1
spinal nerves, and is most commonly used in inguinal herniorrhaphy, as well as in cesarean section and orchiopexy. However, because IHINB
is a truncal nerve block, it requires a smaller volume of anesthetic than TAP block, which is a field nerve block.
Studies comparing the effect of these 2 techniques on pain associated with inguinal hernia repair are limited and often contradictory. In addition,
pain control beyond 1 day postsurgery has not been evaluated for either method. In the current study, researchers led by Onur Okur, MD, from
the Izmir Bozyaka Training and Research Hospital in Turkey, compared the safety and efficacy of TAP block vs IHINB under ultrasound guidance
in patients undergoing inguinal herniorrhaphy.
A total of 90 participants were randomly assigned at a 1:1:1 ratio to receive TAP block, IHINB, or subarachnoid block as a control condition. Pain
scores were measured using the numeric rating scale at 0, 2, 4, 6, 24, and 48 hours and at 1 and 6 months.
Compared with controls, patients receiving TAP and IHINB had significantly lower pain scores at all times. Pain scores were similar between the
nerve block groups, except in a post hoc analysis, in which TAP block reduced pain to a greater extent than IHINB at 24 hours.
Time to first report of pain was longer in patients who had received TAP block or IHINB vs patients in the control group (TAP block, 266.6
minutes; IHINB, 247.2 minutes; control, 79.1 minutes; P<.001).
Patients treated with either nerve block were significantly less likely to require additional analgesics than controls. Additional analgesic
requirements were similar between the TAP block and IHINB groups. Rates of adverse events were similar among the TAP block, IHINB, and
control groups.
Summary and Clinical Applicability
Peripheral nerve blocks are commonly used during inguinal hernia repair, although the optimal technique and the long-term effects of nerve
blocks were unclear until recently. Researchers found that TAP block and IHINB both reduce acute and chronic pain after inguinal herniorrhaphy.
"Truncal and peripheral nerve blocks ameliorate postoperative pain and reduce deleterious side effects resulting from use of opioid analgesics.
Although TAP block and IHINB are both effective in reducing postoperative pain, TAP block is slightly more advantageous in management of
acute postoperative pain in inguinal hernia repair," Dr Okur told Clinical Pain Advisor.

62
"We found that performing either TAP block or IHINB also reduces additional analgesic requirements and the incidence of chronic postoperative
pain. The latter is a particularly important finding, since there are few studies on the subject. Therefore, we strongly recommend that clinicians
perform either of these blocks for inguinal hernia repair operations," he added.
Limitations
Because this was an open-label study, the lack of blinding may have introduced bias.

Reaction:

This is a good article because it provides additional knowledge on such things. So these nerve blocks apparently helps relieve acute pain or any
kind of pain felt after different types of operations, and one especially stated was inguinal herniorrhaphy. This article should be taken into account
and steps should be made in order to eliminate the bias so that if this will be approved, or if it wont be considered biased anymore, then more
hospitals will accept this type of medical management to reduce pain. We know that patients in post-op experience a lot of pain so it would be
better and good to give or suggest activities that help reduce pain felt by the patients. There are many factors that should be considered so that
you can be sure that it will help the patient and not put him/her in any detrimental state, but since this has been conducted and results have been
shown, it just needs more research and better unbiased findings, but by the term itself nerve block then it blocks the nerves that send
transmissions of pain to the patients which is why this is helpful and I think it is good for the patients.

Retrieved from:

http://www.clinicalpainadvisor.com/interventional-pain-management/peripheral-nerve-blocks-effective-for-inguinal-herniorrhaphy-pain-
management/article/674302/

63
Tailored approach in inguinal hernia repair decision tree based on the guidelines

Hernia surgery has become increasingly more complex over the past 20 years due to the introduction of novel endoscopic, but also conventional,
techniques. The term tailored approach is used to describe the differentiated use of the several different techniques in hernia surgery.
Currently, that approach is being used by 82% of experienced hernia surgeons. Implementation of the tailored approach calls for intense
scrutiny as well as widespread experience of the entire field of hernia surgery. The attitude its just a hernia is a thoroughly outdated view that
no longer meets the requirements for successful hernia surgery.
At its 30th annual conference in May 2008 in Seville, the European Hernia Society (EHS) presented for the first time guidelines on treatment of
inguinal hernia, going on to publish these in 2009 in the scientific journal Hernia.
These were followed in 2011 by the guidelines of the International Endohernia Society (IEHS) for endoscopic repair of inguinal hernia.
In 2013, the European Association of Endoscopic Surgery (EAES) published the results of a consensus conference of hernia experts.
In 2014, the EHS published an update with level 1 study of their guidelines.
When the recommendations of the guidelines and of the consensus conference are summarized in terms of the level of evidence (LoE)
according to the Oxford criteria, the following differential therapeutic situations must be distinguished in inguinal hernia repair:
1. Primary unilateral inguinal hernia in men.
2. Primary unilateral inguinal hernia in women.
3. Primary bilateral inguinal hernia in men and women.
4. Primary scrotal inguinal hernia.
5. Primary inguinal hernia after previous pelvic and lower abdominal surgery (radical prostatectomy, cystectomy, vascular surgery, and ascites as
well as peritoneal dialysis).
6. Primary inguinal hernia in patients who cannot be subjected to general anesthesia because of cardiac or pulmonary risk factors.
7. Recurrent inguinal hernia.
8. Emergency surgery for incarcerated inguinal hernia.

Primary Unilateral Inguinal Hernia in Men

Based on scientific LoE 1A according to the Oxford criteria, all adult men (>30 years), suffering from symptomatic inguinal hernia should be
treated using a mesh procedure regardless of the hernia type.
Endoscopic TAPP and TEP procedures as well as the open Lichtenstein technique are the methods of choice for treatment of primary unilateral
inguinal hernia (3). PHS and Plug and Patch (mesh plug) result in comparable outcome (recurrence and chronic pain) as the Lichtenstein
technique (14 years follow-up).
Young, active adult men between 18 and 30 years benefit mostly from endoscopic groin hernia repair because they gain most from early
convalescence.

64
The Shouldice technique is the best LoE 1A method, using only a suture and no mesh. But there are two reasons for not using the
Shouldice technique: even in expert hands, this mesh-free technique has a 10% recurrence rate after 10 years, and numerous prospective
randomized studies and meta-analyses have identified a higher recurrence rate for the open non-mesh techniques (4.417%) compared with the
open Lichtenstein mesh repair (11.4%) (7). Nonetheless, the Shouldice technique continues to be recommended for young adults with a small
indirect hernia (LI). However, the long-term findings of the Danish National Hernia Database have identified for men aged 1830 years who had
undergone primary repair of an indirect inguinal hernia a cumulative 5-year recurrence rate of 1.2% following Lichtenstein operations versus
3.9% after suture techniques. Accordingly, the 3.9% recurrence rate seen after suture methods was threefold higher than the 1.2% rate after
Lichtenstein operation (p = 0.0003).
Therefore, endoscopic TEP and TAPP techniques as well as the open mesh techniques Lichtenstein, Plug and Patch, and PHS currently
represent the gold standard for treatment of unilateral, primary inguinal hernia for adult men as from age 18 years. Among the advantages of the
endoscopic techniques cited in the guidelines of the EHS are lower rates of wound infections and hematomas as well as earlier resumption of
normal, everyday, and working activities compared with the Lichtenstein operation. But on the other hand, the endoscopic procedures take
longer and are associated with a higher seroma ratE.
Besides, the learning curve is longer for the endoscopic techniques. The IEHS guidelines have identified in meta-analyses, with LoE 1A, that
the risk of acute and chronic pain following endoscopic hernia repair is significantly lower than after the open techniques, with and without a
mesh (p < 0.001). Therefore, the grade A recommendation issued is that preference be given to endoscopic repair of inguinal hernia using a TEP
or TAPP technique over the open procedure with and without a mesh, provided that the surgeon has the requisite expertise in endoscopic
techniques.

Primary Unilateral Inguinal Hernia in Women

The Danish Hernia Registry has demonstrated that the risk of recurrence in women following an open technique for primary repair is greater
than after an endoscopic method (10), with 38% of reoperations performed because of a recurrent femoral hernia (11). All recurrent femoral
hernias occurred in women after previous open repair of inguinal hernias. It must therefore be assumed that the femoral hernia was not
diagnosed at the time of primary operation of the inguinal hernia. Because of the diagnostic superiority of endoscopic surgical techniques, the
TEP and TAPP are therefore recommended as the repair techniques of choice for women with an inguinal hernia (3, 10). The endoscopic
surgical techniques have better intraoperative diagnostic possibilities, while providing an option for optimum subsequent treatment of inguinal
and femoral hernia, with demonstrably good results (12, 13).

Primary Bilateral Inguinal Hernia in Men and Women

The EHS guidelines (3) have identified that the endoscopic technique is the most cost-efficient method for patients who continue to be part
of the workforce, with this being particularly true for patients with bilateral hernias (LoE 1B). Likewise, the EAES guidelines (5) recommend the

65
endoscopic technique, in particular, for bilateral inguinal hernia, with equal consideration given to TEP and TAPP. The National Institute of Health
and Clinical Excellence (NICE) in England and Wales also recommends endoscopic techniques for bilateral inguinal hernias. In the hands of very
experienced endoscopic surgeons, comparable outcomes can be achieved for bilateral as for unilateral inguinal hernias (14). If one views the
data in registries, essentially comprising also data for less experienced surgeons, one notes relevant differences in complication rates to the
disadvantage of bilateral endoscopic inguinal hernia repair (15, 16). Hence, this too underscores the importance of the surgeon having the
requisite expertise.

Primary Scrotal Inguinal Hernia

In EAES guidelines (5), scrotal hernia is classified as being a complex condition. For scrotal hernia, only highly experienced endoscopic
hernia surgeons should opt for a laparoscopic technique (4, 17). The challenge in scrotal hernia is ensuring complete dissection of the large
hernia sac from the inguinal canal and scrotum. Failure to remove a large section of the hernia sac will generally result in formation of a
persistent seroma (4). Endoscopic control of bleeding during a scrotal hernia repair is also often very difficult when dissecting the hernia sac from
the spermatic cord structures. Therefore, there is often a higher incidence of postoperative secondary hemorrhages and hematomas.
Accordingly, the EHS guidelines recommend the open mesh techniques (Lichtenstein, Plug and Patch, and PHS) as the techniques of choice for
scrotal hernia (3, 6).
Primary Inguinal Hernia after Previous Pelvic Operations (Radical Prostatectomy, Cystectomy, Vascular Operations, and Ascites as Well as
Peritoneal Dialysis)
Faced with these complex situations, the guidelines of the IEHS (4) and the EAES (5) also recommend that only very experienced
endoscopic hernia surgeons should opt for a minimally invasive procedure.
Following major lower abdominal and pelvic surgery, the EHS therefore recommends the open mesh techniques (Lichtenstein, Plug and Patch,
and PHS) as the preferred techniques (3, 6). The open mesh approach, no doubt, also presents the least risk in the presence of cirrhosis of the
liver with ascites or for patients on peritoneal dialysis.

Primary Inguinal Hernia in Patients Who Cannot be Subjected to General Anesthesia because of Cardiac or Pulmonary Risk Factors

Based on the recommendations of the EHS, the open mesh techniques (Lichtenstein, Plug and Patch, and PHS) under local anesthesia are
the preferred techniques when general anesthesia is not possible for patients assigned to ASA III or IV categories because of cardiac or
pulmonary risk factors (3, 6). However, data from the Swedish Hernia Registry show that the risk of recurrence after primary inguinal hernia
repair is higher under local anesthesia, but that risk is lowest following the Lichtenstein operation (18). Besides, because of the significantly
increased risk associated with general anesthesia, there is no alternative to that procedure for this group of patients with symptomatic inguinal
hernia.

66
Recurrent Inguinal Hernia

In the event of recurrent inguinal hernia following previous open surgery, based on the recommendations of the EHS the endoscopic
technique is the technique of choice (grade A), since the operation is performed in an anatomic layer between the peritoneum and the abdominal
wall in which no previous dissection had been performed (3, 6). Accordingly, an anterior approach, not touching the preperitoneal space, as in
the Lichtenstein operation, should be chosen in the event of a recurrence following previous endoscopic surgical techniques (TEP, TAPP).
The EAES guidelines (5) likewise recommend an endoscopic approach for recurrence following a previous open operation. An endoscopic
reoperation after previous TEP or TAPP calls for widespread experience of minimally invasive inguinal hernia surgery and is also classified as
constituting a complex situation. As recommendation, a Lichtenstein operation should be performed in such a situation.

Emergency Surgery for an Incarcerated Inguinal Hernia

In the presence of an incarcerated inguinal hernia, a diagnostic laparoscopy should be performed first of all (4, 5). The incarcerated bowel or
greater omentum can then be withdrawn from the hernia sac, if necessary making an incision into the cranial hernia ring. Next, a decision must
be taken as to whether parts of the omentum and/or intestines should be resected. In approximately 90% of cases, the data show that this is not
necessary as the organs recover after reposition into the abdominal cavity. Then inguinal hernia repair can be carried out using a TEP or TAPP
technique. If there is a transmural peritonitis, the hernia sac can be first closed with a suture and the open mesh repair (Lichtenstein, Plug and
Patch, and PHS) performed later.
Alternatively, the inguinal hernia can be repaired simultaneously in a different anatomic layer as open mesh repair (Lichtenstein, Plug and
Patch, and PHS). If intestinal resection is needed, simultaneous repair of inguinal hernia should be avoided, opting instead for repair at a later
stage.
Based on the above, the following decision tree (Figure 1) depicts the differentiated methods of inguinal hernia repair using the tailored
approach.

Conflict of Interest Statement


T he authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.

67
Reaction:
There are a lot of approaches possible for inguinal hernia repair, and as stated in the article, there are guidelines as of which among the
repair should be performed on such patient with these different characteristics. It should be based on the gender, age etc. On how to choose
what specific type of hernia repair should be done. The guidelines are very helpful and we think that it is great that there are lots of possible
courses of action rather that just a definite one that generalizes the patient and his or her conditions type and the method of treatment. We
should know as nurses that each patient is different and they should be given care according to his or her specific needs. This article has been
very helpful because It gave us information on the other types of repairs that we did not know about. The dissemination of information is very
important and knowledge acquired should be understood and used fully.

68
CONCLUSION

Our month long experience in the operating room is indeed very memorable for us. We have experienced a lot and encountered various
clients with different situations. Who could forget the long hours weve spent at the side of our clients most especially during perioperative period,
catering to their every need or accompanying them to the hours. Of course, lets not also forget the bonding weve experienced during the days of our
duty as well as preparing for the fulfillment of this case study. But despite all these hardships, we enjoyed a lot and learned a lot in this rotation with
the company of our beloved CI Mr. Kennith C. Misamis, RN. We have concretely realized that the nursing care we provide is such a big help for
them. Because of this rotation it mold us to become more effective and competitive nursing students.

69
REFERENCES

Book:

1. Doenges, M. E. (2002). Nursing Care Plans: Guidelines for Individualizing Patient Care. 6th ed. Philadelphia, USA: F.A. Davis Company.
2. Kozier, B. et al. (2004). Fundamentals of Nursing, Concepts, Process and Practice. 7th ed. New Jersey: Pearson Education Inc.
3. Port, C. M. (2002). Pathophysiology: Concepts of Altered Health States. 6th ed. Philadelphia: Lippincot Williams & Wilkins.
4. Swilson, B. A. et al. (2004). Nurses Drug Guide. New Jersey: Pearson Education Inc.

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