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Grand Case presentation 2

Indirect Inguinal Hernia

jp torralba

on 18 June 2012

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Transcript of Grand Case presentation 2

I. OBJECTIVES A. GENERAL The purpose of this case is to obtain a broad understanding about Indirect Inguinal Hernia (IIH) through the nursing core values guided by the nursing process B. SPECIFIC The case aims to inform and provide proficiency about IIH through its disease process in order to direct appropriate management.

To be able to apply and practice the knowledge obtained regarding care of patient with IIH, such as skills in general assessment specifically, genito-urinary system, pain assessment and pain management

To able to gain self-confidence, empathy and most especially competence in the nursing care of patient with IIH. There is an Indirect Inguinal Hernia incidence rate of approximately 1 in 544 or 0.18% or 500,000 people in the USA. While in the year 2004, the Philippines was extrapolated to have 158,532 cases of inguinal hernias (See. Table 1.1 and Figure 1.1). Indirect hernias usually present during the first year of life, but they may not appear until middle or old age. Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct. There is also a 10% lifetime risk of inguinal herniation. Indirect inguinal hernias are the most common hernias in both men and women. Approximately 90% or a 9 to 1 ratio of all inguinal hernia occurs in males (See Figure 1.2). 60% of cases occur on the right side, while 30% occur on the left side, while 10% occur on both (See Figure 1.3). III. PATIENT PROFILE A. DEMOGRAPHIC DATA Name: V.S.
Address: Caloocan City
Age: 64 y/o
Gender: Male
Civil status: Married
Occupation: Courier
Nationality: Filipino
Religion: Catholic
Date and Time of Admission: March 7, 2010 12am
Diagnosis: Right Indirect Inguinal Hernia B. CHIEF COMPLAINT Pain on the right inguinal area C. PRESENT HISTORY OF ILLNESS 4 days prior to consultation, the patient experienced mild pain at the right inguinal area after eating a heavy meal. The pain was managed by massage and was alleviated. One day prior to admission the patient experienced sudden sharp stabbing pain at the right inguinal area that had swelling after eating again a heavy meal. No amount of massage or positioning relieved the severe pain experienced by the patient and so resulted to admission to the hospital (later that evening or afternoon). D. PAST HISTORY OF ILLNESS Years prior to consultation, patient’s right inguinal area was accidentally hit by a handle of a mason.

3yrs. PTC right inguinal mass was noted. Pain lasted for two days. He did not seek for medical consultation. II. INTRODUCTION This is a case of Mr V.S., 64 years old, male, diagnosed with indirect right inguinal hernia. The group chose the case because of its relatively common incidence among the patients of the surgical ward besides its relative commonality it deems an ideal nursing management. The group focused on a case which involves surgical procedures in order apply what they have learned in their OR concept. The group also wants to focus on the nursing responsibilities needed in pre-operative, intra-operative and post-operative management for patients who are in need of surgery. Inguinal hernia must be promptly assessed and treated before any complications such as strangulation and ischemia to the tissue involved will occur Indirect Inguinal Hernia manifests as a small bulge in one or both sides of the groin that may increase in size; in males, it can present as a swollen or enlarged scrotum. It can also manifest as a discomfort or sharp pain especially when straining, lifting, or exercising that improves when resting. The swelling may subside on its own when the patient assumes a recumbent position or if slight manual pressure is applied externally to the area. Also, there is a feeling of weakness or pressure in the groin or a heavy feeling. A burning, gurgling, or aching feeling at the bulge may also occur. Some patients describe a steady, aching pain, which worsens with tension and improves with hernia reduction. E. FAMILY HISTORY OF ILLNESS According to the patient and his significant others, they have a history of hypertension on their mother’s side and history of diabetes and arthritis on his father side. F. SOCIAL HISTORY The patient works as a courier in a private company and has been in the business for almost 35 years. His work is found at Makati City and far from his home which is located at Caloocan. He has two rides of tricycle and bus to go to his work. His only exercise is walking. G. ALLERGIES No known Allergies H. PHYSICAL ASSESSMENT AND GORDON'S FUNCTIONAL HEALTH PATTERN Date Performed: March 7, 2010 (Sunday) Axillary temperature:

Pulse Rate:

Respiratory rate:

Blood Pressure (sitting):


Height: 36.9oC

88 beats per minute

23 cycles per minute

80 mmHg

52.3 kg

168.5cm VITAL SIGNS IV. ANATOMY AND PHYSIOLOGY V. PATHOPHYSIOLOGY Muscle tissues are replaced by adipose and connective tissue NON-MODIFIABLE FACTORS: Gender: Male
Congenital Failure of the Ingunal Canal to Close MODIFIABLE FACTORS: Occupation (courier)
Blunt Trauma on the Inguinal Area Increase in the abdominal pressure due to straining and trauma Weakening of the Inguinal Tissue Widening of the Inguinal Ligaments Bowel Protrusion in the Inguinal ring Bulging in the right Inguinal Area Cuts of the Blood supply to the herniated bowel segment Strangulation of the Bowel Segment PAIN VOMITING Surgical Treatment: Herniorrhaphy Nursing Diagnosis: Pre-operative 1. Acute Pain
2. Anxiety Nursing Diagnosis: Post-Operative 1. Acute Pain VI. COURSE IN WARD Day 1: March 7, 2010 (Sunday)

His vital signs were checked every four hours. Temperature: 36.9oC, Heart rate: 88 beats per minute respiratory rate: 23 cycles per minute Blood Pressure 130/ 80 mmHg
Physician ordered Hematology (Complete Blood Count), Sodium and Potassium Electrolyte Analysis, and Cardiopulmonary Clearance
The physician also ordered 1L D5LR regulated at 30 gtts/min inserted at the left metacarpal vein.
The following medications were administered, Promethazine (Phenergan) 25mg, Q8, IV, Celecoxib (Celebrex) 400mg, BID, Per Orem .The patient was positioned at supine and moderate highback rest. The patient is for Herniorrhapy on Tuesday (March 9, 2010) at 12:00 noon. Ceftriaxone 1g, IV ordered and given after the release of CBC result and after negative skin test.

Day 2: March 8, 2010 (Monday)
Seen and examined by cardiologist. History and Physical Examination reviewed. Anesthesia rendered. Consent preparation orders were carried out by charge nurse. Patient was placed on NPO post midnight Ranitidine 50 mg, IV q8 ordered and given while on NPO. Pre-operative teachings given.

Day 3: March 9, 2010 (Tuesday)
The patient had pre-operative shower at 11am. Prepared for surgery. Pre-operative medication of Nubain 5mg q8 was given. Brought to Post Anesthesia Care Unit at 2:00 pm with O2 Inhalation at 2-3lpm via nasal cannula, Vital Signs monitored every 15 mins. Still on NPO with IVF on D5LR x 30 gtts/mi, infusing well at the left metacarpal vein. Transferred back to surgical ward at 4pm..

Day 4: March 10, 2010 (Wednesday)
The patient is started on general liquids. The physician ordered to infuse IVF D5LR 1Lx8hrs x 3 cycles. The following medications: Sultamicillin (Unasyn) 750mg/tab, BID, Oral, Diclofenac (Voltaren, Cataflam, Voltaren-XR) 75mg, Q12 x 4doses, IM, Nalbuphine (Nubain)10mg, Q4 x 6doses, IV , Ceftriaxone1gram, Q12, IV, Meloxicam 7.5mg/tab, BID, Oral, Ranitidine 15mg, Q8 while on NPO, IV were then ordered and administered. Patient tried to ambulate and tolerated.

Day 5: March 11, 2010 (Thursday)
The patient is on Diet as tolerated (DAT).
IVF and IV meds consumed;
Patient is for discharge as per doctor’s order. Oral medications for discharge ordered (Sultamicillin750mg/tab two times a day for one week, Meloxicam 7.5mg 1tab two times a day take with food or after meal) VI. LABORATORY EXAMINATION & DIAGNOSTIC PROCEDURES Cardio-Pulmonary Clearance:

surgical risk low

clinical risk intermediate: low intermediate risk for heart complication may go ahead with contemplated procedure

low risk for developing peri-operative complication related to pulmonary and oxygenation problems VII. DRUG STUDY VIII. NURSING THEORY Herniorrhaphy
Pharmacologic strategies Providing comfort measures (pain management and anxiety alleviation)
Teaching activities

Reiterate the importance of compliance in taking medication.

Provide specific details to the patient about when to take the medication whether it should be taken before or after meals.

If any allergies were noted, stop the medication and consult the physician.

Inform the patient to not quit taking the medicines until the physician is aware of it just in case any changes occurred.

Advised the patient to change dressing every morning and apply betadine in the incision area until the wound heals or as ordered by the doctor in the follow-up check up

Inform the patient to avoid stress that would slow down the recovery.

Refrain from heavy lifting and strenuous exercises.

Go back to activities of daily living gradually.

Inform the patient to avoid smoking because it would slow down the healing of the wound for post operative surgery.

Strictly advise the patient, if constipation and straining during bowel movement occurred, consult the physician as soon as possible for it may increase the risk in having another hernia.

Instruct patient on the date and time (7 days after discharge) of his follow check – up in surgery section of Out- Patient Department (OPD).

Encourage an increase in fluid intake.

Encourage the patient to eat nutritious foods like fruits rich in vitamins such as oranges and vegetables such malunggay, kangkong or those high in fiber that could enhance the body built and immune system for fast recovery.

Encourage the patient to eat papaya that would help him for his bowel movement

Encourage the whole family to be spiritually active by praying and attending the church services together.

Advice the family to support the patient as much as they could. XI. BIBLIOGRAPHY Barberio, Judith A. 2010. NURSE’S POCKET DRUG GUIDE 2010 Based on Clinician’s Pocket Drug Reference 2009.Copyright © 2009 by Leonard G. Gomella. Published by The McGraw-Hill Companies,Inc.
George, J.B (November 6, 2010). Care, cure and core. Retrieved November 10,2010, from http://currentnursing.com/nursing_theory/Lydia_Hall_Care_Cure_Core.html
Keogh, Jim 2010 Nursing Laboratory and Diagnostic Tests Demystified Copyright © by The McGraw-Hill Companies

Smeltzer, S., et al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing Eleventh Edition. U.S.: Lippincott, Williams and Wilkins

Wilkinson, Judith (2004) Prentice Hall Nursing Diagnosis Handbook: With NIC Interventions and NOC Outcomes (8th Edition) (Nursing Diagnosis Handbook)

Britannica. Retrieved November 10,2010, from http://www.britannica.com/EBchecked/topic
Kosmix (2010).Tunica vaginalis. Retrieved November 10,2010, from http://www.kosmix.com/topic/tunica_vaginalis_testis

Scribd. Gordon’sFunctional Health Assessment retrieved Novemeber 1, 2010 http://www.scribd.com/doc/38326950/Admission-Assessment

Wikipedia. Peritoneum. Retrieved November 10,2010, from http://www.advancedrenaleducation.com/ Peritoneal Dialysis/Kinetic Principles/BasicPrinciplesofPD/AnatomyofthePeritoneum/tabid/150/Default.aspx

Webmd (2009). Digestive disorder health center. Retrieved November 10,2010, from http://www.webmd.com/digestive-disorders/picture-of-the-intestines

T-C cancer. Anatomy and function of the testicle. Retrieved November 10,2010, from http://www.tc-cancer.com/anatomy.html

Wrong Diagnosis. Inguinal Hernia Statistics. Retrieved November 2, 2010 fromhttp://www.wrongdiagnosis.com/i/inguinal_hernia/prevalence.htm

Wikipedia. Inguinal Hernia. Retrieved September 24, 2010, from
http://en.wikipedia.org/wiki/Inguinal_Hernia XII. APPENDIX OPERATING ROOM RECORD

Hosp. # 439706
And 411164
Service Consultant: Dr. D P
Anesthesiologist: Dr. B
Surgeon: Dr. G
First Assistant: Dr. F
Second Assistant: Dr. R
Anesthesiologist: Dr. P
Anesthesia: Spinal anesthesia
Induction of Anesthesia: 12:05pm
Scrub Nurse: G. P
Circulating nurse: M. F
Duration of Operation: 12:30pm-1:50pm
Pre-Operative Diagnosis: Indirect inguinal hernia, right
Post-Operative diagnosis: Same
Remarks: 2cm internal ring
Empty hernial sac
Specimen: Hernial sac
SpongeInitial Count

Patient in supine position under SAB
Asepsis/ Antisepsis
Sterile draping applied
Transverse inguinal incision done and carried down to the external oblique apmenosis
External oblique apmenosis incised
Hernial are identified and segmental and isolated
High ligation of the hernial are done
Hemostasis done
Placement g mesh and anchored using Prolene 2-0
Anatomic closure by layers
Fascia using Vicryl 2.0 Continuous suture
Subcutaneous layer using Vicryl 2.0 inverted T suture
Skin using Vicryl 4.0 suberticular suture
Sterile dressing done
St. Luke’s College of Nursing
Cathedral Heights
273 Rodriguez Sr. Avenue, Quezon City

Grand Case Presentation



Group 3 & 4 - 4Nu10



Ms. Maureen Eve E. Ambay
Mr. Paolo Dimalanta
Mrs. Josefina Levosada
Mrs. Cecil Baliton

December, 2010 Ensure the patient’s list of medication to be given:

1. Sultamicillin ( 750mg/tab two times a day for one week)
Indications: to prevent inflammation

S/E: headache, anorexia, diarrhea, nausea and vomiting,
rashes fever

2.Meloxicam 7.5mg 1tab two times a day take with food or
after meal:
Indications: Relief of pain
S/E: Gastrointestinal bleeding, diarrhea, dyspepsia,
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