CHAPTER I

GENERAL OBJECTIVE

To enhance knowledge, skills, and attitude in providing quality health care and

management of the client who will undergone Herniorraphy utilizing the nursing process.

SPECIFIC OBJECTIVES

After 8 hours of exposure in the Operating Room (OR), we the nursing students will be able

to:

I. Assess the client health situation to identify health needs and problems.

II. Formulate a nursing diagnosis based on the identified client health needs and problem.

III. Recall the book-based pathophysiology of Hernia and relate to the client present health

status.

IV. Provide quality nursing care that would help alleviate the condition of the client.

V. Develop a Nursing Care Plan (NCP) appropriate to the client.

VI. Identify the different medications used by the client, for its actions, side effects, and apply

the 10 R’s in administering the drugs.

VII. Evaluate the nursing interventions rendered to the client. Properly document the important

data pertaining to the client.

Introduction

Approximately 75 - 80% of all hernias are inguinal hernias, which can occur in people of

any age. Approximately 90% of all inguinal hernia repairs are performed on men.

An inguinal hernia occurs when a defect in the inguinal canal allows the abdominal

contents (usually part of the bowel) to protrude, causing a bulge. The inguinal canal is a tubular

passage through the lower abdominal muscles in the groin. In men the inguinal canal contains the

spermatic cord and blood vessels (SouthernCrossMedicalCareSociety, 2017).

An inguinal hernia occurs in the abdomen near the groin area. They develop when fatty

or intestinal tissues push through a weakness in the abdominal wall near the right or left inguinal

canal. Each inguinal canal resides at the base of the abdomen.

Both men and woman have inguinal canals. In men, the testes usually descend through

their canal by around a few weeks before birth. In women, each canal is the location of passage

for the round ligament of the uterus. If you have a hernia in or near this passageway, it results in

a protruding bulge. It may be painful during movement.

Many people don’t seek treatment for this type of hernia because it may be small or not

cause any symptoms. Prompt medical treatment can help prevent further protrusion and

discomfort.

Inguinal hernias occur mainly in men. Most are thought to be due to ageing - as you get

older, the muscles surrounding your abdomen can become weaker.

CLIENT’S DATA

NAME: Mr. Y

ADDRESS: Laur,N.E

DATE OF BIRTH: December 16, 1977

AGE: 41 years old

GENDER: Male

CIVIL STATUS: Married

NATIONALITY: Filipino

RELIGION: Roman Catholic

EDUCATIONAL ATTAINMENT: College Undergraduate

OCCUPATION: Driver

DATE OF ADMISSION: April 11, 2019

TIME OF ADMISSION: 12:50pm

ATTENDING PHYSICIAN: Dr. G

ADMITTING DIAGNOSIS: Inguinal Hernia

ADMITTING DIAGNOSIS: Sliding Inguinal Hernia

Family History

As stated by the patient, there is no history of illness from his parents.

History of Past Illness

As stated by Mr.Y he had experience the pain of his hernia since 2008 but he did not

consult because it was not that severely painful and can be manage by simply resting.

The pain on his scrotal area seems to be so serious from 2017. He is experiencing

intermittent pain for 1-2hours and usually managed it by pushing back his scrotum and rest for at

least 2 hours. It feels to be in the worse pain when he is lifting or walking for so long.

He started to consult and had a check up on November 2018 at Philppine General

Hospital and according to him the ultrasound revealed that there is abnormal positioning of his

testes, he wasn’t able to come back to have a follow up check up.

Then he consulted to DR.G at Eduardo L. Joson Hospital on January, 2019 to where

diagnostic and laboratory exams were done but he was then given a CP Clearance and needed to

wait for scheduled operation. Then it was April 2019 when the Dr. G called and scheduled him

for operation.

Admitting History

On April 10, 2019 as per advised by her doctor, he was admitted at Surgical Ward and

has been under observation prior to operation scheduled on April 12, 2019.

Status of Present Illness

Upon admission in Operating Room, the patient's initial vital signs were 37°c, 85bpm,

20cpm, and blood pressure of 120/80mmHg. Prior to assessment before the operation, Mr. Y’s

scrotum seems to be bulging.

Other than that, body parts appeared normal.

 Physical Assessment

The table below shows the physical assessment of the patient from head to toe.

Body Parts Normal findings Actual findings Result

Skull Generally round within the The client’s skull is Normal

prominence in the frontal or generally round and no

occipital area tenderness noted upon

No tenderness noted upon palpation.

palpation

Scalp Can be moist or oily The client’s scalp is moist Normal

and no scars noted.

No scars noted

Free from lice, nits and The client’s scalp is free

from lice, nits and
dandruff
dandruff.
No tenderness nor masses on
The client’s scalp has no
palpation
tenderness or masses.

Hair Can be black or brown The client’s hair is black Normal

Eventually distributed, covers and evenly distributed and

covers the whole scalp.
the whole scalp

Face Symmetrical The client’s face is Normal

No involuntary muscle symmetrical and there is

no involuntary muscle
 movement movement.

Eyes Pupils equal, round and The client’s pupils are Normal

reactive to light and equal, round and reactive

accommodation to light and

accommodation.

Ears The ear lobes are bean shaped, The client’s ear lobes are Normal

parallel and symmetrical bean shaped, parallel and

symmetrical.
No discharges or lesions noted

There is no discharges and

no lesions upon inspection

of the client’s ear

Nose and No nasal flaring There is no nasal flaring. Normal

Paranasal Both nares are patent The client’s both nares are
sinuses
No tenderness noted on patent

palpation There is no tenderness

noted upon palpation of

the client’s nose.

Mouth The lips are normally Lips pinkish in color and Normal

symmetrical, pink, smooth, tongue appear slightly red

and moist. There should be no

growths, lumps, or
 discoloration of the tissue.

Teeth should be white with

shiny enamel and smooth

surfaces and edges.

Gums should be symmetrical,

moist and pinkish.

A healthy dorsal tongue is

symmetrical, pink, moist,

slightly rough from the

papillae, possibly with a thin,

whitish coating.

Neck Neck is straight The client’s neck is Normal

straight.
No visible mass or lumps

There is no mass, lumps or

No jugular venous distention
jugular venous distention

upon assessing clients

neck

Chest Normal breath sounds The client’s respiration is Normal

22 cycles per minute.

-vesicular sounds

-bronchial sounds

-bronchovesicular sounds
 Abnormal breath sounds

-rales

-rochi

-wheeze

-stridor

Normal respiration

-adult: 12-20

-children: 15-30

-infants:25-30

-neonates:40-60

Thorax Symmetrical chest expansion, There is symmetrical chest Normal

crackles sound heard upon expansion, and crackles

auscultation. sound was heard upon

auscultation

Abdomen No lesion The client’s abdomen has

no lesions, no tenderness
No tenderness
and no muscle guarding.
No muscle guarding
Extremities Both extremities are equal in The client’s both Normal

size extremities are in equal

size.
No involuntary movement

There is no involuntary
No edema
movement nor edema

Skin Smooth, no blemishes Smooth, no blemishes Normal

Brownish in color
 CHAPTER II
CASE DISCUSSION AND PRESENTATION

DEFINITION

A sliding inguinal hernia is a protrusion of a retroperitoneal organ through an abdominal

wall defect. Frequency of sliding hernias is estimated at 3-8% of all elective operations of
inguinal hernias. Sliding hernias are supposed to be more anatomically challenging for a surgeon
than an uncomplicated non-sliding inguinal hernias. The anatomical and physiological concept of
sliding inguinal hernia is frequently misunderstood by surgeons of all levels of experience. Not
infrequently, any inguinal hernia that is big enough or has any organ (e.g. small intestine) inside
its sac is referred to as sliding hernia. In this chapter we will try to clarify the pathology behind
the sliding inguinal hernia and explain its correct management.
ANATOMY AND PHYSIOLOGY

SCROTUM

Scrotum, in the male reproductive system, a thin external sac of skin that is divided into
two compartments; each compartment contains one of the two testes, the glands that produce
sperm, and one of the epididymides, where the sperm is stored. The scrotum is a unique
anatomical feature of humans and certain other species of land-dwelling mammals. It is
continuous with the skin of the lower abdomen and is located directly behind the penis and in
front of the anus. The scrotal wall is a thin layer of skin lined with smooth muscle tissue (dartos
fascia). The skin contains more pigment than that of surrounding areas and has many sebaceous
(oil-producing) glands and sweat glands, as well as some hair. The two compartments of the
scrotum are distinguished externally by a middle ridge called the raphe. Internally, the raphe
connects to a muscular partition, the septum, which serves to divide the scrotum into its two
areas.
The function of the scrotum is to protect the testes and to keep them at a temperature
several degrees below the normal body temperature. The scrotum thus protrudes from the body
wall: moreover, it contracts from cold, exercise, or sexual stimulation and expands and relaxes
when warm. When contracted, it conserves heat; while relaxed it is smooth and elongated,
permitting the circulation of air that effects cooling. The relatively cool temperature of the
scrotum is thought to be important for the production of viable sperm.
The muscle tone of the scrotum becomes weakened and relaxed in older men. In animals
whose scrotum is always tight against the body, as in rats, boars, and stallions, the testes are
cooled by the intricate blood system that surrounds them. Failure of the scrotum to cool the
testes, which occurs during high fevers or, in some animals, during the hot summer months,
causes temporary sterility.
 PATHOPHYSIOLOGY
(BOOK BASED)
Predisposing factors: Precipitating factors:

 Gender( male)  Overweight

 Weakness a birth  Having large weight loss
 Muscle weakness from aging  Abdominal muscles from poor diet
 One or more inguinal hernia  Lack of exercise
 Straining during urination or bowel
movements
 Smoking

Increased pressure in the

compartment of the abdomen
is develop

Intra-abdominal wall (containing membranes or muscle)

of inquinal canal into scrotum become weakend.

Inguinal ring not close.

Becomes hole and defect.

Part of the small intestine slieds

through the inguinal canal

Swollen and enlarged Weakness and Pain or discomfort

scrotum pressure in the groin
 PATHOPHYSIOLOGY
(CLIENT BASED)

Precipitating factors:

Predisposing factors:  Crash dieting

 Abdominal muscles from poor diet
 Gender( male)
 Lack of exercise
 Undecended
 Smoking
scrotum from
 Occupation (bagger)
birth

Increased pressure in the compartment of the

abdomen is develop

Intra-abdominal wall (containing membranes or muscle) of inquinal

canal into scrotum become weakend.

Inguinal ring not close.

Becomes hole and defect.

Part of the small intestine slieds

through the inguinal canal

Swollen scrotum Weakness and Pain or discomfort

pressure in the groin
 BOK BASED CLIENT BASED
 discomfort or pain in the groin— Intermittent pain that improves when resting
especially when straining, lifting,
coughing, or exercising—that improves
when resting

 feelings such as weakness, heaviness, Pressure in the groin

burning, or aching in the groin

 a swollen or an enlarged scrotum in Enlarged scrotum

men or boys

Medical Management
Pre Op
 On November 13, 2018, the diagnostic exam was done:
 Ultrasound
 Roentgenographic Exam
 On January 30, 2019, the diagnostic exam was done:
 Coagulation
 On January 31, 2019, the diagnostic exam was done:
 Hematology
 Chemistry
 On April 9, 2019, the diagnostic exam was done:
 Urinalysis
 Coagulation
 On April 10, 2019, the following treatment was given:
D5NSS 1L x 8hrs
Nursing Management
 Advised the patient to avoid activities that put pressure on his pelvic muscles. This

includes heavy lifting and straining.

 To relieve pressure on your vagina, lie down and put a pillow under your knees. Or you

can lie on your side and bring your knees up to your chest.

 Provide emotional support to establish a trusting relationship and let the client voice out

her fears.

Surgical Management
 Ask the client to remove jewelry, dentures, and nail polish in the body.
 Monitor vital signs.
 Check for the consents.
 Assess and prepare the surgical site.
 CHAPTER 3
Laboratory Values and Interpretation
DATE:
11/13/18
ULTRASOUND REPORT

Both testes are normal in size and echo pattern. Negative for mass. Epididymis is intact.
Negative for hydrocele

IMPRESSIONS:
Unremarkable Testes
There are Echogenic structures at the Right Inguinoscrotal likely herniated omental fat.

ROENTGENORGAPHIC EXAM
Chest PA
The lungs are clear.
The heart is not enlarged.
The trachea is midline.
The diaphragm are intact.

IMPRESSION:
Essentially Normal Chest
 January 30, 2019

COAGULATION
TEST NORMAL VALUES RESULT INTERPRETATION

PROTHOMBINE TIME
CONTROL’S TIME 11.5 – 15.5 secs. 14.4 NORMAL

PATIENT’S TIE 11.5 – 15 secs 14.8 NORMAL

ACTIVITY 70% - 120% 84.4% NORMAL
INR 0.85 -1.15 1.16 ABNORMAL

January 31, 2019

HEMATOLOGY
TEST NORMAL VALUES RESULT INTERPRETATION

COMPONENTS AND QUANTITY( S.I

UNIT)
ERTHROCYTES COUNT 4.5 - 6.0 x 12/1 4.68 NORMAL

HEMATOCRIT 0.40 - 0.50 0.43 NORMAL

HEMOGLOBIN 120 – 170 g/l 140 ABNORMA

MCV 76 -96 fl 93 NORMAL

MCH 27.0 – 32.0 pg 29.9 NORMAL

MCHC 300 – 350 g/l 323 NORMAL

RDWs 11.5 – 14.5 % 14.4 NORMAL

LEUKOCYTES COUNT 5 – 10 x 10 g/l 8.30 NORMAL

SEGMENTERS 0.50 -0.7 0.57 NORMAL

EOSINOPHRILS 0 – 0.05 0.07 ABNORMA

LYMPOCYTES 0.10 – 0.40 0.36 NORMAL

PLATELET COUNT 150 – 450 x 10 gl 273 NORMAL

BLEEDING TME (2- 4 mins.) 3 mins. 08 secs. NORMAL

CLOTING TIME (2- 4 mins.) 4 mins. 30 secs. ABNORMAL
 CHEMISTRY
SI UNITS INTERPRETATION CONVENTIONAL INTERPRETATION
UNIT
TEST NAME RESULT REFERENCE RESULT REFERECE INTERVAL
INTERVAL

BUN/URA 5.32 2.1 – 7.1 mmol/L NORMAL 31.95 13 - 43 NORMAL

CREATININE 124.64 62 - 115 mmol/L NORMAL 1.41 0.70 – 1.30 ABNORMAL
POTASSIUM 4.08 3.8 – 5.0 mmol/L NORMAL 4.08 3.8 – 5.0 mmol/L NORMAL
SODIUM 141.20 135- 145 mmol/L NORMAL 141.20 135- 145 mmol/L NORMAL

April 9, 2019
Urinalysis
Physical Exam Normal Range Results Interpretation
Color Yellow Yellow Normal
Transparency Clear Slightly turbid Normal
Reaction 5.0-8.0 6.7 Normal
Specific Gravity 1.003-1.030 1.025 Normal
Chemical Exam
Sugar Negative Normal
Protein Negative Normal
Microscopic Exam
Pus cells 1-2 Normal
Red cells 0-2 Normal
Epithelial cells Few Normal
Bacteria Few Normal

COAGULATION
TEST NORMAL VALUES RESULT INTERPRETATION

PROTHOMBINE TIME

CONTROL’S TIME 11.5 – 15.5 secs. 13.5 NORMAL

PATIENT’S TIE 11.5 – 15 secs 12.7 NORMAL

ACTIVITY 70% - 120% 90.6% NORMAL

INR 0.85 -1.15 1.05 NORMAL
 CHAPTER IV
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS OUTCOME AND PLANNING INTERVENTION EVALUATION
IDENTIFICATION
SUBJECTIVE: Risk for infection The client will identify After 2 hours of Independent After 2 hours of
related to invasive interventions to nursing  Note risk factors for nursing
“Naoperahan na procedure prevent/reduce risk of intervention the occurrence of intervention the
infection
ako” as verbalized client will infection. client verbalized
by the client
verbalize  Observe for understanding
understanding of localized signs of of individual
individual infection. causative/risk
causative/risk Rationale: To assess factor.
OBJECTIVE: The client will factor. causative/contributing
demonstrate factors After 6 hours of
-
techniques, lifestyle After 6 hours of  Stress proper nursing
changes to promote nursing handwashing intervention the
safe environment. intervention The techniques by all client able
client will be able caregivers between demonstrate
demonstrate patients. techniques,
techniques, Rationale: A first line lifestyle changes
lifestyle changes defense against to promote safe
to promote safe nosocomial environment.
environment. infections/cross-
contamination Goal was met.
 Provide regular
perineal care.
Rationale: Reduce
risk of infection
 Instruct client in
 techniques to protect
the integrity of skin
and care of the
lesions and
prevention of spread
of infection
Rationale: To promote
wellness

Dependent
 Administer/monitor
medication regimen
and note’s client’s
response
Rationale: To
determine
effectiveness of
therapy/presence of
side effects.
 Emphasize necessity
of taking antibiotics
as directed
Rationale: premature
discontinuation of
treatment when
patients begin to feel
well may result in
return of infection.
 ASSESSMENT DIAGNOSIS OUTCOME AND PLANNING INTERVENTION EVALUATION
IDENTIFICATION
Subjective Ineffective sexually The client will After 4 hours of  Determine After 4 hours of
importance of sex nursing
“makakaapekto yata patterns related to verbalized acceptance nursing
and a description intervention the
ito sa pagsasama altered body of self in altered intervention the of the problem in client will
naming ng akng
condition will the client’s own verbalized
asawa” as verbalized structure client
words acceptance of
by the client verbalized
self in altered
Rationale: Sexual
acceptance of self condition
concerns are often
in altered condition disguised as sarcasm,
humor, or in offhand
work.
 Determine client’s
interpretation of
the altered sexual
activity
Rationale: These
behavior may reflect a
stage of grieving
 Avoid value
judgment
Rationale: They do
not help the patient to
cope
 Provide
atmosphere in
 which discussion
of sexual problems
is permitted.
Rationale: Sense of
trust/comfort
enhances ability to
discuss sensitive
matters.
 Encourage
discussion of
individual situation
with opportunity
for expression of
felings without
judgment.
Rationale: To assist
client to deal with
individual situation
 CHAPTER V
DRUG STUDY
DRUG NAME MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE NURSING
ACTION REACTIONS RESPONSIBILITIES
GENERIC NAME: Inhibits cell-wall  Perioperative  Use cautiously in  Dizziness  If large doses are
Ceftriaxone synthesis, promoting Prophylaxis patients  Fever given, therapy is
osmotic instability; hypersensitive to  Headache prolonged, or
usually bactericidal
penicillin because of  Nausea patient is at high
BRAND NAME:
possibility of cross-  Vomiting risk, monitor for
Keptrix sensitivity with  Pain superinfection
other beta-lactam  Indurations  Monitor patient
antibiotics tenderness at for allergic
the injection reactions
site. throughout
CLASSIFICATION: ceftriaxone
Anti-biotic therapy and after
drug is
discontinued.
DOSAGE AND ROUTE
1g  Monitor I&O,
q 12 renal function
IVP tests for
nephrotoxicity.
 Be alert for
superinfection:
fever, vomiting,
diarrhea, anal/
genital pruritus,
oral mucosal
changes
(ulceration, pain,
erythema).
 DRUG NAME MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE NURSING
ACTION REACTIONS RESPONSIBILITIES
GENERIC NAME: May inhibit  Short-term  Contraindicated in  Headache  NSAIDs may mask
Ketolorac prostaglandin management of patients who have  Dizziness signs and
synthesis to produce moderately previously  Drowsiness symptoms of
anti-inflammatory,
analgesic, and
severe acute demonstrated  Sedation infection because
CLASSIFICATION: antipyretic effects
pain for single hypersensitivity to  Arrhythmias of their antipyretic
NSAIDs dose treatment ketorolac or allergic  Hypertension and anti-
manifestations to  Edema inflammatory
aspirin or other  Palpitations actions.
NSAIDs.  Nasal discomfort  Watch for and
DOSAGE AND ROUTE Hypersensitivity  Throat irritation immediately
30mg reactions ranging evaluate signs and
q8  GI pain
from bronchospasm symptoms of
for 3 doses RTC  Nausea
to anaphylactic heart attack (pain,
IVP  Constipation
shock, have shortness of
 Diarrhea
occurred and breath) or stroke
appropriate  Vomiting
(weakness in one
counteractive  Rash part or side of the
measures must be  Pain at injection body, slurred
available when first site speech)
dose of ketorolac
injection is given
 CHAPTER VI

Evaluation/ Findings

Through assessment and data gathering, certain problems were identified. Problems on risk for infection and Ineffective

sexually patterns were observed. Information and health teachings were imparted which led to increasing client's awareness and

knowledge regards to his condition. This study teaches us to provide clients care more efficiently and competently to achieve effective

and quality nursing care.

Recommendation (METHODS)

The patient must be able to recover health and prevent further complications as possible. This, in turn, will consider having a

healthier status – be it physically, emotionally, mentally, and spiritually. For the patient, recommendations would include but not

limited to the following:

Medications

Advice client and relatives to continue the prescribed medications to ensure optimum recovery.

Exercise

Advise family and client to do passive to active ROM exercises to help the client return to activities of daily living.

Avoid all strenuous and stressful activities that could pressure to the affected area.
Treatment

Treatment includes the maintaining proper hygiene and restricting activities to avoid further stress to the situation.

Health Teaching

Instruct the patient and family about the treatment plan including the need to take medications as prescribed and check

with the physician before taking any new medications. Patient and family teaching addresses proper care to the area and to

watch for and report signs and symptoms of infection. The patient should also be able to verbalize feelings to his family to take

emotional care and actions. He should also be able to express any discomfort in order for the health care provider to carry out

certain measures. A client should be able to establish direct open communication with her family and health care practitioner to

link care and needs.

OPD

Remind the client and his family about the follow-up visits and succeeding visits prescribed by the health care provider.

Diet

UPON RECEIVING AT OR

 NPO

POSTOP
 Instruct to have high protein and high fiber diets such as pineapple, mango, orange, green leafy vegetables, lean meat,

dairy products, and fish.

Spirituality

Interpreting and understanding the diversity of religious and spiritual needs of the client.