Inguinal Hernia Minicase

INGUINAL HERNIA A Mini-Case Study Presented to the College of Nursing of Metropolitan Medical Center College of Arts, Science and Technology

In Partial Fulfillment of the Requirements for Intensive Nursing Practicum

Submitted by: Agaloos, Jojilyn T. Ceña, Glaiza V. Chua, Gerold M. Dela Cruz, Christopher Carl A. Demillo, Jeremy C. Diala, Diana Rose S. Fonacier, Fritzel M. Lozano, Kathleen Kaye D. Narvaez, Anjona Yong, Mikee Elaine Y.

Level IV – A1 2nd Semester (S.Y. 2018-2019)

Introduction Hernias are abnormal protrusions of a viscus (or part of it) through a normal or abnormal opening in a cavity (usually the abdomen). They are most commonly seen in the groin; a minority are paraumbilical or incisional. In the groin, inguinal hernias are more common than femoral hernias. Inguinal hernias occur in about 15% of the adult population, and inguinal hernia repair is one of the most commonly performed surgical procedures in the world. Approximately 800,000 mesh hernioplasties are performed each year in the United States, 100,000 in France, and 80,000 in the United Kingdom. There is morphologic and biochemical evidence that adult male inguinal hernias are associated with an altered ratio of type I to type III collagen. These changes lead to weakening of the fibroconnective tissue of the groin and development of inguinal hernias. Recognition of this process led to acknowledgment of the need for prosthetic reinforcement of weakened abdominal wall tissue. Given the evidence that the use of mesh lowers the recurrence rate, as well as the availability of various prosthetic meshes for the reinforcement of the posterior wall of the inguinal canal, most surgeons now prefer to perform a tension-free mesh repair. Accordingly, this article focuses primarily on the Lichtenstein tension-free hernioplasty, which is one of the most popular techniques used for inguinal hernia repair. Open hernia repair is where an incision, or cut, is made in the groin. The hernia “sac” containing the bulging intestine is identified. The surgeon then pushes the hernia back into the abdomen and strengthens the abdominal wall with stitches or synthetic mesh. Most patients will be able to go home a few hours after surgery, and feel fine within a few days. Strenuous activity and exercise are restricted for four to six weeks after the surgery. Signs and Symptoms: Hernias may be detected on routine physical examination, or patients with hernias may present because of a complication associated with the hernia.         

Characteristics of asymptomatic hernias are as follows: Swelling or fullness at the hernia site Aching sensation (radiates into the area of the hernia) No true pain or tenderness upon examination Enlarges with increasing intra-abdominal pressure and/or standing Characteristics of incarcerated hernias are as follows: Painful enlargement of a previous hernia or defect Cannot be manipulated (either spontaneously or manually) through the fascial defect Nausea, vomiting, and symptoms of bowel obstruction (possible)

Causes 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 Straining during bowel movements or urination Strenuous activity Pregnancy Chronic coughing or sneezing

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. 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. Risk factors Factors that contribute to developing an inguinal hernia include:         

Being male. Men are eight times more likely to develop an inguinal hernia than are women. Being older. Muscles weaken as you age. Being white. Family history. You have a close relative, such as a parent or sibling, who has the condition. Chronic cough, such as from smoking. Chronic constipation. Constipation causes straining during bowel movements. Pregnancy. Being pregnant can weaken the abdominal muscles and cause increased pressure inside your abdomen. Premature birth and low birth weight. Previous inguinal hernia or hernia repair. Even if your previous hernia occurred in childhood, you're at higher risk of developing another inguinal hernia.

Complications Complications of an inguinal hernia include:  

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Pressure on surrounding tissues. Most inguinal hernias enlarge over time if not repaired surgically. In men, large hernias can extend into the scrotum, causing pain and swelling. Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Strangulation. An incarcerated hernia can cut off blood flow to part of your intestine. Strangulation can lead to the death of the affected bowel tissue. A strangulated hernia is life-threatening and requires immediate surgery.

ANATOMY AND PHYSIOLOGY

The inguinal canal is a short passage that extends inferiorly and medially through the inferior part of the abdominal wall. It is superior and parallel to the inguinal ligament. The canal serves as a pathway by which structures can pass from the abdominal wall to the external genitalia. It is of clinical importance as a potential weakness in the abdominal wall, and thus a common site of herniation.

Development of the Inguinal Canal During development, the tissue that will become gonads (either testes or ovaries) establish in the posterior abdominal wall, and descend through the abdominal cavity. A fibrous cord of tissue called the gubernaculum attaches the inferior portion of the gonad to the future scrotum or labia, and guides them during their descent. The inguinal canal is the pathway by which the testes (in an individual with an XY karyotype) leave the abdominal cavity and enter the scrotum. In the embryological stage, the canal is flanked by an outpocketing of the peritoneum (processus vaginalis) and the abdominal musculature. The processus vaginalis normally degenerates, but a failure to do so can cause an indirect inguinal hernia, a hydrocele, or interfere with the descent of the testes. The gubernaculum (once it has shortened in the

process of the descent of the testes) becomes a small scrotal ligament, tethering the testes to the scrotum and limiting their movement

Boundaries The inguinal canal is bordered by anterior, posterior, superior (roof) and inferior (floor) walls. It has two openings – the superficial and deep rings. Walls    

Anterior wall – aponeurosis of the external oblique, reinforced by the internal oblique muscle laterally. Posterior wall – transversalis fascia. Roof – transversalis fascia, internal oblique, and transversus abdominis. Floor – inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis), thickened medially by the lacunar ligament.

During periods of increased intra-abdominal pressure, the abdominal viscera are pushed into the posterior wall of the inguinal canal. To prevent herniation of viscera into the canal, the muscles of the anterior and posterior wall contract, and ‘clamp down’ on the canal Rings The deep (internal) ring is found above the midpoint of the inguinal ligament. which is lateral to the epigastric vessels. The ring is created by the transversalis fascia, which invaginates to form a covering of the contents of the inguinal canal. The superficial (external) ring marks the end of the inguinal canal, and lies just superior to the pubic tubercle. It is a triangle shaped opening, formed by the evagination of the external oblique, which forms another covering of the inguinal canal contents. This opening contains intercrural fibres, which run perpendicular to the aponeurosis of the external oblique and prevent the ring from widening. Contents       

Spermatic cord (biological males only) – contains neurovascular and reproductive structures that supply and drain the testes. See here for more information. Round ligament (biological females only) – originates from the uterine horn and travels through the inguinal canal to attach at the labia majora. Ilioinguinal nerve – contributes towards the sensory innervation of the genitalia Note: only travels through part of the inguinal canal, exiting via the superficial inguinal ring (it does not pass through the deep inguinal ring) This is the nerve most at risk of damage during an inguinal hernia repair. Genital branch of the genitofemoral nerve – supplies the cremaster muscle and anterior scrotal skin in males, and the skin of the mons pubis and labia majora in females. The walls of the inguinal canal are usually collapsed around their contents, preventing other structures from potentially entering the canal and becoming stuck.

Predisposing factors

Precipitating factors Activity: heavy lifting Chronic Cough and Constipation

Gender Male Family History of hernia

Age: 40 Above

Increases IntraAbdominal Pressure in the Abdominal Cavity

Degenerative Process: Weakening of the abdominal muscle

Causing defect or hole in the intraabdominal cavity

Sliding of the Small Intestine in the Inguinal Hole

Protrusion in the inguinal canal of the small intestine

Swollen or enlargement of the inguinal part of the body

Pressure in the scrotal sac

Small intestine occupying the scrotal sac

Nerve Compression Scrotal sac Enlargement Pain on the scrotum

Gradual Blockage of the Intestines

Unable to pass Chyme

Backflow of gastric content Nausea and vomiting

SURGICAL MANAGEMENT During surgery to repair the hernia, the bulging tissue is pushed back in and the abdominal wall is strengthened and supported with sutures (stitches), and sometimes mesh. This repair can be done with open or laparoscopic surgery. TYPES OF ANESTHESIA  General anesthesia is medicine that keeps the patient asleep and pain-free.  Regional anesthesia, which numbs from the waist to feet.  Local anesthesia and medicine to help relax the patient. In open surgery:  The surgeon makes a cut near the hernia.  The hernia is located and separated from the tissues around it. The hernia sac is removed or the hernia is gently pushed back into the abdomen.  The surgeon then closes the weakened abdominal muscles with stitches.  Often a piece of mesh is also sewn into place to strengthen your abdominal wall. This repairs the weakness in the wall of your abdomen.  At the end of the repair, the cut is stitched closed. In laparoscopic surgery:  The surgeon makes three to five small cuts in lower belly.  A medical device called a laparoscope is inserted through one of the cuts. The scope is a thin, lighted tube with a camera on the end. It lets the surgeon see inside the belly.  A harmless gas is pumped into your belly to expand the space. This gives the surgeon more room to see and work.  Other tools are inserted through the other cuts. The surgeon uses these tools to repair the hernia.  The same repair will be done as the repair in open surgery.  At the end of the repair, the scope and other tools are removed. The cuts are stitched closed. INDICATIONS The doctor may suggest hernia surgery if there is pain or the hernia affects the activities of daile living of the patient. If the hernia is not causing problems, surgery may not be needed. However, these hernias most often do not go away on their own, and they may get larger. Sometimes the intestine can be trapped inside the hernia. This is called an incarcerated or strangulated hernia. It can cut off blood supply to the intestines. This can be life-threatening. If this happens, you would need emergency surgery.

Nursing Management PRE OPERATIVE NURSING RESPONSIBILITIES  Secure informed consent  Explain the procedure to the client  Remove any jewelry, hair pins, clothes (except gown)  Remove contact lens  No dentures or partial dentures  No makeup or dark nail polish  Give any pre-operative medications (e.g Ativan lorazepam)  ID band should be placed, or checked depending on patient status, and an allergy band per institution protocol. INTRA OPERATIVE NURSING RESPONSIBILITIES  Maintain safety  Maintain aseptic environment  Ensure that instruments count are correct  Complete documentation POST OPERATIVE NURSING CARE  Returning to light activities soon after going home, but avoiding strenuous activities and heavy lifting for a,few weeks.  Avoiding activities that can increase pressure in the groin and belly. Move slowly from a lying to a seated position.  Avoiding sneezing or coughing forcefully.  Drinking plenty of fluids and eating lots of fiber to prevent constipation.

Diagnostic Test There are several main ways that a doctor can see if a person has an inguinal hernia. These are: Physical exam The doctor will examine the individual, often asking them to stand and cough or strain, as this is the time when a bulge is most likely to occur.

Imaging tests Specially trained technicians will perform imaging tests, including X-rays, either in a doctor's office, an outpatient center, or a hospital. A specialist, known as a radiologist, then interprets the images. Anesthesia is not usually needed. The tests include: Abdominal X-ray: An X-ray machine is positioned over the abdominal area and a small amount of radiation is used to take a picture. Computerized tomography (CT) scan: A person either drinks a solution, or a special dye, known as contrast medium, is injected into a vein. This helps to see blood vessels and blood flow on the X-ray. Ultrasound: A device known as a transducer bounces painless sound waves off organs and body parts to build up an image.

Medical Management Before Surgery: • Informed consent is a legal document that explains the tests, treatments, or procedures that you may need. Informed consent means you understand what will be done and can make decisions about what you want. You give your permission when you sign the consent form. You can have someone sign this form for you if you are not able to sign it. You have the right to understand your medical care in words you know. Before you sign the consent form, understand the risks and benefits of what will be done. Make sure all your questions are answered. • An IV is a small tube placed in your vein that is used to give you medicine or liquids. • Pre-op care: may be given medicine right before the procedure or surgery. • General anesthesia will keep the patient asleep and free from pain during surgery. • Foley catheter is a tube put into your bladder to drain urine into a bag. Keep the bag below the waist. This will prevent urine from flowing back into your bladder and causing an infection or other problems. Also, keep the tube free of kinks so the urine will drain properly. During Surgery: The skin is cleaned with Betadine and Zephiran and covered with sheets. An incision is made in your abdomen to hernia in the groin Once the hernia is seen, the blood vessels attached to it are tied off and cut. The hernia is removed. The surgeon checks for bleeding and the other damage to organs nearby. The incision is closed with stitches and covered with a bandage. • Monitoring: Healthcare providers may check for pulses on the arms or wrists. This helps healthcare providers learn if you have problems with blood flow after your surgery. You may also have any of the following: Heart monitor: This is also called an ECG or EKG. Sticky pads placed on your skin record your heart's electrical activity. Intake and output may be measured. Healthcare providers will keep track of the amount of liquid you are getting. They also may need to know how much you are urinating. Ask healthcare providers if they need to measure or collect your urine. A pulse oximeter is a device that measures the amount of oxygen in your blood. A cord with a clip or sticky strip is placed on your finger, ear, or toe. The other end of the cord is hooked to a machine. • You may need extra oxygen if your blood oxygen level is lower than it should be. You may get oxygen through a mask placed over your nose and mouth or through small tubes placed in your nostrils. Ask your healthcare provider before you take off the mask or oxygen tubing.

NURSING CARE PLAN TOP 3 NURSING DIAGNOSIS 1.) Alteration in comfort related to post operative pain 2.) Risk for infection 3.) Impaired skin integrity CUES Subjective:

NURSING DIAGNOSIS Alteration in comfort related to post operative

N/A

pain or post surgical procedure (herniorrhaphy)

Objectives:  

Facial grimace (when in pain) Guarding behaviour

RATIONALE

PLANNING

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end.

Short Term Goal:

Reference:Textbook of Medical-Surgical Nursing 13th Edition Authors: Brunner & Suddarths Page: 865

After 8 hours of combined

After 15-30 minutes of nursing intervention, the client will be able to: Identify and use appropriate interventions to manage pain and discomfort.

INTERVENTION Independent:  Assess the severity, frequency, and characteristic of pain

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Determine and document presence of possible pathophysiologica l and psychological causes of pain (cholecystectomy. surgery) Note location of surgical procedures

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collaborative nursing intervention, the client will be able to:  of comfort and reduce pain as described using a pain

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Monitor Vital signs

independent, dependent and

EVALUATION Short Term Goal:

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Long Term Goal:

Client will express feelings

RATIONALE This may rule out worsening of underlying condition or development of complications. To monitor if there are any changes in the client’s health status Procedure such as surgery, or occurs suddenly with the onset of a painful condition

After 15- 30 minutesof nursing intervention, the client will be able to: . Identify and use appropriate interventions to manage pain and discomfort. Goal Met!!! Long Term Goal: After 8 hours of combined independent, dependent

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This can influence the amount of postoperative pain experienced. Presence of known

and collaborative nursing intervention, the client will be able to:

scale.

Therapeutic:  Provide quiet environment 

or unknown complication may make the pain more severe than anticipated 

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Encourage diversionary measures 

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Change dressing frequently.

Dependent:  Administered opoids (morphine) for pain reliever as ordered by the physician

To minimize stress that patient is experiencing

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Emphasize the importance of rest periods after every activities Emphasize prevention of carrying of heavy materials

This medication can relief pain

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Client will express feelings of comfort and reduce pain

as described Facilitates diversionary using a pain activity to detract scale. from pain. To prevent irritation in the incision site. Goal: MET!!!

Health Teachings: 

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To reduce pain perception and inflammation To prevent opening of the incision site

Discharge Plan 

Medications- Use any pain medicines as instructed by the surgeon or nurse. You may be given a prescription for a narcotic pain medicine. Over-the-counter pain medicine (ibuprofen, acetaminophen) can be used if the narcotic medicine is too strong.  Take pain medications as prescribed  Also take antibiotics as prescribed to prevent infection.

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Exercise- Give time for the operated site to heal for about few weeks. You may gradually resume normal activities, such as walking, driving, and sexual activity, when you are ready. But you probably will not feel like doing anything strenuous for a few weeks.  DO NOT drive if you are taking narcotic pain medicines  DO NOT lift anything over 10 pounds or 4.5 kilograms (about a gallon or 4 liters jug of milk) for 4 to 6 weeks, or until your doctor tells you it is OK. If possible avoid doing any activity that causes pain, or pulls on the area of surgery.  Check with the surgeon before returning to sports or other high-impact activities. Protect the incision area from the sun for 1 year to prevent noticeable scarring.

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Treatment  If there are stitches on the skin, they will need to be removed at a follow-up visit with the surgeon. If stitches under the skin were used, they will dissolve on their own.  The incision is covered with a bandage.  It should be kept clean and dry at all times.  Make sure you or your child gets plenty of rest the first 2 to 3 days after going home. Ask family and friends for help with daily activities while your movements are limited.

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Health Teaching  Do not get the bandage or wound wet for 48 hours.  If strips of tape were used to close your incision, don't pull them off. Let them fall off on their own.  Remove any gauze bandage in 48 hours.  Wash your incision with mild soap and water. Pat it dry. Don't use oils, powders, or lotions on your incision. Do not soak your incision or take tub baths until cleared by your healthcare provider.

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Outpatient/Referral  Keep follow-up appointments during your recovery. These allow your healthcare provider to check your progress and make sure you're healing well. You may also need to have your stitches, staples, or bandage removed. During office visits, tell your healthcare provider if you have any new symptoms. And be sure to ask any questions you have.

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Diet  Eating some high-fiber foods  Drink plenty of water can help keep the bowels moving  Include fruits, vegetables, legumes, and whole grains in your diet each day.