Bulacan State University College of Nursing City of Malolos, Bulacan

A Case study of Indirect Inguinal Hernia

Presented by: Group 2A BSN 3D Nerissa Federis Marjelene Flores Jaecelyn Junio Joanna Marie Llano Hannah Gail M. Lorenzo Jeffrey C. Lumba Presented to: Sir Marcial Espiritu, RN, MSN

Table of Contents:
I. Introduction.Page2 II. Objectives.Page6 III. Nursing Assessment...Page8 IV. Anatomy and Physiology ..Page19 V. Pathophysiology .Page21 VI. Patient and His Care.Page37 VII. Nursing Problem Prioritization.Page47 VIII. Nursing Care Plan.Page49 IX. Health Teaching..Page52 X. Discharge Planning .Page70 XI. Conclusion..Page71 XII. Bibliography.Page71

I.INTRODUCTION This is the case study of baby S.A.M, a 4 year old client from Tambubong, Baliuag, Bulacan, he was admitted at Baliuag District Hospital last May 14, 2013 at 1:15 p.m with a chief complaint of Indirect Inguinal Hernia and Undescended Testes. A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. Hernias by themselves may be asymptomatic (produce no symptoms) or cause slight to severe pain. Nearly all have a potential risk of having their blood supply cut off (becoming strangulated). When the content of the hernia bulges out, the opening it bulges out through can apply enough pressure that blood vessels in the hernia are constricted and therefore the blood supply is cut off. If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply. Different types of abdominal-wall hernias include the following:

Inguinal (groin) hernia: Making up 75% of all abdominal-wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect. Both occur in the groin area where the skin of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area. Distinguishing between the direct and indirect hernia, however, is important as a clinical diagnosis. o Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible site for a hernia in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age. o Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in an area where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age. Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated. Not all hernias that are irreducible are strangulated (have their blood supply cut off ), but all hernias that are irreducible need to be evaluated by a health-care provider.

Umbilical hernia: These common hernias (10%-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than half an inch), this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are pregnant or who have given birth (due to the added stress on the area).

Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness in which a hernia may develop. This occurs after 2%-10% of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return.

Spigelian hernia: This rare hernia occurs along the edge of the rectus abdominus muscle through the spigelian fascia, which is several inches to the side of the middle of the abdomen.

Obturator hernia: This extremely rare abdominal hernia develops mostly in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting. Because of the lack of visible bulging, this hernia is very difficult to diagnose.

Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

Hernia Causes:Although abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness.Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. Examples include: obesity,heavy lifting,coughing,straining during a bowel movement or urination,chronic lung disease and 4

fluid in the abdominal cavity. A family history of hernias can make you more likely to develop a hernia. The signs and symptoms of a hernia can range from noticing a painless lump to the severely painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen (an incarcerated strangulated hernia).Reducible Hernia: It may appear as a new lump in the groin or other abdominal area. It may ache but is not tender when touched. Sometimes pain precedes the discovery of the lump. The lump increases in size when standing or when abdominal pressure is increased (such as coughing). It may be reduced (pushed back into the abdomen) unless very large. Irreducible hernia: It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it. Some may be chronic (occur over a long term) without pain. An irreducible hernia is also known as an incarcerated hernia. t can lead to strangulation (blood supply being cut off to tissue in the hernia). Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting. Strangulated hernia: This is an irreducible hernia in which the entrapped intestine has its blood supply cut off. Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting). The affected person may appear ill with or without fever. This condition is a surgical emergency. Hernia Diagnosis:If you have an obvious hernia, the doctor may not require any other tests (if you are healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body area with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If you have an inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.

Our client have a Indirect Inguinal Hernia (Reducible Hernia).The diagnostic procedure done with our client is Physical Examination.The other laboratory examinations like Hematology, Urinalysis, and X-ray. The patients medication were Morphine sulfate,Ketamine,Paracetamol, Mefenamic acid. During gestation, a boy's testicles develop inside his abdomen, and then, sometime before birth, they push through a tunnel in the tissue between the groin and the abdomen (called the inguinal canal) and descend into the scrotal sac.In girls, the ovaries descend through the tunnel and into the pelvis. At that point, the passage through the abdominal wall should close up.In about 5 percent of babies (mostly boys, and especially those who were premature), the opening remains large enough to allow a loop of the intestine to poke down into the tunnel. Inguinal hernias do not improve on their own. You'll notice a firm, oblong lump about the size of your thumb either in your baby's groin area or the scrotum. You may not notice the lump for weeks or even months after your child is born.It may bulge out when he's active or crying, then disappear back into the abdomen when your baby is relaxed. Hernias occur more often in children who have one or more of the following risk factors: a parent or sibling who had a hernia as an infant, cystic fibrosis, developmental dysplasia in the hip, undescended testes, abnormalities of the urethra. About 25% of males and 2% of females develop inguinal hernias; this is the most common hernia in males and females.Data from developing countries is limited hence the exact prevalence and incidence is not known. Gender and anatomic distribution of Hernias is believed to be similar to developed countries. Generally most of the hernias occur in the groin in adults.Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct.Indirect inguinal hernias are the most common hernias in both men and women; a right-sided predominance exists.Incisional and ventral hernias account for 10% of all hernias. Only 3% of hernias are femoral hernias.Between 10% and 30% of children have an abdominal wall hernia; most hernias of this type close 5

spontaneously by age 1 year. The incidence of incarcerated or strangulated hernias in children is 10-20%; 50% of these occur in infants younger than 6 months. Sex: Approximately 90% of all inguinal hernia occur in males. Femoral hernias (although rare) occur almost exclusively in women because of the differences in the pelvic anatomy. The female-to-male ratio of Obturator hernias is 6:1. Age:Indirect hernias usually present during the first year of life, but they may not appear until middle or old age. Direct hernias occur in older patients as a result of relaxation of abdominal wall musculature and thinning of the fascia. Umbilical hernias usually occur in infants and reach their maximal size by the first month of life. Most hernias of this type close spontaneously by the first year of life, with only a 2-10% incidence in children older than 1 year. HerniaIncidence http://www.medindia.net/surgicalprocedures/hernia-incidence.htm#ixzz2TahgRVDl We chose this case because we are aiming to gain more knowledge and explain all the necessary information about Indirect Inguinal Hernia. In addition, our group will learn the needed action for this type of disease in hospital setting aside from the knowledge acquired in Nursing Education. And this study also aims to be a reference for future studies and researches of other nursing students.

II. OBJECTIVES CLIENTS OBJECTIVES GENERAL To render the necessary nursing intervention for the patient having Indirect Inguinal Hernia.

SPECIFIC Knowledge Skills To conduct an assessment for the client having Indirect Inguinal Hernia. For the clients mother to be able to manage her son in times of sickness triggers. To be able to practice self care activities appropriately. To evaluate an assessment for the client having Indirect Inguinal Hernia. To develop awareness for the clients mother understand her sons disease. To able to understand the importance of complying with the clients medication.

Attitude To be able to improve discipline in order to manage himself greatly. To be able to comply with treatments to promote recovery. To be able to build trust with the hospital personnel.

STUDENTS OBJECTIVES GENERAL For us, nursing students to obtain a broad understanding about Indirect Inguinal Hernia through completing the necessary action and data for this case study.

SPECIFIC Knowledge Skills To do the necessary nursing intervention in hospital for client with Indirect Inguinal Hernia. To give the known medication for client with Indirect Inguinal Hernia. To do the necessary nursing intervention in hospital for client with Indirect Inguinal Hernia. To increase knowledge about Indirect Inguinal Hernia. To learn the probable cause, sign and symptoms of Indirect Inguinal Hernia. To improve knowledge about how to do the ideal nursing intervention for clients with Indirect Inguinal Hernia.

Attitude To observe and understand the behavior of client having Indirect Inguinal Hernia. To develop our nursing responsibilities. To give the proper care and build a genuine nurse-patient relationship conducive to good health.

III. Nursing Assessment A.BIOGRAPHIC DATA Name: Baby S.A.M Age: 4 years old Sex: Male Civil Status: Single Position in the family: Only child Address: Tambubong, Baliuag, Bulacan Birth date: May 27, 2008 Occupation: none Nationality: Filipino Religion: Roman Catholic Educational Attainment: Date of Admission: May 14, 2013Time: 1:15pm Initial diagnosis: Indirect Inguinal Hernia Right: undescended testis Right for Herniotomy Final diagnosis: Indirect Inguinal Hernia Right: undescended testis Right for Herniotomy B. REASON FOR VISIT/CHIEF COMPLAINT Simula nung 5 months old palang siya, may luslos na sya sa kanang singit niya, tapos ngayong 4 years old lang siya pwedeng ipaopera sabi ng Doctor. As verbalized by the clients mother.

C. HISTORY OF PRESENT ILLNESS Patients condition started since he was a 4 months old baby as he cry actively it bulge out, then disappear back into the abdomen when he stoped crying. The client was admitted in the hospital on May 14, 2013at 1:15pm. The patient was medicated with Dolan, Atropen, Paracetamol, Dormicum, Ceporex, Ketazol and Sensorcaine.

D. HISTORY OF PAST ILLNESS The patient mother stated that baby S.A.M develop an Asthma but disappeared when the baby reached 2 years old. According also to his mother he experienced coughs and colds. She does not have any regular medical and dental check-ups. He has a complete vaccine.

VACCINES BCG

AGE Any time at birth School entrance

NUMBER OF DOSE 1

DOSE 0.05ml 0.01ml

ROUTE ID ID IM Oral IM Subq. Right deltoid

SITE

DPT OPV Hepa B Measles

1 months 1 months At birth 9 months

3 3 3

0.5ml 2 gtts 0.5ml 0.5ml

Upper outer portion of the thigh Mouth Outer portion of the thigh Outer part of the arm

E. Family Health Illness History (GENOGRAM) According to the clients mother, the clients grandfather at her side, died due to lung cancer a long time ago. At the clients father side, his grandfather is with hypertension and Diabetes Mellitus. With regards to his mothers siblings, one already died due to vehicular accident. And to his fathers sibling, one had an asthma.

BA 62 (+) hpn, DM

NA 60

GM 65 (+)Cancer

SM 63

DA 34 TA 29

PA 26

AAM 23

MM 24

BM 25

LM 27 (+) asthma

JM 33

Legend: SAM 4 YRS OLD (+) IIH Female

Male (Kozeir 8th edition, p. 434 volume 1) Client 10

(+) IIH- Indirect Inguinal Hernia (+) hpn- Hypertension (+) DM- Diabetes Mellitus (+) asthma

F. Functional Health Pattern 1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN Prior to Hospitalization During Hospitalization

According to the clients mother, the client is playful and doesnt complain After the surgery, the client stated that his circumcised penis hurts but of any pain regarding his sons hernia. the incision from herniotomy doesnt hurt that much. He stated that he wants to play and go out to the hospital already. 2. NUTRITIONAL METABOLIC PATTERN

Prior to Hospitalization

During Hospitalization After the surgery, The client was ordered with DAT once fully awake. He is with an IVF of D5 0.3 NaCl 500 cc at 40-42 gtts/min. 72 HOUR DIETARY RECALL
Date Noted May 12,2013 (Sunday) Time of the Day Breakfast and Lunch (noon time) Foods Taken 1 small bowl of Tinola with two small pcs of chicken 1 bottle (350mL) of Milk

According to the Clients mother, Before the client was hospitalized He used to drink Bottled milk about 350mL thrice a day, In morning then after siesta then before he goes to sleep. He used to eat a lot. And drinks at least 5 glasses of water a day.

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Dinner (evening)

May 13, (Monday)

2013 Breakfast (morning)

Lunch

Dinner

1 small bowl of adobo with one piece chicken 1 bottle (350mL) of water 3 pcs of pandesal 1 cup of coffee (150ml) 1 small bowl of pinakbet 1 cup of rice 2 glasses of water (500 ml) 1 small Bowl of Lugaw with 1 small pc of chicken 1 bottle (350mL) of water

May 14, 2013 (Tuesday)

Breakfast (morning)

NPO

Lunch

NPO

Dinner

1 small bowl of

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Lugaw 1 bottle (350mL) of water

3. ELIMINATION PATTERN Prior Hospitalization During Hospitalization

According to the clients mother, the client used to defecate at According to the clients mother, the client defecates once a day. His urine is just the same least once a day and urinates for at least 3-4 times a day. before he was hospitalized. He perspires much due to pain by his circumcision. Character Stool Solid stool Odor Frequency Discomfort No 1time Having odor discomfort due to pain in the circumcised penis. waterno 2-3 times Having colored foul a day discomfort urine odor due to pain from circumcision. The clients perspire because of the pain Color Brown

Character Stool solid

Odor Frequency Discomfort foul 1 time No odor Discomfort Regular waterno 3-4 times No Urine urination colored foul a day discomfort urine odor Perspiration : The clients perspires much because he always used to play with his cousins.

Color brown

Urine Regular urination

Perspiration : experiencing

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4.

ACTIVITY/EXERCISE PATTERN During Hospitalization Sligghtly Dependent with his mother Feeding =3 Bathing =2 toileting = 2 dressing = 2 grooming = 2 bed mobility = 2

Prior to Hospitalization Fully dependent with his mother Feeding =4 toileting =2 grooming =2 Bathing =2 dressing =2 bed mobility =4 LEGEND: 0- Full Self Care 1- requires use of equipment or device 2- requires assistance or supervision from other person 3- requires assistance or supervision from other person/ device 4 dependent and does not participate

LEGEND: 0- Full Self Care 1- requires use of equipment or device 2- requires assistance or supervision from other person 3- requires assistance or supervision from other person/ device 4 dependent and does not participate

5. SLEEP/REST PATTERN

Prior to Hospitalization

During Hospitalization

The client, as stated by her mother, was always sleeping at exactly The client sleeps at 9PM to 6AM, to be exact, he sleeps at 9 hours. He 8PM and wakes up at 6AM during school days. To be exact, he sleeps for cant sleep in the afternoon because he is not comfortable in the hospital and about 10 hours. But sometimes, he used to be awake before lunch. And stated that, mainit kasi po dito. then he used to take a nap for at least 2 hours in the afternoon.

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6. COGNITIVE PERCEPTUAL PATTERN Prior to Hospitalization During Hospitalization

The client has no problem in vision, hearing and sensory The client has no problem in vision, hearing and sensory perception. perception.

7. ROLE RELATIONSHIP PATTERN Prior to Hospitalization During Hospitalization

The client is an only child but used to play with his cousins. When his His father leaves at work to take care of him together with his mother in mother is at school, his auntie takes good care of him. the hospital.

8. COPING STRESS TOLERANCE Prior to Hospitalization During Hospitalization

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After doing school works, He used to play with his cousins to relieve stress.

The client talks to his mother to relieve stress of staying in the hospital without TV.

9. VALUES BELIEF PATTERN Prior to Hospitalization During Hospitalization

The client is a Roman Catholic and goes to church to attend mass every The client believed that praying to God will make him recover from his Sunday. surgery easily.

G. Growth and Development THEORY PSYCHOSOCIAL COGNITIVE PSYCHOSEXUAL MORAL

STAGE

Preschool (3 to 5 years) Initiative vs. Guilt

Pre operational stage 2 to 7 Years

Phallic stage

Pre-conventional morality Stage 1: Obedience or punishment orientation

3-6 years old genitalia

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Exploration

DEFINITION

Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.

Children begin to think symbolically and learn to use words and pictures to represent objects. They also tend to be very egocentric, and see things only from their point of view. Developemental changes

The third stage of psychosexual development is the phallic stage, spanning the ages of three to six years, wherein the child's genitalia are his or her primary erogenous zone. It is in this third infantile development stage that

This is the stage that all young children start at (and a few adults remain in). Rules are seen as being fixed and absolute. Obeying the rules is important because it means avoiding punishment.

children become aware of their Children at this stage tend to be egocentric and struggle to bodies, the bodies of other see things from the perspective children, and the bodies of of others. While they are getting better 17 their parents; they gratify

with language and thinking, they still tend to think about things in very conrete terms

physical curiosity by undressing and exploring each other and their genitals, and so learn the physical (sexual) differences between "male" and "female" and the gender differences between "boy" and "girl".

FINDINGS

PASS

PASS

PASS

PASS

REMARKS

Positive. The client , shows that he has the power to question what is happening to him.

Positive. The client is in pre operational stage ask a lot of things to his mom and explain it by using some gestures or

Positive. The client has more on his feelings on his mother.

Positive. He obeys when in command.

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pictures.

IV. Anatomy and Physiology

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The inguinal canal is a passage in the anterior (toward the front of the body) abdominal wall which in men conveys the spermatic cord and in women the round ligament. The inguinal canal is larger and more prominent in men. Each person has two, on the left and right sides of the abdomen. The small intestine (or small bowel) is the part of the gastrointestinal tract following the stomach and followed by the large intestine and is where much of the digestion and absorption of food takes place. The superficial inguinal ring (subcutaneous inguinal ring or external inguinal ring) is an anatomical structure in the anterior wall of the human abdomen. It is a triangular opening that forms the exit of the inguinal canal, which houses the ilioinguinal nerve, the genital branch of the genitor femoral nerve, and the spermatic cord (in men) or the round ligament (in women) The deep inguinal ring (internal or deep abdominal ring, abdominal inguinal ring, internal inguinal ring) is the entrance to the inguinal canal. The spermatic cord is the name given to the cord-like structure in males formed by the vas deferens and surrounding tissue that run from the abdomen down to each testicle The testicle is the male gonad in animals testes are components of both the reproductive system and the endocrine system. The primary functions of the testes are to produce sperm (spermatogenesis) and to produce androgens, primarily testosterone.

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V. Pathophysiology MODIFIABLE RISK FACTORS NON MODIFIABLE RISK FACTORS Age Gender Hereditary

asthma

Weak abdominal wall

Increased pressure in the compartment of the abdomen

Intra abdominal wall (membranes and muscles) of the inguinal canal into the scrotum becomes weakened

Causing malfunction of the inguinal ring

Inguinal ring will not closed

Evolves to a hole or defect 21

Fatty substance or part of the small intestine slides through the inguinal canal

Pain or discomfort to the affected organs

Scrotum enlarged or swollen

INDIRECT INGUINAL HERNIATION

A. PHYSICAL ASSESSMENT VITAL SIGNS: PR=131 bpm TEMPERATURE=37.7 degree Height = 35 Weight = 35.2 lbs BMI : 14.7 Underweight PAIN SCALE: 3/5 according to Wong Baker Face Pain Scale May 15, 2013 RR=26 cpm

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS General appearance

ACTUAL FINDINGS

REMARKS

1. Body built in relation to clients age, lifestyle & health 2. Clients posture & gait, standing, sitting & walking 3. Clients overall hygiene & grooming 4. Body & breath odor

Inspection

Proportionate and varies with lifestyle Relax, erect posture, coordinated body movements Neat No body odor or minor body odor relative

He has a proportionate (mesomorph) body built which is appropriate with his lifestyle n/a

Normal

Inspection

n/a

Inspection

He is neat and clean.

Normal

Inspection

no body odor There are sign of restlessness, the patient is irritated and cries at time Weak in appearance Cooperative once kept calm

Normal

5. Signs of distress in posture or facial expression 6. Obvious signs of health or illness 7. Clients attitude 8. Clients affect/mood; appropriateness of the clients response

Inspection

No distress noted

deviation from normal due to pain felt by the patient Deviation from normal due to pain felt by the patient Normal

Inspection Inspection

Healthy appearance Cooperative

Inspection

Appropriate to the situation

Appropriate to the situation

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS Understandable and in a moderate pace; exhibits thought association answer to question appropriately Has a sense of reality

REMARKS

9. Quantity of speech, quality & organization

Inspection

Understandable, moderate pace; exhibits thought association Logical sequence; makes sense; has sense of reality. SKIN

Normal

10. Relevance & organization of thoughts

Inspection

Normal

1. Skin moisture 2. Skin Texture 3. Skin turgor

Inspection Inspection Inspection and palpation

moisture in skin fold and axillae smooth Springs back

Moist skin folds smooth Springs back

Normal Normal Normal

Hair and Nails 1. Fingernails plate shape to determine its curvature & angle Convex curvature, angle of nail plate about 160 degrees. Convex and has less than 180 degree

Inspection

Normal

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PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS Highly vascular and pink in light skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks. Intact epidermis. Smooth texture. Prompt return of pink or usual color (generally less than 4 seconds.)

ACTUAL FINDINGS

REMARKS

2. Fingernail & toenail bed color

Inspection

Pinkish in color

Normal

3. Tissues surroundings nails 4. Fingernail & toenail texture 5. Blanch test of capillary refill

Inspection Palpation

He has an intact epidermis with no hangnails Smooth nail texture The color return to the original color in 2 seconds

Normal Normal

Palpation

Normal

1. Evenness of growth over the scalp 2. Hair thickness & thinness 3. Presence of infections or infestations 4. Texture & oiliness over the scalp

Inspection Palpation Inspection

Evenly distributed hair. Thick/thin hair. Not present.

His hair is well distributed He has a thick hair Not present.

Normal Normal Normal

Palpation

Silky, resilient hair.

Silky, resilient hair.

Normal

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SKULL Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour. Smooth, uniform consistency; absence of nodules or masses. FACE Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Symmetrical facial movements. Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Facial movements are symmetrical

1. Size, shape & symmetry

Palpation

Head is symmetrically round.

Normal

2. Nodules or masses & depressions

Palpation

No mass or nodules noted;

Normal

1. Facial features

Inspection

Normal

2. Symmetry of the facial movements

Inspection

Normal

EYEBROWS & EYELASHES Hair evenly distributed; skin intact. Eyebrows asymmetrically aligned equal movement. Eyelashes curl slightly outward. Eyebrows and eyelashes are both evenly distributed, symmetrical aligned. Eyelashes curl slightly outward.

1. Evenness of distribution & direction of curl

Inspection

Normal

26 CORNEA

1.Clarity & color

Inspection

Transparent, shiny and smooth; details of the iris are visible. In older people, a thin grayish white ring around the margin, called arcussenilis, may be evident. IRIS EYELIDS

Details of iris are visible. Transparent, shiny and smooth.

Normal

1. Shape & color

Inspection

Flat and round PUPILS

Flat and round and uniform in color.

Normal

1. Color, shape & symmetry of size

Inspection

Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border.

Firm and equal pupils

Normal

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1. Surface characteristics & ability to blink

Inspection and Palpation

Skin intact, no discharge, no discoloration. Lids close symmetrically approximately 15-20 involuntary blinks per minute; bilateral blinking. When lids open, no open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered. CONJUNCTIVA

Eyelids skin are intact, no noted discharge, and no noted discoloration. Lids close symmetrically. Client exhibited 18 involuntary blinks per minute.

Normal

1. Bulbar conjunctivas color, texture & presence of lesions 2. Palpebral conjunctivas color, texture & presence of lesions

Inspection

Transparent; capillaries sometimes evident.

Transparent, capillaries evident, no discharge was noted. Shiny, smooth and pale in color

Normal

Inspection

Shiny, smooth, pink or red in color. SCLERA Sclera appears white (yellowish in dark- skinned clients).

Deviation from normal due to starvation

1. Color & clarity

Inspection

Sclera appears white

Normal

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

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EARS AURICLE Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10cm from vertical. Color is same with facial skin, symmetrical with each other, auricle aligned with outer canthus of eye, about 10 cm vertical Both pinna recoils after being folded. Mobile, firm and not tender.

1. Color & symmetry of size &position

Inspection

Normal

2. Texture & elasticity & areas of tenderness

Palpation

Mobile, firm and not tender, pinna recoils after it is folded. EXTERNAL EAR CANAL Distal third contains hair follicles and glands. Dry cerumen in various shades of brown HEARING ACUITY TEST

Normal

1. Cerumen, skin lesions, pus & blood

Inspection

No noted pus, blood and odor. Minimal cerumen noted. Distal third contains hair follicles.

Normal

1. Clients response to normal voice tones

Inspection

Normal voice tones audible

Client responds to normal voice tones

Normal

NOSE 1. Shape, size or color & flaring or discharge from the Symmetric and straight Inspection No discharge or flaring No discharge and/or flaring noted. Symmetrical on both Normal

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nares

Uniform color

sides. Also uniform in color.

2. Presence of redness, swelling, growths & discharge or nares using the flashlight

Mucosa pink Inspection Clear, watery discharge No lesions. Inspection Nasal septum intact and in midline, intact Air moves freely as the client breathes through the nares

Mucosa are intact and pinkish; minimal moist noted inside; no swelling or nodules found. Nasal septum is intact and in midline Air moves freely as the client breathes through each nares No tenderness, no lesions noted. No displacement of bone & cartilage.

Normal

3. Position of nasal septum 4. Test patency of both nasal septum 5. Tenderness, masses displacement of bone cartilage & &

Normal

Inspection

Normal

Palpation

Not tender; no lesions

Normal

LIPS Uniform pink color 1. Symmetry of contour color & texture Soft, moist, smooth texture Inspection and Palpation Symmetry of contour Ability to purse lips Symmetry of contour Ability to purse lips Uniform pale to pink color Soft, moist, smooth texture Deviation from normal due to starvation

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TEETH 1. Inspect for color, number & condition & presence of dentures 20 baby teeth Inspection Smooth, white, shiny tooth enamel GUMS Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums 20 baby teeth, 4 front teeth are with cavities Deviation from normal due to teeth cavities

1. Color & condition

Inspection

Slightly pale gums, moist, firm texture

Deviation from normal due to starvation

TONGUE/FLOOR OF THE MOUTH 1. Color & texture of the mouth floor & frenulum Inspection and Palpation Smooth tongue base with prominent veins Smooth tongue base with prominent veins Normal

31

Central in position Pink in color (some brown pigmentation on tongue borders in darj-skinned clients); moist; slightly rough; thin white coating Smooth, lateral margins, no lesions Raised papillae (taste buds) Moves freely, no tenderness

2. Position, color & texture, movement & base of the tongue

Inspection and Palpation

Centered; pink in color, slightly rough, has thin white coating, smooth, no lesions; moves freely.

Normal

ABDOMEN Unblemished skin, uniform in color, silver white striae (stretch marks) or surgical scars. Flat, rounded (convex) or scaphoid(concave) Audible bowel sounds

1. Skin integrity

Inspection

Uniform in color with surgical incision

Deviation from normal due to surgical procedure done

Normal Convex in shape.

2. Abdominal contour

Inspection

3. Bowel Sounds

Auscultation

Audible bowel sounds

Normal

32

Summary of Physical Assessment: General Appearance: Sign of Distress in Posture and Facial Expression - There are sign of restlessness, the patient is irritated and cries at time Obvious Signs of health or illness- Weak in appearance Conjunctiva: Palberal conjunctivas color texture and presence of lesions- Shiny, smooth and pale in color Lips: Symmetry of contour color and texture- Uniform pale to pink color, soft , ,oist snooth texture, symmetry of contour Gums: Color and condition- pale, firm texture. Abdomen: Skin Integrity - Uniform in color with surgical incision

33

COMPLETE BLOOD COUNT April 25,2013 T 42.2 degree

TEST WBC RBC HGB HCT PLT PCT WBC FLAGS DIFF: % LYM % MON % GRA 8.8 x 109 4.2 x 1012 124 g/L 0.354 L/L 208 x 109/L 0-166 x 10-2/L 41.4% 17.5% 4.1 %

ACTUAL FINDINGS 3.5 10 x109 3.80 5.0 x 1012 110 - 165 0.350 500 150 390 0.100 0.600 17.0 48.0 % 4.0 10.0 % 43.0 76.0 %

NORMAL FINDINGS

Chrisger L. Santos Medtech Lic # 46436 HEMATOLOGY April 17, 2013

TEST HGB HCT WBC PLATELET COUNT SEGMENTERS LYMPHOCYTES 147 g/L 0.40 g/L 11.5 x x 109/L 208 x 109/L 53.0 47.0

ACTUAL FINDINGS

NORMAL FINDINGS

Chrisger L. Santos Medtech Lic # 46436

34

URINALYSIS April 17, 2013

TEST Color Characteristic Reaction SPGP Albumin Sugar WBC RBC Epithelial Cells Bacteria Light Yellow Slightly Cloudy Alkaline 1.015 Negative Negative 0-2 01 few few FINDINGS

April 25 , 2013
TEST Color Characteristic Reaction SPGP Albumin Sugar WBC RBC Epithelial Cells Bacteria Yellow Cloudy Acidic 1.030 Negative Negative 2-3 03 few few FINDINGS

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Chrisger L. Santos Medtech Lic # 46436 RADIOLOGIC EXAM Chest FINDINGS: Both lung fields are essentially clear. Sinuses and diaphragm are intact. Heart is within normal limits. Lux Evelyn C. Trinidad MD, MPA Radiologist

36

VI. THE PATIENT AND HIS CARE A. Medical Management a. IVF, Nebulization, NGT, TPN, Oxygenation therapy

MEDICAL MANAGEMENT TREATMENT

DATE ORDERED/ DATE PERFORMED/ DATE CHANGE OR D/C

GENERAL DESCRIPTION

INDICATIONS/ PURPOSES

CLIENTS RESPONSE TO THE TREATMENT

NURSING RESPONSIBILITIES

Intravenous fluidD5 0.3 NaCl 500cc (0.3% Dextrose in Sodium Chloride)

Date ordered: Date performed: Date change:

Hypotonic Solution 40-42 gtts/min

Used to provide free water and treat cellular dehydration. Has lower concentration than the body fluids.

Signs and symptoms of dehydration were not noted such as dry skin.

Prior: Review physicians order During: Watch closely for signs and symptoms of fluid overload. Monitor I & O After: Maintain patent IV line, watch for irritation in the insertion site. Monitor I & O continuously.

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Intravenous fluidD5LR 1L (5% Dextrose in Lactated Ringers Solution)

Date ordered: Date performed: Date change:

Hypertonic Solution Fast drip

It used to supply water and electrolytes (e.g. Calcium, potassium, sodium and chloride.) Treatment for persons needing extra calories who cannot tolerate fluid overload.

Signs and symptoms of dehydration were not noted such as dry skin.

Prior: Review physicians order During: Watch closely for signs and symptoms of fluid overload. Monitor I & O After: Maintain patent IV line, watch for irritation in the insertion site Monitor I & O continuously

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b. Drugs Generic/ BrandName/ Classification Generic Name: Ibuprofen Brand Name: Dolan Classification: analgesic; antipyretic DATE (ordered, given, changed, discontinue) Route of Administration, Dosage, Frequency Given orally,250mg/5mL Susp tsp for 8hrs. Mechanism Action Clients Response Nursing Responsibilities

Blocks the prostaglandins, substances our body releases in response to illness and injury. Prostaglandins cause pain and swelling (inflammation); they are released in the brain and can also cause fever.

----

Prior: Take the patients vital signs During Advised the patient to take it with meals or milk if GI intolerance occurs. Advise the patient to report any signs of N&V, diarrhea or constipation. Monitor input and output continuously. After: Monitor input & output continuously. Assess for possible side effects.

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Generic Name: Atropine Sulfate Brand Name: Artopen Classification: Cholinergic blocking drug

5 mL IV push

To suppress salivation, perspiration, and respiratory tract secretions; to reduce incidence of laryngospasm, reflex bradycardia arrhythmia, and hypotension during general anesthesia.

----

Prior: Monitor vital signs.HR is a sensitive indicator of patients response to atropine.

During: The nurse should be alert in to changes in quality, rate, and rhythm of HR and respiration and to changes in BP and temperature. Monitor input & output. After: Monitor input & output continuously. Assess for possible side effects ----Prior: make sure that the patient to have no allergies in acetaminophen During: Monitor pulse and respiration After: Assess for patients comfort Prior:

Generic Name: Paracetamol Brand Name: Aeknil Classification: Analgesic,Antipyretic Generic Name: Midazolam Hydrochoride

300mg IV push

Reduces the synthesis of prostaglandins which are responsible for the mediation of pain and fever.

5mg/mL IV push

Short-term sedation

-----

Postoperative amnesia 40

Brand Name: Dormicun Classifications: Benzodiazepine

Monitor pulse and respiration

During: Monitor BP, pulse and respiration continuously during IV administration. Oxygen and resuscitative equipment should be available in case of respiratory depression. After: Assess for patients comfort Given orally,susp 250 mg/5mL Susp tsp q8h Inhibits synthesis of bacterial cell wall, causing cell death. ----Prior: Monitor vital signs During: Advised the patient to take it with meals for GI upset. Advised the patient to report any adverse effect such as rash, yellow discoloration of the skin. Monitor input & output. After: Advised the patient to consume 23L/day of fluids to prevent dehydration. Monitor input & output continuously.

Generic Name: Cephalexin Monohydrate

Brand Name: Ceporex Classifications: Antibiotic, Cephalosporin (first generation)

Generic Name: Ketamine hydrochloride

5mL IV push

Anaesthesia for operations of short duration and in 41

------

Brand Name: Ketazol Classifications: Anaesthetic

case of painful diagnostic interventions. Induction of anesth prior to the administration of IV anesth.

Prior: Monitor vital signs Explain to the patient that this can cause dizziness, drowsiness; nausea, and vomiting.

During: Monitor BP, pulse and respiration continuously during IV administration Generic Name: Bupivacaine HCL Brand Name: Sensorcaine Classification: Amide type local anaesthetic Spinal Anaesthesia 5mL Block the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. Prior: Inform the patient that they may experience temporary loss of sensation and motor activity, usually in the lower half of the body, following proper administration of spinal anesthesia. During: Maintain a patent airway. Monitor cardiovascular and respiratory vital signs and the patient's state of consciousness. ---After:

Assess for patients comfort Monitor input & output

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After: Assess for patients comfort

c. Diet Type of diet Date started General description Foods that are easily digested Indications/purpose Specific foods taken Lugaw Water Clients response to the diet The client understands why he needs to take a soft diet. Nursing responsibilities

Soft diet

Foods which are easily digested and pass quickly through your digestive system. These help to reduce the amount of time food stays in the intestines and make bowel motions soft and easy.

Prior: Weigh the child before feeding to make sure that the child receives the right amount of food. After: Record the fluid intake and output intake. Prior: Tell the purpose of DAT to the patient.

DAT

Diet as tolerated All the foods that the client

To regain his strength.

Breads Rice Cereals Fresh vegetables

The client understands why he needs to eat nutritious food.

During: Monitor and check the food intake.

43

can ingest.

fruits

Make sure food the is nutritious and beneficial to his present situation.

44

d.Activity/Exercises

Type of Exercises

Date Started

General Description

Indication/purpose

Clients Response to the Activity

Nursing Responsibilities

Ambulation

The act of travelling by foot; is a healthy form of exercise.

It can help prepare and condition the body for the additional stress that surgery will cause. Improve muscle tone and strength in his abdomen.

Prior: Explain to him why he needs to perform exercises. During: Assits patient while performing the exercises.

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B. Surgical Management Surgical management Date performed General description Indication and purpose Client response Nursing responsibilities

Herniotomy

An operation for hernia that involves opening the hernia sac,returning the contents to their normal place,oblitering the hernia sac,closing the opening with strong sutures.

Performed to close or mend the The patient is in weakened abdominal wall. pain.

Prior: Explain to the procedure to the client. Take the vital signs.

During: Maintain a patent airway. Monitor cardiovascular and respiratory vital signs and the patient's state of consciousness.

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After: Assess for patients comfort.

VII. Nursing Problem Prioritization DATE IDENTIFIED CUES PROBLEM/ NURSING DIAGNOSIS May 17, 2013 Subjective: medyo mainit siya as verbalized by the mother of the client. Objectives: > Febrile(37.6 C) > warm to touch >irritable >pale >weak in appearance >restless Altered body temperature related to inflammatory process -We include this in prioritization because the patient is already warm to touch and he is restless. JUSTIFICATION

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May 17, 2013

Subjective: medyo masakit po as verbalized by the client.

Acute pain related to surgical incision on right inguinal area

-We include this in prioritization because the patients wong baker scale is already 3/5.

May 17, 2013

Objective: > facial grimace > wong baker scale 3/5 > guarding behavior Subjective: Decreased mobilization related to di pa siya masyado makakilos as discomforts on operation site verbalized by the mother of the patient. Objective: >irritable >restless >cries at time Activity intolerance related to Subjective: discomforts on operation site di pa siya masyado makakilos as verbalized by the mother of the patient. Objective: >irritable >restless >cries at time

-We include this in prioritization because the patient cant move normally and not doing his usual activities.

May 17, 2013

-We include this in prioritization because the patient cant move normally and most of the time he is depending on his mother.

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VIII. Nursing Care Plan ASSESSMENT Subjective: medyo mainit siya as verbalized by the mother of the client. DIAGNOSIS Altered body temperature related to inflammatory process PLANNING Short term goal: After 1-2 hours of nursing intervention the patients body temperature will decrease from 37.7 C to at least 37.5 C Promote surface cooling by means of rendering tepid sponge bath Promote bed rest Encourage the mother to remove wet clothing of the patient Discuss to the mother the importance of adequate fluid intake of the patient Helps reduce high temperature to reduce tension to provide comfort After 1-2 hours of nursing intervention the patients body temperature decreased from 37.7 C to 37.1 C INTERVENTION RATIONALE EVALUATION

Objective: >Febrile(37.7 C) >warm to touch >irritable >weak in appearance >restless >cries at time >V/S as follows: BP: 90/50 mmHg RR: 26 cpm CR: 131 bpm

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ASSESSMENT

DIAGNOSIS

PLANNING Short term goal: After 2-4 hours of nursing intervention the client will be able to: Report pain is relieved from 3/5 to 1/5

INTERVENTION

RATIONALE

EVALUATION

Subjective: Acute pain related to medyo masakit po as surgical incision on verbalized by the client. right inguinal

Provide comfort measures , quiet environment, and calm activities Instruct in and encourage use of relaxation techniques Keep the area clean and dry, carefully dress wounds, support incision, prevent infection

Objective: > facial grimace > wong baker scale 3/5 > guarding behavior > irritable > restless > cries at time >V/S as follows: BP: 90/50 mmHg RR: 26 cpm CR: 131 bpm

To promote After 2-4 hours of nonpharmacologic nursing intervention al pain the client was able to: management Report pain is To distract relieved from 3/5 attention and to 1/5 reduce tension To assist natural bodys repair

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ASSESSMENT Subjective: di pa siya masyado makakilos as verbalized by the mother of the patient.

DIAGNOSIS

PLANNING Short term goal:

INTERVENTION

RATIONALE

EVALUATION

Decreased mobilization related to discomforts on operation site

After 3-5 hours of nursing intervention the client will be able to: to move willingly on his own

Provide comfort measures , quiet environment, and calm activities Make yourself available all the time Support and assist the client in doing such activities Keep the area clean and dry, carefully dress wounds, support incision, prevent infection

To promote nonpharmacolo gical pain management To help patient do his activities To help patient do his activities To assist natural bodys repair

After 3-5 hours of nursing intervention the client was able to: to move willingly on his own demonstrate techniques and behaviors that enable safe moving or doing activities

Objective: >irritable >restless >cries at time >V/S as follows: BP: 90/50 mmHg RR: 26 cpm CR: 131 bpm

demonstrate techniques and behaviors that enable safe moving or doing activities

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IX. Health Teaching LEARNING OBJECTIVES After 30-45 minutes of health teaching, the clients mother will be able to:

LEARNING CONTENTS

STRATEGIES

TIME ALLOTMENT

RESOURCES

EVALUATION

a .know what is Indirect Inguinal Hernia

b. know the causes, and risk factor of Indirect Inguinal Hernia

c .know the sign, test and symptoms of Indirect Inguinal Hernia

d. know the possible

A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. Hernias by themselves may be asymptomatic (produce no symptoms) or cause slight to severe pain. Nearly all have a potential risk of having their blood supply cut off (becoming strangulated). When

Interactive discussion

30-45 minutes

Manila Paper- 5.00 Bond Paper-5.00

After 30-45 minutes of health teaching ,the clients mother was able to:

Lecture discussion

Transportation-50.00 Total:60.00

Pamphlet giving Manpower: BSN 3-D, Group 2A a .Gain knowledge about Indirect Inguinal Hernia Materials: Pamphlets and visual aids b. Understand the causes, and risk factor of Indirect Inguinal Hernia

c .Understand the sign, test and symptoms of Indirect Inguinal Hernia

52

treatment to Indirect Inguinal Hernia

the content of the hernia bulges out, the opening it bulges out through can apply enough pressure that blood vessels in the hernia are constricted and therefore the blood supply is cut off. If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply. Different types of abdominal-wall hernias include the following: Inguinal (groin) hernia: Making up 75% of all abdominal-wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two 53

d. Gain knowledge about possible treatment to Indirect Inguinal Hernia

different types, direct and indirect. Both occur in the groin area where the skin of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area. Distinguishing between the direct and indirect hernia, however, is important as a clinical diagnosis. o Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible site for a 54

hernia in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age. o Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in an area where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age. Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and 55

nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the midthigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated. Not all hernias that are irreducible are strangulated (have their blood supply cut off ), but all hernias that are irreducible need to 56

be evaluated by a health-care provider.

Umbilical hernia: These common hernias (10%-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than half an inch), this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain 57

a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are pregnant or who have given birth (due to the added stress on the area).

Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness in which a hernia may develop. This occurs after 2%-10% of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return. Spigelian hernia: This rare hernia occurs along the edge of the rectus abdominus muscle 58

through the spigelian fascia, which is several inches to the side of the middle of the abdomen.

Obturator hernia: This extremely rare abdominal hernia develops mostly in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting. Because of the lack of visible bulging, this hernia is very difficult to diagnose. Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, 59

epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

Hernia Causes:Although abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness.Any condition that increases the pressure of the abdominal cavity 60

may contribute to the formation or worsening of a hernia. Examples include: obesity,heavy lifting,coughing,strai ning during a bowel movement or urination,chronic lung disease and fluid in the abdominal cavity. A family history of hernias can make you more likely to develop a hernia. The signs and symptoms of a hernia can range from noticing a painless lump to the severely painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen (an incarcerated strangulated hernia).Reducible Hernia: It may 61

appear as a new lump in the groin or other abdominal area. It may ache but is not tender when touched. Sometimes pain precedes the discovery of the lump. The lump increases in size when standing or when abdominal pressure is increased (such as coughing). It may be reduced (pushed back into the abdomen) unless very large. Irreducible hernia: It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it. Some may be chronic (occur over a long term) without pain. An irreducible hernia is also known 62

as an incarcerated hernia. t can lead to strangulation (blood supply being cut off to tissue in the hernia). Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting. Strangulated hernia: This is an irreducible hernia in which the entrapped intestine has its blood supply cut off. Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting). The affected person may appear ill with or without fever. This condition is a surgical emergency.

Hernia Diagnosis:If you have an obvious 63

hernia, the doctor may not require any other tests (if you are healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body area with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If you have an inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.

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LEARNING OBJECTIVES After 30-45 minutes of student nurse-client interaction, the patients mother will be able to: - State the uses of pain management.

LEARNING CONTENTS

STRATEGIES

TIME ALLOTMENT

RESOURCES

EVALUATION

- Utilize different nonpharmacological pain management. - Manifest a relief in pain.

Definition of no pharmacological pain management.- Nonpharmacological or natural therapies are things you can do or think about that help decrease your pain. These therapies do not involve taking medicines, but work along with your medicines. People have used "natural" ways to help with pain and healing from the very beginning of time.* The different nonpharmacological pain management.Breathing exercises, Music therapy, Massage, Distraction, Heat and

Interactive discussion

30-45 minutes

Manila Paper- 5.00 Bond Paper-5.00

After 30-45 minutes of student nurse-client interaction, the patients mother was be able to: - State the uses of pain

Lecture discussion

Transportation-50.00 Total:60.00

Return Demonstration Manpower: Pamphlet giving BSN 3-D, Group 2A

management.

- Utilize different nonMaterials: Pamphlets and visual aids pharmacological pain management. - Manifest a relief in pain.

65

Cold, Laughter * How to do deep breathing exercises.

LEARNING OBJECTIVES After 30-45 minutes of student nurse-client interaction, the patients mother will be able to: - State the uses of Tepid sponge bath to relieve fever. - make client manifest signs of relief from hyperthermia

LEARNING CONTENTS

STRATEGIES

TIME ALLOTMENT

RESOURCES

EVALUATION

A tepid sponge bath can reduce fever and stress when performed correctly. Most generally, this type of care is offered in a hospital setting to lower an elevated temperature but can be completed easily at home. "Textbook of Basic Nursing" advises that the bath must be administered for at least 30 minutes to be effective. Constant monitoring of the patient's body

Interactive discussion

30-45 minutes

Manila Paper- 5.00 Bond Paper-5.00

After 30-45 minutes of student nurse-client interaction, the patients mother was be able to: - State the uses of Tepid

Lecture discussion

Transportation-50.00 Total:60.00

Pamphlet giving Manpower: BSN 3-D, Group 2A

sponge bath to relieve fever. - make client manifest

Materials: Pamphlets and visual aids

signs of relief from hyperthermia

66

temperature is essential, so that it does not drop below normal. Preparation Explain to the patient what you will be doing. The bath is ineffective if the patient is nervous or frightened. Record the temperature before beginning the bath. Gather the needed supplies: bath basin, several washcloths, towels and a bath sheet. Fill the bath basin with tepid water, 80 to 90 degrees Fahrenheit. You may need to refill the basin several times throughout the bath, to prevent the water from becoming too cool. Soak four washcloths in the tepid water and 67

wring out the excess. Place one washcloth under each of the patient's arms and one on each side of his groin. The blood vessels are close to the skin in these areas, and this will help to cool the patient more effectively. At first, the patient will be chilled by this; allow several minutes for his body to adjust to the temperature of the water.

Bathing Sponge each of the patient's limbs for five minutes. Keeping the lower half of the patient covered, begin sponging his arms and chest. Work your way to the legs, keeping the patient covered with a towel in the areas you are 68

not bathing. Sponge the back and buttocks for ten minutes. This time is essential to lowering the temperature effectively. Continue to monitor the patient's temperature at intervals throughout the bath procedure. Replace the tepid water if chilled. If at any time the patient becomes chilled and begins shivering, stop the bath.

Discontinue the bath once the temperature has reached a normal level. Cover the patient with the bath sheet.

69

X. Discharge Planning Medication Advise the clients parents that medications should be taken regularly as prescribed, on exact dosage, time, & frequency Report any side effects or adverse effect of the medication

Exercise/Environment Advise the clients caregiver to give the patient some time to heal. For about a week, avoid strenuous activities. He may gradually resume normal activities, such as walking or playing when he is ready.

Treatments Inform clients caregiver to fully participate in continuous treatment. Make sure the patient get plenty of rest when get home for the first 2 or 3 days. Advise the clients parents that they may apply a cold compress to the incision area for 20 minutes at a time for pain for the first few days. Wrap the compress or ice in a towel. Compliance to the medication.

Health Teaching Teach all about the post operation care of herniotomy; how to care of the operation site. Advise the clients parents to take good care of the patients incision and dressings. And will need to keep the incision covered with bandages for the first 2 to 3 days. The parents may wash the area with mild soap and water after the stitches are gone.

70

Out Patient Follow scheduled check-up by the doctor Advise the clients parents to take good care of the patients incision and dressings. Advise the clients caregiver to report any unusual condition of the operation site.

Diet High-fiber diet to prevent straining (pushing) during bowel movements. Raspberries, pears, whole-wheat pasta, cooked barley, beans and broccoli are good sources of fiber. Advise to drink more liquids after surgery.

Spiritual Always believe, pray, trust and have faith to God

Conclusion In our two days of handling and rendering care to our client SAM we gain more knowledge about the indirect inguinal hernia and we are able to identify the potential problems of our client. With the help of health teachings and other interventions, parents of S. we are able to learn how to recognize signs and symptoms and other risk factors of the condition of their son. We are also able to know the necessary interventions to our client after the surgery. They also learned how to do simple interventions for the clients problems. They had also recognized the importance of compliance to treatment regimen in order to manage the condition of their son.

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And at the end of this paper, we the Group 2 of BSN 3D were glad that we acquire the necessary knowledge and important nursing interventions on our chosen case, indirect inguinal hernia. We are honored to do this study and are also hoping that this study will be used as one of a source for the future student nurses in their case studies.

XII. Bibliography http://en.wikipedia.org/wiki/Inguinal_hernia http://prezi.com/ncllii1j-14b/indirect-inguinal-hernia/ http://www.scribd.com/doc/25970590/Case-Hernia http://www.scribd.com/doc/49841652/Final-Case-Study-Hernia-1 http://www.ehow.com/way_5747279_tepid-sponge-bath-procedures.html

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