BULACAN STATE UNIVERSITY
City of Malolos, Bulacan COLLEGE OF NURSING
In Partial Fulfillment of the Requirements in NCM 104 B (RLE)
A Case Study of a 27 year old male, with Incarcerated Inguinal Hernia who underwent Herniorrhaphy Submitted to:
Ms. Kathleen B. Ong R.N Mr. Marvie Cadacio R.N
Mr. Floresco Adaoag R.N Ms. Jesusa Capispisan R.N Submitted by: Group Leader:
FAJARDO, Ma. Janine M. Members:
DELLOSA, Rowena A.
GUTIERREZ, Lenita D.
ENTERESO, Jennica D.
INOCENCIO, Graceline L.
EUGENIO, Oliver B.
ISAGUNDE, Avon Loraine S.P.
GARCIA, Pauline G.
JORE, Edward John JOSE, Grace Anne S.
INTRODUCTION
This is a case study of a 27 year old male with Incarcerated Inguinal Hernia who underwent Herniorrhaphy who was admitted at Bulacan Medical Center, Malolos, Bulacan last, November 17, 2010. A Hernia is a protrusion of an internal organ or part of an organ through a tear, hole or defect in the wall of a body cavity (ie the abdominal wallmuscle). Inguinal Hernia is a condition in which intra-abdominal fat or part of the small intestine bulges through a weak area in the lower abdominal muscle which in this case occurs in the inguinal ring, the opening to the inguinal canal. An Incacerated Inguinal Hernia on the other hand, is a hernia that becomes stuck in the groin or scrotum and cannot be massaged back into the abdomen. Common causes and risk factors of Incarcerated Inguinal Hernia are as follows; lifting heavy objects, obesity, pregnancy, genetic predisposition, and persistent coughing such as smokers cough. Inguinal Hernia happens most often in males than in females. The study of a patient with Incarcerated Inguinal Hernia has been chosen by this group for its significance and connection to us students who are in depth search for knowledge and experience as we study this case, which one of the main focus of a third year level students who are studying Medical Surgical Nursing. The study of its occurrence occurrence,, medical medical and nursing nursing managemen managementt along with the responsibil responsibilities ities,, causation causation and possible possible complicatio complications, ns, advantage advantage and disadvanta disadvantage ge would provide better better understanding on how our responsibilities as soon-to-be nurses should be, by gaining knowledge, skills and learning through hands-on experiences, observation through the use of critical thinking skills and patient centered interaction and assessments. •
Objectives:
GENERAL OBJECTIVE:
2
•
To obtain a comprehensive understanding and learning of the client’s experienced health problem and for us student nurses to perform responsibilities and respond promptly to the needs of the patient for his recovery and promotion of well being. STUDENT CENTERED OBJECTIVES: •
KNOWLEDGE: -To be able to familiarize self about the disease; Incarcerated Inguinal Hernia - To be able to identify the different signs and symptoms of the disease. -To be able to know the possible prevention and proper management of inguinal hernia.
•
SKILLS:
-To be able to apply nursing interventions that can help manage patient’s condition. -To be able to pertain pr oper nursing management to help prevent the occurrence of possible complications. . -To be able to build up skills to augment nursing practice.
•
ATTITUDE:
-To be able to develop an optimistic outlook towards providing holistic care of patient -To be able to provide support during the treatment process -To be able to promote encouragement to the patient 3
CLIENT CENTERED OBJECTIVES: •
To establish therapeutic communication and rapport with the patient for effective patient-nurse interaction all throughout the care providing process.
•
To carry-out proper Nursing Interventions that will promote patient’s comfort and safety.
•
To educate patient regarding his condition, hence be able to provide awareness regarding the management of the disease. NURSING ASSESSMENT
A. Biographic Data
Name: Patient RM Address: San Jose Del Monte, Bulacan Religion: Catholic Age: 27 Sex: Male Race: Asian Marital Status: Single Educational Attainment: High School Graduate
Date of Admission: November 17, 2010;
Occupation: Carpenter
Time of Admission: 5:05PM
B. Chief Complai Complaint: nt:
*“Nahihirapan akong umihi at masakit ang ari ko, nagsuka na din ako kaya dinala na ako sa hospital” as verbalized by the client. C. History of Past Illness For his childhood illnesses, he experienced asthma, mumps and chicken pox. He also said that he was able to complete the immunizations when he is a child. He has an allergy in cement powder, he feels itchy whenever it touches his skin. It was his first time to be hospitalized. As for his asthma, he took herbal medicines as given by his grandmother. 4
D. History of present illness Patient RM was admitted at Bulacan Medical Center at 5:05 PM of November 17, 2010. He said that he had difficulty in urinating and he feel pain in his groin every time he walks He said that this happened after he played basketball last November 16, 2010 from 8 AM to 3 PM having only little time of rest.
E. Family Family History History
According to patient RM both her paternal and maternal family has history of Heart attack and hypertension. His father has complications in gall bladder and liver. His aunt have history of pneumonia. GENOGRAM Paternal Family R 70
C 58
B 55
Maternal Family
L 75
R 53
G 50
L 75
A 48
R 45
Ms 72
A 40
R 58
R 55
L 53
E 50
J 47
Legend - male male
E L 45 42 - Patient - fema female le -Hea -Heart rt Atta Attack ck
- Lung Infection
- Pn Pneumonia
- complication in gall bladder & liver B 29
R 27
C 25
E 21
R 20
R 18
C 16
-
Hype Hypert rten ensi sion on
- dece deceas ased ed 5
FUNCTIONAL HEALTH
Prior to Hospitalization
During
to Hospitalization
PATTERN 1. Health Perception and health Management Pattern
2. Nutritional and Metabolic Pattern
For him, he said that he is a healthy man. He does He rated his health as 3 in the scale of 1-10 in the present exercises and he is also goes to gym. Before because he thecan’t do his regular activities. He stated that there hospitalization, he doesn’t experience any illness and any is also pain that is why he think that he is unhealthy. pain in his body. He think that his sickness happened because of over fatigue. For him, being healthy is having no illness.
November 14 Breakfast:
November 15 Breakfast:
November 16 Breakfast:
1 cup coffee
1 bowl of porridge
None
(230 ml)
1 pc egg
he never ate
Patient RM is in NPO diet during his hospitalization.
1 glass of water 2 glasses of water anything for he 2 cups of rice
continue to
1 pc fried
vomit
galunggong
Lunch:
Lunch:
(medium size)
2 cups rice
½ cup noodles
Lunch:
1 slice of chicken
1 glass water
2 cups of rice
leg part with one
1 slice of pork cup of tinola soup 6
with sinigang
2 glasses of water
soup 2 glasses of
Dinner:
Dinner:
water
None
None
Dinner:
he never ate
he never ate
2 cups of rice
anything for he
anything for he
1 slice of pork continue to vomit
continue to
with sinigang
vomit
soup. 2 glasses of water 3 days prior to admission, patient RM ate regularly with good appetite but since November 15, 2010, he experienced vomiting and he had a poor appetite that is why he can’t eat fully.
3. Elimination Pattern
Urine Color: amber
Stool Color: brown
Urine Color: tea colored
Stool Color: brown
Odor: pungent
Odor: foul smell
Odor: pungent
Odor: foul smell
Frequency: 3-5 times a
Frequency: once a day
Frequency: 3-4 times a day
Frequency: 2 times a week
day
Consistency: semi formed
Amount: 1000ml/ day
Consistency: liquid form
Amount: 1200ml/ day Patient RM also experienced vomiting, he said that he
4. Activity and Exercise Pattern
His urine and stool output had decreased during the time
had vomited 3 times, each vomit is about 200 ml and the
of his hospitalization. His stool formation is in liquid form
content of it depends on the food he ate. _0_ Feeding
and he defecated only twice in one week. _II_ Feeding 7
_0_ Dressing
_II_ Dressing
_0_ Bathing
_II_ Bathing
_0_ Grooming
_II_ Grooming
_0_ Toileting
_II_ Toileting
_0_ Bed Mobility
_II_ Bed Mobility
_0_ General Mobility
_II_ General Mobility
Level 0 - Full Self Care
Level 0 - Full Self Care
Level I - Requires equipment or device
Level I - Requires equipment or device
Level II - Requires assistance or supervision from another Level II - Requires assistance or supervision from another person.
person.
Level III - Requires assistances or supervision from
Level III - Requires assistances or supervision from another
another or device.
or device.
Level IV – is dependent and does participate.
Level IV – is dependent and does participate.
Patient RM is fully independent with all his activities prior During hospitalization, Patient RM’s level of activity had
5. Sleep Rest Pattern
to admission. He is active in playing basketball and he
decreased. He needs an assistant for every activity that he
often goes to gym. Sleep 9PM 8PM 10PM Awake 7AM 8AM 7AM Total 10 hrs 12 hrs. 9hrs. The time of sleep of Patient RM is regular prior to his
does because his body feels weak according to him. According to Patient RM, he can’t sleep inside the hospital,
admission. He is not taking noontime naps.
environmental factors. When he sleep, he wakes up
every time he tries to sleep, he is easily disturbed by the noise inside the ward. He can’t do noontime naps because of the
immediately that is why he feels that his sleep is so fast. He 6. Cognitive Perceptual Pattern
He easily learns things when somebody teaches or lectures
can’t find ways to relax himself. There are no changes in his cognitive pattern during his 8
7. Self Perception Pattern
8. Role Relationship Pattern
him. He can easily express and verbalize his thoughts. For him, he said that he is responsible and industrious.
hospitalization. Patient RM said that he thinks that he doesn’t have a purpose
Even though he is getting annoyed easily, he still performs
right now. He verbalized “nahihiya na ako kasi nahihirapan
the tasks that are assigned to him.
na sa akin yung nanay ko.”
He lives with his mother and siblings. They are a nuclear
During the hospitalization, he depends almost everything to
type of family in their household. His family is not
his mother because of his inability to do things.
dependent to him because he has many other siblings. He usually spends time with his friends, cousin and his playmates in basketball. His work is good for him and his income is just enough for him. With regards to their neighbors, they are in good terms. 9. Sexuality Reproductive Pattern
He has no problems with regards to his sexual relationship.
He doesn’t do any sexual activity during hospitalization.
He is using withdrawal method when doing sexual intercourse and he doesn’t have problems doing it. 10. Coping Stress Tolerance Pattern
When feeling tensed, he relieves himself by saying some
To cope up with stress, Patient RM just talks to his relatives
jokes. He drinks alcoholic beverages sometimes. He talks
that visit him.
to his cousin to open any problem so that he can solve it. For him, having a work is one of the big changes in his life. 11. Value Belief Pattern
For him, family comes first. He is not the kind of person
He always pray to God every time during hospitalization. He
that is very faithful, he just believes but does not attend
said that God gives him the strength inside he hospital.
mass or worships. 9
Growth and Development Stage Definition
Psychosocial Gener ativity VS Stagnation Creativity, productivity, concern
Psychosexual Genital Energy is directed toward sexual
Cognitive Formal-Oper ational Phase Use rational thinking and
Moral Law-and-Order Orientation The person wants established
for others, self indulgence , self maturity and function and
reasoning is deductive and
rules from authorities and the
concerns, lack of interest in
development of skills headed to
futuristic.
reason for decisions and
commitments
cope with environment.
behaviors that social and sexual rules and traditions demand the
Analysis
The client is productive then
He is well mature in the sense
He is moody and uneasy. He
response. He is a moody in then. And
before he is admitted in the
that he works for his family and
shows rational thinking in
more moody now. He abides
hospital. He also works for his
develop skill for his well being.
following Doctors order. And
rules of the doctors for his own
self progress and to give his part
He is not a kind of person that
things that are advised to him
well being. His decisions are
in his family. Now that he is
would be at ease without doing
for his own well being.
based on his own belief.
admitted he feels a bit
something.
unworthiness for he can’t work and his activities are limited due to pain.
ANATOMY AND PHYSIOLOGY GASTROINTESTINAL SYSTEM REPRODUCTIVE SYSTEM
10
The human male reproductive system (or male genital system) consists of a number of sex organs that are a part of the human reproductive process. In the case of men, these sex organs are located outside a man's body, around the pelvic region. The main male sex organs are the penis and the testes which produce semen and sperm, which as part of sexual intercourse fertilize an ovum in a woman's body and the fertilized ovum (zygote) gradually develops into a fetus, which is later born as a child 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. testes are components of both the reproductive system (being gonads) and the endocrine system (being endocrine glands). The respective functions of the testes are producing sperm and producing hormone Testosterone. scrotum (also referred to as the cod or scrot) is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the abdomen, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly pubic hairs at puberty. The spermatic cord is the name given to the cord-like structure in males formed by the ductus deferens and surrounding tissue that run from the abdomen down to each testicle.
The human abdomen (also called the belly) is the part of the body between the pelvis and the thorax. Anatomically, the abdomen stretches from the thorax at the thoracic diaphragm to the pelvis at the pelvic brim. The pelvic brim stretches from the lumbosacral angle (the intervertebral disk between L5 and S1) to the pubic symphysis and is the edge of the pelvic inlet. The space above this inlet and under the thoracic diaphragm is termed the abdominal cavity. The boundary of the abdominal cavity is the abdominal wall in the front and the peritoneal surface at the rear.
PATHOPHYSIOLOGY Modifiable Factor:
- Occupation (Carpenter) - Activity (Basketball) - Previously diagnosed with Inguinal Hernia
Non-Modifiable Factor:
11
Excessive use of abdominal muscles
Increased pressure in the compartment of the abdomen develops
Intra-abdominal wall (containing membranes or muscles) becomes weakened
Relaxation of abdominal wall musculature
Thinning of the fascia
Evolves into a Part of the small intestine pushes through a hole in the abdominal wall, slides through the inguinal
The loop part of the small intestine got trapped in the hernia sac
Bulges through a weak area in the muscles and appear on the right side of the scrotum
12
Compression of the scrotum
Cell damage
Inflammatory response
Redness
Blood vessel near the site of injury are dilated
Increased permeability of capillary
Plasma leak from blood stream into
Insterstitial Filtration
Heat
WBC, enter tissue and begin to engulf bacteria
Inflammation
Swelling of tissue of scrotum
Inflamed tissue reaches nociceptors
Stimulation of pain receptors
13
PAIN
B. Definition of the Disease
Inguinal Hernia - is a condition in which intra-abdominal fat or part of the small intestine, also called the small bowel, bulges through a weak area in the lower
abdominal muscles. It occurs in the groin - the area between the abdomen and thigh. This type of hernia is called inguinal because fat or part of the intestine slides through a weak area at the inguinal ring, the opening to the inguinal canal. An inguinal hernia appears as a bulge on one or both sides of the groin.
C. Modifiable and Non-modifiable Factors
•
Modifiable Factors
Occupation
-If the work requires prolonged standing and lifting of heavy objects, the intra-abdominal wall may become weakened.
•
Non-modifiable Factors
Se x - Inguinal hernia is more common in males than females.
-Approximately 90% of all inguinal hernia repairs are performed on males.
Age
14
-Since abdominal walls weaken as a person ages, inguinal hernia tends to occur in the middle-aged and elderly. -Direct inguinal hernia occurs in older patients as a result of relaxation of abdominal wall musculature and thinning of the fascia.
D. Causes -Prolonged standing, lifting, and straining to have a bowel movement -During uterine development, the testes descend out of the abdomen into the scrotum. These pass out of the abdominal cavity into the inguinal canal via the deep (internal) ring and then into the scrotum via the superficial (external) ring. -Marked obesity -Heavy lifting -Excessive coughing or sneezing -Straining with defecation or urination -Chronic obstructive pulmonary disease (COPD) -Family history of hernias
E. Signs and Symptoms
-A small bulge in one or both sides of the groin that may increase in size and disappear when lying down; in males, it can present as a swollen or enlarged
scrotum
-Discomfort or sharp pain - especially when straining, lifting, or exercising (that is relieved when resting) -A feeling of weakness or pressure in the groin -A burning, gurgling, or aching feeling at the bulge
PHYSICAL ASSESSMENT
BODY PART ASSESSED
TECHNIQUE
NORMAL FINDINGS
ACTUAL FINDINGS
REMARKS
15
A.GENERAL APPEARANCE
1.Body built
INSPECTION
Proportionate
Proportionate: Mesomorph
2.Posture
INSPECTION
Relaxed, erect posture
Can not
stand comfortably
Normal Deviation from normal due to leg injury at the right
3.Dress, grooming, hygiene(odor)
INSPECTION
Clean, neat, no bad odor
Clean, with slight body odor
side of the legs Deviation from normal due
4.Obvious physical deformities
INSPECTION
No deformities :healthy
Not in healthy appearance
to poor hygiene Deviation from normal due
5.Height
INSPECTION
5’5”
6.Weight
INSPECTION
50kg
appearance
to lack of exercise
B. VITAL SIGNS
1.Temperature 2.RR
INSPECTION INSPECTION
36.5-37.5°C 12-20 RPM/CPM
36.2°C 12RPM/CPM
Normal Normal
3.PR/ BP
INSPECTION
60-100BPM/ 120/80mmHg
64BPM/ 100/70mmHg
Normal
INSPECTION
Responsive: responds to
Responsive: responds to
Normal
questions clearly and
questions clearly and
C. MENTAL STATUS
1.Level of consciousness
2. Orientation
INSPECTION
appropriately Cooperative
appropriately Cooperative
Normal
3. Language and Communication
INSPECTION
Understandable; exhibits thought
Understandable; exhibits thought
Normal
association
association
D. SKIN AND NAILS
INSPECTION
1.Examine the expose part
INSPECTION
Convex curvature: smooth
Lesion due to wound cause by
Deviation from normal due
texture, intact epidermis
surgery at hypogastric area
to irritation and obstruction
Highly vascular and pink in
Highly vascular and slightly pale
color, prompt return to pink
in color, prompt return to pink
2. Nails
INSPECTION AND PALPATION
of airway Normal
16
E. HEAD AND FACE 1.Skull condition and proportion
2.Palpate for mass, presence of
INSPECTION
PALPATION
infestation; tenderness and hair conditions 3.Face(symmetry and movements)
INSPECTION
color in 2-3 seconds
color in 2-3 seconds
Normocephalic and
Normocephalic and
symmetrical ;smooth skull
symmetrical ;smooth skull
contour Smooth: uniform consistency;
contour uniform consistency; absence of
absence of nodules or masses
nodules or masses
Symmetrical facial features and
Symmetrical facial features and
movements; palpebral fissures
in equal movement
Normal
Normal
Normal
equal in size F. EYES 1.Eyebrows
2.Eyelids
INSPECTION INSPECTION
Hair evenly distributed: skin
Hair evenly distributed: skin
intact; eyebrow symmetrically
intact; eyebrow symmetrically
aligned: equal movement Skin intact: no discharge; no
aligned: equal movement Symmetric in position
Normal
symmetrically S ymmetric movement
Symmetr ic movement
Normal
INSPECTION AND
Bulbar; transparent; capillaries
Bulbar; transparent; capillaries
Normal
PALPATION
sometimes evident. Palpebral;
sometimes evident. Palpebral;
INSPECTION INSPECTION
shiny: smooth: pink orvred White Black in color; equal in size:’
shiny: smooth: pale in color White Black in color; equal in size:’
round: briskly reactive to light
round: briskly reactive to light
and accommodation
and accommodation
Reaction to light: illuminated
Reaction to light: illuminated
INSPECTION
Normal
discoloration: lids close 4.Eyeballs symmetr ic movement 5.Conjnctiva(bulbar and palpebral)
6.Sclera 7.Pupils
INSPECTION
Normal Normal
17
pupil constricts (direct response):
pupil constricts (direct response):
no illuminated pupil constricts
no illuminated pupil constricts
(consensual response)
(consensual response)
Reaction to accommodation:
Reaction to accommodation
pupils constricts when looking at near objects: pupils converge when object is move toward the 8. Lacrimal apparatus 9. Visual acuity G. EARS 1.auricles
INSPECTION AND PALPATION INSPECTION
nose. Peripheral vision is intact No edema or tearing
No
Able to read news print
Able to read news print
Normal
Color same as facial skin:
Color same as facial skin:
Normal
symmetrical: aligned with the
symmetrical aligned with the
edema or tearing
Normal
2.Pinna
PALPATION
lower cantus of the eye lower cantus of the eye Mobile: firm: pinna recoils after Mobile: firm: pinna recoils after
Normal
3.External Canal 4.Heaing Acuity 5.Septum 6.Muccus membrane 7. Patency
INSPECTION INSPECTION INSPECTION INSPECTION PALPATION
it is folded No discharge Normal voice tone audible Intact and In midline Pinkish Air moves freely in and out of
it is folded No discharge; dry cerumen Normal voice tone audible Intact and In midline Pinkish Air moves freely in and out of
Normal Normal Normal Normal Normal
8. nasal cavity 9.Siuses H. MOUTH 1.Lips
INSPECTION PALPATION
the nasal cavities No obstructions Not tender
the nasal cavities No obstructions Not tender
Normal Normal
INSPECTION
Uniform pink color: moist: Uniform brownish in color:
smooth texture: symmetry of
moist: smooth texture: symmetry
contour
of contour
Normal
18
2. Mucosa
INSPECTION AND
Uniform pink color
Uniform pink color
Normal
3.Tongue
PALPATION INSPECTION AND
Central position: pink color,
Central position: pink color,
Normal
PALPATION
moves freely: no tenderness
moves freely: no tenderness
4. Teeth
INSPECTION
32 permanent teeth, smooth,
2 permanent teeth with tooth
Deviation from normal due
5. Gums
INSPECTION AND
shiny white tooth enamel Pink gums, moist firm texture
decay Pink gums, moist firm texture
to poor oral hygiene Normal
Midline Pinkish Pink ad smooth: no discharge Present
Midline Pinkish Pink and smooth: no discharge Present
Normal Normal Normal Normal
Coordinated: smooth movement
Coordinated: smooth movement
Normal
PALPATION I.PHARYNX 1.Uvula 2.Mucosa 3.Tonsils 4.Gag reflex J. Neck 1.Muscle str ength
INSPECTION INSPECTION INSPECTION INSPECTION INSP ECTI ON AND RANGE OF
2.Trachea
MOTION INSPECTION AND
with no discomfort with no discomfort Central placement in midline of Central placement in midline of
Normal
3.Palpate Thyroid
PALPATION INSPECTION AND
the neck Lobes are not palpable
the neck Lobes are not palpable
Normal
Breast are round and generally
Even with the chest wall,
Normal
symmetric: no tenderness,
generally symmetric: no
PALPATION K.BREAST AND AXILLA 1.Breast symmetry and contour
INSPECTION
2.Skin characteristics
INSPECTION AND
masses and lesions Skin uniform in color; skin
tenderness, masses and lesions Skin uniform in color; skin
Normal
3.Nipple condition and presence of
PALPATION INSPECTION AND
smooth and intact Bilaterally round and dark brown
smooth and intact Bilaterally round and dark brown
Normal
in color: no presence of
in color
discharge
PALPATION
19
discharge L. CHEST AND LUNGS 1.Shape and configuration
INSPECTION
Anteroposterior to transverse
Spine is vertically aligned
Normal
diameter ratio of 1:2; Spine is vertically aligned 2. Lung expansion
PALPATION
Full and symmetric chest
Full and symmetric chest
Normal
3. Fremitus
PALPATION
expansion Bilateral symmetry of vocal
expansion Bilateral symmetry of vocal
Normal
fremitus Quiet, rhythmic, effortless Vesicular and bronchovesicular Less than 90
fremitus Normal in breathing pattern Normal in breath sound Less than 90
Normal Normal Normal
INSPECTION AND
No Pulsation
No Pulsation
Normal
b. Tricuspid
PALPATION INSPECTION AND
No Pulsation; no lifts or heaves
No Pulsation; no lifts or heaves
Normal
c. Apical
PALPATION INSPECTION AND
Palpation visible in 50% of adult
No lift or heave
Normal
4.Breathing pattern 5. Breath sound 6. Costal angle
INSPECTION AUSCULTATION INSPECTION AND PALPATION
M. CARDIOVASCULAR 1.Precordium a. Aortic and pulmonic
PALPATION
and palpable I most PMI in 5
th
LICS at or medial to MCL: No d. Epigastric
INSPECTION AND
lift or heave Aortic pulsations
Aortic pulsations
Normal
e. Auscultating the heart
PALPATION AUSCULTATION
S1: usually heard at all sides.
S2: usually heart at all sites,
Normal
Usually louder at apical area
louder at the base of the heart
areas above
S2: usually heart at all sites, 20
louder at the base of the heart S3: in children and young adults 2. Carotid artery
PALPATION
AND
AUSCULTATION
S4: older adults Symmetric pulse volume, full
Symmetric pulse volume,
pulsations: thrusting quality
thrusting quality remain same
remain same when client breaths,
when client breaths
Normal
turns head and changes from sitting to supine position: elastic 3. Jugular vein N. ABDOMEN 1.Skin condition
2.Contour and symmetry
INSPECTION
arterial wall Veins not visible
Veins not visible
INSPECTION
Uniform in color
Not uniform in color cause by
Deviation from normal due
surgery
to irritation and obstruction
Not symmetry in contour
of airway Deviation from nor mal due
INSPECTION
Symmetric contour
Normal
to irritation and obstruction 3.Abdominal bowel sounds 4. Presence of muscle guarding,
AUSCULTATION INSPECTION AND
extension and rebound tenderness
PALPATION
Audible bowel sounds No Tenderness
Audible bowel sounds Presence of tenderness
of airway Normal Deviation from normal due to leg injury at the right side of the legs.
O. UPPER AND LOWER EXTREMETIES 1.Motor strength
INSPECTION
Equal strength on each body side
unilaterally weak
Deviation from normal due to leg injury at the right
2.Muscle tone 3.Presence of lesions, deformities
PALPATION INSPECTION
Normally firm No lesions; no deformities: no
Normally firm Presence of lesions, no
side of the legs. Normal Deviation from normal due 21
and varicosities
tenderness
deformities, no varicosities
to irritation
LABORATARY RESULTS:
LABORATORY
DATE ORDERED/
INDICATION/
PROCEDURE
DATE RESULT IN
PURPOSES
Urinalysis
Date ordered:
ACTUAL VALUES
NORMAL VALUES
ANALYSIS/
NURSING
INTERPRETATION
RESPONSIBILITIES (prior, during, after) PRIOR:
To obtain and
Color: Amber
Color: Amber
Normal
11/17/10
provide the
Characteristics:
Characteristics:
Normal
11:59 pm
practitioner
Turbid
Turbid
Date result:
with
Specific Gravity:
Specific Gravity:
11/18/10
information to
1.020
1.010-1.025
evaluate the
Reaction: Acidic
Reaction: Acidic
Normal
tract disease and
client’s health
Sugar: none
Sugar: none
Normal
helps evaluate
status through
Albumin: -
Albumin: -
Normal
overall body
urine
Pus: 15.20/hpr
Pus: -
examination.
RBC: 3-5/hpf
RBC: 0-2/hpf
Epithelial cells: few
Epithelial cells:
Bacteria: few
Bacteria: none
Positive, it indicates
does not need to
Crystals: few
Crystals: none
that there is infection.
restrict food or
Normal
fluids.
Creatinine: 134.8
Creatinine: 90-139
mmol/L
mmol/L
Explain that this test aids in tha
Normal
diagnosis of renal or urinary
function.
Inform the patient that he
Notify the laboratory practitioner of medications the 22
patient is taking that may affect test results; these medications can be restricted.
Explain how to collect a cleancatch specimen.
DURING:
Confirm the patient’s identity using two patient identifiers according to facility policy.
Collect a random cleancatch urine specimen of at least 15ml.
Obtain a first23
voided morning specimen if possible. AFTER:
Tell the patient to resume his usual diet and medications stopped before the test, as ordered.
Check for the color and characteristics of the urine.
Hematology
Date ordered:
It is a test used
WBC: 12.4 x 10 9/L
WBC: 5.0-10.0 x 10
Increased due to
9/L
infection and
Document all
findings. PRIOR:
11/20/10
to measure
4:52pm
analyte and to
inflammation of small
consent for
determine the
intestine.
management is
Normal
signed and
Date result:
blood type and
11/21/10
compatibity on across
RBC: 4.17 x 10 12/L
RBC: 3.80-5.80 x 10
12/L HGB: 138 g/L
matching for HCT: .423
Ensure that the
approved.
HGB: 110-165 g/L
Normal
HCT: .350-.500
Normal
Check for the ID band to 24
blood
PLT: 260 x 10 g/L
PLT: 150-390
Normal
determine the
transfusion
PCT: 189 x 10 21/L
PCT: 100-500
Normal
proper client to
purposes.
MCV: 85
MCV: 80-97
Normal
be examine.
MCH: 27.7 pg
MCH: 36.5-33.5
Normal
MCHc: 326 g/L
MCHc: 315-350
Normal
order of the
RDn: 14.9 %
RDn: 10.0-15.0
Normal
doctor.
MPV: 7.3 fL
MPV: 6.5-11.0
Normal
PDn: 15.1 %
PDn: 10.0-18.0
Normal
Check for the
Explain that hematocrit and RBC indices are tested to detect
11/20/10
WBC
anemia and other abnormal
%LYM: 8.6 L%
%LYM: 17.0-48.0
Decreased due to
blood
underlying viral
conditions.
infection which is
%MON: 42%
%MON: 4.0-10.0
Explain that the
infection with
red blood cell
"opportunistic"
count is used to
pathogens.
evaluate the
Increased due to tissue
number of RBC
injury and acute
and to detect
infection.
possible blood disorder.
%GRA: 87.2%
%GRA: 43.0-76.0
Increased
#LYM: 1.01 x 10 9/L
#LYM: 1.2-3.2
Normal
Explain that the white blood cell
#MON: 0.5 x 10 9/L
25
#GRA: 10.9 x 10 9/L
#MON: 0.3-0.8
Normal
count test id
#GRA: 1.2-6.8
Increased
used to detect an infection or inflammation. DURING:
Confirm the patient’s identity using two patient identifiers according to facility policy.
Perform a fingerstick using a heparinized capillary tube with a red band on the anticoagulant end.
Fill the capillary tube from redbanded end to about two-thirds 26
capacity; seal this end with clay. AFTER:
Make sure that the subdermal bleeding has stopped before removing pressure.
Instruct the patient that he may resume his usual diet, activity, and medications discontinued before the test as ordered. (WBC)
Document the findings.
Report to the physician the possible 27
abnormal values Electrolyte Result
11/23/10
that have seen. PRIOR:
To measure
the concentration
of the physician.
of sodium, K,
calcium,
Ensure the client’s identity.
chloride,
DURING:
magnesium
Check the order
Collect a
and
specimen to
phosphate.
determine the
It provides
electrolyte
cellular reaction.
balance. Analyte
Na 135.9 mmol/L
AFTER:
135-148 mmol/L
Normal
K 3.95 mmol/L 3.5-5.3 mmol/L
Normal
Ca - mmol/L
Increased due to stone
1.1-1.32 mmol/L
actual findings.
formation Cl 95.7 mmol/L 96-107 mmol/L
Check for the
Measure the concentration of
Normal
the Na, K, Ca, Cl.
Increased fluid intake and replacement of lost electrolytes are usually 28
sufficient to restore fluid balance in patients who are mildly or moderately dehydrated..
Adults may replace lost electrolytes by drinking sports beverages, such as Gatorade or Recharge.
PATIENT AND HIS CARE A. Medical Management
29
Medical
Date ordered/Date
Management
performed/Date
Treatment
change
Client’s General Description
Indications/Purposes
Response to
Nursing Responsibilities
the treatment
Intravenous fluid
Date Ordered-
-Hypertonic solution
Is a sterile, non pyrogenic solution
The client skin
of D5LR 1000cc
11/17/10
-Dextrose 5% in Lactated
for fluid and electrolyte
became moist.
Ringers is indicated as a
replenishment in a single dose
-ensure that consent for management is
Date performed-
source of water,
container for intravenous
signed and approved
11/17/10
electrolytes and calories
administration.
regulated @ 25gtts/min,
or as an alkalinizing Date Change-
PRIOR:
-gather all the necessary supplies before you begin
agent.
11/18/10 - Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, Date Ordered11/21/10
the bag is not leaking, and the bag is not expired
Date performed11/21/10
- Select either a mini or macro drip administration set and uncoil the tubing. Do
Date Change11/22/10
not let the ends of the tubing become contaminated. DURING:
Date Ordered-
-Ensure that right drops are given
11/22/10
Date performed-
- ensure that all medications inserted in the 30
B.DRUG STUDY Generic Name/
Date Ordered,
Brand name
Given/ Date
Route of
General Action
Indication/Purpose
Nursing
Administration,
Side Effects
responsibilities
GN: Cefuroxime
Changed Nov. 18. 2010
dosage, frequency Route: TIV
Cefuroxime is a well
Lower Respiratory
PRIOR:
Sodium
4am-12nn-8pm
Dosage: 750 mg
characterized and
tract infection due to S.
•
Check doctors order.
Frequency: q 8 hours
effective antibacterial
pneumoniae, H.
•
Perform ANST prior Abdominal Pain
Nov.19,2010
agent which has
Influenzae (including
to administering
4am
bactericidal activity
ampicillin resistant),
drugs.
against a wide range
Klebsiella species, S.
of common
aureus, S. pyrogenes
hypersensitivity
pathogens, including
and E. coli
reactions to
BN: Zinacef
•
Diarrhea / Loose stools, N/V,
Determine history of
β-lactamase
cephalosporins,
producing strains.
penicillins and history of allergies particularly to drugs before therapy is initiated. DURING: •
Be alert for adverse reactions and drug interaction. AFTER:
•
Inform the patient 31
about the possible side effects of the GN: Ketorolac
Nov.19,2010 st
1 dose 8am BN: Toradol
Possess anti-
Short term
Dosage: 30 mg
inflammatory
management of pain
•
Frequency: q 6 hours
analgesic and
(not to exceed 5 days
(note type, location,
antipyretic effects
total for all routes
and intensity) prior
indicates as a single
combined)
to and 1-2 hr
Nov.21, 2010 nd
2 dose 8:30am
drugs. PRIOR:
Route: TIV
X3 more dose
Assess pain
or multiple dose
following
Nov.22,2010
regimen on a regular
administration.
12 nn
or as needed schedule
•
Headache,Dizziness, drowsiness, diarrhea, Nausea, dyspepsia
Caution patient
for the management
to avoid concurrent
of moderately severe
use of alcohol,
acute pain that
aspirin, NSAIDs,
requires analgesia at
acetaminophen, or
the opioid level,
other OTC
ussually in a
medications without
postoperative setting.
consulting health care professional. •
Advise patient
to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black 32
stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. DURING: Be alert for
•
adverse reaction of the drug. AFTER: Inform the
•
patient about the possible side effects of the drugs. Advise patient
•
to report any discomfort on the IV GN: Ranitidine
insertion site. PRIOR:
Nov.19,2010
Route: TIV
Completing inhibits
Perioperative to
8am
Dosage: 50 mg
gatric acid secretion
suppress acid
Frequency: q 8 hours
by blocking the effect
secretion,prevent stress
for epigastric or
hallucinations,
of histamine on
ulcers & prevent
abdominal pain and
headache,
histamine H2
aspiration
frank or occult blood
Arrhythmias, Altered
receptors. Both
pneumonitisin
in the stool, emesis, or taste, black tongue,
BN: Zantac Nov.20, 2010 4am-8pm
While NPO
•
Assess patient
Confusion, dizziness, drowsiness,
33
Nov.21, 2010
daytime & nocturnal
combination with H1
gastric aspirate.
12nn-8pm
basal gastric acid
histamine antagonist to
secretion, as well as
treat certain types of
that it may cause
induced hepatitis,
Nov.22,2010
food & pentagastrin
urticaria & as
drowsiness or
nausea
12nn-8pm
stimulated gastric acid
prophylaxis to reduce
dizziness.
are inhibited.
the incidence of
•
•
Inform patient
constipation, dark stools, diarrhea, drug-
Inform patient
Nov.23,2010
NSAID – induced
that increased fluid
4am-12nn
duodenal ulcers.
and fiber intake may minimize
Nov.24,2010
constipation.
8pm
DURING: •
Advise patient
to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly. AFTER: •
Inform patient
that medication may temporarily cause 34
stools and tongue to appear gray black. PRIOR:
GN: Ceftriaxone
Nov.19,2010
Route: TIV
Ceftriaxone usually is
Lower respiratory tract
Sodium
12nn-8pm
Dosage: 1 g
bactericidal in action.
infections due to
•
Frequency: q 8 hours
Like other
Streptococcus
doctors order.
Nov.20, 2010
cephalosporins, the
pneumoniae,
•
4am-12nn-8pm
antibacterial activity
staphylococcus aureus,
ANST prior to
of the drug results
Haemophilus
administering
Nov.21, 2010
from inhibition of
influenzae, Klaebsiella
drugs.
4am-12nn-8pm
mucopeptide
pneumoniae and E.coli
BN: Rocephin
Nov.22,2010 12nn-8pm
•
Check the
Diarrhea, nausea, rashes, electrolyte disturbances and pain
Perform
Assess
synthesis in the
patient’s
bacterial cell wall.
underlying condition before starting
Nov.23,2010
therapy.
4am-12nn
DURING: •
Be alert
Nov.24,2010
for adverse
12nn-8pm
reaction & drug interaction. AFTER: •
Inform the
patient about the possible side effects of 35
GN: Metronidazole
the drug. PRIOR:
Nov.18.2010
Route: TIV
Hinders growth of
Indicated in the
4am-12nn-8pm
Dosage: 500 mg
Several organisms,
treatment of serious
•
Frequency: q 8 hours
including most
infectious caused by
infection before
pain, anorexia,
Nov.19,2010
anaerobic bacteria and
susceptible anaerobic
starting therapy &
nausea, diarrhea, dry
4am-12nn-8pm
protozoa.
bacteria.
regularly thereafter mouth, furry tongue,
BN: Flagyl
Assess patient’s
seizures, dizziness, headache, abdominal
to monitor drug’s
glossitis, unpleasant
Nov.20, 2010
effectiveness.
taste, vomiting
12nn-8pm
•
Inform patient
that medication may Nov.21, 2010
cause an unpleasant
4am-12nn
metallic taste. DURING:
Nov.22,2010 12nn-8pm
•
Be alert for
adverse reaction & drug interaction..
Nov.23,2010 4am-12nn
•
IV infusion
may cause thrombophlebitis at
Nov.24,2010 12nn-8pm
site, observe closely. AFTER: •
Monitor
neurologic status during and after IV infusions. 36
•
Inform patient
that medication may cause dark urine.
C. Diet Type of Diet
NPO (Nothing per orem)
Date started/Date Changed
Date Started: 11/17/10 Date Changed: 11/24/10
General description
Is a medical instruction meaning to
Indication/Purposes
prevention of aspiration pneumonia
Specific foods taken
NONE
Client responses to the diet
The patient’s SO
Nursing Responsibilities PRIOR:
complied with the
-explain to the patient
withhold oral
ordered diet of
what NPO is.
food and fluids
the patient.
for a certain period of time for
-ensure that an IV
various reasons, like
fluid is to be inserted
to avoid aspiration in
to replace the loss of
unconscious
water and food
preoperative and preprocedural clients who will receive
DURING: -Assess the patient
anesthesia or 37
condition.
conscious sedation.
AFTER: -Monitor V/S of the patient.
Generalized liquid diet
Date Started: 11/24/10 Date Changed: 11/25/10
Plain water
Increased hydration.
PRIOR:
A liquid diet helps
A liquid diet is often
maintain adequate
used before tests,
-explain to the patient
hydration, provides
procedures or surgeries
what generalized
some important
that require no food in
liquid diet is.
electrolytes, such as
your stomach or
sodium and
intestines
DURING:
potassium, and gives
-discuss to him the
some energy at a time
right fluid he
when a full diet isn't
mustacquire.
possible or
AFTER:
recommended -monitor clients diet. -monitor client’s response to the diet. -monitor I&O. D. Activityu/Exercise
38
Type of Exercise
Date ordered/ Date
General Description
Indication/Purposes
change
Ambulation
Date ordered11/20/10
Client’s Response to the exercise
Changing position in bed,
Promote good blood
walking and prescribed
circulation.
exercise promotes Date change-
Nursing Responsibilities
circulation.
PRIOR: -explain to the benefits of early ambulation to the patient.
DURING: -Observe and assess patient. AFTER: Monitor his condition.
•
Surgical Management
A. Brief description Inguinal hernia repair, also known as herniorrhaphy, is the surgical correction of an inguinal hernia. An inguinal hernia is an opening, weakness, or bulge in the lining tissue (peritoneum) of the abdominal wall in the groin area between the abdomen and the thigh. The surgery may be a standard open procedure through an incision large enough to access the hernia or a laparoscopic procedure performed through tiny incisions, using an instrument with a camera attached (laparoscope) and a video monitor to guide the repair. When the surgery involves reinforcing the weakened area with steel mesh, the repair is called hernioplasty. 39
Purpose Inguinal hernia repair is performed to close or mend the weakened abdominal wall of an inquinal hernia
Date Ordered : November 17, 2010 05:30pm Date Performed : November 18, 2010 12:00am
B. Patient’s response to operation
Prior to operation: The client is aware of the operation and not afraid of it. During the Operation: The client is unconscious during the operation as a result of the anesthetics given to him. After the Operation: The client is weak in appearance; conscious and coherent; febrile. Exhibits guarding behavior.
C. Nursing Responsibilities 40
Prior to Operation:
Monitor V/S
Secure consent for Mash Herniorraphy
Remove all accessories of the client
Maintain on NPO status
Consume IVF as instructed for hydration
Change clothing to operating gown
Relieve patient’s anxiety by explaining the procedure
Prepare all surgical materials needed
During the Operation:
Check V/S
Assess level of consciousness
Check patient’s chart for o
Consent form
o
IVF order
Counting of all the instruments
Site for incision preparation
Notify surgeon that patient is ready
Assist surgeon 41
Count all the materials used
Document the procedure done
After the Operation:
Maintain patient flat on bed
Monitor V/S every 15 minutes for 2 hours until stable then every 1 hour
Check doctor’s post-op orders and adjust IVF accordingly
Post-op meds given
With NGT intact for decompression
Emphasize NPO
Monitor I/O
NURSING PROBLEM PRIORITIZATION
NUMBER
PROBLEM/NURSING DIAGNOSIS
JUSTIFCATION
1
Acute Pain
Using ABCD’s of life as pain is represented by the pain should be at high priority in this case. Pain is highly subjective and presence of this can affect many facets of a person’s functioning
42
2
Impaired Tissue integrity
Using Maslow’s Hierarchy of Needs, to maintain tissue integrity is one of the physiologic needs of an individual, further more this is an actual problem and should be given priority.
3
Risk for infection
Since this is a potential problem it should be prioritize next to the actual problem. Risk f or infection belongs to the second level of Maslow’s Hierarchy of Needs which is safety and security
NURSING CARE PLAN •
ACUTE PAIN
43
CUES
NURSING DIAGNOSIS
SCIENTIFIC KNOWLEDGE
SUBJECTIVE:
Acute pain related
“Sobrang sakit
to actual tissue
Herniorraphy ( mechanical trauma/tissue injury)
nang tahi ko” as
damage
verbalized by the
secondary to
patient.
presence of surgical incision
OBJECTIVE: •
at the RLQ of the 27
year old male •
Post
abdomen
PLANNING
Long Term Goal: •
After 30 minutes of
INTERVENTION
INDEPENDENT:
Sensitizations of nociceptors
Note location of
•
•
GOAL MET:
The patient was able
the amount of pain
to report reduction of
the client will be
experienced presence
pain from pain scale
able to report
of known/ unknown
of 9/10 it was reduce
reduction of pain
complications may
to 7/10
•
surgical procedures
from pain scale of Release of substance P ( neurotransmitter 9/10 it will be that assist in transmission of reduced to 7/10 impulses across the synapse) Short Term Goal:
- mash
EVALUATION
As this can influence
•
nursing intervention Release of Biochemical mediators
RATIONALE
After 15 minutes of
wake the pain more severe than anticipated
•
Note when pain occurs
•
To medicate
A-delta fibers Herniorraphy •
Pai
Transmit signals to thalamus
Faci
Somatic sensory cortex
Gua
rding behavior •
Irrit
prpphylactically as
the client will be
every evening)
appropriate
pharmacological
al grimace •
(e.g. only ambulation
able to identify non-
n scale of 9/10 •
nursing intervention
Pain perception •
•
Provide comfort
•
To promote non-
methods that provide
measures (assist in
pharmacological pain
relief from pain.
position changes,
management
After 15 minutes of
nurse’s presence, quite
nursing intervention
and calm activities)
44
IMPAIRED TISSUE INTEGRITY
•
CUES
NURSING DIAGNOSIS
SUBJECTIVE:
Impaired Tissue
“Sobrang sakit nang
Integrity related to
tahi ko” as
surgical incision at
verbalized by the
RLQ of the abdomen
SCIENTIFIC KNOWLEDGE
Occurrence of inguinal Hernia
PLANNING
Long Term Goal: •
Need for intentional trauma (surgery)
intervention the
•
Post-
Impaired Tissue integrity
mash
•
Cont
Reference: Fundamental of Nursing, 7th Edition, Kozier
( location size)
comparative
display progressive
Inspect wound daily for
baseline
improvement in
changes
wound healing and
For
Promotes
The client was able to
complication to occur
will prevent
occur.
RLQ of the
interventions/
wound healing and
Short Term Goal: •
Assess surgical wound
progressive
movements
ical incision at
GOAL MET:
prevented
complication to
Surg
•
timely
rolled
•
•
EVLUATION
to display
improvement in
Herniorraphy
•
client will be able
OBJECTIVE:
RATIONALE
INDEPENDENT;
nursing
Incision at RLQ of the abdomen
patient.
After 48 hours
INTERVENTION
•
Change wound dressing
revision of plan
aseptically
of care
Keep the wound
dry and clean
further
Cleanse the area
complication
To prevent
of wound gently
After series of
with the use of
nursing
required 45
abdomen.
intervention the
solutions
client will be able
to:
Cover with sterile gauze
Identify
•
Provide optimum
appropriate
nutrition including
interventions
Vitamin C. and increase
that promotes
protein intake
wound healing
Demon
strate behaviors
Provide
positive nitrogen •
Encourage adequate rest
balance to aid in
periods
tissue healing
and interventions
that facilitates
fatigue/ limit
healing
metabolic
demands and
Identify
maximize energy
situations (fever, for more than 24 hours)
To prevent
DEPENDENT:
Provide
available for healing.
46
that suggest
appropriate and healing
referral to
devices (splints)
physician to
prevent serious
the surgical
complications
incision from skin
to occur
and tissue
To support
breakdown.
•
RISK FOR INFECTION CUES
NURSING DIAGNOSIS
SUBJECTIVE:
Risk for infection to
No cues
actual tissue damage
OBJECTIVE:
secondary to
Surgical incisions at @RLQ Post Mash Herniorrhap hy
SCIENTIC KNOWLEDGE
Occurrence of inguinal Hernia
Long Term Goal: •
Need for intentional trauma (surgery)
presence of surgical incision at RLQ
PLANNING
Incision at RLQ of the abdomen
The client will
INTERVENTION
RATIONALE
INDEPENDENT:
EVALUATION
•
GOAL MET:
Assess surgical incision
The client remained
remain free of any
for localized sign of
free of any symptoms
symptoms of
infection
of infection after 24
•
Change surgical wound
hours of nursing
dressing as indicated
the spread of
intervention
using aseptic technique.
microorganisms
infection after 24
•
To prevent
hours of nursing intervention.
Skin is not intact
Risk for infection 47
Short Term Goal: •
Reference: Fundamentals of Nursing 7th edition, Kozier
•
The client will
Keep wound clean and
dry
promotes
able to identify methods that will
microbial growth Remove and replace
be useful in
dressing if it is already
bacterial
reducing the risk
soak
colonization
Encourage position
infection after 8
changes and deep
blood circulation
hours of nursing
breathing exercise
and prevent
of acquiring
•
As moisture
•
•
To reduce
To aid in
intervention
further
The client will be
respiratory
able to
DEPENDENT:
demonstrate
•
infection
Administer and monitor
techniques that
medication regimen and
will be useful in
note client’s response
its effectiveness
To determine
the prevention of
and presence of
infection after 8
untoward side
hours of nursing
effects. 48
intervention •
After 8 hours of nursing intervention the client will be able to verbalized understanding of individual risk factors that will prevent him in acquiring infection
DISCHARGE PLANNING
MEDICATIONS •
•
Medications prescribed by the physician include:
Cefuroxime 500mg BID
Mefenamic Acid 250mg PRN for pain
Instruct the client to take the antibiotic for 7-14 days as prescribed.
49
•
Patient was advised to continue home medications to maintain a normal functioning of the body and to maintain homeostasis.
•
The treatment regimen ordered by the physician must be followed strictly and should not be stopped to prevent aggravation of the condition.
EXCERCISE •
Instruct patient to do active r ange of motion (R.O.M.) to restore normal body functions.
•
Advise the patient to do light exercise, such as walking to limit fatigue.
TREATMENT •
Instruct patient to follow the health teaching provided by the health educator, including all medications for faster recovery.
HEALTH TEACHING •
Avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining) that may cause the hernia to increase in size
•
Attention to rest, within 3 months after surgery to avoid vigorous activity and avoid heavy physical labor.
•
Emphasize proper daily wound cleaning.
•
Emphasize proper hand hygiene.
OUTPATIENT FOLLOW-UP CARE •
Instruct the patient to seek or return after a week at Bulacan Medical Center- Out-Patient Department. 50
•
Getting adequate rest during the client’s first week at home will do r each to prevent the possibility of this complication.
DIET •
Advise the patient to maintain g general liquid diet as ordered by the physician.
•
Instruct patient to have proper diet especially foods rich in Vitamin (Citrus fruits; orange), protein for faster wound healing.
•
Maintain adequate hydration.
SPIRITUAL •
Seek God’s help and guidance by means of praying and holding their faith to our Almighty God. CONCLUSION
In this case study Incarcerated Inguinal Hernia was given more understanding by proponents. It has been noted that incarcerated inguinal hernia is the protrusion of a tissue through the wall of the cavity in which it is normally contained, and a serious complications from a hernia result from the trapping of tissues in the hernia -- a process called incarceration. Trapped tissues may have their blood supply cut off, leading to damage or death of the tissue which the nurse should monitor and watch-out for. By this, early detection of the illness seemed necessary for it can prevent complications or even death. The case study has enabled us to obtain comprehensive learning, and help us in identifying and understanding the possible problems that compromise the health of the patient, fortunate nursing care interventions was developed the physical, mental and emotional well-being of the patient. Its goal has been met through objectives that have been specially focused on both the client and student’s welfare. We acquired and enhanced our knowledge about the disease, the factors that contribute to the development of the client’s condition. Build trust and gained respect among the nurses and was able to deepen information about his condition. Met the needs of the client in the best way possible, either physically, mentally, socially, spiritually and emotionally . BIBLIOGRAPHY
51
