A hernia is a protrusion or projection of an organ or organ part through the wall of the cavity that normally contains it. An inguinal hernia occurs when either the omentum, the large or small intestine, or the bladder protrudes into the inguinal canal. In an indirect inguinal hernia, the sac protrudes through the internal inguinal ring into the inguinal canal and, in males, may descend into the scrotum. In a direct inguinal hernia, the hernial sac projects through a weakness in the abdominal wall in the area of the rectus abdominal muscle and inguinal ligament. Inguinal hernias make up approximately 80% of all hernias. Repair of this defect is the most frequently performed procedure by both pediatric and adult surgeons. Hernias are classified into three types: reducible, which can be easily manipulated back into place manually; irreducible or incarcerated, which cannot usually be reduced manually because adhesions form in the hernial sac; and strangulated, in which part of the herniated intestine becomes twisted or edematous, possibly resulting in intestinal obstruction and necrosis.
An inguinal hernia is the result of either a congenital weakening of the abdominal wall (when the processus vaginalis fails to atrophy and close) or weakened abdominal muscles because of pregnancy, excess weight, or previous abdominal surgeries. In addition, if intra-abdominal pressure builds up, such as related to heavy lifting or straining to defecate, a hernia may occur. Other causes include aging and trauma.
Nursing care plan assessment and physical examination
An infant or a child may be relatively symptom-free until she or he cries, coughs, or strains to defecate, at which time the parents note painless swelling in the inguinal area. The adult patient may complain of pain or note bruising in the area after a period of exercise. More commonly, the patient complains of a slight bulge along the inguinal area, which is especially apparent when the patient coughs or strains. The swelling may subside on its own when the patient assumes a recumbent position or if slight manual pressure is applied externally to the area. Some patients describe a steady, aching pain, which worsens with tension and improves with hernia reduction.
On inspection, the patient has a visible swelling or bulge when asked to cough or bear down. If the hernia disappears when the patient lies down, the hernia is usually reducible. In addition, have the patient perform a Valsalva’s maneuver to inspect the hernia’s size. Before palpation, auscultate the patient’s bowel; absent bowel sounds suggests incarceration or strangulation. You may be able to palpate a slight bulge or mass during this time and when the examiner slides the little finger 4 to 5 cm into the external canal that is located at the base of the scrotum. If you feel pressure against your fingertip when you have the patient cough, an indirect hernia may exist; if you feel pressure against the side of your finger, a direct hernia may exist. Palpate the scrotum to determine if either a hydrocele or cryptorchidism (undescended testes) is present.
A delay in seeking healthcare may result in strangulation of the intestines and require emergency surgery. In the adult population, surgical intervention to correct the defect takes the patient away from home and the work setting and causes anxiety.
Nursing care plan primary nursing diagnosis: Pain related to swelling and pressure.
Nursing care plan intervention and treatment plan
If the patient has a reducible hernia, the protrusion may be moved back into place and a truss for temporary relief can be applied. A truss is a thick pad with an attached belt that is placed over the hernia to keep it in place. Although a truss is palliative rather than curative, it can be used successfully in elderly or debilitated adult patients who are poor surgical risks or who do not
desire surgery. Collaboration with the surgical team is necessary to prepare the patient and family for surgery. If the hernia is incarcerated, manual reduction may be attempted by putting the patient in Trendelenburg’s position with ice applied to the affected side. Manual pressure is applied to reduce the hernia. Surgery then may occur within 24 to 48 hours. The surgeon replaces hernial contents into the abdominal cavity and seals the opening in a herniorrhaphy procedure. In a hernioplasty, the surgeon reinforces the weakened area with mesh or fascia. Intravenous fluids are administered to prevent dehydration, especially for the newborn who is prone to fluid shifts. The patient should be able to tolerate small oral feedings before discharge and should be able to urinate spontaneously. Postoperatively, inspect for signs and symptoms of possible peritonitis, manage nasogastric suction, and monitor the patient for the return of bowel sounds. As with any postoperative patient, monitor the patient for respiratory complications such as atelectasis or pneumonia; encourage the patient to use an incentive spirometer or assist the patient to turn, cough, and deep breathe every 2 hours.
The nurse explains what to expect before, during, and after the surgery. Parents, especially those of a newborn, are anxious because their child requires general anesthesia for the procedure. If possible, use preoperative teaching tools such as pamphlets and videotapes to reinforce the information. Allow as much time as is needed to answer questions and explain procedures.
The nurse also instructs patients and parents on the care of the incision. Often, the incision is simply covered with collodion (a viscous liquid that, when applied, dries to form a thin transparent film) and should be kept clean and dry. Encourage the patient to defer bathing and showering and instead to use sponge baths until he or she is seen by the surgeon at a follow-up visit. Explain how to monitor the incision for signs of infection. Infants or young children who are wearing diapers should have frequent diaper changes, or the diapers should be turned down from the incision so as not to contaminate the incision with urine. Teach the patient or parents about the possibility of some scrotal swelling or hematoma; both should subside over time.
If the patient does not have surgery, teach the signs of a strangulated or incarcerated hernia: severe pain, nausea, vomiting, diarrhea, high fever, and bloody stools. Explain that if these symptoms occur, the patient must notify the primary healthcare provider immediately. If the patient uses a truss, she or he should use it only after a hernia has been reduced. Assist the patient with the truss, preferably in the morning before the patient arises. Encourage the patient to bathe daily and to apply a thin film of powder or cornstarch to prevent skin irritation.
Nursing care plan discharge and home health care guidelines
Teach the patient signs and symptoms of infection: poor wound healing, wound drainage, continued incisional pain, incisional swelling and redness, cough, fever, and mucus production. Explain the importance of completion of all antibiotics. Explain the mechanism of
action, side effects, and dosage recommendations of all analgesics. Caution the patient against lifting and straining. Explain that he or she can resume normal activities 2 to 4 weeks