Abdelrahman Alkilani, RN. BSN.MSN- Year 1

Nursing Care of Patients withHernia

• Define Hernia.• Enumerate the different types of Hernias.• State the clinical manifestations of Hernias• Discuss the pathophysiology of Hernia• State the complications of Hernias.• Describe the diagnostic tests required for patients with Hernia• Describe the medical and surgical management provided for

patients with hernia. • Explain the nursing management of patients with Hernia.

Objectives

• It is the protrusion of an organ orpart of an organ through the wallof the cavity that normally contains it.• It is classified by location.

Hernia

• Inguinal hernia• Umbilical hernia• Incisional or ventral hernia• Hiatal hernia

Types of Hernia

• Pathophysiology

• Often are congenital, caused by improper closure of the tract that develops as the testes descend into the scrotum during fetal development.• Or acquired defects that result from

weakness of the posterior inguinal wall

Inguinal hernia

• Indirect inguinal hernia• Are caused by improper closure of the tract

that develops as the testes descend into scrotum before birth.• A sac of abdominal contents protrudes

through the internal inguinal ring into the inguinal canal.• It often descends into the scrotum.• often not evident until adulthood, when

increased intra-abdominal pressure and dilation of inguinal ring allow contents to enter the channel.

Inguinal hernia

Inguinal hernia

• Direct inguinal hernias• Are acquired defects that result from

weakness of the posterior inguinal wall.• Usually affect older adults

• Clinical Manifestations • May produce no manifestations• May cause a lump, swelling, or bulge in the groin,

particularly with lifting or straining.• May cause sharp pain or a dull ache that radiates into the

scrotum. • A palpable mass may be present in the groin, although it

may be felt only with increased intra-abdominal pressure (as occurs during coughing).

Inguinal hernia

Umbilical hernia

• Pathophysiology• Pregnancy and obesity contribute to the

development of umbilical hernias in adults• May be congenital and evident during infancy, or

acquired as the tissue closing the umbilical ring weakens, allowing protrusion of abdominal contents.• More common in women.

• Clinical manifestations• May cause sharp pain on coughing or

straining or a dull, aching sensation.

Umbilical hernia

• Pathophysiology• Occurs at a previous surgical incision or

following abdominal muscle tears• Contributing factors include poor wound

closure, postoperative infection, age or debility, obesity, and excess incisional stress caused by vigorous coughing.

Incisional or ventral hernia

• Clinical manifestation• Characterized by a bulge at the incisional site,

often noted when the client pulls to a sitting position from lying position.

Incisional or ventral hernia

• Pathophysiology• Sliding hiatal hernia, the gastroesophageal junction

and the fundus of the stomach slide upward through the esophageal hiatus.

• Contributing factors include:• weakened gastroesophageal-diaphragmatic

anchors• shortening of the esophagus• or increased intra-abdominal pressure.

Hiatal hernias

• Pathophysiology• In a paraesophageal hiatal hernia, the junction

between the esophagus and stomach remains in its normal position below the diaphragm while a part of the stomach herniates through the esophageal hiatus. • Further classified as type II, III, or IV.

Depending on the extent of herniation, with type IV having the greatest herniation.

Hiatal hernias

• Clinical Manifestations• Sliding hernia:

• 50% of patients with sliding hernia are asymptomatic.• Heartburn• Regurgitation• Dysphagia

• • Paraesophageal hernia:

• Sense of fullness after eating or chest pain, or there may be no symptoms.• Reflux usually doesn’t occur, because the gastroesophageal sphincter is intact.

Hiatal hernias

• If the content of hernia cannot be returned to the abdominal cavity, it is said to be incarcerated.• Incarceration increases the risk of

complications, including obstruction and strangulation.

Complications

• Obstruction occurs when the lumen of the bowel contained within the hernia becomes occluded.• A strangulated hernia develops when

blood supply to bowel and other tissues in the hernia sac is compromised, leading to a necrosis.• The affected bowel can infarct, leading to

perforation with contamination of the potential cavity

Complications

• Diagnosis is made by physical examination• The client is examined in a supine or standing position• A bulge may be seen or felt when the client coughs or bears down.

• Diagnosis of hiatal hernia can be confirmed by:• X-ray• Barium swallow• Fluoroscopy

Diagnostic tests

• Surgical repair, or herniorrhaphy, is the usual treatment for hernia• Abdominal wall defect is closed by suturing or with

wire or mesh over the defect.• If incarceration has occurred or strangulation

is suspected, the abdomen is explored at the time of surgery and any infarcted bowel restricted.

Medical and surgical management

• Hiatal hernia:• Frequent, small feedings that can pass easily through the esophagus.• The patient is advised not to recline for 1 hour after eating, to prevent

reflux or movement of the hernia• The patient is advised to elevate the head of bed on 4-8 inches blocks to

prevent the hernia from sliding upward.• Surgery is indicated in about 15% of patients.

• May require emergency surgery to correct torsion (twisting) of the stomach or other body organ that leads to restriction of blood flow to that area.

Medical and surgical management

Assessment Nursing diagnosis Goal Interventions Outcome

Bulging at hernia site

Risk of ineffective tissue perfusion related to hernia and the possibility of obstruction and strangulation

Complications will be avoided next 24 hours

Watch for and immediately report signs of incarceration and strangulation

There is no signs of complications within 24 hours

Nursing process

Assessment Nursing diagnosis Goal Interventions Outcome

Patient is complaining of pan 5 on score

Acute pain relate to swelling and pressure

The patient will express feelings of comfort.

- Watch for and immediately report signs of incarceration and strangulation.

- Administer I.V. fluids and analgesics for pain as ordered.

- Place the patient in Trendelenburg's position to reduce pressure on the hernia site

Pain was relieved from 5 to 2 on score

Nursing process

Assessment Nursing diagnosis Goal Interventions Outcome

patient said that he often have oral regurgitation after meals

Risk of aspiration related to reflux of gastric content

Client will be able to state the steps in preventing aspiration after 2 hours of nursing interventions

- Instruct to take small frequent meals

- Encourage not to take meal 2 hours before bed time

Patient has no episodes of oral regurgitation after 2 hours of interventions

Nursing process

Assessment Nursing diagnosis Goal Interventions Outcome

Patient has repeated doubts regarding surgery

Fear and anxiety related to hospitalization

Pt to be free from anxiety with 2 hours of interventions

- explain the procedure to the patient in simple terms

- introduce the patient to similar patients who had undergone the surgery

Pt is relieved of fear and anxiety as he state it.

Nursing process

• It is the protrusion of an organ or part of an organ through the wall of the cavity that normally contains it.• Inguinal hernia, Umbilical hernia, Incisional or ventral hernia, and

Hiatal hernia• Main manifestation is bulging or pain.• Incarceration leads to obstruction or strangulation• Diagnosed mainly with physical exam• Surgical repair is the treatment• Nurses play a significant role in care of patients with hernia.

Summary

• Write about 2 pages about the risk factors of each type of hernia which we covered in our session?

• To be submitted on Tuesday 17th Nov, 2015.

Assignment

• Smeltzer, Bare, Hinkle, and Cheever. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, (2013).

• Priscilla LeMone, Medical surgical Nursing (fourth edition). Pearson international edition.

References

Thanks