Week 12: Chp 58: Hernias Flashcards
What is a Hernia?
a protrusion of abdominal contents through an area of weakened muscle in the abdominal cavity
-typically occur because of weakened abdominal muscles accompanied by increased abdominal pressure
Risk Factors for developing a Hernia
- obesity
- smoking
- excessive wound tension
- malnutrition
- pregnancy
- certain medication such as immunosuppressive agents
Where does a hernia most frequently occur?
in the abdominal cavity; with the intestines protruding through an abnormal opening
Reducible
if the contents can easily be placed back into the abdominal cavity manually or lying down, it is known as reducible
Irreducible/ incarcerated hernia
if the contents cannot be placed back into the abdominal cavity
-it can become strangulated, affecting intestinal flow and/or blood supply
Strangulated hernia
if the blood supply is obstructed and the patient may present with symptoms of an intestinal obstruction
Common causes of Hernias
straining (straining to urinate or have a bowel movement), lifting heavy objects, sudden twists, pulls or muscle strains, weight gain, and chronic cough
-a weakened area of abdominal muscle due to a previous abdominal surgery
Age-related changes
while people age, muscular tissue becomes infiltrated and replaced by adipose and connective tissue, which increased risk of development of a hernia
Types of Hernias
- Inguinal
- Femoral
- Umbilical
- Ventral or Incisional
Hernia: Inguinal
occurs in the groin, between the abdomen and thigh, intra-abdominal fat or part of the small intestine protrudes through weakened muscles of the lower abdomen through the inguinal canal
-typically present above the inguinal ligament and extend below it
>Indirect Inguinal Hernia
>Direct Inguinal Hernia
Indirect Inguinal Hernia
congenital hernias
-develop in the womb
>male fetus; the spermatic cord and testicles normally descend through the inguinal canal into the scrotum; if the individual ring does not close normally after birth, the muscle is weak causing fat or intestine to slide through this weakness
>female fetus; the female organs or small intestine slides into the groin through the weakened abdominal muscles
-may not become obvious until later in life
Direct Inguinal Hernia
- occurs only in males
- due to connective tissue degeneration that causes weakened muscles in adulthood
- fat or small intestine slides through the weakened muscle into the groin
- common symptom of groin hernias: feeling of heaviness or discomfort that is most noticeable when straining or lifting; the pressure is released when the patient stops straining or lies down
- if patient is experiencing significant pain, incarceration or strangulation should be suspected
Hernia: Femoral
more common in females
- fat in the femoral canal enlarges and pulls contents from the peritoneum into the hernia sac
- 40% present as incarcerated or strangulated hernia and must be treated as an emergency
- typically present below the inguinal ligament
Hernia: Umbilical
occur more frequently in women
- due to increased abdominal pressure, usually related to obesity or multiparity (giving birth to more than 1 child)
- typically the omentum or peritoneal fat that incarcerates (constricts blood flow) into the hernia
- can be congenital and appear in infancy
Hernia: Ventral or Incisional
form from previous abdominal surgical incision
- may be due to inadequate healing from an infection, inadequate nutrition, smoking, immunosuppressive medications, connective tissue disorders, or obesity
- the highest incidence occurs with midline abdominal wound incisions, with upper abdominal incisions having higher incidence than lower abdominal incisions
- abdominal wound dehiscence can also lead to ventral hernia
- patient complains of a bulge in the abdominal wall along an old incision site
Clinical Manifestations of a Hernia
typically present with a bulge or visible swelling, often associated when coughing or bearing down
-ache that radiates into the area of the hernia
Clinical Manifestations of Strangulation Hernia
-abdominal distension
-nausea + vomiting
-pain
-fever
-tachycardia
>this is a medical emergency and the patient must be prepared for surgery immediately to prevent the development of gangrene
How are Hernias Diagnosed?
based on physical examination alone, but if this is not definitive, a herniography (a radiographical examination of a hernia after the introduction of contrast medium), ultrasound, CT scan, or magnetic resonance imaging (MRI) can confirm diagnosis
-a CT or MRI may be needed to differentiate between inguinal and femoral
Most common treatment of hernias
surgery
What happens if the patient is a poor surgical risk?
a truss, or binder may be applied
a Truss
a firm pad held in place against the hernia by a belt that reduces the hernia and prevents contents from protruding through the weakened muscle
-may be unilateral or bilateral, and the hernia must be reduced prior to the application of the truss
The surgical procedure to repair a hernia is called?
herniorrhaphy
When Mesh is used during surgical repair, the procedure is called what?
hernioplasty
Hernioplasty
when mesh is used during surgical repair
- a synthetic or biological material called mesh, is placed to reinforce the area of weakness and prevent recurrence of the hernia
- the mesh reinforces the defective are and enhances a lower incidence of recurrence
Herniorrhaphy
surgical procedure to repair a hernia
-may be performed through laparoscopic surgery or through an open laparotomy; has a shorter recovery time
Surgical Management if the hernia is strangulated
- patient will be hospitalized
- temporary colostomy may be required in extensive surgeries
Colostomy
surgically created opening on the abdomen in which the large intestine is connected for the elimination of fecal matter
Post-op management
-similar to care of patients undergoing any other abdominal surgery
-coughing is discouraged; coughing places pressure on the site of repair and increases the incidence of recurrence of hernia
>the patient should be instructed to splint the surgical area when coughing to provide support
Complications of hernias
-strangulation of the intestine; which impeded intestinal flow and the blood supply to the intestines; result in intestinal obstruction and/ or necrosis of bowel tissue
Complications related to surgery with general anesthesia to correct hernias
nausea, vomiting, urinary retention, sore throat, headache
- recurrence of hernia
- wound infections; but are rare unless undergone an extensive surgery
How to prevent complications such as pneumonia and venous thromboembolism (VTE) after surgery?
deep breathing and early ambulation
Safety Alert: Strangulated hernia
patients with a strangulated hernia may present with clinical manifestations of an intestinal obstruction; this is an emergency and the patient must be prepared for immediate surgery to prevent gangrene from developing
-strangulation S+S: abdominal distention, nausea, vomiting, pain, fever, and tachycardia
The clinical manifestations of a hernia ae related to what?
their location and type of hernia
>bulging or swelling at the site of the hernia
>ache that radiates in the area of the hernia
>feelings of fullness or pressure in the area of the hernia
-strangulated hernia: painful engorgement of the hernia, nausea, vomiting, and abdominal distension
Nursing Diagnoses
- acute pain r/t the surgical incision
- knowledge deficit r/t postoperative care and home care
Nursing Assessments
- Vital signs
- Pain
- Intake and Output
- Surgical Site
Assessment: Vital Signs
increased heart rate and respirations may be indicative of pain and/or bleeding
-elevated temperature may be indicative of infection
Assessment: Pain
pain results from the surgical incision and manipulation of abdominal contents during the surgical repair
-adequate pain management allows the patient to resume normal activities sooner
Assessment: Intake and Output
urinary retention is a complication as a result of the effects of general anesthesia
- if the surgery is performed in an outpatient setting, the nurse should have the patient urinate and measure this recording before discharge
- if the patient is admitted to the inpatient facility, intake and output should be measured for 24 hours to ensure that the patient is not retaining urine
Assessment: Surgical Site
the surgical site should be well-approximated
-swelling or drainage may be indications of early infection
Nursing Actions
- deep breathing and early ambulation
- administer pain medications as needed
- give patient prescription for pain medication prior to discharge
- apply ice pack to scrotum and elevate scrotum
- begin diet with clear liquids, advancing diet as tolerated to patients preoperative diet
Actions: deep breathing and early ambulation
promote lung expansion and prevent atelectasis and VTE
Actions: Administer pain medications as needed
essential for the patient to recover to an optimal level and to prevent complications such as atelectasis and VTE
-pain results from the surgical incision and manipulation of abdominal contents during the surgical repair; adequate pain management allows the patient to resume normal activities sooner
Actions: give patient prescription for pain medication prior to discharge
patient will require pain medications at home, and this will promote the patient to return to normal activities of daily living
Actions: Apply ice pack to scrotum and elevate scrotum
the ice pack and elevation are used to reduce swelling; a scrotal support may also be sued to reduce swelling and elevate the scrotum
Action: Begin diet with clear liquids, advancing the diet as tolerated to patients preoperative diet
nausea and vomiting are common after anesthesia, and the patient should exercise steps to prevent nausea and vomiting
Nurse Teachings
- coughing is discouraged
- avoid heavy lifting for several weeks
- pain management techniques
- observe incisions for redness, swelling, heat, drainage, which indicate infection
Teachings: Coughing is discouraged
coughing causes undue pressure on the surgical site and can possibly lead to recurrence of the hernia
-if coughing is necessary, the surgical site should be splinted with pillows to prevent pressure on the site
Teachings: Avoid heavy lifting for several weeks
heavy lifting can place undue pressure and straining on the surgical site and lead to reoccurrence of the hernia
Teachings: Pain management techniques
the patient will be discharged with a prescription for pain medication
- the nurse should teach the patient about the medication and to avoid driving or operating machinery while taking this medication
- if the pain is unrelieved by the medication, this should be reported to the healthcare provider
Teachings: Observe incisions
for redness, swelling, heat, and drainage, which indicate infection
-report fevers, chills and increasing pain to their healthcare provider; these are clinical manifestations of infection and should be reported to healthcare provider ASAP
Evaluating Care outcomes
- recovering from hernia repair return to previous level of functioning within 6 to 8 weeks after surgery depending on extent
- stable vital signs, absence of infection, and normal bladder and bowel function
What is the focused outcome of a patient who is a poor surgica candidate?
focus on patient comfort and ensuring a clear understanding of the clinical manifestations of strangulation
The nurse correlates strangulated hernias with what finding?
impede blood flow to the intestines
