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I.

PATIENTS ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patient’s Name: J.R.T
2. Address: La Paz Tarlac
3. Age: 3 months old
4. Sex: Male
5. Birth Date:08/29/09
6. Rank in the family:2nd child
7. Nationality: Filipino
8. Civil Status: Child
9. Date of Admission: 08/25/09
10.Order of Admission: N/A
11. Attending Physician: Dr. Jessie De Leon

CHIEF COMPLAINT: Scrotum Enlargement

HISTORY OF PRESENT ILLNESS: One day prior to admission, patient was confined because of having scrotal mass, nonreduceable accompanied
with fever. The patient sought consult to a private clinic and was diagnosed of Indirect Inguinal Hernia bilateral. Due to financial problem, patient
decided to transfer to TPH hence admitted.

PAST HEALTH HISTORY/ STATUS


• Identify the clues that may aid in diagnosing the present illness
1. Childhood Illnesses: The patient has no history of childhood illnesses although she has experienced colds and cough in the past
months..
2. Immunization: The patient has incomplete immunization. He only have 1 BCG and 1Hepa B
3. Major Illnesses: The patient was hospitalized because of Indirect Inguinal Hernia Bilateral.
4. Current Medication: The patient’s current medication is paracetamol and piperacillin for maintenance for her illness.
5. Allergies: no allergies noted
FAMILY ASSESSMENT
NAME RELATION AGE SEX OCCUPATION EDUC’L ATTAINMENT
Rolando father 27y/o M Farmer High school Graduate
Rebecca mother 27y/o F Housewife High school Graduate
Gwyneth sister 3y/o F

F. SYSTEMS REVIEW- (Gordon’s 11 Functional Health Patterns Assessment, more patient’s more than 3 y/o)

1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN


• Subjective: According to patient’s mother, they bring him in the hospital for check up whenever the patient has minor illness
like colds, cough and fever. His mother gives him vitamins for his health maintenance.
2. NUTRITIONAL – METABOLIC PATTERN
• Subjective: dietary and fluid intake
 Appetite: according to his mother, he had a good appetite. She drinks 8 bottles(6 0z) of milk and 2-3 bottles of
water a day
 Usual Daily Menu
• Food - 8 bottles of milk a day
• Water - 2-3 bottles day
• Beverages - none

3. ELIMINATION PATTERN
• Subjective:
 Bowel habits: Usually he defecates 2x a day and doesn’t have any alteration upon defecation. According to his
mother, bowel is usually yellow cylindrical and soft.
• Color: brown
• Odor: pungent, affected by food type
• Consistency: soft form
• Laxative use if any: none
 Bladder: She has no problem in urination. Patient usually urinate 4-6x a day
• Color: pale yellow
• Odor: mildly aromatic
• Alterations if any: none

4. ACTIVITY – EXERCISE PATTERN


• Subjective:
 Self – care ability
_II__Feeding _II__Dressing _II__Grooming
_II__Bathing _II__Toileting _II_ Cooking
_II__Bed mobility _II__Home maintenance ___others

Legend
0 – full care
I – requires use of equipment
II – requires assistance or supervision from others
II – requires assistance or supervision from another, and equipment and a device
IV – dependent; doesn’t participate

5. COGNITIVE – PERCEPTUAL PATTERN


• Subjective:
 Hearing: no abnormalities noted
 Vision: no abnormalities noted
 Sensory perception: Good response
 Learning styles: Watching and observing others.

6. SLEEP – REST PATTERN


• Subjective: According to his mother the patient sleeps most of the time and can sleep easily at morning and night.
Usually he sleep at 8 o’clock in the morning then he awake at 10 o’clock then sleep again at 11 o’clock and awake
again around 4 o’clock in the afternoon then he sleep again at 7 o’clock in the evening until 5 o’clock in the morning.
7. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
• Subjective: The patient is only a child and cannot tell what he feels.

8. ROLE RELATIONSHIP PATTERN


• Subjective: The patient has good relationship with his family

9. SEXUALITY-REPRODUCTIVE PATTERN
• Subjective: not active in sexual intercourse because he was only a child.
 For both sexes
Contraception: none
Sexual activities: none
Special health reproductive problems: none
History of sex abuse: none

10.COPING-STRESS TOLERANCE PATTERN


• Subjective: According to his mother the patients reduces his stress and cope with his disease by sleeping most of the
time and comfort by his mother.

11.VALUE-BELIEF PATTERN
• Subjective: His mother stated that they don’t believe in any superstitious belief on health. And she also stated that it is
better to consult to a physician for early prevention of sickness. The patient’s religion is INC.

G. HEREDO-FAMILIAL ILLNESS

• PATERNAL- Hypertension and DM


• MATERNAL- None
H. DEVELOPMENTAL HISTORY

THEORIST AGE SEX PATIENT DESCRIPTION


Ericson- Psychosocial theory Birth male The child shows loved, trust and security with the caregiver. And
Trust- Mistrust to12months he becomes insecure and mistrustful to a person he didn’t know.
to 18
months

I-PHYSICAL ASSESSMENT

A. General Survey: 1. Patient has on stages of recovery.


2. Actual height: 59 cm. Weight: 7kg. Head Circumstance: 41cm. Chest Circumstance: 36cm.
Abdominal circumstance:32cm
B. Vital Signs – T-37.9 CR:107 RR-57
C. Regional Exam – utilize IPPA technique
Hair, head and face: round shape, evenly distributed, good hygiene
Inspection: black, short and thin hair
Palpation: round shape head
Percussion:
Auscultation:
Eyes: pupils are equal and round reactive to light and accommodation
Nose: no discharges noted
Ears: symmetrical ears and no discharges noted
Mouth and Throat: pinkish gums, and with productive cough noted.
Neck and Lymph nodes: Symmetry: Symmetrical Growth: none
Skin: brown complexion
Nails: clean,short nails
Thorax and Lungs: with wheezing noted
Cardiovascular: normal (heart rate-107bpm)
Breast and Axilla: not assess
Abdomen: round abdomen
Extremities: not assess
Genitals: the scrotum is enlarge
Rectum and Anus: not assess
Neurological/ Cranial nerves
• Note: Breast, genitals, rectum and anus are strictly assessed only with CI. (ASK PARENTAL/PATIENT
CONSENT)
• No IE for pregnant women

II. PERSONAL / SOCIAL HISTORY


Habits/vices: none
Caffeine – cups/day: none
Smoking – sticks/packs/day: none
Alcohol – brand/ bottles/day: none
Tea – cups/day: none
Drugs – marijuana etc/ OTC drugs: none
Lifestyle: sedentary lifestyle
Social affiliation: Playing with her sister.
rank in the family: 2nd child in the family
travel (within 6 mos):none
educational attainment: none

III. ENVIRONMENTAL HISTORY


The patient lives in a rural area where the houses are far to each other

PEDIATRIC HISTORY
Maternal and Birth History
 Date of birth: August 29,2009
 Birth weight: cannot remember
 Type of delivery: NSD
 Condition after birth: no abnormalities
 Hospital: Tarlac Provincial Hospital
b. Mother
 Complications of delivery: none
 Anesthesia: local anesthesia
 Exposure to tetranogens: none
c. Neonates
 Neonatal history: there was no abnormalities
 Feeding history
 Type of feeding: Breastfeeding and Bottle-feeding

IV. INTRODUCTION:

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 wall
muscle). A hernia may be likened to a failure in the sidewall of a pneumatic tire . The tire's inner tube behaves like the organ and the sidewall like the body
cavity wall providing the restraint.

Hernias may be present at birth, or be acquired later in life after repetitive heavy strain or injury to this abdominal wall muscle. Hernias may occur commonly
in such areas as the lower abdomen or groin areas (Inguinal Hernia), at the region around the navel (Umbilical Hernia), or even through a prior surgical
incision (Incisional Hernia). Hernias can re-occur in an area of a previous hernia repair (Recurrent Hernia). But Hernias can and do occur anywhere on the
abdominal wall, and are given other various names such Femoral, Epigastric, Spigelian or Sports Hernia. The basic problem remains the same, the muscle
container of the abdominal wall no longer holds the contents safely and securely in place. As pressure inside the abdomen pushes the abdominal contents
through this defect, a bulge is created, and pain, burning or aching are experienced. These symptoms gradually increase in intensity with time as the hernia
gradually enlarges, stretching surrounding tissue and irritating local nerve pain fibers.
Surgery is recommended to alleviate symptoms and prevent the hernia from becoming caught (Incarcerated) in the muscle tear or defect and having its blood
supply damaged (Strangulated).

The two types of inguinal hernia have different causes.

Indirect inguinal hernia. Indirect inguinal hernias are congenital hernias and are much more common in males than females because of the
way males develop in the womb. In a male fetus, the spermatic cord and both testicles—starting from an intra-abdominal location—normally
descend through the inguinal canal into the scrotum, the sac that holds the testicles. Sometimes the entrance of the inguinal canal at the inguinal
ring does not close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the small intestine slides through the
weakness into the inguinal canal, causing a hernia. In females, an indirect inguinal hernia is caused by the female organs or the small intestine
sliding into the groin through a weakness in the abdominal wall.
Direct inguinal hernia. Direct inguinal hernias are caused by connective tissue degeneration of the abdominal muscles, which causes weakening
of the muscles during the adult years. Direct inguinal hernias occur only in males. The hernia involves fat or the small intestine sliding through the
weak muscles into the groin. A direct hernia develops gradually because of continuous stress on the muscles. One or more of the following factors
can cause pressure on the abdominal muscles and may worsen the hernia:

• sudden twists, pulls, or muscle strains


• lifting heavy objects
• straining on the toilet because of constipation
• weight gain
• chronic coughing

Symptoms of inguinal hernia include

• 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 improves when resting
• a feeling of weakness or pressure in the groin
• a burning, gurgling, or aching feeling at the bulge

V. ANATOMY AND PHYSIOLOGY


VI. PATHOPHYSIOLOGY
Increased pressure in the
compartment of the abdomen is
develops

Intra-abdominal wall (containing membranes or muscle)


of inguinal canal into the scrotum becomes weakened

Causing the inguinal ring not to


close

Evolves into a hole or defect

through the inguinal canal


Fat or part of the small intestine slides

pressure in the groin


scrotum Feeling of weakness or Pain or discomfort
Swollen or enlarged of
VII. LABORATORY AND DIAGNOSTIC EXAMINATIONS

DATE: Dec. 2, 2009


TYPE OF EXAMINATION: Hematology
RESULTS NORMAL VALUES SIGNIFICANCE
WBC- 10.8 4.1- 10.9 G/L Normal no infection
LYM-5.1 0.6-.4.1 abnormal with infection
MID- 1.6 0.0- 1.8 Normal
RBC-3.46 T/L 4.20-6.30 T/L Indicates anemia
HGB- 88 g/l 120- 160 g/l Indicates anemia
HCT- .278 L/L .370-.510 L/L
MCV- 80.9 fl 80.0- 97.0 fl Normal
MCH-25.4 pg 26.0- 32.0 pg
MCHC- 317. g/l 310.-360. g/l Normal
PLT- 561. G/L 140.-440. G/L Indicates infection

CHEST X-RAY RESULT:


Lungs field are clear. The heart is within normal in size. Aorta is unremarkable. Diagrams and bony thorax are intact.

VIII. DRUG STUDY


1) GENERIC NAME: Salbutamol
BRAND NAME: Ventolin
CLASSIFICATION: Bronchod
DOSAGE: 1 dose q 6 hours
INDICATION:
Mechanism of Action Side effects Contraindication Adverse reaction Nursing
consideration
Improves ventilation May decrease in Contraindicated in CNS: tremors, -Obtain baseline
potassium level patient’s hypersensitive to dizziness assessment of
drugs or any of it’s CV: tachycardia and patient’s respiratory
components hypertension status and assess
GI: nausea and frequently
vomiting throughout therapy.
Metabolic: - Be alert for
hypokalemia adverse reaction
Musculoskeletal: -Asses patient and
muscle cramps family’s of drug
therapy
2) GENERIC NAME: Paracetamol
BRAND NAME:
CLASSIFICATION: Analgesic/Antipyretic
DOSAGE: 60mg IVP q4 hour
INDICATION: Mild pain/fever
Mechanism of Action Side effects Contraindication Adverse reaction Nursing
consideration
Produces analgesia Skin rashes, blood Hypersensitivity to Anorexia,nausea,vomitin >do not take other
by unknown disorders and a swollen acetaminophen g dizzeness, lethargy,chill medication
mechanism but it is pancreas have containing
centrally pain acting occasionally happened acetaminophen w/o
in the CNS by in people taking the mediacl advice
increasing the pain drug on a regular basis >do not use this
threshold by direct for a long time. medication with out
action medical direction
by inhibiting cyclo for: fever persisting
oxygenase.reduces longer than 39.5ºc
fever by direct action
on hypothalamus heat
regulating center
3)GENERIC NAME: Piperacillin
BRAND NAME: Piptazo
CLASSIFICATION: Antibacterial
DOSAGE: 600 mg IVP q8 hours
INDICATION: Treatment of susceptible infections such as septicemia, acute and chronic respiratory tract infections, skin and soft tissue
infections, and urinary tract infections due to susceptible strains of Pseudomonas, Proteus, and Escherichia coli and Enterobacter; active
against some streptococci and some anaerobic bacteria; febrile neutropenia.
Mechanism of Action Side effects Contraindication Adverse reaction Nursing
consideration
Inhibits cell-wall Diarrhea, nausea, Contraindicated in CNS: Confusion, -Tell patient to
synthesis during vomiting, headache, or patients hypersenditivity convulsions, report adverse
bacterial dizziness, extreme to drug or other drowsiness, fever. reactions promptly
multiplication tiredness, easy penicillins. Endocrine & -Monitor
bruising/bleeding, metabolic: Electrolyte hematologic and
dark/cloudy urine, imbalance, coagulation
change in the amount hypokalemia parameters
of urine, severe -Before giving drug,
abdominal/stomach Neuromuscular & ask patient about
pain , yellowing skeletal: Myoclonus allergic reaction to
eyes/skin penicillin.
, persistent Renal: Acute interstitial
nausea/vomiting, nephritis, acute renal
seizures failure
4)GENERIC NAME: Furosimide
BRAND NAME: Lasix
CLASSIFICATION: Loop Diuretic
DOSAGE: 4mg IVP
INDICATION: Acute Pulmonary edema,Hypertension
Mechanism of Action Side effects Contraindication Adverse reaction Nursing
consideration
A potent drug that -May decrease Contraindicated in CNS: vertigo, headache, -If oliguria
inhibits sodium and granulocyte, platelet, patients hypertensive to dizziness, paresthesia. developes or
chloride reabsorption and WBC count. drug and in those with CV: orthostatic increases, drug may
at the proximal and -May increase anuria. hypotension need to be stopped.
distal tubules and the cholesterol glucose, EENNT: transient -Moinitor fluid
ascending loop of Bun, creatinine, and deafness, blurred eye or intake and output
henle. uric acid level. lowed vision. and electrolyte,
GI: abdominal BUN, and carbon
discomfort, and pain, dioxide levels
diarrhea. frequenly.
GU: nocturia, polyuria, -to prevent nocturia;
frequent urination give P.O and I.M
MUSCULOSKELETAL: preparation in the
muscle spasm morning.
-Drug may not be
well absorbed orally
in patient with
severe heart failure.

IX. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY


1. Altered body temperature may be related to inflammatory process.
2. Risk for infection related to surgical incision secondary to Herniotomy

X. NURSING CARE PLAN

ASSESSMENT NSG. DX SCIENTIFIC GOALS INTERVENTION RATIONALE EVALUATION


BACKGROUND
Subjective: Altered body Because of the After 1-2 hours >Assess V/S >serve as data Goal met. The
“medyo mainit temperature may be surgical incision of nursing baseline patient body
related to
siya” as verbalized the tissue is intervention the >Promote surface >to decrease temperature
inflammatory
by the mother of the process. injured. This patient body cooling by means temp. through decreased from
patient. could lead the temperature will of rendering evaporation 37.9ºC to 37ºC
tissue to inflame. decreased from Tepid Sponge
37.9 ºC to 37 ºC Bath
Objective: >Promote bed rest > to reduce
>Febrile(37.9ºC) metabolic
>warm to touch demands
>irritable >Administer anti- >To help reduce
>pale-looking pyretic the fever
>weak in appearance >Encourage the >for further
>restless mother to remove decrease of body
>cries at time wet clothing of temp.
>V/S as follows: the patient
RR:57bpm >Discuss to the >to prevent
CR:107bpm mother the dehydration
importance of
adequate fluid
intake of the
patient
ASSESSMENT NSG. DX SCIENTIFIC GOALS INTERVENTION RATIONALE EVALUATION
BACKGROUND
Subjective: Risk for infection Because of the After 1-3hrs of >Establish rapport >to gain trust to Goal met, as
related to surgical broken skin, nursing patient and evidenced by the
Objective: incision traumatized tissue interventions, the caregiver patient’s mother
>febrile(37.9) secondary to on the injured site patient’s mother >Assess general >to get data verbalization of
>irritable Herniotomy has occurred. will able to condition of the baseline understanding the
>cries at time This could lead to verbalize patient factors having
>fatigue the invasion of understanding of >Monitor vital >to determine any infection that may
>restlessness pathogenic the factors having signs abnormalities affect the patient
>weak in appearance microorganism infection that may >Administer >to assess
therefore affect the patient. antibiotic as causative factors
increasing the indicated
risk of infection >Encourage the >to reduce
and may result to mother to change existing factors
further dressings of the
complications if patient as needed
not prevented >Encourage the >to reduce
mother to cleanse existing factors
with solution the
sites of wound of
the patient daily
>Instruct the >to promote
patient the wellness
techniques to
protect integrity
of skin, care of
lesions and
prevention of
spread of
infection.
XI-ONGOING APPRAISAL
Summary of patient’s health status, day to day appraisal

XII-DISCHARGE PLAN(Health Teachings)


Panpacific University North Philippines
Urdaneta City, Pangasinan
College Of Nursing

Case Study
Indirect Inguinal Hernia Bilateral

Submitted to:
Ms. Ruby-Ruth Pascual

Submitted by:
Vivien S. Pajela
BSN IV-A