THEORITICAL BACKGROUND

HERNIA

I. Disease Concept
1.1 Definition / description hernia
A hernia is a protrusion prostusi or contents of a cavity through a defect or weak
parts of the wall of the respective cavity. In abdominal hernia, abdominal contents
protrude through a defect or weak parts of the musculo-aponeurotik lining the
abdominal wall (Huda and Kusuma, 2016).
A hernia is a weakness of the abdominal muscle wall which passes through a
segment of the stomach or other abdominal structures that stand out. Hernias can also
penetrate past some other defect in the abdominal wall, passing through the
diaphragm, or pass other structures in the abdominal cavity. A hernia is a weakness
of the abdominal muscle wall which passes through a segment of the stomach or
other abdominal structures that stand out. Hernias can also penetrate past some other
defect in the abdominal wall, passing through the diaphragm or other structure
passing through the abdominal cavity (Ignatavicius, 2006).
Hernia is divided into two categories, according to its location and hernia hernia
according to the nature or tingkatanya.
The hernia by lying :
a. Inguinal Hernia lateral (indirect)
hernia occurs through the internal inguinal ring located lateral to the inferior
epigastric vasa, along the inguinal canal and out kerongga stomach through the
external inguinal ring. Hernia is higher in infants and young children.
b. Inguinal Hernia Medial (direct)
This hernia occurs through the inguinal posteromedial wall of the inferior
epigastric vasa in a triangular area bounded Haselbach.
c. Femoral hernia
occurred through the femoral ring and is more common in women than in men.
This hernia started as a cap for the femoral dikanalis enlarged gradually drawing
peritoneum and consequently the bladder into the bag.
d. Umbilical hernia
 Umbilical Stem intestinal past the rings. largely a learned disorder. Umbilical
hernias are common in women and in patients who possess state of increased
intra-abdominal pressure, such as pregnancy, obesity, ascites, or abdominal
distension. This type of hernia occurs in the previous surgical incision has healed
is inadequate because of problems such as post-operative infections and
inadequate nutrition.
e. Herniaskrotalis
An inguinal hernialateral reach the scrotum.
According to the nature or level:
a. Hernia reponibel
In this hernia hernia contents can be out. Intestines will come out when standing
or straining, and sign in again if lying down or push enter. In this reponibel hernia
patient does not complain of pain and no symptoms of intestinal obstruction.
b. Ireponibel hernia
is the reverse of reponibel hernia (hernia from coming back) is usually caused by
adhesions in the peritoneal sac contents.
c.incarcerated hernia
In this herniacontents of the stomach or intestines enters the hernia sac can not be
returned accompanied by a special flow interruption. Clinical features of intestinal
obstruction to the image of the liquid electrolyte balance and acid-base. This
situation could be pinched by a ring hernia hernia. So that the contents of the bag
can be trapped and unable to get back into the abdominal cavity, resulting in
disruption passase and this is more intended hernia hernia irreponibel
d. Hernia Strangulated
In this hernia blood vessels that affects the bowel into the hernia sac is
sandwiched so that intestinal bleeding loss system so that necrosis of the intestine.
At the local inspection intestine can not be inserted back accompanied by
tenderness.
1.2 Etiology
According to Huda and Kusuma (2016), hernias can be caused by several things,
which are as follows:
1.2.1 Congenital
 Congenital due to weakness in the muscles is one of the risk factors associated
with factors increase intra-abdominal pressure. Muscle weakness can not be
prevented by exercise or exercises.

1.2.2Obesityis
one cause of the increase in intra-abdominal pressure due to the amount of fat
that is clogged and slowly push the peritoneum. This can be prevented with
weight control.
1.2.3 Pregnant women
In pregnant women there are usually intra-abdominal pressure increased,
especially in the uterus and surrounding area.
1.2.4 Straining
Straining can also cause an increase in intra-abdominal pressure.
1.2.5 Lifting heavy loads
Lifting heavy weights can also lead to an increase in intra-abdominal pressure.
1.3 Signssymptoms
andAccording to Huda Kusuma (2016), marks hernia symptoms are as follows:
1.3.1 The form lumps out msuk / hard and that often seems to lump in the groin
1.3.2 The presence of pain at the bump area when it wedged accompanied by feelings of
nausea
1.3.3 there are symptoms of nausea and vomiting or distension if there are complications
1.3.4 In the event of an inguinal hernia pain stragulata be intensified as well as the
overlying skin becomes red and hot
1.3.5 small femoral hernias may contain bladder wall, causing the symptoms of urinary
pain (dysuria) haematuria (blood urine) in addition to a lump undergroin
1.3.6 diaphragmatic herniacause stomach area pain with shortness of breath
1.3.7 or coughWhen push the hernia lump will grow
1.4 Pathophysiology
In the first stage it is tearing of the annulus fibrosus circumferentially. Because of the
repetitive traumatic force, tear it becomes larger and the resulting radial tear. If this
happens, the risk of trauma HNP just waiting for the next time only. Style
precipitation it can be assumed as traumatic when they wanted to enforce style body
slip time, lifting heavy objects, and so on.
 Herniated nucleus pulposus can achieve the corpus vertebrae above or below. Can
also penetrate directly into the vertebral canal. In the event of elevated pressure on
the intervertebral discs suddenly and lasts a long meal nucleus pulposus material will
stand out to fill the annulus fibrosus are damaged. Protrusion of the nucleus to the
rear lateral and dorsal root nerve pressure (containing sensory nerve fibers) that runs
within the vertebral canal will meninmbulkan pain. Movements that change the
position of the spine such as bending, sneezing and coughing will add to the pain.
Damage to the intervertebral discs can be caused because the process is degenerative
eg, the less resilience, decrease in collagen tissue, and reduced water content with
age, bone trauma striped, genetic factors, spinal surgery, abnormal posture such as
kyphosis, lordosis, due to spinal abnormalities such as spondylitis, spinal stenosis.
1.5 Investigations
According to Huda and Kusuma (2016), the investigation of the hernia is as follows:
1.5.1 X-rays of the abdomen showed 'abnormal levels of gas in the intestinal / bowel
obstruction
1.5.2 A complete blood count and serum electrolytes can show hemoconcentration
(increased hematocrit), an increase in white blood cells and electrolyte imbalance
1.6 Complications
1.6.1,recurrent hernia
1.6.2 Damage to the blood supply, nerve testis or if the patient is male,
1.6.3 excessive bleeding / surgical wound infection,injury to the intestinal
1.6.4 ( if not careful),
1.6.5 After Herniografi hematoma can occur
1.6.6 Fostes urine and feces
1.6.7 Residip
1.6.8 Complications long a testicular atrophy due to lesions.
1.7 Penatalaksaan
According to Huda and Kusuma (2016), hernia containment procedures are of two
kinds, namely:
1.7.1 Conservative (Townsend CM)
Pengobaan conservative repositioning limited action and the use of a brace or
support to maintain the contents of the hernia that has to be repositioned, not a
definitive measure so it can come back, consisting of:
a. Repositioning
 Repositioning is an attempt to restore the contents of the hernia into
peritonil or abdominal cavity. The repositioning is done bimanual. The
repositioning carried out in patients with hernia reponibilis by way of using
two hands. The repositioning is not performed on an inguinal hernia
strangulate except in children.

b. Injections
Do sclerotic fluid injection in the form of alcohol which causes the area
around the hernia hernia door experience sclerosis or narrowing so that the
hernia contents out of the cavity peritonil
c.belt hernia
Given thehernia patients is still small and refuse surgery
1.7.2 Operative
hernia operation can be done in three stages, namely:
a. Herniotomy
Opening and cutting bag and returns hernia hernia contents of the
abdominal cavity,herniotomy is liberation operation hernia bag up to his
neck, the bag was opened and the contents of the hernia hernia dibebaskkan
if there are adhesions, then repositioned, sutured hernia belt bag as high as
possible and then cut.
indications
Hernioplastik herniotomyand performed on patients who undergo hernia
which can not be returned with conservative therapy.
action process
herniotomy
Make an incisionsloping two fingers above the SIAS, then The inguinal
canal is opened, separating funikulus and hernia bag is released from the
rope sperm, do duplication (manufacture bags hernia), then the hernia
contents released if there are adhesions, and then repositioned. Hernia belt
pouch sewn-as high as possible and then cut.
Technics operation herniotomy - herniorafi Lichtenstein
inguinal hernia lateral and medial:
1. Patients in the supine position and general anesthesia, spinal anesthesia
or local anesthesia
 2. Do incision oblique 2 cm medial SIAS to the pubic tubercle
3. Incision deepened until it aponeurosis MOE (muscular Obligus
abdominis externus)
4. aponeurosis MOE opened sharply
5. funikulus spermatikus freed from the surrounding tissue and crocheted
ribbon and bag hernia identified
6. Fill hernia inserted into the cavity of the abdomen, bags hernia sharp
and blunt to the annulus of the internal
7. pouch hernia ligated as high-fat preperitonium, followed by herniotomy
8. Bleeding treated, followed by hernioplasty with mesh
9. surgical wound was closed layer by layer
surgery complication
1. blood
2. of surgical wound infection
3. intestinal injury
4. bladder injury
5. testicular injury
Post-surgical Care
Post-surgical patients were treated and observed the possibility of
complications such as bleeding and save oma operation range
b. Hernioraphy
Starting from bindinghernia neck and hung on the conjoint tendon (thickening
between the free edges m.obliquus intraabdominalis and which inserts into the
abdominal m.transversus in tuberculum pubicum)
c. Hernioplasty
sewed conjoint tendon at the inguinal ligament that lost LMR / closed and
the abdominal wall so much stronger because of muscle covered.
1.8 Pathway

Faktor pencetus:

Aktivias berat, bayi prematur, kelemahan dinding abdominal,

intraabdominal tinggi, adanya tekanan

Hernia

Hernia umbilikalis Hernia para umbilikalis Hernia inguinalis

kongenital

Kantung hernia melewati Kantung hernia memasuki

dinding abdomen celah inguinal
Masuknya omentum organ
intestinal kekantong
umbilikalis

Prostusi hilang timbul Dinding posterior canalis

inguinal yang lemah

Gangguan suplai darah ke

intestinal Ketidaknyamanan
abdominal
Benjolan pada region
inguinal

Nekrosis intestinal

Intervensi bedah

relatif/konservatif
Diatas ligamentum iguinal
mengecil bila berbaring

Pembedahan
 Insisi bedah Asupan gizi kurang Mual

Nafsu makan menurun

Peristaltik usus menurun

Resti perdarahan
Intake makanan inadekuat
Resti infeksi

Terputusnya jaringan Ketidakseimbangan

saraf nutrisi kurang dari
kebutuhan tubuh

Nyeri

Kantung hernia memasuki

celah insisi
Hernia insisional

Heatus hernia
Kantung hernia memasuki
rongga thorak
II. Client care plan with impaired hernia

2.1 Assessment
2.1.1 Nursing history
a. Current medical history
Hernias can occur with symptoms of pain, nausea and vomiting.
b. History Formerly Disease
Assessment favor is reviewing whether the client previously had suffered
from hernia, a complaint in childhood, hernias from other organs, and other
diseases such as diabetes mellitus aggravate hernias. Ask about medications
commonly taken by clients on relevant past, these medications include
drugs OAT and antitussives. Note the terjai side effects in the past.
Examine more deeply about how much weight loss (BB) in the last six
months. Weight loss in clients with hernias are closely related to the healing
process as well as the presence of anorexia and nausea that is often caused
by drinking OAT.
c. Family Disease History
In pathology Hernia is not lowered, but nurses need to ask whether the
disease is experienced by other family members as a predisposing factor in
the house.
2.1.2 Physical examination:
Data focus
a. Inspection areas Inguinal and femoral
hernias Although defined as any protrusion of a viscus, or part thereof,
through a normal or abnormal opening, 90% of all Inguinal hernias are found
in the area. Usually, impulse hernia more clearly seen than in the tangible.
Encourage the patient turned his head to the side and coughing or straining.
Do the inspection area Inguinal and Femoral to see lumps suddenly during the
cough, which may indicate hernia. If it looks a sudden bump, ask the patient to
cough again and compare it with the impulse impulse on the other side. If the
patient complains of pain during coughing, determine the location of the pain
and recheck the area.
b. Palpation Inguinal Hernia
Inguinal Hernia palpation done by putting the right index finger in the scrotum
above the testicles check left and pressed into the skin of the scrotum. There
should be a scrotal skin enough to reach the external inguinal ring. Finger nails
must be positioned facing outwards and into the finger pad. Examiner's left
hand can be placed on the patient's right hip for better support. Right index
examiner must follow dilateral spermatic cord into the inguinal canal parallel to
the inguinal ligament and moved upwards towards the external inguinal ring,
which is superior and lateral to the pubic tubercle. The external ring can be
widened and penetrated by a finger. With the index finger is placed on the
external ring or in the inguinal canal, ask the patient to turn his head to the side
and coughing or straining. If there hernia, it will feel a sudden impulse to touch
the tip or finger pads examiner. If there is a hernia, tell the patient lying supine
and see if the hernia can be reduced using gentle pressure and continuously
during that time. If the inspection carried out by the skin of the scrotum hernia
which is quite a lot and done slowly, this action does not cause pain
(Tambayong, 2000).
Pre-operative patient assessment (Doenges, 2000) are included:
1. Circulation
symptoms: a history of heart problems, CHF, pulmonary edema, peripheral
vascular disease, or vascular stasis (increased risk of thrombus formation).
2. Ego integrity
Symptoms: anxiety, fear, anger, apathy; multiple stress factors, such as
financial, relationship, lifestyle.
Symptoms: can not break, increasing tensions / sensitive excitatory;
sympathetic stimulation.
3. Food / liquid
Symptom: pancreatic insufficiency / DM, (predisposition to hypoglycemia
/ ketoacidosis); malnutrition (including obesity); dry mucous membranes
(barring entry / preoperative fasting period).
4. Respiratory
Symptoms: infection, chronic conditions / cough, smoking.
 5. Security
Symptoms: allergic / sensitive to drugs, food, plaster, and solutions; Immune
deficiency (peningkaan risk of systemic infection and delayed healing); The
emergence of cancer / cancer therapy is the latest; A family history of
malignant hyperthermia / reaction to anesthesia; A history of hepatic disease
(effect of detoxification of drugs and can change coagulation); A history of
blood transfusion / transfusion reaction.
Signs: the emergence of infectious exhausting process; fever.
6. Counseling / Learning
Symptoms: pengguanaan anticoagulation, steroids, antibiotics,
antihypertensives, cardiotonic glokosid, antidisritmia, bronchodilator,
diuretic, decongestant, analgesic, anti-inflammatory, anticonvulsant drugs
or tranquilizers and well-counter, or recreational drugs. The use of alcohol
(risk of kidney damage, which affects the coagulation and choice of
anesthesia, and also the potential for postoperative withdrawal).
2.1.3 Investigations
According to Huda and Kusuma (2016), the investigation of the hernia is as
follows:
a. X-rays of the abdomen showed 'abnormal levels of gas in the intestinal / bowel
obstruction
b. complete blood count and serum electrolytes can show hemoconcentration
(increased hematocrit), increased white blood cells and electrolyte imbalances
2.2 nursing diagnoses that may arise
Diagnosis 1: acute pain (Practical nursing, 401)
2.2.1 definition of
sensory and emotional experience unpleasant arising from tissue damage
actual and potential, sudden onset or slow of moderate to severe intensity
2.2.2 Definingcharacteristics:
a. Change in appetite
b. Changes in blood pressure
c. Changes in heart rate
d. Changes in respiratory frequency
2.2.3 Factors related
Agentinjuries (eg biological, chemical, physical, psychological)
Diagnosis 2: Nutrition less than body requirements (Practical Nursing, 396)
2.2.4 Definition of
nutritional care is not enough to meet the needs of metabolic
2.2.5 Definingcharacteristics:
a. Abdominal cramps
b. Abdominal pain
c. Avoid foods
d. Weight 20% or more below ideal body weight
e. Nausea and vomiting
associated factors 2.2.6
a.biological
Bfactors.Economic factors

2.3 Planning

Diagnosis 1: Acute pain (Practical Nursing, 401)

2.3.1 Objectives and expected outcomes
a. Objectives
1. Painlevel
2. Pain control.
3. Comfort level
b. Expected outcomes
1. Ability to control pain (tau cause pain, was able to use nonpharmacological
techniques to reduce pain, seek help)
2. Reported that the pain is reduced by the use of pain management
3. Able to recognize pain (scale, frequency and signs of pain)
2.3.2 Intervention nursing and rational
a.Intervention:Perform a comprehensive pain assessment including location,
characteristics, duration, frequency, quality and precipitation factor
Rationale: To know the state of pain
b. Interventions:Observation of nonverbal reactions of discomfort
Rationale:Knowing the pain
 c. Intervention:Teach about non-pharmacological treatment, pain management
Rationale:Management of pain makes the patient feel more comfortable
d. Intervention:Collaborate with your doctor if there is a complaint and action for
pain is not managed
Rationale:Helps to reduce pain
Diagnosis 2: Nutrition less than body requirements (Practical Nursing, 396)
2.3.1 Objectives and expected outcomes
a. Objectives
1. Nutritional status
2. Fluid intake
3. Weight control
b. Expected outcomes
1. An increase in body weight in accordance with the aim of
2. The ideal weight according to height
3. Able to identify the nutritional needsof nursing interventions and rational
2.3.2
a.Intervention:Assess for food allergies
Rasioanl:To determine the presence of allergy
b.Intervention:Provide information about the nutritional needs
Rasioanl:information critical apparatus so that the patient understands the
importance of nutrition for the body needs
c. Intervention:Instruct the patient to increase the protein and vitamin
Rasioanl: To meet the needs of the body
d.Intervention: Collaboration with a nutritionist to determine the amount of
calories and nutrients needed by patients
Rasioanl:For the fulfillment of appropriate nutrition
2.4 Evaluation
2.4.1 Diagnosis 1: Acute pain (Practical Nursing, 401)
S:- Clients say the pain was reduced
- Clients say tastes eating good
O: - blood pressure normal client
- the client normal cardiac Frequency
- Frequency breathing normal client
A: -The problem is resolved
 P: -Intervention discontinued

2.4.2 Diagnosis 2: nutrition less than body requirements (Practical Nursing, 396)
S:- client said eating good
O: - clients want to spend eating
- abdominal pain is reduced client
- An increase in body weight in accordance with the purpose of
A: -the problem is resolved
P: -Interventionterminated.
 REFERENCES

Huda, A. And Kusuma. 2000. The nursing careplan,issue 3, Jakarta: EGC.

Huda, A. and Kusuma, H. 2016. Practical Nursing Volume1.Jogjakarta: MediAction

Ignatavicius, Donna, et.all. 2006. Medical Surgical Nursing. Philadelphia: WB

SaundersCompany.

Tambayong, dr. Jan.2000. Pathophysiology for Nursing. Jakarta: EGC

Clinical Teacher Clinical Instructure

(Zaqqyyah Huzaifah Ns.,M.Kep) (Muhammad Ridha Ramadhani S.Kep.,Ns)

NIK: 0124121984059002001 NRPB: 91.132.1.17