Perioperative Nursing Assessment and Care: Inguinal Hernia in Infants

This essay provides an in-depth analysis of perioperative nursing care for an 18-month-old male patient, Adam, who underwent surgery for an incarcerated inguinal hernia. The essay details the anatomy and physiology related to the condition, preoperative assessments, intraoperative procedures, and postoperative care. It discusses the importance of early diagnosis and intervention, highlighting the potential complications of untreated inguinal hernias in infants. The preoperative care included pain management, monitoring vital signs, and educating the parents. The intraoperative procedure involved a laparoscopic open mesh repair, with continuous monitoring of the child's vitals. Postoperative care focused on pain management, respiratory support, and monitoring for complications. The essay emphasizes the crucial role of nursing interventions in ensuring a positive outcome for pediatric patients undergoing hernia repair.

ASSESSMENT TASK 2- ESSAY
INTRODUCTION
The main purpose and focus of this essay are to present the sophisticated and compelling
knowledge and understanding for the patient group with special interest within the
perioperative and postoperative nursing environment. The essay is aimed at providing the
overall explanation of the anatomy, physiology, of the condition chosen for the understanding
in this essay, also the perioperative, the care during the operative field and post-operative
nursing assessment and care is being identified and discussed as a crucial part of this essay.
The case study indicating and discussing the hernia in the 18 months old male patient for
whom the surgery is being planned and treatment is being advanced is discussed. Since
decades the hernia surgery, treatment and management has been a great revolution
specifically in the paediatric group to ensure better services, and healthy life to the individual.
The treatment modalities to treat and cure paediatric hernia has revolutionized the lives of
many patients and has developed a range of new emphasis on the application of trusses. The
whole phenomenon and management have been developed around 4 centuries ago by the
French surgeon Ambroise Pare who discovered the method to reduce the paediatric hernia
and the efficacy of application of trusses (Abdulhai et al, 2017). It was understood that
inguinal hernia in children are mostly congenital and that they can be cured if provided
effective management. Despite of several researches and advancements in medical science
even today the non-surgical means to treat hernia in children has not been identified.
Moreover, the essay will provide the brief description of the anatomy and physiology related
to the patient’s condition, and the application of this knowledge for preoperative,
intraoperative and postoperative care (Shalaby et al, 2015). The discussion of the essay will
be well supported by the evidence-based literature and will be inclusive of national standards
and best practice standards that would help in determining the links between the theory and
the practice.
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BODY
This essay is focused on the case of an 18 months old male patient, Adam (pseudonym) who
was undergone with the inguinal hernia surgery. Adam was born at 36 weeks gestational with
the birth weight of 2300g, he was presented at the paediatric outpatient department with the
complaint of increasing swelling at the left labial region since last 5 days. The parents also
complained of on and off swelling three times after he was born at the same region (Abdulhai
et al, 2017). On the admission the swelling appeared to be larger than previous states, on
palpation and physical examination a tender mass was palpated, the mass was situated in the
left inguinoscrotal region with inflamed reddish scrotal skin. To confirm the diagnosis the
client was sent for the ultrasonography exam the report provided details of dilated fluid filled
bowel loop present in the inguinoscrotal region. There was a reduced peristaltic activity and
mild amount of fluid was identified in the herniated sac. The cavity around the bowel seemed
to have laterally pushed the left testis (Abdulhai et al, 2017). The diagnosis was of the
incarcerated hernia as the activity identified in the loop ruled out the strangulation in the
hernia cavity. Moreover, it was identified that the echogenic mesentery was attached to the
dilated loop at the ring region of superficial inguina. The colour doppler scan showed
vascularity of this region confirming the viability of the loop (Abdulhai et al, 2017). As an
emergency treatment the laparotomy was performed on this patient and herniated loop was
replaced in the abdomen along with the ligation of the herniated sac for the wellbeing of the
child (Chang et al, 2016).
Inguinal hernia is common in preterm infants due to the inefficacy of the closure of the
process vaginalis (a covering or peritoneum that encloses the testicles into the scrotum), this
leads to entry of bowel into the inguinal canal. Inguinal hernia is a common presentation on
right side with 60% of the cases and 30% on left side that includes ovaries, testis, omentum,
fallopian tubes, uterus and even urinary bladder (Davies et al, 2020). Incarceration is one of
the most important complication of inguinal hernia in infants. The incarceration of hernia in
paediatric age group occurs with an approximate frequency of 31% in all cases as seen in the
case of Adam (Davies et al, 2020). Bowel, ovaries or fallopian tubes are the organs that are
commonly incarcerated in this situation, the case presented with the incarceration of the
bowel. In case of the bowel containing hernia the risk of incarceration is greatly increased
and it does not resolve on its own (Chang et al, 2016). The incarcerated hernia will further
rapidly progress to strangulation, that is the condition with vascular compromise and
infarction of the organs that are incarcerated. Open inguinal hernia repair is the only best
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modality and treatment applied in case of incarcerated inguinal hernia in infants. With the
overall diagnosis and physical presentation of the patient Adam underwent the laparotomy
surgery to resolve the issue (Esposito et al, 2016). The open hernia repair is also known as
hernioplasty. The surgery requires a wide amount of preoperative, intraoperative and
postoperative care to enable to develop a well-presented outcome for the patient.
The pre-operative care of the patient in this case included the management of the child patient
with inguinal hernia, pain management is one of the crucial scopes to be considered
preoperatively in the case of inguinal hernia in infants (Davies et al, 2020). The team has to
decide whether the pain management by administration of paracetamol or morphine is require
for the patient before the surgery (Chen et al, 2017). If still the presentation shows to be
irreducible the surgery is well indicative. Adam was kept overnight under observation if the
hernia reduces and to be planned for the surgery the next day (Esposito et al, 2016). The
preoperative care for the patient with inguinal hernia within 18 months was as followed, the
child with a preterm labour and gestation, has to be followed with one-week GP appointment,
the information is well discussed with parents related to the incidence of the bilateral hernia,
risk of injuries to testis during surgery, recurrence rate and testicular atrophy (Davies et al,
2020).
The preoperative care of the patient includes, ensuring continuous monitoring of the vitals
and examination of the hourly system, including cardiorespiratory, blood pressure, SpO2,
skin temperature etc. (Chen et al, 2017) the preoperative care for this patient includes several
preparations for the surgery and close monitoring to ensure that the kid is stable and is able to
undergo a surgery for hernia repair (Thomas et al, 2016)). The preoperative preparation
includes the blood test, ECG, medical examination and EKG depending on the age of the
patient. The urgent repair was suggested for the patient due to incarceration of the bowel to
the hernia and the risk of strangulation (Chang et al, 2016). The clinical symptoms of the
patient included fever, pain in the area of hernia, and skin redness at scrotal region.
The nursing care preoperatively for this case included various interventions to relieve the
patient’s pain and enhance the family wellbeing. The patient was provided with ice pack for
the inguinal region and scrotal region to ease the pain (Shalaby et al, 2015). The medications
were administered as prescribed by the physician and surgeon to relief the child for the pain.
The parents were encouraged to change the diaper of the child on regular basis, child was
provided with some distractions with providing a calm and soothing environment with toys
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and play. The parents were instructed to hold the child during feeding and enable him to burp
frequently and remove the swallowed air (Chen et al, 2017). The parents were also educated
on the right approach to relieve the pain for the child and how the child would be able to be
managed and follow up preoperatively (Davies et al, 2020). As for the child more than
12months of age the night before the surgery the child is not provided with any solid food
and non-clear liquid that includes milk, formula and juices or candy. Adam was also not
provided any food items including these guidelines and was kept under strict observation.
The nurse also reassured the parents on regular intervals before the surgery and also educated
them on what to be prepared for before the surgery (Esposito et al, 2016).
The intraoperative procedure was prepared and performed for the child in this case to repair
the hernia. The inguinal hernia repair is most probably done using open technique, here the
laparoscopic open mesh repair was chosen to be the appropriate technique for the left side
indirect inguinal hernia repair (Thomas et al, 2016). The laparoscopic transabdominal
preperitoneal hernia repair was scheduled. The anaesthesia was followed as general due to the
age of the child and with neuromuscular blockade (Esposito et al, 2016). The low volume
intravenous fluid protocol was utilized to be able to reduce the distention of bladder during
operation (Acharya et al, 2016). Following the anaesthesia, the child patient was positioned in
supine position on the table. As per the age of the child the single port technique was utilized.
Under general anaesthesia, 0.5 cm trans-umbilical skin incision was made for the insertion of
the 0.5cm port (Shalaby et al, 2015). To reduce the post-surgical pain for the patient the local
anaesthesia was also administered at the incision site before the incision was made (Dreuning
et al, 2019). The exploration was done to make a final diagnosis of the hernia, the non-
absorbable suture is hooked on to the outer hook of the two hooked core needles, with the
blunt tip, 0.2 cm incision is made lateral to the epigastric vessel and the needle was pierced
through the abdominal wall into the extraperitoneal space (Shalaby et al, 2015). The child
was continuously being monitored for his vitals by the nurse. To ensure the safe practice and
minimal invasiveness the Vas deferens and spermatic vessels were kept away (Abd-Alrazek
et al, 2017). The normal saline was injected into the cavity to form hydrodisection (Acharya
et al, 2016). After the suture passes through the needle was inserted in peritoneum and suture
was kept in the abdomen (Davies et al, 2020). The needle goes to same side and the suture
was drawn back with the other hook. The suture knot is tied extracorporeally and the internal
ring is closed. Moreover, the testis of the patient is drawn down while the internal ring was
closed. The hernia sac is removed through the small incision and the intestine was placed
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back in the abdomen as the bowel was in the hernia sac (Chen et al, 2017). Moreover, the
opening in the lower abdomen was closed as explained above. The dissolvable tiny sutures
were placed on the other skin to suture back the incision. The incision was covered by the
simple dressing and the whole procedure took around 40minutes (Esposito et al, 2016).
During this time the nurse reassured the parents outside and updated them for the surgery
procedure.
After the surgery, the post-operative care and services are determined and applied. After
surgery the blood pressure, heart rate, temperature and respiratory rate of the child was
monitored on regular and continuous basis. Monitoring these signs and examining the clinical
presentation of the patient helps in identifying any post-operative complications if present at
an early stage (Dreuning et al, 2019). The child is placed with the breathing tube to ease in
ventilation and the parents were supported and informed regarding the tube (Chen et al,
2017). The caudal anaesthesia was provided for the child to wake up without any pain after
surgery. The post-operative nursing care plan included following interventions-
The interventions for acute pain, the nurse assessed the incision pain and the non-verbal signs
of pain such as crying, lethargy and grimace (Esposito et al, 2016). Assessing these factors
helps determine the initiation and need for analgesic therapy for pain relief in the children.
The analgesics, are the drugs such as NSAIDs that are administered to relief the pain caused
due to surgery and incision (Shalaby et al, 2015). The patient is encouraged and the parents
are educated to maintain the position for comfort (Abd-Alrazek et al, 2017). The position
plays a huge role in pain relief, as facilitating more non-dependent position helps decrease the
pain caused by strain and incision. For further relief of the pain the patient was provided with
the ice compress at the groin and scrotal region, the application of ice helps reduce swelling
and reduces pain (Thomas). The parents were encouraged to change the diapers on a regular
basis to reduce the risks of infection post-operatively. In order to reduce the fluid imbalance,
the nursing interventions were administered, including the administration of the oral fluids,
parental guidance and education on how and what food items and fluids to be included in the
child’s diet on regular basis to promote better electrolyte and fluid balance and reduce fluid
imbalance (Dreuning et al, 2019). Encourage the child for frequent repositioning, and educate
the parents to reposition the child during sleep, repositioning helps in better circulation and
reduces the chances of additional post-operative complications (Abd-Alrazek et al, 2017).
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Moreover, the discharge or post-operative home care education has to be provided to the
parents, therefore, nurses develop the discharge plan with patient and family education
including providing in-depth understanding of hernia and inguinal hernia and how it is being
treated (Thomas et al, 2016). Instructions for the signs of inflammation, pus, swelling,
redness or pain around the incision was provided to the parents. Secondary infection to the
surgical site can be a common presentation and an early diagnosis can help in treatment.
Education to the parents regarding keeping the incision clean and covered in simple dressing
were provided to enable them to care for the child post-discharge (Shalaby et al, 2015). The
parents were also informed regarding the risks associated with recurrence and the relapse
depends on the general health of the child inf future with his lifestyle habits and
presentations. The parents of the child were also explained the importance of taking each
medication, including the antibiotic s and pain management therapy, with their mechanism on
the child’s body and advantages of it for the surgical outcomes (Dreuning et al, 2019).
Moreover, the overall procedure went appropriately and the child was well managed and
treated for the indirect left side inguinal hernia at 18months.
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CONCLUSION
The essay was aimed at providing the overall explanation of the anatomy, physiology, of the
condition chosen for the understanding in this essay, also the perioperative, the care during
the operative field and post-operative nursing assessment and care is being identified and
discussed as a crucial part of this essay. The case study indicating and discussing the hernia
in the 18 months old male patient for whom the surgery is being planned and treatment is
being advanced is discussed. Since decades the hernia surgery, treatment and management
has been a great revolution specifically in the paediatric group to ensure better services, and
healthy life to the individual. Inguinal hernia is common in preterm infants due to the
inefficacy of the closure of the process vaginalis (a covering or peritoneum that encloses the
testicles into the scrotum), this leads to entry of bowel into the inguinal canal. Inguinal hernia
is a common presentation on right side with 60% of the cases and 30% on left side that
includes ovaries, testis, omentum, fallopian tubes, uterus and even urinary bladder.
Incarceration is one of the most important complication of inguinal hernia in infants. The
incarceration of hernia in paediatric age group occurs with an approximate frequency of 31%
in all cases as seen in the case of Adam. Bowel, ovaries or fallopian tubes are the organs that
are commonly incarcerated in this situation, the case presented with the incarceration of the
bowel. In this case, appropriate nursing measures were developed that helped in appropriate
treatment and management of the indirect inguinal hernia in an 18 years old male patient
using the laparotomy transabdominal single port surgery.
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