I.

PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patients Name: Mr. R.E.
2. Address: Urdaneta City, Pangasinan
3. Age: 27
4. Sex: Male
5. Birth Date: November 17, 1985
6. Rank in the Family: 4
th
child
7. Nationality: Filipino
8. Civil Status: Single
9. Occupation: Service Crew at a fast food chain
10. Date of Admission: August 28, 2013 9:30 AM
11. Order of Admission:
Please admit patient, secure for consent, TPR every shift and record please, nothing per orem
post-midnight, attach all laboratory results: Chest X-ray, Electrocardiogram results, Urinalysis,
and Complete Blood Count., IVF 5% Dextrose in Lactated Ringers Solution 1 Liter to run at 30
gtts/min, IV medications: Cefoxitin (Foxitin) 1 gm IV every 8 hours after negative skin test
(ANST), Omeprazole (Zefxon) 40 mg IV once a day, for mesh Herniorrhapy right 8:00am August 29,2013
and secure for consent, notify OR/anesthesiologist, inform undersigned once admitted and refer
accordingly.
12. Admitting Diagnosis: Inguinal hernia right
13. Attending Physician: Dr. Arlene P. Pavo

B. CHIEF COMPLAINT: Inguinal mass right

C. HISTORY OF PRESSENT ILLNESS:

Patients condition started about 8 years ago prior to admission when he noticed inguinal mass at
right, reducible. Until few months PTA he experienced pain in the both testicles so patient
decided to undergo herniorrhapy.

D. PAST HEALTH HISTORY:
1. Childhood Illness: He experienced measles, mumps and chickenpox during his elementary grades; he also
experienced common cough and colds.
2. Immunization: According to the mother the only vaccine was not given to him is a Hepa-B vaccine. To
breakdown the vaccines given: He was immunized with BCG, 3 doses of DPT and 3 doses of OPV including 3
doses of measles vaccine. And he was immunized also with a flu vaccine last week of May.
3. Major Illness: No known major illness.
4. Current Medications: Patients only current medication PTA is a vitamin supplement (Ascorbic Acid-Poten-
Cee).
5. Allergies: Patient is not allergic to any drugs, and no known allergies to any foods.


E. FAMILY ASSESSMENT:

Name Relation Age Sex Occupation Educational Attainment
Mrs. M.E Mother 60 Female Housewife College graduate
Mr. F.E Father 62 Male Retired Teacher College graduate
Ms. I Sister 35 Female Teacher College graduate
Ms. J Sister 32 Female Nurse College graduate
Ms. F Sister 31 Female Caregiver College undergraduate

F. SYSTEM REVIEW:
1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN
Clients Perception of Health: He perceived health as Kung may nararamdaman kana maiging mag pa
check-up ka na, hindi iyong hihintayin mong lumala pa, mas okay pag healthy ka lagi kasi.
Clients Perception about Illness: Perceived illness as pag may sakit ka naapektuhan talaga lahat,
pati trabaho, madaming gastos.
Health Maintenance and Habits: He said para maging physically fit ako, kailangan tama lang iyong
kinakain ko, tapos nag i exercise ako pagkagising, at saka my work naman ako kaya okay naman at
syempre kailangan din ang hygiene, kailangan laging malinis.
Compliance with prescribed medications and treatment:
2. NUTRITIONAL METABOLIC PATTERN:
Prior to Admission:
Appetite: He has a good appetite; he eats all what foods are prepared in their house.
Usual Daily Menu:
Food Vegetables, fried fish, pork meals, including preserved foods like hotdogs, tocino and
hams.
Water 4-5 glasses of water per day
Beverages He drinks juices, when it comes to liquor he drinks occasionally (once in 2 months).

During Confinement:
Appetite: He has a good appetite; he eat foods given at lunch and supper, he was under NPO at August
28, 2013 post-midnight, and at August 29, 2013 morning he undergone Herniorrhapy thats why foods and
fluids are restricted for few hours.



3. ELIMINATION PATTERN
Prior to admission
Bowel Habits:
Color: Brown
Odor: Foul
Consistency: 1-2 times a day
Laxative use: none
If any: none
Bladder Habits:
Color: yellow
Odor: aromatic
Consistency: 4-5 times a day
Alteration if any: None

During confinement:

Bowel Habits:
Color: Brown
Odor: Foul
Consistency: 1times a day
Laxative use: none
If any: none
Bladder Habits:
Color: yellow
Odor: aromatic
Consistency: 5-7 times a day
Alteration if any: None

4. ACTIVITY- EXERCISE PATTERN- Self care ability
Prior to Admission:
0- Feeding 0- Dressing 0- Grooming
0- Bathing 0- Toileting 0- Cooking
0- Bed mobility 0- Home maintenance

During Confinement:
0- Feeding I- Dressing 0- Grooming
I- Bathing 0- Toileting
0- Bed mobility 0-
Legend:
0- Full Care.
I- Requires use of assistance .
II- Requires assistance and supervisions by others.
III- Requires assistance or supervisions from another and equipments and devices.
IV Dependent, doesnt participate.

5. COGNITIVE PERCEPTUAL PATTERN
Hearing: He can hear normal conversations in the room.
Vision: He can see clearly from across the room and he doesnt wear eyeglasses.
Sensory: He is able to feel when touched. He can taste his food and he can differentiate various
kinds of scent.
Learning Styles: He can follow instructions and listens and responds to the interview appropriately.

6. SLEEP- REST PATTERN
Sleep habits: He does sometimes watching television in his room while lying on bed, but usually
because of his work shifts it varies and he just lie on be and go asleep.
Sleeping problems: None
Hours of sleep: Maximum of 6 hours
Sleeping alterations: None
Sleeping aids: He uses two pillows.

7. SELF- PERCEPTION AND SELF- CONCEPT PATTERN
Feeling about current state: Mabuti naoperahan na din ako, para hindi ko na din ito prinoproblema,
sabi naman ng doctor mabilis naman makarecover sa ganito, okay naman ako ngayon as verbalized.
Description of self: Gusto ko laging tulungan ang mga magulang ko dahil matanda na din sila, mabait
ako, mapagmahal sa family pati sa mga kaibigan at mga katrabaho as verbalized.
Known capabilities and weaknesses: He can dance and sing well but no known weaknesses.
Self-worth: Mahal ko ang sarili ko, kaya nag desisyon na ako na mag pa opera, para hindi na din ako
mahirapan as verbalized.

8. ROLE- RELATIONSHIP PATTERN
kailangan kong tumulong sa mga magulang ko, kailangan kong magtrabaho lagi para masustentuhan din
sila hindi lang ang sarili ko as verbalized.
Sa community naman, sumusunod naman ako sa mga rules na sinasabi nila as verbalized.

9. SEXUALITY- REPRODUCTIVE PATTERN
He was circumcised when he was 10 years old.

10. COPING- STRESS TOLERANCE PATTERN
Perception of stress and problems: Yang mga problema part ng buhay, hindi mo kailangan problemahin,
gawan mo lang ng tamang solusyon, matatapos din yan as verbalized.
Coping methods and support systems: Lagi lang akong nagdarasal, wala ng iba pag hindi ko na kaya
sinsabi ko naman kila mamat papa as verbalized.

11. VALUE- BELIEF PATTREN
Values, goals and philosophical beliefs: Naniniwala ako na mayroong Diyos, nag iisa lang siya as
verbalized.
Religious and spiritual beliefs: kailangan mong manampalataya lagi sa kanya as verbalized.



G. HEREDO- FAMILIAL ILLNESS






Legend:
- Hypertension
H. DEVELOPMENTAL HISTORY
Theorist Age Sex Normal Patients Description
Erick
Erickson

Young
Adulthood
Intimacy
Vs.
Isolation
(18-35
years
old)
27 Male
Occurring in young adulthood (ages
18 to 40); we begin to share
ourselves more intimately with
others. Successful completion of
this stage can lead to comfortable
relationships and a sense of
commitment, safety, and care within
a relationship. Avoiding intimacy,
fearing commitment and relationships
can lead to isolation, loneliness,
and sometimes depression.

During hospitalization
the patients family
support was very
significant to him.
He is happy when his
friends visited him post-
operatively.


Grandfather Grandmother
Grandmother
Grandfather
Father Mother
Patient
HPN
HPN HPN HPN
HPN
I. PHYSICAL ASSESSMENT
A. General Survey
1. Overall appearance and grooming: The patient was lying on bed, conscious and coherent, and appeared
sleepy.
2. Actual height and weight vs. ideal body weight: He stands about 59 (70.8 inches) and weighs about 68 kg
(149.6 lbs).


BMI

=

=20.98/normal
3. Symptoms of distress: Masakit iyong sugat ko as verbalized with pain scale of 7/10, napansin kong
namumula iyong sugat ko as verbalized.
4. Posture and gait: Patients posture and gait are not assessed because he is remained flat on bed after
the surgery.
5. Affect and mood: The patients mood was appropriate to verbal responses.
6. Relevance and organization of thoughts: The patients thought was organized, and answers are relevance
to questions being asked.
7. Vital signs of the day of physical examination (1:30 pm)
Temperature: 36.9 Respiratory rate: 17 breaths per minute
Pulse rate: 87 beats per minute Blood pressure: 120/80 mmHg

B. Regional exam- utilize IPPA technique
1. Hair: Hair is evenly distributed, thick, its texture is dull and smooth and no presence of
infestation noted.
2. Head and face: Clients head is normocephalic. Its circumference is 55 cm. Skull has a smooth
contour. No deformities, nodules or masses were noted. Client has symmetrical facial features. Facial
skin color is the same with the other body parts. No edema and hollowness were noted. Facial
movements are symmetric.

3. Eyes: Clients eyebrows are symmetric and move at the same time. Skin around eyes is intact.
Eyelashes are evenly distributed. No presence of lesions and tenderness on eyelids. Both eyes blink
at the same time. Sclerae are whitish. No swelling was noted. Pupils are black, round and have smooth
borders. Client can see object on the periphery. Both eyes have coordinated movement. He could read
signs from across the room and could read prints at a closer range.

4. Nose: Clients nose is straight and symmetric. Its color is uniform and the same as the facial skin.
No flaring or nasal discharge was observed. No presence of tenderness and masses was noted. Nasal
hair is present. Nasal septum is intact and in midline.

5. Ears: Clients ears are symmetrical in size and aligned with outer canthus. Both auricles are firm,
mobile and returned back to their normal position after being folded. No presence of tenderness and
lesions were noted. There is presence of earwax in both ears. Client is able to hear normal
conversation in the room.

6. Mouth and throat: Clients lips are pinkish and moist. Contour is symmetric and client was able to
pursed lips. Buccal mucosae are pinkish. He doesnt wear dentures. Teeth are whitish. Gums are
pinkish. Clients tongue is in midline, pinkish in color. It moves freely without tenderness. Hard
palate is pinkish. Soft palate is smooth and pinkish in color. Uvula is at midline of soft palate.
Tonsils are slightly pinkish and smooth. No presence of inflammation. Gag reflex was elicited.

7. Neck and lymph nodes: Clients head is on the center of the neck. Both sides of the neck are
symmetric. Skin is intact and free of lesion. Client was able to move neck without any discomfort.
Lymph nodes are not palpable.

8. Skin: Skin color is the same with the color of other parts of the body and extremities are warm to
touch and slightly pinkish in color.

9. Nails: Clients nail beds are pinkish. Capillary refill is 1-2 seconds. Nails are strongly attached
to nail beds. No sign of clubbing was noted.

10. Thorax and lungs: No tenderness upon palpation. Respiration is 17 breaths per minute.
11. Cardiovascular: Pulse rate is 87 beats per minute with evenly spaced beats. Blood pressure is
120/80 mm Hg. Capillary refill is 1-2 seconds.
12. Breast and axilla: No presence of gynecomastia. There is presence of dark, coarse hair on
clients axillae. Lymph nodes are not palpable and there is no tenderness upon palpation.

13. Abdomen: There is presence of surgical incision in the right lower abdomen approximately 8-9 cm
in length. Presence of redness in the incision site noted and positive pruritus noted as verbalized
by the patient. Borborygmus was not audible upon auscultation.

14. Musculoskeletal/Extremities: Client is able to protract and retract his mandible without any
pain. He is able to move and rotate his neck without any abnormal sound and pain. Spine is in
midline. Shoulders are symmetric and firm. Able to rotate. No deformities on 10 fingers. Able to move
hands and wrist without pain. No deformities on 10 toes.
15. Genitals: Presence of indwelling foley catheter, which is intact to urine bag draining at 200
cc level with amber yellow color of urine. No presence of pubic hair upon inspection. Testicles
16. Neurological/Cranial nerves: Client is oriented to person, time and place. He is able to follow
instructions. He speaks clearly and responds to questions appropriately. Mood is appropriate to
verbal responses.
I-Olfactory: Patient was able to detect and correctly identifies three odors. (Alcohol, coffee, and soft
drink).
II-Optic: He could read signs from across the room and could read prints at a closer range.
III-Occulumotor: Eyes move smoothly and bilaterally in six cardinal fields of gaze.
IV-Trochlear: Eyes moves smoothly in upward and downward movements.
V-Trigeminal: Patient can clench teeth tightly. Masseter muscles bulge when teeth are clenched. On
palpation, both masseter muscles feel equal in size and strength. Patient was able to identify the same
facial and temperature sensation bilaterally, and tells when and where he feels it.
VI-Facial: With symmetrical facial contours, lines, wrinkles, with symmetrical facial movement. Patient
was able to retained puffed cheeks despite of efforts to collapse them. And able to resists efforts.
VII- Abducens: Eyes moves smoothly in sideward movements.
VIII- Acoustic: With equal hearing in both ears. Other cranial nerves functions are not assessed.
II. PERSONAL/SOCIAL HISTORY
A. Habits
a. Caffeine: 3-5 cups of coffee per day.
b. Smoking: Not
c. Alcohol: Occasionally
d. Tea: Not
e. Drugs: Not

B. Lifestyle: Simple lang naman ang buhay namin, at nabibili naman ang mga needs and wants as verbalized.
C. Social Affiliation: None
D. Rank in the family: 4
th
child
E. Travel (within 6 months): None
F. Educational Attainment: College undergraduate (Bachelor of Science in Commerce).

III. ENVIRONMENTAL HISTORY
According to our client, he lives with his parents in a concrete house with adequate living space. The
house is located a few meters away from a local road. Their water supply comes from the water district
through faucets. However, they buy drinking water from a refilling station. Their toilet is flushed with
water. Their garbage is burned in a pit in their backyard. They have neighbors, in which they live in a
one compound composed of their relatives. The nearest hospital at their place was Urdaneta sacred Heart
hospital likewise the clinic was Urdaneta Health Center.



IV. INTRODUCTION

An inguinal hernia is an abdominal fat or part of the intestine slides through a weak area at the inguinal
ring, the opening to the inguinal canal. It can occur any time
from infancy to adulthood and is much more common in males
than females. Inguinal hernias tend to become larger with
time.
Lifting heavy objects, sudden twists, pulls and or muscle
strains are the following factors can cause pressure on the
abdominal muscles and may worsen the hernia.
The signs and symptoms are:
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

To diagnose inguinal hernia, a thorough physical examination
is to be done. The surgery done to our patient is an Open hernia repair. In open hernia repair, also called
HERNIORRHAPHY, the surgeon makes an incision in the groin, moves the hernia back into the abdomen, and
reinforces the muscle wall with stitches. Usually the area of muscle weakness is reinforced with a synthetic
mesh or screen to provide additional support an operation called HERNIOPLASTY

V. ANTOMY AND PHYSIOLOGY

The inguinal canal is approximately 4 cm long.
Directed obliquely infero-medially through the inferior part
of the anterolateral abdominal wall. The canal lays parallel
and 2-4 cm superior to the medial half of the inguinal
ligament.
This ligament extends from the anterior superior iliac spine
to the pubic tubercle.
It is the lower free edge of the external oblique
aponeurosis.
The main occupant of the inguinal canal is the spermatic
cord in males and the round ligament of the uterus in
females.
The canal also transmits the blood and lymphatic vessels and
the ilio-inguinal nerve (L1 collateral) from the lumbar
plexus forming within psoas major muscle.
For the passage of the spermatic cord from the scrotum to
the abdominal cavity.

VI. PATHOPHYSIOLOGY














































Predisposing factors:
Gender Male- 25 times more
often than females, 9:1 ratio
Age- 27 years old
Precipitating factors:
Occupation- heavy lifting
Increased abdominal pressure developed
Intra-abdominal wall of the inguinal ring
into the scrotum becomes weakened
Part of the intestines slides through a
weak area of the inguinal canal
Defects in the muscular wall of the inguinal ring
Intestines descends in the scrotum
Causing the inguinal ring not to close well
Evolves into a hole or defect
Inguinal mass right Pain in the groin Swelling in the right testicle
INGUINAL HERNIA
MESH HERNIORRHAPY
Post-operative:
Acute pain related to postsurgical incision.
Impaired skin integrity related to postsurgical incision.
Risk for infection related to inadequate primary defense: broken skin.
VII. LABORATORY RESULTS AND DIAGNOSTIC EXAMINATIONS











DATE TYPE OF EXAMINATION RESULTS REFERENCE RANGE SIGNIFICANCE
August 28, 2013 COMPLETE BLOOD COUNT (CBC)
Red blood cells
(RBC)
5.49 3.8-5.4 Normal
Hemoglobin (HGB) 14.9 g/L 12-16 g/L Normal
Hematocrit (HCT) 46.7 38-47 Normal
White blood cells
(WBC)
7.4 5-10.0 Normal
Platelet (PLT) 355 150-400 Normal

Creatinine 1.2 mg/dL M:0.5-1.5 md/dL Normal
Blood Urea Nitrogen (BUN) 16.23 mg/dL 5-23 md/dL Normal

CHEST X-RAY PA Lung fields are clear
and normovascular,
Heart is not enlarged
with normal,
Great vessels,
diaphragm,
costophrenic recesses
are unremarkable,
Intact bony ribs.


Normal
URINALYSIS

Color: Yellow
Transparency: Clear
Reaction: Alkaline (7.5)
Specific gravity: 1.015 (Normal)
Sugar: Normal
Pus cells: 0
RBC: 0
Epithelial cells: Rare
Bacteria: Rare
Mucus Threads: Rare
VIII. DRUG STUDY

Generic Name: Cefoxitin
Brand Name: Foxitin
Drug Classification: Antibiotic, 2
nd
generation Cephalosporins
Dosage: 1 gram IV every 8 hours
Indication: Prophylaxis


Mechanism of Action

Adverse Effect

Contraindication

Side Effect

Nursing Interventions
Inhibits bacterial
cell wall synthesis,
by binding to one or
more of the
penicillin binding
proteins; inhibits
final
transpeptidation
step of
peptidoglycan
synthesis, resulting
in cell wall death.
Nephrotoxicity
Thrombocytope-
nia
Anaphylaxis
Hypersensitivity to
drugs containing
cephalosphorins.
Diarrhea Assess bowel pattern.
Replace fluids and
electrolytes losses.
Advise or provide good
perianal care. Diarrheal
stool is oftentimes highly
acidic. This causes anal
soreness and irritation in
the perianal area.
Promote rest because it
reduces peristalsis.
Diet:
Small amounts of
bland foods.
Low fiber diet.
BRAT diet (banana,
rice, apple, tea).
Avoid excessively hot
or cold fluids
because these are
stimulants.
Potassium rich foods
and fluids.
Perform skin test and if
ANST was noted drug can be
administered.
Observe the protocol for
drug preparation.
Administer the drug
properly.






Generic Name: Omeprazole
Brand Name: Zefzon
Drug Classification: Anti-ulcer, proton pump inhibitor
Dosage: 40 mg IV once a day
Indication: Preoperative and post-operative patients.


Mechanism of Action

Adverse Effect

Contraindication

Side Effects

Nursing Interventions
Suppresses gastric
secretion by
inhibiting hydrogen
or potassium ATPase
enzyme system in the
gastric parietal
cell; characterized
as a gastric acid
pump inhibitor,
since it blocks the
final step of acid
production.
Hematuria
Pancytopenia

Hypersensitivity to
the drug.
Headache





Dizziness






Diarrhea

Instruct patient to report
pain immediately if pain
arises.
Promote a quiet environment
and bed rest

Keep bed in low position
with side rails up.
Instruct and assist client
to rise and change
positions slowly in order
to reduce dizziness.

Assess bowel pattern.
Replace fluids and
electrolytes losses.
Diet:
Small amounts of
bland foods.
Low fiber diet.
BRAT diet (banana,
rice, apple, tea).
Avoid excessively hot
or cold fluids
because these are
stimulants.
Potassium rich foods
and fluids.
Perform skin test and if
ANST was noted drug can be
administered.
Observe the protocol for
drug preparation.
Administer the drug
properly.


Generic Name: Kerolac
Brand Name: Ketanov
Drug Classification: NSAID, Non-Opioid analgesic
Dosage: 30 mg IV every 8 hours times 3 doses
Indication: For pain


Mechanism of Action

Adverse Effect

Contraindication

Side Effects

Nursing Interventions
Inhibits
prostaglandins
synthesis in body
tissues by
inhibiting at
cyclooxygenase 2
isoenzymes; leading
to analgesic and
anti-inflammatory
effects.
Nephrotoxicity
Blood
dyscrasias

Hypersensitivity to
the drug.
Drowsiness












Nausea





Vomiting






Explain that drowsiness is
a usual symptom may be
present.

Keep bed side rails up to
prevent from injury

Instruct and assist client
to rise and change
positions slowly to reduce
drowsiness.

Relieve sensation of nausea
by providing ice chips.
Position the patient to
semi-high fowlers position
to prevent from aspiration.

Provide good oral measures
Administer metoclopramide
as ordered.

Perform skin test and if
ANST was noted drug can be
administered.
Observe the protocol for
drug preparation.
Administer the drug
properly.







Generic Name: Metoclopramide
Brand Name: Plasil
Drug Classification: Anti-emetic
Dosage: 10 mg IV every 8 hours as needed
Indication: For nausea and vomiting


Mechanism of Action

Adverse Effect

Contraindication

Side Effect

Nursing Interventions
Blocks dopamine
receptors in
chemoreceptor
trigger zone of CNS
and sensitizes to
acetylcholine;
increases upper GI
motility but not
secretions;
increases lower
esophageal sphincter
tone.
Pancytopenia

Hypersensitivity to
the drug.
Sedation










Explain that sleepiness and
drowsiness is a usual
symptom may be present.
Keep bed side rails up to
prevent from injury.
Promote bed rest.
Instruct and assist client
to rise and change
positions slowly.
Perform skin test and if
ANST was noted drug can be
administered.
Observe the protocol for
drug preparation.
Administer the drug
properly.






















IX. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY:

1. Acute pain related to postsurgical incision.
2. Impaired skin integrity related to postsurgical incision.
3. Risk for infection related to inadequate primary defense: broken skin.


X. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective:

Pain scale of
7/10 as
verbalized.

Objective:
Right
lower
quadrant
incision
(approxi
mately
8-9 cm)
Guarding
behavior
Facial
mask of
pain

Vital signs:
BP=120/80 mmHg
PR=87bpm
RR=17
breaths/min
Temp= 36.9









Acute pain
related to
postsurgi-
cal
incision.
After 1
hour of
nursing
interventi
ons the
patients
pain will
be
alleviated
from a
scale of
7/10-2/10.
Assess the nature of
pain.

Monitor vital signs.





Eliminate additional
stressors of discomfort
whenever possible.





Elevate the head of the
bed 25-30 degrees if not
contraindicated.
Provide comfort measures
(relaxation exercises,
biofeedback, breathing
exercises and music
therapy.

Appropriate pain
management will provide
comfort.
Heart rate, respiratory
rate and temperature
which are usually altered
in acute pain.
Patients may experience
exaggeration of in pain
or decrease ability to
tolerate painful stimuli
if environmental,
intrapersonal factors are
further stressing them.
To reduce abdominal
tension and helps
relieving pain.
To promote non
pharmacological pain
management. Techniques
are used to bring about a
state of physical and
mental awareness and
Goal
Partially
Met:

After 1 hour
of nursing
interventions
the patients
pain
alleviated
from a scale
of 7/10-3/10.
























Provide rest periods to
facilitate sleep and
relaxation.

Administer Ketorolac as
ordered.








Document the patients
response to pain
medication
tranquility. The goal of
these techniques is to
reduce tension,
subsequently reducing
pain.
Pain may result from
fatigue, which may
exaggerate pain and
exhaustion.

This drug inhibits
ascending pain pathway in
limbic system, thalamus,
midbrain, and
hypothalamus by binding
to cyclooxygenase 2
receptor sites, thus
altering pain perception
and response.
Patients have
individualized pain
tolerance levels.














ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective:
Napansin ko
namumula iyong
sugat ko as
verbalized.

Objective:

Right
lower
quadrant
incision
(approxim
ately 8-9
cm).
Redness
at
incision
site
noted.
(+)
pruritus
noted.




Impaired
skin
integrity
related to
postsurgical
incision.
After 1-2
hours of
nursing
interventions
the patient
will be able
to show signs
of wound
healing after
48 hours as
evidenced by
intact wound,
wound is less
than 8.5 cm
in length,
absence of
redness and
absence of
pruritus in
the wound.
Assess characteristics
of the incision site
(color, texture,
temperature, and
hydration) using
aseptic technique.

Assess wound for
intactness.



Assess condition of
stitches and report any
closures that appear to
have loosened or fallen
out.



Assess wounds and
dressings for
suspicious drainage


Emphasize the
importance of hand
washing before contact
with the post-operative
patient.
Presence of
abnormal
characteristics
predisposes the
wound to separate
and infection

Wound dehiscence
occurs with
excessive stress on
a new incision

Especially
important during
the first 48 hours
before wound
strength begins to
develop

Presence of yellow,
green or brown
fluid indicates
presence of
fistula.

Hand washing
remains the most
effective
prevention of
infection
Goal Met:
After 2 hours
of nursing
interventions
the patient
showed signs of
wound healing
as evidenced by
intact wound,
wound is 7.5 cm
in length,
absence of
redness and
absence of
pruritus in the
wound.

Use aseptic technique
during wound dressing.




Periodically assess the
wound


Advise the significant
to start mobilizing or
changing position every
2 hours.

Limits the
introduction of
pathogens


To monitor progress
of wound healing.


It promotes proper
circulation.



























ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Objective:

Right
lower
quadrant
incision
(approxim
ately 8-9
cm).
Redness
at
incision
site
noted.
(+)
pruritus
noted.




Risk for
infection
related to
inadequate
primary
defense:
broken skin.
After 1-2
hours of
nursing
interventions
the patient
will be able
to remain
free from
infection for
48 hours, as
evidenced by
absent of
purulent
discharge
from wound
site.
Monitor for the following
for signs of infection:
Swelling, increased pain;
purulent discharge.





Elevated temperature.







Color of respiratory
secretions if present.



Appearance of urine.




Monitor white blood cell
count.



Any suspicious
drainage should be
cultured; antibiotic
therapy is determined
by pathogens
identified at
culture.
Temperature greater
than 37.7 may
suggests infection;
very high temperature
accompanied by
swelling and chills
may indicate
septicemia.
Yellow or yellow
green sputum is
indicative of
respiratory
infection.
Cloudy, foul-smelling
urine with visible
sediment is
indicative of urinary
tract infection.
An increasing WBC count
indicates the bodys
efforts to combat
Goal Met:
After 1 hour
of nursing
interventions
the patient was
able to remain
free from
infection after
48 hours, as
evidenced by
absent of
purulent
discharge from
wound site.

Assess for exposure to
individuals with active
infections.
Maintain asepsis for
dressing changes and wound
care, catheter care and
handling; and peripheral
IV.
Wash hands and teach other
caregivers to wash hands
before contact with
patients and between
procedures with the
patient.



Encourage intake of
protein and calorie rich
foods.


Encourage fluid intake of
2-3 L per day if not
contraindicated.
pathogens.
This provides warning
for potential
infection.
Use of aseptic
technique decreases the
chances of transmitting
pathogens to patient.

Friction and running
water effectively
remove microorganisms
from hands. Washing
between procedures
reduces the risk of
transmitting pathogens
from one area to
another.
Thus maintain optimal
nutritional status.
Protein is needed for
the repair and growth
of cells.
Fluids promote diluted
urine and frequent
emptying of bladder;
reducing stasis of
urine, in turn, reduces
the risk of bladder
infection.

XI. ONGOING APPRAISAL

August 29, 2013 10:30 AM

Client was transferred to recovery room after the operation. With ongoing IVF of 5% Dextrose in Lactated
Ringers Solution at 650 cc level infusing at 30 gtts/min. With IFC intact to urine bad draining at 100 cc
level with urine color of light yellow. Client was placed on supine position. Ensured safety by raising the
side rails. Cardiac monitor and SpO2 were placed and monitored. Vital signs were taken every 15 minutes for 2
hours as follows:
10:30
BP: 130/90
RR: 23
PR: 97
Temp: 37.2
SpO2: 100%
10:45
BP: 130/80
RR: 24
PR: 98
Temp: 37.4
SpO2: 99%
11:00
BP:130/90
RR:22
PR:99
Temp: 37.1
SpO2: 99%
11:15
BP: 130/80
RR: 21
PR:97
Temp: 37.0
SpO2:100%
11:30
BP: 130/80
RR: 20
PR: 98
Temp: 37.1
SpO2: 100%
11:45
BP:120/90
RR: 21
PR: 96
Temp: 36.9
SpO2:99%
12:00
BP:120/90
RR:21
PR: 97
Temp: 37.0
SpO2:100%
12:15
BP:120/980
RR: 20
PR:98
Temp:37.0
SpO2:99%
12:30
BP:120/80
RR: 22
PR: 97
Temp: 36.8
SpO2:100%


August 29, 2013 1:30 PM

He was lying flat on bed awake. With ongoing IVF of 5% Dextrose in Lactated Ringers Solution at 300 cc
level infusing at 30 gtts/min. With IFC intact to urine bad draining at 200 cc level with urine color of
light yellow. Vital signs taken as follows:
Temperature: 36.9 Respiratory rate: 17 breaths per minute
Pulse rate: 87 beats per minute Blood pressure: 120/80 mmHg

XII. DISCHARGE PLAN
Medication: Instructed client the importance of adhering to any medication regimen prescribed by the doctor.
Exercise: Encouraged gradual, progressive increasing activity with rest periods.
Treatment: Instructed client the importance of working with the doctor to monitor his condition because other
testing and treatment may be required to prevent future complications.
Clinical Follow-up: Explained the need of maintaining regular medical checkups.
Diet: Emphasized the importance of eating a well-balanced diet or adhering to an indicated nutritional intake.


In partial fulfillment in the Requirements of RLE NCM 106
Urdaneta Sacred Heart Hospital, Inc
1
st
semester. S.Y. 2013-2014
Presented to the College of Nursing

A Case Study of a 27 year old male, with Inguinal Hernia who underwent Mesh Herniorrhapy

LENDL DEO V. OSIAS, RN, MAN
CLINICAL- INSTRUCTOR

Presented By: BSN-IV, Group 6
TADOKORO, KAORI
TALIO, RUSSEL
TAEDO, MHAR EDLIRRAINE
TAMBOT, PATRICK DOMINIC
UMIPIG, ROBIN
VALDEZ, GRETCHEN
VENTURA, MARK DANIEL
VICTORIO, LILIBETH
YABES, JOANNA MARIE