2. Objectives
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At the end of this session, the participants will be able to:
Define hernia
Understand the epidemiology of hernia
Explain types of hernia
Express etiologies & clinical manifestations of hernia
Identify diagnostic evaluation & management of hernia
State how to develop nursing care plan for patient with hernia
Describe complications of hernia
3. Outlines
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Introduction to hernia
Epidemiology
Etiology
Pathophysiology
Clinical manifestations
Diagnostic evaluation
Differential diagnosis
Management of hernia
Nursing process & health education
Complications
References
4. Introduction to Hernia
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Definition
Hernia is a protrusion of a viscus through an abnormal opening or a weakened area
in the wall of the cavity in which it is normally contained.
Hernia may occur in any part of the body, but it usually occurs within the abdominal
cavity.
The most important elements in the development of hernia are congenital, muscle
weakness & increased intra-abdominal pressure.
5. Introduction Cont’d…
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Components
Sac: Is a diverticulum of peritoneum & is made up the mouth, neck & body of sac
Coverings: Derived from layers of the abdominal wall through which the sac passes
Contents: Can be anything from the omentum, intestines, ovary or urinary bladder
(NAJAH M. N. Rasikh, 2013)
6. Epidemiology
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According to United State statistics, 10% of the populations develop some types of
hernia during their life.
More than one million abdominal hernia repairs are performed each year
Inguinal hernia repairs constitute nearly 770,000 of these cases
Approximately 75% of all hernias are inguinal; 50% are indirect & 25% are direct
About 14% of hernias are umbilical
About 10% of hernias are incisional with F to M ratio of 2:1 (Matthews RD, 2008)
7. Cont.…..
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Only 3-5% of hernias are femoral
Interparietal, supravesical, lumbar, sciatic & perineal hernias are rare
According to international statistics, data from developing countries are limited
Consequently, accurate determinations of incidence & prevalence are unavailable
Current epidemiologic assessments suggest that gender & anatomic distributions are
similar to those in more developed countries
(Ruhl CE et al, 2007 & Rutkow IM et al, 2003)
8. Classification
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1. Reducible
Hernias that easily return to the abdominal cavity are called reducible
This type of hernia can be reduced manually or may reduce spontaneously when
the person lies down
Reducible hernia impacts an expansible impulse on coughing
2. Irreducible
If the hernia cannot be placed back into the abdominal cavity, it is known as
irreducible
9. Cont.….
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Incarcerated
There are adhesions between the sac & the contents, but there is no obstruction or
interference with blood supply
The hernia simply will not reduce
Obstructed
A hollow viscus is trapped within the sac & obstruction occurs
The blood supply remains intact
This is a common cause of small bowel obstruction
10. Cont.….
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Strangulated
The arterial blood supply to the contents of the sac is compromised
In such a hernia unless surgical relief is undertaken the contents of the sac will
become gangrenous
11. Cont.….
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SIR Hernia
S: Strangulated
Blood supply is cut off, emergency surgery situation
I: Incarcerated
Hernia is trapped outside the peritoneal cavity
R: Reducible:
Hernia moves back into the peritoneal cavity
13. Inguinal Hernia
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The inguinal hernia is the most common type of hernia and occurs at the point of
weakness in the abdominal wall.
75% of all abdominal wall hernias
More common in men (25%) than women (2%)
Direct inguinal hernia
Usually occur only in male adults and are caused by a weakness in the
muscles of the abdominal wall that develops over time
14. Indirect Inguinal Hernia
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Caused by a defect in the abdominal
wall that iscongenital, or presentat
birth
(Fitzgibbons RJ et al, 2015)
16. Femoral Hernia
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The femoral canal is the way that the femoral artery, vein, and nerve leave the
abdominal cavity to enter the thigh.
Although normally a tight space, sometimes it becomes large enough to allow
abdominal contents (usually intestine) into the canal.
This hernia causes a bulge below the inguinal crease in roughly the middle of the
thigh.
Rare & usually occurring in women, these hernias are particularly at risk of
becoming irreducible & strangulated.
17. Femoral Hernia Cont’d…
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Femoral hernias are more frequent in women
This is because of the wider shape of the
female pelvis
Femoral hernias are rare in children
Common in obese or pregnant women
(Stabilini C, 2023)
18. The Umbilical Hernia
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An umbilical hernia occurs when intestine, fat, or fluid pushes through a weak spot in the belly
This causes a bulge near the belly button, or navel
Congenital
Is common in newborns
Most close spontaneously by two to three years of age
Less than ½ inch –closes gradually by age two
Large hernias –surgery at age 2-4 years
Acquired
Increased in intra-abdominal pressure, commonly seen in obese or pregnant women
20. Ventral or Incisional Hernias
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Are due to weakness of the abdominal wall at the site of previous surgical incision.
Results from inadequate healing of the incision
This is b/c of postoperative wound infection, inadequate nutrition, & obesity
Occurs after 2-10% of all abdominal surgeries
May return even after surgical repair (20-45%)
(Bittner R. et al, 2014)
22. Epigastric Hernia
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o Occurs between the navel & the lower part of the rib cage in the midline of
the abdomen
o Usually composed of fatty tissue and rarely contain intestine
o Formed in the area of relative weakness of the abdominal wall
o Often painless and unable to be pushed back into the abdomen when first
discovered
24. Hiatal Hernia
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Part of the stomach protrudes up diaphragm into the chest
Two types hiatal hernia
Sliding Hiatus Hernia
The distal oesophagus and cardia slides into the thorax with an intact
gastroesophageal junction and therefore usually asymptomatic
Rolling Hiatus Hernia
Most of the stomach rolls into the thorax, the stomach may also undergo a twist
26. General Etiologies of Hernia
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Any condition that increases pressure in the intra-abdominal cavity may contribute to the
formation of hernia
Marked obesity
Heavy lifting things
Coughing or sneezing
Straining during a bowel movement or urination
Ascites, COPD
Pregnancy, birth defect or congenital
Hereditary/ Family history of hernia (Akbulut S. et al, 20110)
30. Clinical Manifestations
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A hernia may be readily visible, especially when the person tenses the abdominal
muscles.
Herniation may disappear when patient lies down.
There may be some discomfort as a result of tension.
If the hernia becomes strangulated, the patient will experience severe pain and
symptoms of a bowel obstruction, such as vomiting, cramping abdominal pain,
and distention.
31. Clinical Cont’d…
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Small to moderate size hernia don’t usually causes any symptoms.
Large hernia may be noticeable and cause some discomfort.
Pain when lifting heavy object
Tenderness
Bulging
Severe symptoms
Severe & sudden pain
Nausea & vomiting, & constipation
34. Management
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Non-medical Treatment
Avoid food that cause acid reflux or heartburn such as spicy food
Don’t lie down or bend over after a meal
Exercise
Stop smoking
Avoid gassy drinks
Avoid lift heavy object
35. Management Cont’d…
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Medical treatment
1. Antibiotic (used if the patient has strangulated hernia)
IV cefoxitin (Mefoxin) 1 g 6-8hourly
Ampicillin 250-500mg 6 hourly
2. H2 receptor blocker ( used if the patient with hiatal hernia)
Famotidine 40mg daily
Ranitidine 150mg BD
36. Management Cont’d…
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3. PPI ( used if the patient with hiatal hernia)
Lansoprazole 15-30mg daily
Osomeprazole 20-40mg daily
Omeprazole 20-40mg daily
Pantoprazole 20-40mg daily
4. Antianxiety Agents
Dormicum 7.5-15 mg PRN
5. NSAIDs (for patients with mild to moderate pain)
Ibuprofen (Advil) 100mg 6hourly
Ketoprofen 50-75mg 6hourly
37. Management Cont’d…
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Non-Surgical treatment
Truss (Inguinal hernia)
Some patients with hernias wear a truss, a pad placed over the hernia and held
in place with a belt.
The truss is worn to keep the hernia from protruding.
38. Management Cont’d…
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Surgical treatment
Nissen fundoplication
Is a laparoscopic procedure performed for patients with gastroesophageal reflux
disease
During this procedure, the upper part of the stomach is wrapped around the LES to
strengthen the sphincter, prevent acid reflux, and repair a hiatal hernia.
The Nissen fundoplication is usually performed as a laparoscopic (minimally
invasive) procedure.
39. Management Cont’d…
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Herniorrhaphy
Surgery is the treatment of choice for hernias and prevents strangulation
Treatment of hernias is by laparoscopic surgery
The surgical repair of a hernia is known as a herniorrhaphy
Involves returning the displaced tissues to their proper
Hernioplasty: Is a type of hernia repair surgery where a mesh patch is sewn over
the weakened region of tissue
41. Nursing Process
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Nursing Diagnosis
Pre-operative for hernia repair
Fear and anxiety related to undergoing surgery
Post-operative for hernia repair
Acute pain related to surgical intervention
Risk of infection related to surgical site
Hiatal hernia
Risk for aspiration related to reflux of gastric content
42. Nursing Process Cont’d…
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Nursing diagnosis
Fear and anxiety related to undergoing surgery
Goal
Patient’s fear and anxiety will be reduced
Intervention
Assess patient’s level of anxiety mild, moderate, severe or panic by interviewing the
patient to assess patient in an effective way to provide nursing care
Encourage patient to express his feeling or concern about the surgery due to
acknowledgement of his feeling can reduce anxiety
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Explain the details of surgery that patient will undergo to reduce his fear and anxiety
Emphasize doctor’s explanation to the patient to makes patient more clearly and
acknowledge about the procedure
Explain the possible outcomes about the surgery so patient have preparation of
facing it after the surgery
Encourage patient to use therapeutic touch techniques to promote comfort vice versa
Encourage patient listen to the smooth music to reduce the anxiety level
44. Nursing Process Cont’d…
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Encourage patient’s relatives stay by patient’s side before the day of surgery
to give emotional and spiritual support to the patient, so patient will reduce
the feeling of fear
Administer relaxant medication such as dormicum 7.5mg PRN to the patient
to reduce fear and anxiety
Evaluation
The patient’s level of anxiety towards surgery is reduced
45. Nursing Process Cont’d…
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Nursing diagnosis
Pain related to surgical site
Goal
Patient’s pain score will be reduced from 10 to 3 during hospitalization
Interventions
Assess patient vital sign such as blood pressure, temperature, pulse & respiration as
high blood pressure may indicate patient having pain
Assess patient for the pain score using numerical pain score to evaluate the severity
of the pain
46. Nursing Process Cont’d…
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Teach patient to put pillow at the surgical site while coughing to reduce pain and
pressure to the area
Teach patient deep breathing exercise and do frequent turning to relax the muscle &
promote venous return
Encourage patient to take high fiber and drink 1-2 liter per day if no contraindication
to prevent patient from constipation which can contribute pain during pass motion
Administer analgesic as ordered by the doctor. E.g. IM pethidine 50-150 mg 3-4hr or
PRN helps to minimize pain
47. Nursing Process Cont’d…
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Plan & limit patient’s activity to reduce the movement as more movement can cause
friction at the area
Assess patient’s surgical site for signs symptoms of infection as severe itchiness,
purulent exudates, redness & swelling and worsening pain indicates infection
Place patient in Trendenlenberg’s position to promote venous return & reduce
pressure on the hernia
Encourage patient reduce weight to minimize abdominal pressure from excess fats
48. Nursing Process Cont’d…
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In male a jock strap or suspensory bandage may be used it helps to provide support to the
area
Apply truss only after a hernia has been reduced. For best result apply it in the morning
before patient gets out of bed it provide support
Apply powder for protection surround the truss to prevent friction which can irritated the
skin area
Evaluation
Pain is reduced, evidenced by patient’s pain score has reduced from eight to four
49. Nursing Process Cont’d…
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Nursing diagnosis
High Risk of infection related to surgical incisions
Goal
Reduce the risk of infection during hospitalization
Intervention
Assess patient vital sign to detect if patient has fever which may indicates infection
Monitor the sign & symptoms of infection provide further treatment to the patient
Take swabs specimen for culture to detect the type of bacteria that cause infection
50. Nursing Process Cont’d…
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Maintain strict aseptic technique when perform dressing to decrease the spreading of
infection
Make sure to change the dressing when it’s fully soaked with blood, pus or when
necessary to prevent accumulation of the bacteria cause infections
Educate patient to perform effective hand wash after toileting, before meals &
after self-care as it can reduce the number of microorganisms
Encourage patient to take food high in protein & vitamin c to promote wound
healing & boost immune system
51. Nursing Process Cont’d…
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Ask patient to complete the course of antibiotic as doctor prescribed to prevent risk from
getting infections
Educate patient not to expose dressing unnecessarily & do not scratch the incision site to
prevent further tissue injuries & invading of microorganisms
Educate patient not to apply any lotion or powder that is not prescribed by the doctor to
prevent infections to the surgical site
Educate patient sign & symptoms of infection
Evaluation: Patient is free from infection during hospitalization
52. Nursing Process Cont’d…
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Nursing diagnosis
Risk for aspiration related to reflux of gastric content
Goal
Client will be able to fully understand & implement ways to prevent regurgitation &
aspiration
Interventions
Assess patient usual ways after meal to know and possibly correct improper way
that leads to regurgitation
53. Nursing Process Cont’d…
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Monitor client’s weight under standard condition to know and plan for
necessary weight reduction regime
Assess patient routine meal timing and amount to make necessary adjustment
Teach patient deep breathing exercise when feeling nauseated to help relax
the muscle on tension during forceful backing of gastric materials
Encourage patient to take high protein and low fat diet to minimize the
episodes of heartburn
54. Nursing Process Cont’d…
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If patient dependent, assist patient in elevate head of bed during meals and
30minutes to an hour after meal to facilitate movement of food & prevent
possibilities of backflow
Advice patient to take small but frequent meals to facilitate complete gastric
empty
Advice patient to take warm water or soup during meals to promote flushing
of digested material down the alimentary canal
55. Nursing Process Cont’d…
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Encourage patient to avoid taking meals 2hour before sleep. This is to prevent
backflow of the stomach content to the trachea
Administer antacids to minimize heartburn, gastric hyperacidity & reduce
regurgitation
Evaluation
Client has understood the ways to prevent regurgitation and aspiration
56. Health Education
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Educate patient to assess for any signs & symptoms of infection at the
surgical site
Advise patient come for follow-up to monitor patient progress/condition
Educate patient to avoid wearing tight clothing to minimize abdominal
pressure
Encourage patient avoid lifting heavy object or doing heavy exercise at least
six weeks
Use proper lifting technique
57. Health Education Cont’d….
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Maintain normal weight
Exercise regularly
Teach the client to avoid smoking
Advice patient to eat a vitamin-rich diet such as vitamin C and protein to
promote wound healing
Encourage patient to take high fiber food to prevent constipation
59. References
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Akbulut S, et al, (20110). A familial tendency for developing inguinal hernia: Study
of a single family
Bittner R. et al, (2014). Update of Guidelines for laparoscopic treatment of
ventral and incisional abdominal wall hernias
Stabilini C, (2023). International guidelines for groin hernia management
Fitzgibbons RJ et al, (2015). Clinical practice. Groin hernia in adults
Ruhl CE, et al, (2007). Risk factors for hernia among adults in the United State
population
