Posted: January 17th, 2023

NRSG370 Assessment Task 3: Case Study – Medical/Surgical

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NRSG370 Assessment Task 3: Case Study – Medical/Surgical #1
Bianca Lane, 20 years of age, Peritonitis following ruptured appendix
Ms. Bianca Lane presented to the Emergency department with a history of 2-3 days of severe Right Lower Quadrant abdominal pain, lack of appetite, nausea and fever.
She has a past medical history of asthma and depression, with her current prescribed and compliant medications list which includes:
• Salbutamol
• Seretide
• Sertraline
Physical examination of the abdomen and an ultra-sound diagnosed a perforated appendix, which required emergency laparoscopic surgery. Bianca is now 36 hours post-operative and her observations are as follows:
• BP 94/45mmHg
• HR 136
• Temp 38.5°Celcius
• RR 24/min and shallow
• SpO2 95% on room air
She has been complaining of increasing nausea, feeling ‘bloated’ and increasing centralised abdominal pain, that is worse with any movement and respiration, giving it a score of 7/10.
Physical examination identifies a distended rigid abdomen, with generalised abdominal guarding and no bowel sounds.
To investigate her condition further, a FBC, electrolytes, blood cultures and an abdominal X-ray were organised. Pathology results reveal a raised white blood cell (WBC) count and CRP, blood cultures are pending. Abdominal X-ray identifies oedematous and gaseous distention of the small and large bowel.
You are the RN caring for Melody post-operatively on the surgical ward.

Sample answer:

Inguinal Herman Repair
Student Name
Institutional Affiliation

Inguinal Herman Repair
Introduction
Open mesh inguinal hernia is among the common diseases which often occur in cases when the soft tissues protrude through a defect area or a weakness area on the lower abdominal muscles of a patient. In most cases, the soft tissues protruding occurs in the groin area or near the groin area. It is a common disease that has a high susceptibility rate affecting men compared to women in Australia. In evaluating the case presented, it is quite apparent that there are multiple risk factors that might play a significant role in triggering the occurrence of open inguinal hernia in multiple patients. The risk factors might correlate to the patients’ health background and might due to health risk factors such as obesity, or in some instances people who engage in weight lifting (Kulacoglu, Celasin, & Oztuna, 2019). Nurses are usually asked with the sole responsibility of acquiring historical data from the patent to understand potential risk factors which might have led to the occurrence of Open inguinal hernia among various patients. In this case, the report will aim at evaluating the current health situation of the patient through applying clinical reasoning to determine the health issues affecting the patient and identify a suitable health solution for the benefit of the patient.
Person’s situation
Mr Ling is a patient who has currently been admitted to the surgical ward after suffering from an open mesh inguinal hernia repair. Mr Ling and in-depth history of inguinal mass, an R non-reducible tender, and post beginning on a new gym weight lifting routine. In addition, the information offered by the patient indicates that he is suffering from obesity with a high body mass index of 30 and also a former smoker. The patient has also been recently diagnosed with hyperlipidemia and hypertension and has been subjected to strict medication. The other health issues affecting the patient is that he is currently suffering from mild congestive heart failure (Esposito et al., 2018). On health assessment conducted upon the patient, important signs highlighted by the patient is that he had a pain score of 7/10, blood pressure of 17/90, body temperature of 39.30C, RR: 25, SpO2 95% on room air, and HR:100 regular. The physical assessment conducted upon the patient indicated that he was often confused and restless, dry skin, green oozing released by post-op surgical wound which was also tender to touch. The other aspect noticed from the physical assessment was the left calf was red and larger than that of the right. The other significant elements indicated by the patient was that he had an elevated CRP, neutrophils, and WC, open bowels, and haemoglobin rate of 16.5 gm/dl.

Patient’s health information
In evaluating the information offered by Mr Ling during the health assessment period are vital in providing an overview of the health issue affecting the patient. One of the significant findings offered by the health assessment of Mr Ling is that he has a high body mass index of 30 which is a clear indicator that he is obese. The nursing tool indicates that a male having a BMI of 30.0 and above qualifies to be obese as the standard BMI of males is considered to be 18.2-24.9. Obesity is one of the significant risk factors which might lead to patients developing I as obesity plays a vital role in acting as a potential risk factor that might lead to the development of abdominal wall hernias (Wheeler et al., 2019). In this case, obesity is responsible for increasing the patents blood pressure to 17/90 and causing strain on the patient’s abdominal muscles thus leading to the abdominal muscles becoming weaker and more likely to develop hernia. In addition, an increase in weight over time weight is vital in promoting growth of the hernia on the patient (Dikshit et al., 2018). Health information offered by the patient highlights that he engages in weight lifting which is a potential risk factor. Studies conducted have indicated that if weight lifting is performed an improper manner, there is a high susceptibility rate that might lead to straining of abdominal muscles and thus leading to development of hernia (Molegraaf, Kaufmann, & Lange, 2018). The other primary symptom indicated by the patient is confusion which is likely caused by nausea. Dry skin and swelling are also a clear indicator of its symptoms which the patient is currently facing (Matikainen et al., 2018). The symptoms are due to bleeding which occurs within the incision thus leading to swelling and drying of the skin.
Nursing problems/issues
There are significant nursing issues based on information offered by health assessment procedure. One of the nursing issues highlighted by the patient historical data is the issue of obesity which is vividly indicated by the high BMI of 30 of Mr Ling. Obesity is a nursing issue linked to the condition as it will increase the patients’ blood pressure to 17/90 and causing strain on the patient’s abdominal muscles thus leading to the abdominal muscles becoming weaker and leading to the potential development of hernia. In addition, an increase in weight over time weight is vital in promoting growth of the hernia on the patient (Rausa et al., 2019). The other nursing problem indicated by Mr Ling correlates to his weightlifting behaviours which happen to be a significant risk factor. Weight lifting as mentioned, will play a vital role in causing the straining of abdominal muscles and thus leading to the development of hernia (Elkhateeb et al., 2019). The other major health issue indicated by the patient is the presence of dry skin and swelling releasing a green oozing and pain of the swollen area.
Goals
There will be the need for establishing nursing goals which will be associated with reducing or eliminating the nursing problems identified on the patient. One of the nursing goals will be to ensure that the swollen area and the green oozing being extracted and dry skin is included in the nursing care goals (Sultan et al., 2018). The other issue that will be required to be dealt with by the patient is through dealing with nausea affecting the patient’s well-being. The other nursing issue affecting the patient that will be needed to be handled with byte nursing care and high blood pressure.

The nursing care of the person
The nursing care help that will be subjected to the patient will be linked to the patient’s historical data. One of the nursing strategies which will be integrated into the care will be based on dealing with the issue of obesity. Obesity, as indicated, is linked to the high blood pressure levels affecting the patients that have led its development (Perez, & Krpata, 2018). The nursing strategy will be vital in ensuring that the patient is restricted to follow a strict diet routine with the core aim of reducing the BMI of the patient into a standard level (Huerta et al., 2018). The other nursing care strategy which will be considered will aim at offering Mr Ling a safe workout plan that will ensure that his working out activities fail to trigger the development of hernia of the patient (Morrison, 2018). The other suitable treatment procedure which can be administrated to the patient is through administration of an appropriate analgesic due to the severity of pain caused by the incision (Pavlosky et al., 2019). Application of ice to the incision will also be beneficial to the patient as it will lead to creating comfort towards by dealing with the green oozing being ejected by the wound.

Nursing Strategies
Lichtenstein’s repair is among the leading nursing strategies, which can be applied while dealing with pain and discomfort on the patient. In this case, laparoscopic methods will reduce the risk of chronic pain, which is causing discomfort on the patient (Sereysky et al., 2019). In this case, the most suitable meshes which will be applicable to the patient will be the lightweight meshes which will be useful in reducing chronic pain (Melkemichel, Bringman, & Widhe, B. 2019), (Vuille-dit-Bille et al., 2018). In addition, the nursing strategy will also have to take into consideration fixation technique of handling the chronic pain, and in this case glue will be more considerable in reducing discomfort caused by chronic pain in the patient. Surgery is also the other option that can be considered in the removal of mesh and triple neurectomy through application of a posterior strategy (Tan, & Blatnik, 2018).

Personal outcome

Based on the nursing strategies applied to the patient, the learning outcome of the procedure will be to identify a suitable nursing care method that will assist in eliminating the symptoms which the patient is currently facing (Van Hessen et al., 2018). The nursing strategies will play a significant function in offering guidelines for dealing with these patients.
Conclusion
All in all, open mesh inguinal hernia is a common disease that occurs in cases when the soft tissues protrude through a defect area or a weakness area on the lower abdominal muscles of a patient. The report applied clinical reasoning to determine the health issues affecting the patient and identify a suitable health solution for the benefit of the patient. It has a high susceptibility rate of affecting men compared to women in Australia. In evaluating the case, it is quite apparent multiple risk factors might trigger the occurrence of open inguinal hernia (Jacobsen, & Reynolds, 2018). Historical data acquired from the patients can be used by nurses to understand potential risk factors which might have led to the occurrence of the health condition. In this case, Lichtenstein repair, laparoscopic methods, and surgery can be applied in dealing with various symptoms correlating to open mesh inguinal hernia.

References
Dikshit, V., Jadhav, D., Ali, I., Mody, P., & Srivastava, N. (2018). Delayed complications after open inguinal hernia repair: a comparison of two techniques. International Surgery Journal, 5(8), 2742-2746.
Elkhateeb, A. I., Makhlouf, G. A., Hanna, R. S., Aly, M. S., & Shehata, A. M. (2019). Application of cyanoacrylate for mesh fixation in open inguinal hernia repair. The Egyptian Journal of Surgery, 38(1), 131.
Esposito, C., Escolino, M., Farina, A., Iannazzone, M., Cortese, G., Del Conte, F., … & Montupet, P. (2019). Laparoscopic Inguinal Hernia Repair. In ESPES Manual of Pediatric Minimally Invasive Surgery (pp. 519-524). Springer, Cham.
Huerta, S., Timmerman, C., Argo, M., Favela, J., Pham, T., Kukreja, S., … & Zhu, H. (2019). Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Outcomes and Predictors of Complications. Journal of Surgical Research, 241, 119-127.
Jacobsen, G. R., & Reynolds, J. L. (2018). Inguinal Hernia Repair in the Setting of Bowel Injury/Resection. In Surgical Principles in Inguinal Hernia Repair (pp. 149-151). Springer, Cham.
Kulacoglu, H., Celasin, H., & Oztuna, D. (2019). Individual mesh size for open anterior inguinal hernia repair: an anthropometric study in Turkish male patients. Hernia, 1-7.
Matikainen, M., Aro, E., Vironen, J., Kössi, J., Hulmi, T., Silvasti, S., … & Paajanen, H. (2018). Factors predicting chronic pain after open inguinal hernia repair: a regression analysis of randomized trial comparing three different meshes with three fixation methods (FinnMesh Study). Hernia, 22(5), 813-818.
Melkemichel, M., Bringman, S. A. W., & Widhe, B. O. O. (2019). Long-term Comparison of Recurrence Rates Between Different Lightweight and Heavyweight Meshes in Open Anterior Mesh Inguinal Hernia Repair: A Nationwide Population-based Register Study. Annals of surgery.
Molegraaf, M., Kaufmann, R., & Lange, J. (2018). Comparison of self-gripping mesh and sutured mesh in open inguinal hernia repair: a meta-analysis of long-term results. Surgery, 163(2), 351-360.
Morrison, J. (2018). A case for open inguinal hernia repair. International Journal of Abdominal Wall and Hernia Surgery, 1(3), 69.
Pavlosky, K. K., Vossler, J. D., Murayama, S. M., Moucharite, M. A., Murayama, K. M., & Mikami, D. J. (2019). Predictors of laparoscopic versus open inguinal hernia repair. Surgical endoscopy, 33(8), 2612-2619.
Perez, A. J., & Krpata, D. M. (2018). Preperitoneal (Stoppa) Open Inguinal Hernia Repair. In Surgical Principles in Inguinal Hernia Repair (pp. 45-51). Springer, Cham.
Rausa, E., Asti, E., Kelly, M. E., Aiolfi, A., Lovece, A., Bonitta, G., & Bonavina, L. (2019). Open inguinal hernia repair: A network meta-analysis comparing self-gripping mesh, suture fixation, and glue fixation. World journal of surgery, 43(2), 447-456.
Sereysky, J., Parsikia, A., Stone, M. E., Castaldi, M., & McNelis, J. (2019). Predictive factors for the development of surgical site infection in adults undergoing initial open inguinal hernia repair. Hernia, 1-6.
Sultan, A. A. E. A., Ismail, M. S. K., Salama, M. M., & ELAnany, M. I. (2018). Comparison between Cyanoacrylate, Sutureless and Polypropylene Sutures in Mesh Fixation on Lichtenstein Tension-free in the repair of Open Inguinal Hernia. The Egyptian Journal of Hospital Medicine (October 2018), 73(1), 5795-5806.
Tan, W. H., & Blatnik, J. A. (2018). Open Inguinal Hernia Repair. In Surgical Principles in Inguinal Hernia Repair (pp. 39-44). Springer, Cham.
Van Hessen, C. V., Roos, M. M., Frederix, G. W. J., Verleisdonk, E. J. M. M., Clevers, G. J., Davids, P. H. P., & Burgmans, J. P. J. (2018). One-stop routing for surgical interventions; a cost-analysis of endoscopic inguinal hernia repair. Improving TEP inguinal hernia repair, 107.
Vuille-dit-Bille, R. N., Fink, L., Leu, S., Soll, C., Villiger, P., & Staerkle, R. F. (2018). Long-term Quality of Life and Chronic Pain after Inguinal Hernia Repair in Women. Clin Surg, 3, 2007.
Wheeler, D. W., Bhatia, A., Mani, V., Kinna, S., Bell, A., Boyle, Y., … & Lee, M. C. (2019). Evaluation of Postsurgical Hyperalgesia and Sensitization After Open Inguinal Hernia Repair: A Useful Model for Neuropathic Pain?. The Journal of Pain.

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