Rajiv Gandhi University of Health Sciences



PROFORMA FOR THE REGISTRATION OF SUBJECT FOR DISSERTATION

“A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING INGUINAL HERNIA AMONG INDUSTRIAL WORKERS IN SELECTED INDUSTRIES OF TUMKUR WITH A VIEW TO DEVELOP AN EDUCATIONAL PAMPHLET”

SUBMITTED BY;

JOSE CHERIAN

MEDICAL SURGICAL NURSING

RAMANAMAHARSHI COLLEGE OF NURSING

TUMKUR

2011-13

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BENGALURU, KARNATAKA

PROFORMA FOR THE REGISTRATION OF

SUBJECT FOR DISSERTATION

|1 |NAME OF CANDIDATE AND ADDRESS |Mr. JOSE CHERIAN |

| | |1 YEAR M Sc NURSING |

| | |RAMANAMAHARSHI COLLEGE OF NURSING, TUMKUR |

|2 |NAME OF THE INSTITUTION |RAMANAMAHARSHI COLLEGE OF NURSING |

|3 |COURSE STUDY AND |I YEAR M.SC. NURSING |

| |SUBJECT |MEDICAL SURGICAL NURSING |

|4 |DATE OF ADMISSION TO COURSE | |

|5 |TITLE OF THE TOPIC |A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME |

| | |ON KNOWLEDGE REGARDING INGUINAL HERNIA AMONG INDUSTRIAL WORKERS IN |

| | |SELECTED INDUSTRIES OF TUMKUR WITH A VIEW TO DEVELOP AN EDUCATIONAL |

| | |PAMPHLET |

6. BRIEF RESUME OF THE INTENDED WORK

Introduction

“To acquire knowledge one must study but to acquire wisdom one must observe”

An inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also called the small bowel, bulges through a weak area in the lower abdominal muscles. An inguinal hernia occurs in the groin—the area between the abdomen and thigh. This type of hernia is called inguinal because fat or part of the intestine slides through a weak area at the inguinal ring, the opening to the inguinal canal. An inguinal hernia appears as a bulge on one or both sides of the groin. An inguinal hernia 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.

The majority of hernias occur in males. Nearly 25% of men and only 2% of women in the United States will develop inguinal hernias. Inguinal hernias occur nearly three times more often in African American adults than in Caucasians. Among children, the risk of groin hernia is greater in premature infants or those of low birth weight. Indirect inguinal hernias will occur in 10–20 children in every 1,000 live births.

The inguinal ligament is a tight band located between the thigh and the stomach and there are several weak spots along it.

Obesity, pregnancy, heavy lifting, chronic coughing, constipation and straining to pass stools can cause the intestine to push against the abdominal wall, and a part of intestine may slip through a weak spot, creating a lump. This lump is called a hernia.

A hernia consists of a sac - the peritoneum - which may contain a piece of intestine (an intestinal loop). It is often able to move inside your body, meaning that it disappears when you lie down, and reappears when you stand up or are straining to pass a stool. The hernia itself is harmless.

However, a hernia can be dangerous if it gets trapped in the weak spot in the abdominal wall and becomes tender. This is known as a strangulated hernia. If the intestinal loop is damaged, its contents can leak out. Gangrene and peritonitis, which can be life-threatening, may occur as a result. Strangulation is an emergency requiring urgent surgery.

The two types of inguinal hernia have different causes.

Indirect inguinal hernia. Indirect inguinal hernias are congenital hernias and are much more common in males than females because of the way males develop in the womb. In a male fetus, the spermatic cord and both testicles—starting from an intra-abdominal location—normally descend through the inguinal canal into the scrotum, the sac that holds the testicles. Sometimes the entrance of the inguinal canal at the inguinal ring does not close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the small intestine slides through the weakness into the inguinal canal, causing a hernia. In females, an indirect inguinal hernia is caused by the female organs or the small intestine sliding into the groin through a weakness in the abdominal wall.

Indirect hernias are the most common type of inguinal hernia. Premature infants are especially at risk for indirect inguinal hernias because there is less time for the inguinal canal to close.

Direct inguinal hernia. Direct inguinal hernias are caused by connective tissue degeneration of the abdominal muscles, which causes weakening of the muscles during the adult years. Direct inguinal hernias occur only in males. The hernia involves fat or the small intestine sliding through the weak muscles into the groin. A direct hernia develops gradually because of continuous stress on the muscles. One or more of the following factors can cause pressure on the abdominal muscles and may worsen the hernia:

• sudden twists, pulls, or muscle strains

• lifting heavy objects

• straining on the toilet because of constipation

• weight gain

• chronic coughing

Indirect and direct inguinal hernias usually slide back and forth spontaneously through the inguinal canal and can often be moved back into the abdomen with gentle massage

Symptoms of inguinal hernia include:

• 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, the doctor takes a thorough medical history and conducts a physical examination. The person may be asked to stand and cough so the doctor can feel the hernia as it moves into the groin or scrotum. The doctor checks to see if the hernia can be gently massaged back into its proper position in the abdomen.

In adults, inguinal hernias that enlarge, cause symptoms, or become incarcerated are treated surgically. In infants and children, inguinal hernias are always operated on to prevent incarceration from occurring. Surgery is usually done on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient. The two main types of surgery for hernias are as follows:

• “Open” hernia repair. In open hernia repair, also called herniorrhaphy, usually the area of muscle weakness is reinforced with a synthetic mesh or screen to provide additional support—an operation called hernioplasty.

• Laparoscopy. Laparoscopic surgery is performed using general anesthesia. The surgeon makes several small incisions in the lower abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached to one end. The camera sends a magnified image from inside the body to a monitor, giving the surgeon a close-up view of the hernia and surrounding tissue. While viewing the monitor, the surgeon uses instruments to carefully repair the hernia using synthetic mesh1.

Diagnosis/Preparation

Reviewing the patient's symptoms and medical history are the first steps in diagnosing a hernia. The surgeon will ask when the patient first noticed a lump or bulge in the groin area, whether or not it has grown larger, and how much pain the patient is experiencing. The doctor will palpate the area, looking for any abnormal bulging or mass, and may ask the patient to cough or strain in order to see and feel the hernia more easily. This may be all that is needed to diagnose an inguinal hernia. To confirm the presence of the hernia, an ultrasound examination may be performed. The ultrasound scan will allow the doctor to visualize the hernia and to make sure that the bulge is not another type of abdominal mass such as a tumor or enlarged lymph gland. It is not usually possible to determine whether the hernia is direct or indirect until surgery is performed.

Preparation

Patients will have standard preoperative blood and urine tests, an electrocardiogram, and a chest x ray to make sure that the heart, lungs, and major organ systems are functioning well. A week or so before surgery, medications may be discontinued, especially aspirin or anticoagulant (blood-thinning) drugs. Starting the night before surgery, patients must not eat or drink anything. Once in the hospital, a tube may be placed into a vein in the arm (intravenous line) to deliver fluid and medication during surgery. A sedative may be given to relax the patient.

Aftercare

The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon. Patients should also report a fever, and men should report any pain or swelling of the testicles. The surgeon may remove the outer sutures in a follow-up visit about a week after surgery. Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair. To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery. The postoperative activities of patients undergoing repeat procedures may be even more restricted.

Prevention of indirect hernias, which are congenital, is not possible. However, preventing direct hernias and reducing the risk of recurrence of direct and indirect hernias can be accomplished by:

• maintaining body weight suitable for age and height

• strengthening abdominal muscles through regular exercise

• reducing abdominal pressure by avoiding constipation and the build-up of excess body fluids, achieved by adopting a high-fiber, low-salt diet

• lifting heavy objects in a safe, low-stress way, using arm and leg muscles2

If a hernia is not surgically repaired, an incarcerated or strangulated hernia can result, sometimes involving life-threatening bowel obstruction or ischemia.

6.1 NEED FOR THE STUDY

A hernia is a lump that results from a part of the intestine (bowel) slipping through a weakness in the abdominal wall. The most common hernias are inguinal hernias (groin hernias).

There are three types of inguinal hernia:

• indirect inguinal hernia which is common in children - they may be present at birth - and young people. They are mostly seen in males but can also occur in females.

• direct inguinal hernias mostly afflict adults especially middle-aged and elderly men.

• femoral hernia is rarer than the other types and mainly affects women.

The opinion of a specialist doctor is usually necessary to determine which type of hernia is present3.

Importance

• An inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also called the small bowel, bulges through a weak area in the lower abdominal muscles. An inguinal hernia occurs in the groin—the area between the abdomen and thigh.

• An inguinal hernia can occur any time from infancy to adulthood and is much more common in males than females.

• Direct and indirect hernias are the two types of inguinal hernia, and they have different causes.

• Symptoms of an inguinal hernia usually appear gradually and include a bulge in the groin, discomfort or sharp pain, a feeling of weakness or pressure in the groin, and a burning, gurgling, or aching feeling at the bulge.

• An incarcerated inguinal hernia is a hernia that becomes stuck in the groin or scrotum and cannot be massaged back into the abdomen.

• A strangulated hernia, in which the blood supply to the incarcerated small intestine is jeopardized, is a serious condition and requires immediate medical attention. Symptoms include extreme tenderness and redness in the area of the bulge, sudden pain that worsens quickly, fever, rapid heart rate, nausea, and vomiting.

• An inguinal hernia is diagnosed through a physical examination.

• Inguinal hernias may be repaired through surgery. Surgery is performed through one incision or with a laparoscope and several small incisions.

• Surgery for inguinal hernia is usually done on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient.

• Complications from inguinal hernia surgery are rare and can include general anesthesia complications, hernia recurrence, bleeding, wound infection, painful scar, and injury to internal organs4.

Description

About 75% of all hernias are classified as inguinal hernias, which are the most common type of hernia occurring in men and women as a result of the activities of normal living and aging. According to the National Center for Health Statistics, about 700,000 inguinal hernias are repaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus, which is one reason these hernias occur more frequently in men.

Hernias are divided into two categories: congenital (from birth), also called indirect hernias, and acquired, also called direct hernias. Among the 75% of hernias classified as inguinal hernias, 50% are indirect or congenital hernias, occurring when the inguinal canal entrance fails to close normally before birth. This condition is found in 2% of all adult males and in 1–2% of male children. Indirect inguinal hernias can occur in women, too, when abdominal pressure pushes folds of genital tissue into the inguinal canal opening. In fact, women will more likely have an indirect inguinal hernia than direct. Direct or acquired inguinal hernias occur when part of the large intestine protrudes through a weakened area of muscles in the groin.

About 60% of hernias found in children, A congenital indirect inguinal hernia may be diagnosed in infancy, childhood, or later in adulthood, influenced by the same causes as direct hernia. There is evidence that a tendency for inguinal hernia may be inherited.

A direct and an indirect inguinal hernia may occur at the same time; this combined hernia is called a pantaloon hernia.

Because inguinal hernias do not heal on their own and can become larger or twisted, which may close off the intestines, the prevailing medical opinion is that hernias must be treated surgically when they cause pain or limit activity. Protruding intestines can sometimes be pushed back temporarily into the abdominal cavity, or an external support (truss) may be worn to hold the area in place until surgery can be performed. Sometimes, other medical conditions complicate the presence of a hernia by adding constant abdominal pressure. These conditions, including chronic coughing, constipation, fluid retention, or urinary obstruction, must be treated simultaneously to reduce abdominal pressure and the recurrence of hernias after repair5.

Hernia operations are among the most common procedures performed today.

Most hernias result from a tear in the lining, or fascia, beneath the abdominal muscles, allowing the intestines to protrude. In many cases, this process begins at birth and is an inherited condition.

While far more common in men, they are quite frequent in women as well. These hernias affect people of all age groups, from infants to seniors.

Four different types of hernias account for almost 100 % of the hernias repaired by surgeons: 

|Type |Location |Frequency |Defect |

|Inguinal |Groin |93% |Fascia |

|Incisional |Entire Abdomen |5% |Fascia |

|Ventral/umbilical |Upper Abdomen |1% |Fascia |

More common in males than females.

Indirect hernias - most common overall

Femoral hernias - more common in females.

Most common side for inguinal and femoral hernias is the right side; explanation: delay atrophy of processus vaginalis

A paediatric inguinal hernia can appear / occur at any age, but the peak incidence is during infancy and early childhood with  80 to 90% occurring in boys. 

About 3% to 5% of healthy, full-term babies may be born with an inguinal hernia and one third of hernias of infancy and childhood appear in the first 6 months of life.  In premature infants the incidence of inguinal hernia is substantially increased, up to 30%.  In just over 10% of cases, other members of the family have also had a hernia at birth or in infancy.

The occurrence of an inguinal hernia in boys is related to the development and descent of the testes. The testes develop within the abdomen and at around the seventh month of pregnancy they descend into the scrotum.  On their way through the abdominal wall, they pass through the inguinal canal.  After they reach the scrotum, the opening behind should close.  Failure to close adequately results in a hernia with an opening remaining in the abdominal wall at this point6.

Statistics on Hernia

Groin hernias occur in approximately 2% of the adult population and 4% of infants. Their relative frequencies are as follows:

• Inguinal 80%

• Incisional 10%

• Femoral 5%

• Umbilical 4%

• Epigastric ................
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