Disease Concept

1.1 Definition / description of hernia diseases

Hernia is a prosthesis or protrusion of the contents of a cavity through a defect or a weak

portion of the cavity wall. In the abdominal hernia, the contents of the abdomen protrude
through a defect or weak part of the abdominal musculo-aponeurotic layer (Huda and
Kusuma, 2016).

A hernia is a weakness of the abdominal muscle wall passing through a segment of the
abdomen or other prominent abdominal structures. The hernia may also pass through several
other defects within the abdominal wall, through the diaphragm, or through other structures
in the abdominal cavity. A hernia is a weakness of the abdominal muscle wall passing
through a segment of the abdomen or other prominent abdominal structures. The hernia may
also pass through several other defects within the abdominal wall, through the diaphragm or
through other structures in the abdominal cavity (Ignatavicius, 2006).

Hernia is divided into 2 categories, namely the hernia according to its location and hernia
according to its nature or level.

The hernia according to its location is:

A. Hernia Inguinalis Lateralis (indirek)

This hernia occurs through the internal inguinal inguinal which lies on the lateral side of the
inferior epigastric epic, down the inguinal canal and out of the abdominal cavity through the
external inguinal grin. This hernia is higher in infants and young children.

B. Hernia Inguinalis Medialis (direct)

This hernia occurs through the posteromedial inguinal wall of the inferior epigastric vein in
the area bounded by the Haselbach triangle.
C. Femoral hernia

It occurs through the femoral ring and is more common in women than in men. This hernia
begins as an enlarged femoral diaper cockroach gradually draws the peritonium and
consequently the bladder enters the sac.

D. Umbilical hernia

The intestinal trunk passes through the umbilical ring. Most of the abnormalities obtained.
The umbilical hernia is common in women and in patients with elevated intra-abdominal
stress, such as pregnancy, obesity, ascites, or abdominal distension. This type of hernia
occurs in previous surgical incisions that have healed inadequately due to postoperative
problems such as infections and inadequate nutrition.

E. Skrotalis hernia

Is a lateral inguinal hernia that reaches the scrotum.

By its nature or level:

A. The hernia is reponible

In this hernia the contents of the hernia can go in and out. The intestines will come out if
standing or striking and entering again when lying down or pushed in. In this reponibel
hernia the patient does not complain of pain and there are no symptoms of bowel obstruction.

B. Irrigible hernia

The opposite of a reponible hernia (hernia not re-entry) is usually caused by attachment of
the sac bag to the peritoneum.
 C. Inhalation hernia

In this hernia the contents of the stomach or intestines that enter into the hernia sac can not be
returned accompanied by a special flow disorder. Clinical features of intestinal obstruction
with an overview of electrolyte and acid-base fluid balance. This condition of the hernia can
be squeezed by the ring of the hernia. So the contents of the bag can be trapped and can not
return to the abdominal cavity, as a result of passage disorders and this hernia is more
intended irreponibel hernia

D. Strangulata hernia

In this hernia the blood vessels that affect the intestines that enter into the hernia sac are
pinched so that the intestine loses its hemorrhage system resulting in necrosis of the intestine.
On the local examination of the intestine can not be re-entered in the presence of tenderness

1.2 Etiology

According to Huda and Kusuma (2016), the hernia can be caused by several things, including
the following:

1.2.1 Congenital

Congenital due to muscle weakness is one of the risk factors associated with increased
intra-abdominal pressure factor. Muscle weakness can not be prevented by exercise or
exercise.

1.2.2 Obesity

Obesity is one of the causes of increased intra-abdominal pressure because of the

amount of fat clogged and slowly pushing the peritoneum. This can be prevented by
weight control.

1.2.3 Pregnant women

In pregnant women there is usually an increased intra-abdominal pressure especially in

the uterine region and surrounding areas.
1.2.4 Mengejan

Mengejan can also cause increased intra-abdominal pressure.

1.2.5 Lifting of heavy loads

Lifting heavy weights can also cause increased intra-abdominal pressure.

1.3 Symptom Signs

According to Huda and Kusuma (2016), signs of hernia symptoms are as follows:

1.3.1 A lump-out / lump-out bump and often a lump in the groin

1.3.2 The presence of pain in the lump region when the contents are pinched with
nausea

1.3.3 There are symptoms of nausea and vomiting or distension when complications
have occurred

1.3.4 In case of inguinal hernia the stragulata of pain will increase and the skin above
becomes red and hot

1.3.5 A small femoral hernia may contain a bladder wall causing symptoms of urinary
pain (dysuria) with hematuria (blood urine) in addition to a lump under the thigh

1.3.6 Diaphragmatic hernia causes pain in the abdominal area with shortness of breath

1.3.7 When pushing or coughing the hernia lumps will grow large

1.4 Pathophysiology

In the first stage the tear of the annulus fibrosus is circumferential. Because of the
repetitive traumatic force, the tear becomes larger and radial tearing occurs. If this
happens, then the risk of HNP is just waiting for the next trauma time alone. The
precipitation force can be assumed as a traumatic force when trying to straighten the
body when it slips, lifting heavy objects, and so on.
 Herniation of the nucleus pulposus can be attached to the spinal corpus above or below
it. Can also break directly into the vertebral canal. If there is a sudden elevation of
pressure on the intervertebral discs and prolonged feeding of the material the nucleus
pulposus will stand out in filling damaged annulus fibrosus. The protrusion of the
lateral backward nucleus and suppressing the dorsal nerve roots (containing sensory
nerve fibers) that travel in the vertebral canal will give rise to pain. Movements that
change the position of the spine such as bending, sneezing and coughing will increase
the pain. Damage to the intervertebral disc may be due to a degenerative process such
as reduced bending strength, decreased collagen tissue, and decreased water content
with age, trauma, genetic factors, spine surgery, posture abnormalities such as
kyphosis, lordosis, due to spinal disorders Such as spondylitis, spinal stenosis.

1.5 Investigations

According to Huda and Kusuma (2016), investigation of hernia is as follows:

1.5.1 Abdominal X-ray shows abnormal levels of gas in the intestine / bowel
obstruction

1.5.2 Complete blood count and serum electrolyte may show hemoconcentration
(increased hematocrit), increase in white blood cells and electrolyte imbalances

1.6 Complications

1.6.1 Recurrent hernia,

1.6.2 Damage to the supply of blood, testes or nerves if male patient,

1.6.3 Excessive bleeding / surgical wound infections,

1.6.4 Bowel injury (if not careful),

1.6.5 After Herniography Hematoma can occur,

 1.6.6 Fostes urine and feces,

1.6.7 Residues,

1.6.8 Old complications are testicular atrophy due to lesions.

1.7 Management

According to Huda and Kusuma (2016), the management of hernias there are two
kinds, namely:

1.7.1 Conservative (Townsend CM)

Conservative experiments are limited to the act of repositioning and wearing a support
or support to retain the contents of the repositioned hernia, not a definitive action to
recur, consisting of:

A. Reposition

Repositioning is an attempt to restore the contents of the hernia into the peritonil
or abdominal cavity. Repositioning is done bimanually. Repositioning is
performed in patients with reponibilis hernia by means of two hands.
Repositioning is not performed on strangulate inguinal hernia except in children.

B. Injection

Conducted injection of sclerotic fluid in the form of alcohol around the hernia that
causes the hernia door to experience sclerosis or narrowing so that the contents of
the hernia out of the peritonil cavity

C. Belt hernia

Given to patients whose hernia is small and refuse surgery

1.7.2 Operative

Hernia surgery can be done in three stages, namely:

A. Herniotomy

Open and cut the hernia pouch and restore the contents of the hernia to the
abdominal cavity

B. Hernioraphy

Starting from binding the neck of the hernia and hanging it on the conjoint tendon
(thickening between the free edge of intraabdominal m.obliquus and the
transdominal abdominalis abdominalis in the tuberculum pubicum)

C. Hernioplasty

Stitch the conjoint tendon on the inguinal ligament so that the LMR is lost /
closed and the abdominal wall becomes stronger because it is covered in muscle.
Pathway

Faktor pencetus:

Aktivias berat, bayi prematur, kelemahan dinding abdominal,

intraabdominal tinggi, adanya tekanan Hernia

Hernia umbilikalis Hernia para umbilikalis Hernia inguinalis

kongenital

Kantung hernia melewati Kantung hernia memasuki

dinding abdomen celah inguinal
Masuknya omentum
organ intestinal kekantong
umbilikalis

Prostusi hilang timbul Dinding posterior canalis

inguinal yang lemah

Gangguan suplai darah ke

intestinal Ketidaknyamanan
abdominal
Benjolan pada region
inguinal

Nekrosis intestinal

Intervensi bedah

relatif/konservatif
Diatas ligamentum iguinal
mengecil bila berbaring

Pembedahan

Insisi bedah Asupan gizi kurang Mual

 Nafsu makan menurun
Peristaltik usus menurun

Resti perdarahan
Intake makanan inadekuat
Resti infeksi

Terputusnya jaringan Ketidakseimbangan

saraf nutrisi kurang dari
kebutuhan tubuh

Nyeri

Kantung hernia memasuki

celah insisi
Hernia insisional

Heatus hernia
Kantung hernia memasuki
rongga thorak
II. Client care plan with hernia disorders

2.1 Assessment

2.1.1 Nursing history

A. History of the disease now

Hernias can occur with symptoms of pain, nausea and vomiting.

B. Past medical history

Supportive assessment is to examine whether a previous client has suffered

from Hernia, a complaint in childhood, a hernia from another organ, and
other diseases that aggravate a hernia such as diabetes mellitus. Ask about
medicines commonly drunk by clients in the past relevant, these medications
include OAT and antitussive drugs. Note the side effects that occurred in the
past. Assess more in depth about how far weight loss (BB) in the last six
months. The BB decrease in clients with Hernia is closely related to the
healing process of the disease as well as the presence of anorexia and nausea
which is often caused by drinking OAT.

C. Family Disease History

Hernia pathology is not inherited, but the nurse needs to ask whether the
disease has been experienced by other family members as a predisposing
factor in the home.

2.1.2 Physical examination: focus data

A. Inspection of the regions Inguinal and femoral

Although the Hernia can be defined as any Viscus projection, or part of it, through
normal or abnormal holes, 90% of all Hernias are found in the Inguinal region.
Usually, Hernia impulses are more clearly seen than to be touched. Invite the
patient to turn his head sideways and cough or strain. Perform an inspection of the
Inguinal and Femoral areas to see the onset of a sudden lump during a cough,
which may indicate a hernia. If a sudden lump appears, ask the patient to cough
again and compare this impulse to the impulse on the other side. If the patient
complains of pain during coughing, determine the location of the pain and
reexamine the area.

B. Palpation of Inguinal Hernia

Palpation of the Inguinal Hernia is done by placing the right index finger in the
scrotum above the left testicle and pressing the scrotum skin inside. There should
be enough scrotal skin to reach the external inguinal ring. The finger should be
placed with the nail facing out and the finger pad into the inside. The examiner's
left hand can be placed on the patient's right hip for better support. The right
index finger should follow the dilenic spermatic cord into the inguinal canal
parallel to the inguinal ligament and move upwards toward the external inguinal
ring, which lies superior and lateral from the pubic tubercle. The external ring can
be widened and entered by the fingers. With your index finger placed on the
external ring or inside the inguinal canal, ask the patient to turn his head sideways
and cough or strain. Had there been a Hernia, there would have been a sudden
impulse touching the tip or pad of the examiner's finger. If there is a Hernia, have
the patient lie on his back and see if the Hernia can be reduced by the gentle and
continuous pressure of the day. If the inspection carried out by the skin of the
scrotum hernia which is quite a lot and done slowly, this action does not cause
pain (Tambayong, 2000).

Preoperative patient assessment (Doenges, 2000) includes:

1. Circulation

Symptoms: a history of heart problems, CHF, pulmonary edema, peripheral

vascular disease, or vascular stasis (increased risk of thrombus formation).
2. Integrity of the ego

Symptoms: feelings of anxiety, fear, anger, apathy; Multiple stress factors, such
as financial, relationships, lifestyle.

Signs: unable to rest, tension / excitatory enhancement; Sympathetic stimulation.

3. Food / liquid

Symptoms: pancreatic insufficiency / DM, (predisposition to hypoglycemia /

ketoacidosis); Malnutrition (including obesity); Dry mucous membrane
(restriction of preoperative fasting period).

4. Breathing

Symptoms: infection, chronic condition / cough, smoking.

5. Security

Symptoms: allergy / sensitive to drugs, food, plaster, and solution; Immune

deficiency (increased risk of sitemic infection and delayed healing); The
emergence of the latest cancer / cancer therapy; Family history of malignant
hyperthermia / anesthetic reaction; History of hepatic diseases (effects of drug
detoxification and may alter coagulation); History of blood transfusion /
transfusion reaction.

Signs: the emergence of a laborious infection process; fever.

6. Counseling / Learning

Symptoms: pengguanaan anticoagulation, steroids, antibiotics, antihypertensives,

cardiotonic glokosid, antidisritmia, bronchodilator, diuretic, decongestant,
analgesic, anti-inflammatory, anticonvulsant drugs or tranquilizers and well-
counter, or recreational drugs. The use of alcohol (risk of kidney damage, which
affects the coagulation and choice of anesthesia, and also the potential for
postoperative withdrawal).
 2.1.3 Investigations

According to Huda and Kusuma (2016), investigation of hernia is as follows:

A. Abdominal X-rays show abnormal levels of gas in the intestine / bowel

obstruction

B. Complete blood count and serum electrolytes can show hemoconcentration

(increased hematocrit), increase in white blood cells and electrolyte imbalance

2.2 Possible nursing diagnoses

Diagnosis 1: Acute pain (Practical Nursing Care, 401)

2.2.1 Definitions

Unpleasant sensory and emotional experiences arising from actual and potential
tissue damage, sudden or slow onset of mild to severe intensity

2.2.2 Character restriction

a. changes of appetite

b. changes in blood pressure

c. changes in heart frequency

d. changes in breathing frequency

2.2.3 Related factors

Injury agents (eg biological, chemical, physical, psychological)

Diagnosis 2: Nutrition imbalance is less than body needs (Practical Nursing Care, 396)
2.2.4 Definitions

Nutritional care is not enough to meet metabolic needs

2.2.5 Character restrictions

a. abdominal cramps

b. abdominal pain

c. avoid the food

d. weight 20% or more under ideal weight

e. nausea and vomiting

2.2.6 Related factors

A. Biological factors

B. Economic factors

2.3 Planning

Diagnosis 1: Acute pain (Practical Nursing Care, 401)

2.3.1 Objectives and results criteria

A. Aim

1. Pain level

2. Pain control

3. Comfort level
 B. Criteria results

1. Ability to control pain (know the cause of pain, able to use non-pharmacology
techniques to reduce pain, seek help)

2. Reporting that pain is reduced by using pain management

3. Be able to recognize pain (scale, frequency and signs of pain)

2.3.2 Nursing and rational intervention

A. Interventions: Perform a comprehensive pain assessment including location,

characteristics, duration, frequency, quality and precipitation factors

Rational: To know the state of pain

B. Intervention: Observation of nonverbal reactions from discomfort

Rational: Know the existence of pain

C. Intervention: Teach about non-pharmaceutical handling, pain management

Rational: Pain management makes the patient feel more comfortable

D. Intervention: Collaborate with your doctor if there are complaints and actions for
pain not working

Rational: Helps reduce pain

Diagnosis 2: Nutrition imbalance is less than body needs (Practical Nursing Care,
396)

2.3.1 Objectives and results criteria

A. Aim

1. Nutritional status

2. Fluid intake
 3. Weight control

B. Criteria results

1. The existence of weight gain in accordance with the purpose

2. Ideal weight according to height

3. Be able to identify nutritional needs

2.3.2 Nursing and rational intervention

A. Intervention: Assess for food allergies

Ratioanl: To know the existence of allergies

B. Intervention: Provide information on nutritional needs

Ratioanl: Pemerian information for patients understand the importance of nutrition

for the needs of the body

C. Intervention: Instruct patients to increase protein and vitamins

Ratioanl: To meet the needs of the body

D. Intervention: Collaboration with a nutritionist to determine the number of calories

and nutrients the patient needs

Ratioanl: For the fulfillment of appropriate nutrition

2.4 Evaluation

2.4.1 Diagnosis 1: Acute pain (Practical Nursing Care, 401)

S: - Client says the pain is decreasing

- The client says his appetite is good

O: - Normal client blood pressure

- Normal cardiac heart frequency

 - Normal breathing frequency of client

A: The issue is resolved

P: Intervention stopped

2.4.2 Diagnosis 2: Nutrition imbalance is less than body needs (Practical Nursing Care,
396)

S: - Client says eat good

O: - The client wants to eat

- The client's abdominal pain is reduced

- The existence of weight gain in accordance with the purpose

A: The issue is resolved

P: Intervention stopped
 III. Bibliography

Doengoes. E. Marilyn. 2000. Rencana asuhan keperawatan, edisi 3, Jakarta: EGC.

Huda, A. dan Kusuma, H. 2016. Asuhan Keperawatan Praktis Volume 1. Jogjakarta:

MediAction

Ignatavicius, Donna, et.All. 2006. Medical Surgical Nursing. Philadelphia: W.B

SaundersCompany.

Tambayong, dr. Jan.2000. Patofisiologi untuk Keperawatan. Jakarta : EGC