Acknowledgement

I , Sunita Chaudhary, a student of Bachelor in Nursing Science 1 st year would like to

express my gratitude to our Respected coordinator, Mam Sanchita Subedi and our
faculty members,Mam Meera Niraula for providing for providing me an opportunity to
accomplish ,help & co-operation in searching and accomplishing my case study.
I’m also very grateful to JF Institute of Health sciences as well as kanti Children Hospital
for providing me along with friends this opportunity to carry out our case study for the
fulfilment of our curriculum.
I would like to warmly thank to our Professor Madam Radha Ranabhat who gave us the
opportunity to visit & perform our duty in this hospital & carry out our case study.
Aggregately, I’m thankful to all staff of Kanti Children Hospital, my friends and all those
who directly as well as indirectly helped me to complete my case study smoothly.
 Table of contents
S.N. Contents Page no.
1. OBJECTIVE OF CASE STUDY

2. RATIONALE FOR SELECTION OF CASE

3. INTRODUCTION OF PATIENT

4. HISTORY TAKING

5. PHYSICAL EXAMINATION

6. DEVELOPMENTAL TASKS & CRISIS

7. DISEASE PORTION
 DEFINITION
 RISK FACTORS
 PATHOPHYSIOLOGY
 CLINICAL FEATURES
 MANAGEMENT
 COMPLICATIONS
8. DRUGS PROFILE
9. NURSING CARE PLAN

10. DAILY PROGRESS REPORT

11. HEALTH TEACHING

12. DISCHARGE TEACHING

13. LEARNING FROM CASE STUDY

14. FOLLOW UP
15. SUMMERY AND CONCLUSION

16. REFERENCES
 OBJECTIVE
General objective:-
 To collect information about patient & disease
 To broaden the knowledge about the disease process
 To provide effective nursing management in hospital setting until the client is ready for
discharge

Specific objectives:-
 To provide holistic nursing care to the patients with the application of nursing process
 To identify the cause, clinical features, diagnostic investigation, complications.
 To recognize the developmental tasks of differential task of different age group in
planning the nursing action.
 To provide education & concealing to the client for the betterment of health.
 To select patient with the problem that is occurred in her pregnancy and provide nursing
care in priority basis.
 To provide knowledge about follow-up care

RATIONALE FOR SELECTING THE CASE

 For the fulfillment of criteria of curriculum
 To collect detail information about the disease condition.
 To upgrade the knowledge regarding the inguinal hernia.
 To provide holistic nursing care to the client by applying nursing theory.
 To provide physical & psychological support to client and client’s party.
INTRODUCTION OF THE PATIENT
Patient name ,Aayan Subedi was admitted on 2074-12-5 in surgical ward with diagnosis of right
Inguinal Hernia .
Biological Data
Name: Aayan Subedi
Age /Sex: 3months/Male
Address: Syangja
Religion: Hindu
Bed no: 222
IP no: 129308
Date of admission: 2074-12-5
Diagnosis: right Inguinal Hernia
Surgical procedure: Herniotomy
Date of surgery: 2074-12-6
Attending doctor: Dr RPC/AT
Information: Mandira Adhakari
Relation with patient: Mother

Chief complain
At the time of admission: lump in the Right inguinal region for 1 months
At the time of assessment: anxiety, protrusion is seen in the right inguino scrotal region while
crying.

History of past illness:

According to the informant, patients was apparently well before 1and half year back when
he developed swelling in the right inguino scrotal region gradually increasing in size,
disappearing on lying on supine position.
Obstetric History:
ANC checkup: done
Frequency: 4 times
Place: Hospital normal Delivery
Illness/Infection during pregnancy: no
Type of delivery: normal vaginal delivery
Duration of pregnancy: 37 weeks
Condition of baby at birth: cried immediately
Weight: 2.5Kg
Any problem in birth: no
Dietary Pattern
Diet: artificial Feeding
Frequency: 3-4 times/day
Type food childlike: rice /dal/vegetables/milk /biscuits
Frequency of food intake through day: 2 times large meal and 2 times small meal
Eat by: self

IMMUNIZATION STATUS
Type of vaccine Given Age of completion Remarks
BCG ✔ At the time of birth BCG was given
DPT/Hepatitis B/
Hib 6 weeks
1st 9 weeks DPT/Hepatitis B/Hib
2nd ✔ 12 weeks Dose completed
3rd
Polio
1st 6 weeks Polio dose completed
2nd ✔ 9 weeks
3rd 12 weeks
Measles(MR) × Completion of 9 months Measles vaccine
provided
Japanese × In 12 months JE vaccine provided
encephalitis
vaccine (JE)
Growth & Development
Growth & Age Remarks
Development
Rolling over In 5 months baby rolled from back to side .In 8mths baby X
rolled from back to abdomen
Sitting In 10mths baby sat steadily unsupported X
Crawling Baby Started crawling at around 11 months X
Standing Baby stood holding furniture at around 12-13 months X
Walking Baby started walking after walking after her first birth X
day at around 13 months
Running Baby started running clumsily at around 15 months X
Smiling Age of 1st smile was around 2-3 months ✔

Family Background
Total no. of family:
SN Names of family Relation Age Education Occupatio Health
members with n Status
child Age
1. Bhanu Subedi Father 28 Master Office Good
2. MandiraAdhakar Mother 22 twelve housewife good
i
3. Aayan Subedi son 3month - - good
s
Family Tree
Physical Examination: I performed physical examination of my patient on2074-12-. While
doing physical examination, I did head-toe examination & used the following methods for
physical examination.
 Inspection
 Percussion
 Palpation
 Auscultation
 Measurement

General appearance: child is conscious, well oriented to time, place, person, cheerful,
well gait, good personal hygiene.

Vital signs:
 Temperature -98.8 °F
 Pulse -120beats /min
 Respiration – 32 breath/min

Weight: 11 kg
Height:
Head Circumference:
Chest circumference:
Arm Circumference
 to time ,place & person
- Gait balance: normal and straight gait.
- Co-ordination: coordinately voluntary
movement.
-reflexes:biceps,triceps,plantar,knee jerk
reflex are normal
-Homan’s sign: absent

Findings
 Swelling in the right inguinoscrotal region on crying.
Developmental task
Book picture Patient picture
 Differentiation of himself from  Able to differentiate himself from
others,particularly the mothers others
 Hold hand in tight fists that
reflects present  Grasping reflex present
 Head control
 Social smile  Can hold head

 Smiling response

Developmental crisis
Children typically master Erikson’s second stage of development, autonomy vs. Shame, between
the ages of 3 months. In the stage of development, your toddler learns to do things for himself
and exert his own emerging sense of individuality. As his skills develop, he develop sense of
pride & confidence in his abilities and begins the important task of building positive self-esteem.
Children who are thwarted at this stage & not allowed to develop naturally may develop a sense
of shame or guilt and lack confidence in their abilities.
Disease Profile
“Right Inguinal Hernia”
Hernia is the protrusion of an organ or a part of organ through the abdominal opening in the wall
of cavity that normally contains it. Usually, hernia has3 parts, the orifice-through which it
hernia sac & it contains contents. The danger from herniation arises when the protrusion
is constricted, impairing circulation or when the protrusion interferes with the function or
development of other structures.
Incidence
10-20 per 1000 live births , with 30% occurring in the preterm infant & 5 times more common
in male children than in female.
Causes
Hernia may be congenital or acquired . Congenital hernia develops due to incomplete
development of the wall during embryologic development period . Acquired hernia may
develops due to the weakness of the due to illness or injury . It may be due to prolonged
distention due to tumors , obesity or increased intra-abdominal pressure ddue to staining or
prolonged coughing.
Types of Hernia

A. Umbilical Hernia
It is the protrusion of intestine or omentum through the defect in the umbilicus fascia due
to imperfect closure or weakness of the umbilical ring. It is one of the most common
hernia in infants .It is especially common among among premature and low birth weight
babies & babies with Down syndrome. It appears as soft swelling or protrusion around
the umbilicus, usually reducible with the finger. The protrusion is more prominent when
the infant is crying .Incarceration is rare. The defect resolves spontaneously by 3-5 years
of age.

B. Inguinal hernia
It is the condition in which the large & small intestine, peritoneum or bladder protrudes
into the inguinal canal. It is most common at all childhood hernias and occur more
frequently in boys .Right sided inguinal hernia (60%) is more common than left sided
94(40%) but may be bilateral(10%) also.
Risk Factors:
i. Prematurity & low birth weight
ii. Associated with urologic conditions like hypospadias, epispadias,
iii. Abdominal wall defect like omphalocele
iv. Family history
v. Obesity
vi. Chronic cough & straining habit

Inguinal hernia is further sub divided into:

 Reducible hernia
 Incarcerated hernia
 Strangulated hernia

According to origin
 Direct inguinal hernia: here, the abdominal contents protrude from the weak abdominal
wall. It is less among children.
 Indirect inguinal hernia: Here the abdominal contents protrude from the internal ingunal
ring. It is the common hernia seen in children.
According to origin:
 Reducible hernia: In this type of inguinal hernia, portion of intestine gets into the cut in
the abdominal wall, which can be replaced back into original position without any need
of the surgery.
 Incarcerated hernia: In some cases the projection cannot be positioned back into place
without operation since a few adjoining tissues or parts have developed mutually.

 Strangulated hernia: The herniated part gets twisted with the adjoining parts &
sometimes , lead to obstructing of the general blood flow and the action of muscle that
need urgent attention & require surgery to avoid fatal condition.

Pathophysiology:
a) Incomplete closure of process us virginals( a pouch of peritoneum that is carried
into the scrotum by the descent of the testicle and which in the scrotum forms the
tunica vaginalis)
b) Descent of intestinal portion
 c) The descent portion is tightly caught into the sac
d) Compromise of blood supply to the portion
e) Incarceration or gangrene of the portion

Clinical Manifestations

 Presence of painless inguinal swelling that varies in size

 Swelling disappears during the period of rest or by gentle compression
and reappear during cry, cough or strain for longer period
 Thickening of cord in groin on palpation
 Sometimes, the loop of intestine becomes partially obstructed, producing,
symptoms such as tenderness, abdominal distension, anorexia and
irritability
 Problem in dececation as well as loop becomes irreducible that leads to
complete intestinal obstruction
Diagnostic evaluation
Book picture Patient picture
 History taking  History taking
 Physical examination  Physical examination
 USG to visualize and conform the  USG shows right indirect inguinal
mass is due to hernia hernia
 Chest x-ray & ECG to monitor the  Blood test serology test, CBC
functioning of lungs & heart
 Blood and urine tests

Lab investigation
Tests Observations Reference range
Hemoglobin 12.6 11.5-15gm/dl
Leukocytes 5700/mm3 4000-11000/mm3
Thrombocytes 210000/mm3 150000-400000/mm3

Management/treatment
Book picture Patient picture
Surgery Herniotomy
 Heriorrhaphy: removal of hernia
sac with repair posterior wall of
inguinal canal
 Herioplasty : herniotomy with
 reinforcement of the posterior wall
of inguinal canal with synthetic
mesh
 Herniotomy: removal of hernia sac

Complications

a. Hematoma formation
b. Obstruction
c. Hydrocele
d. Testicular pain and swelling
e. Recurrence

C. Epigastric hernia
A type of hernia which is seen in the epigastric region of the abdominal wall. It is seen
just below the sternum of ribs cage. It is most common among adults 2-3 % of all
abdominal hernias are epigastria hernias.

D. Femoral hernia
It is the herniation of the intestine through the femoral ring. It is rare in children. Initial
symptoms such as swelling in the groin areas associated with severe abdominal pain can
be seen.

Drug profile
 Syp. Cefixime -3-5ml PO BD
Generic name :cefixime
Trade name : suprax
Functional class : antibiotics
Chemical name : third generation cephalosporins
Action:
It is third generation broad spectrum cephalosporins . it inhibits the bacterial cell
wall synthesis.
Uses:
-lower respiratory tract infections, infection of genito-urinary tract, intra-
abdominal infections, prophylaxis for operative as single dose, laryngitis.
Dosage and routes:
  Child : 8mg/kg once or daily or 4mg/kg in 2 divided doses
 Adult: 200mg twice daily or 400mg once a day
Contraindication:
-hepatic impairment
-renal impairment
-hypersensitivity

Side effects
Diarrhea, sore throat and joint pain, red skin rashes, numbness or tingly feeling,
swelling in hands or feet

Nursing consideration:
 Dose should be taken in the same time each day to maintain bio availability.
 Instruct patient that GI upset may occur especially, diarrhea
 Once reconstituted, keep the suspension at room temperature to maintain
potency for 14 days.
Syp. Flexon: 5ml PO TDS
Generic name: contains ibuprofen 10mg & paracetamol 125mg
Trade name: flexon
Functional Class: NSAIDs
Chemical class: anti-inflammatory, analgesic with anti-pyretic effect
Action: it works by blocking the production of prostaglandin that is released in the body during
pain.

Indications:
 Fever
 Headache
 Arthralgia
 Pain in the body

Side effects:
Nausea, vomiting, diarrhea, renal problems, constipation, stomach pain, allergic
reaction, indigestion, stomach ulcers

Contraindication
 Hypersensitivity
  Hypertension
 Peptic ulcers
 Bleeding disorders
 Breast feeding
 Hepatic or renal problems
Nursing considerations:
 Always administer after meal or with food to decrease GI upset
 Discontinue the drug if the patient is complaining of tinnitus, dimness in vision, mental
confusion, drowsiness, thirst, sweating.
Nursing diagnosis
Preoperative diagnosis
 Anxiety related to hospitalization as evidenced by patient’s facial expression, restlessness
and excessive cry.

Postoperative diagnosis
 Acute pain related to surgical incision as evidenced by cry, irritability & facial
expression.
 Alteration in comfort related to pain at surgical site secondary to disease conditions.
 Disturbed sleeping pattern related to pain surgical site as evidenced by irritability &
lethargy.
 Deficient knowledge related to disease condition & prognosis as evidenced by frequent
questioning by parents.
 Risk for infection related to invasive procedure secondary to disease conditions.
Assessmen Nursing Nursing Planning Interventi Rationale Evaluati
t diagnosis goal on on

Subjective Anxiety The - To -the -it helps to -goal was

data: related to patient access the patient provide partially
patient hospitalizati will have general seemed baseline met as
said “I on as reduced condition anxious & data for patient
want to go evidenced anxiety of the restless further was
home” by patient’s after 5 patient. interventio involved
facial hours of -patient ns. in play
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data: restlessness interventi patient in placed in -it provides &reduce
verbalizati and cry on the supine comfort to d anxiety
on comforta position. patient. to some
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- positions. was - It helps
restlessnes involved divert
s - To in the play mind of
provide therapy. patient and
dimension thus
al -patient’s relieves
therapy. visitors anxiety.
were -it helps to
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provide knowledge knowledge
knowledg regarding level of
e about disease patient.
disease condition. - It helps to
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Subjectiv Disturbe Patient will - to access -patient - it helps toGoal were
e data d have sleep slept only provide not met as
:patient sleeping normal pattern of 5 hrs at baseline patient was
said “ I pattern sleeping patient. night data forunable to
cannot related pattern according further sleep at
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well at surgical day of the informant. n. evidence by
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Objectiv evidence interventio - to -visitors -it helps to verbalizatio
e data : d by n. prevent were control n.
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yawning y and lights at ward . noise.
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-- encourage to cover sleep.
lethargic visitors to the patient
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warm sawl. noisy
fluids at environme
nights. -visitors nt and
were imduces
-to encourage sleep.
encourage d to - it inhibits
visitors to provide PG
talk softly warm milk synthesis
while at night. thereby
patient is reducing
sleeping - pain.
syrup,flexo
-to n 5ml TDS
provides was
pain provided.
medicatio
ns as
prescribed
.
Assessme Nursing Nursing Planning Intervation Rationale Evaluatio
nt diagnosis goal n
Subjecive Deficient Knowledg - To access - Parents -it helps to Goal was
data :
knowledg e level the understandi provide fully met
child e related related to understandi ng level was baseline data as
mother to disease disease ng level was assessed. for further knowledg
said “isconditions conditions assessed. intervention. e level of
this and will be -good IPR parents
disease prognosis increased -to maintain with family - It helps to was
recurrent” as with in good IPR and parents build trust enhanced
evidenced my shift. with in was and helps and
Objective by parents. maintained. them to curiosity
data : frequent ventilate level was
Curiosity questionin -to -knowledge their reduced.
of parents g by knowledge regarding feelings.
to know parents. regarding inguinal
about the disease hernia -it enhance
disease conditions complicatio the
Frequent and ns and its knowledge
questionin prognosis. prognosis level of
g was given. patient.
- To provide
knowledge -parents -it helps in
about care were the better
of wound advised to prognosis
site. keep the and to
wound site prevent from
-to clean and further
encourage maintain complication
them to hygiene of s.
provide child.
nutritious - It helps fast
diet child. -parents wound
were healing
encouraged process.
to give
nutritious
diet.
Health teaching provided during hospitalization
Health education plays a vital role in hospital situations in caring patient. It is most useful in
preventing disease, promoting and curing the disease conditions. it is one of the essential aspects
in nursing management. A nurse is responsible to provide appropriate information about the
factors which are associated with the disease conditions which will help the mother /care
provider aware of the details about the health. So it is important to provide health education on
following.
 To promote health
 To prevent illness & infection & achieve normal health.

 To provide further complications

 To maintain and fulfill the nutritional needs

I have gave different informal health teaching to the parents of my patient including the
following points:
 Adequate rest in the initial days to prevent him from fatigue but no restrictions for play &
exercise.
 Provide good skin care to maintain skin integrity
 Personal hygiene maintenance
 About disease conditions, medications and ways to prevent its complications.
 About safety measures for prevention of infection as patient is in risk for infection.
 About wound care.

Discharge teaching
Discharge teaching is an integral part of nursing process. The entire plan of the hospital care is
great towards of the patients . it is the nurse responsibility to plan the patient contunity of care at
home . Discharge teaching can help to prevent the secondary complications, promote health and
maintain normal life style, health and to prevent complications . it is the most important aspecst
in providing holistic nursing care .
Objectives of discharge nursing care :
 To promote and maintain health as well as prevent from illness in the home after
discharge .
 To consider primary health care concept in helth teaching plan .
 To provide need based health care and education.
As my patient was discharged on2074-12-. I gave discharge teaching to his family on following
topic on the day of discharge :
 Nutrition & fluids intake : I encouraged the visitore to provide high protein diet for early
wound healing . I also encouraged them for adequate fluid intake .
 Personal hygine to prevent infection and disease.
 Rests & sleep
 To intake medicine at right time & in right dose.
 About the follow up: I informed the visitors to bring the patient for follow up after 7 days
in OPD for suture removal.
 Maintain safety measures to prevent accidents and injuries while playing.
 Wound care and infections prevention: I informed the visitors t perform dressing of
patients wound site on alternate day at nearby clinic.
 To prevent higher degree of body heat (fever) by minimizing risk of infection.
 To give information on regular follow up visit at 2-3 weeks following surgery to observe
the incision site.

Follow up
The care of the patients does not end after the discharge from the hospitals .it continues until the
follow up of the patient is done. Follow up visit is very important for the evaluation of the
general conditions and progress of the patients.
The main objectives of follow up visit are as follows:
 To access & promote the health status of the patients.
 To find out progress of the patient’s condition.
 To evaluate the use of knowledge and skill which they have learnt in the hospital.
 To know further problems.
 To help the patients to manage problems.
 To prevent further complications.
  To add health teaching for the maintenance an promotions of physical, mental, social,
cultural, and spiritual well-being of the patients.

Summary and conclusion

During my practicum posting in kanti children hospital, I selected patient named .he was
admitted on 2074-12-. I observed him for 3 days and provided nursing care as needed.
During his hospitalization, I provided him a holistic care. I provided his family about the
information regarding disease conditions and its prognosis. I also got the chance to do through
study on this disease conditions with medication and diagnostic procedure. I provided health
teaching to his family about disease condition, nutrition, rest, sleep, antenatal visits, and
medications.
During this case study I got chance to maintain good IPR with the patient and patient’s family
and also got chance to relieve their anxiety by explaining the disease conditions with its
prognosis. I tried my best to complete this case study. My objective of this case study are
completely met.

Learning from the case study

Case study is very ideal way of practice for learning. It helps us in comprehensive study of a
selected patient in comparison with book and in real situation. Throughout my case study I
gained a lot of important things such as:
 About the patient and their cultural beliefs
The patient’s family background and their cultural beliefs such as what kind of
practices they apply during the period of illness. I got to know about my patient’s
behavior as well as his family members.
 About disease
During the case study of right inguinal hernia, I got chance to get much more
knowledge about disease, its causes, management and diagnosis, treatment regimen.
I also got chance to do comparison between the book picture a patient picture.
 References
 Shrestha Tumla(2012):Essential child health nursing ,1st edition ,Medhavi
Publication, Nepal
 Upreti kamala (2011) :Child health nursing, Publisher Ms. Hemma Uperety, Nepal
ISBN-978-99372-3749-9
 Wong D.L(2001):Wong’s Essential of pediatric Nursing. Harcourt Publications
India .ISBN-0-323-00989-1
 Mosby’s ,Drugs references,2nd edition,2015,Elsevier Inc. , India
 https://www.healthline.com/health/inguinal-hernia
 https://en.wikipedia.org/wiki/Hernia
 emedicine.medscape.com/article/438378-overview