Hernia is a protrusion or projection of an organ or organ part through an abnormal opening in the

containing wall of its cavity, a hernia results. An inguinal hernia occurs when the omentum, the
large or small intestine , or the bladder protrudes into the inguinal canal. In an indirect inguinal
hernia, the sac protrudes through the internal inguinal ring  into the inguinal canal and, in males,
may descend into the scrotum. In a direct inguinal hernia, the hernial sac projects through a
weakness in the abdominal wall in the area of the rectus abdominal muscle and inguinal
ligament.

Inguinal hernias can be direct which is herniation through an area of muscle weakness, in
the inguinal canal, and inguinal hernias indirect herniation through the inguinal ring. Indirect
hernias, the more common form, can develop at any age but are especially prevalent in infants
younger than age 1. This form is three times more common in males.

Causes for Inguinal Hernia

An inguinal hernia is the result of either a congenital weakening of the abdominal wall, traumatic
injury, aging, weakened abdominal muscles because of pregnancy, or from increased intra-
abdominal pressure (due to heavy lifting, exertion, obesity, excessive coughing, or straining with
defecation).
Inguinal hernia is a common congenital malformation that may occur in males during the seventh
month of gestation. Normally, at this time, the testicle descends into the scrotum, preceded by
the peritoneal sac. If the sac closes improperly, it leaves an opening through which the intestine
can slip, causing a hernia.

Complications for Inguinal Hernia

Inguinal hernia may lead to incarceration or strangulation. That can interfere with normal blood
flow and peristalsis, and leading to intestinal obstruction and necrosis.
Nursing Assessment

Nursing care plan for Inguinal Hernia

Patient History, an infant or a child may be relatively free from symptom until she or he cries,
coughs, or strains to defecate, at which time the parents note painless swelling in the inguinal
area. On adult patient may occurs of pain or note bruising in the area after a period of exercise.
More commonly, the patient complains of a slight bulge along the inguinal area, which is
especially apparent when the patient coughs or strains. The swelling may subside on its own
when the patient assumes a recumbent position or if slight manual pressure is applied externally
to the area. Some patients describe a steady, aching pain, which worsens with tension and
improves with hernia reduction

Physical Examination, If the patient has a large hernia, inspection may reveal an obvious
swelling in the inguinal area. If he has a small hernia, the affected area may simply appear full.
As part of your inspection, have the patient lie down. If the hernia disappears, it’s reducible. Also
ask him to perform Valsalva’s maneuver; while he does so, inspect the inguinal area for
characteristic bulging. 

 Auscultation should reveal bowel sounds. The absence of bowel sounds may indicate
incarceration or strangulation. Palpation helps to determine the size of an obvious hernia.
It also can disclose the presence of a hernia in a male patient.
Diagnostic tests

Commonly No specific laboratory tests are useful for the diagnosis of an inguinal hernia.
Diagnosis is made on the basis of a physical examination. Although assessment findings are the
cornerstone of diagnosis, suspected bowel obstruction requires X-rays and a white blood cell
count, which may be elevated.

Treatment for Inguinal Hernia

The choice of Inguinal Hernia therapy depends on the type of hernia. For a reducible hernia,
temporary relief may result from moving the protruding organ back into place. Afterward, a truss
may be applied to keep the abdominal contents from protruding through the hernial sac.
Although a truss doesn’t cure a Inguinal Hernia, the device is especially helpful for an elderly or
a debilitated patient, for whom any surgery is potentially hazardous. Herniorrhaphy is the
preferred surgical treatment for infants, adults, and otherwise healthy elderly patients. This
procedure replaces hernial sac contents into the abdominal cavity and seals the opening. Another
effective procedure is hernioplasty, which involves reinforcing the weakened area with steel
mesh, fascia, or wire. Strangulated or necrotic hernia requires bowel resection. Rarely, an
extensive resection may require a temporary colostomy.

1. Clarify your data collection goals.  Sounds straight forward enough but is often
overlooked.  For example, what problem are you trying to solve by collecting this data? 
Many people grow frustrated when they are asked to collect data and are not even told
why.  Then, once this person has the data the person who asked for it in the first place
can’t be bothered.  You will lose any ounce of credibility you may have had if you take
this approach.
2. Develop operational definitions and procedures.  Here we need to be very clear as to
what we are measuring, how it is to be measured, and who is to measure it. Often times
we will employ sampling in which case we need to define a sampling plan.
3. Validate the measurement system.  Good golly Ms. Molly is this step ever butchered by
most people!  True story… several years ago I was working with a supplier of my former
company.  They made plastic parts.  They used this $300k “automated optical inspection”
machine to measure critical “black diamond” dimensions.  They wanted my help with
running a DOE.  I asked if a measurement system analysis had been done.  They assured
me the machine had been recently calibrated to the “gold standard.”  I said, “that’s nice
and have you done a MSA?”  Long story short we did an MSA and learned that due to a
programming issue (a topic for another blog) their measurement system was useless. 
They had been running like this for years supplying parts to a $50B market cap company
and had no clue what dimensions these parts really were.  Ouch.  Moral of the story…
confirm your measurement system!
 4. Begin data collection.  Isn’t it funny how this 4th step of the 5 step process is where most
people want to start?  Using all the knowledge from the previous steps we now go off and
collect our data.
5. Continue improving measurement system and ensure people are following the data
collection guidelines.  Measurement systems need to be verified often.  A good whack to
a camera can really mess things up.  Also, as with anything related to continuous
improvement sustaining a process is the hardest part.  Data collection is no different.

There are three main methods of data collection:

 
People asked to verbally described their
Interactive interviewing
experiences of phenomenon.
People asked to write descriptions of  their
Written descriptions by participants
experiences of phenomenon.
Descriptive observations of verbal and non-
Observation
verbal behavior.
Types of Observations

Okay, so you've decided that you think observational research is for you. Now you only have to
pick which kind of observation to do.

 Direct (Reactive) Observation

In direct observations, people know that you are watching them. The only danger is that
they are reacting to you. As stated earlier, there is a concern that individuals will change
their actions rather than showing you what they're REALLY like. This is not necessarily
bad, however. For example, the contrived behavior may reveal aspects of social
desirability, how they feel about sharing their feelings in front of others, or privacy in a
relationship. Even the most contrived behavior is difficult to maintain over time. A long
term observational study will often catch a glimpse of the natural behavior. Other
problems concern the generalizability of findings. The sample of individuals may not be
representative of the population or the behaviors observed are not representative of the
individual (you caught the person on a bad day). Again, long-term observational studies
will often overcome the problem of external validity. What about ethical problems you
say? Ethically, people see you, they know you are watching them (sounds spooky, I
know) and they can ask you to stop.

Now here are two commonly used types of direct observations:

1. Continuous Monitoring:
Continuos monitoring (CM) involves observing a subject or subjects and
recording (either manually, electronically, or both) as much of their behavior as
possible. Continuos Monitoring is often used in organizational settings, such as
evaluating performance. Yet this may be problematic due to the Hawthorne
Effect. The Hawthorne Effect states that workers react to the attention they are
getting from the researchers and in turn, productivity increases. Observers should
be aware of this reaction. Other CM research is used in education, such as
watching teacher-student interactions. Also in nutrition where researchers record
how much an individual eats. CM is relatively easy but a time consuming
endeavor. You will be sure to acquire a lot of data.
2. Time Allocation:
Time Allocation (TA) involves a researcher randomly selecting a place and time
and then recording what people are doing when they are first seen and before they
see you. This may sound rather bizarre but it is a useful tool when you want to
find out the percent of time people are doing things (i.e. playing with their kids,
working, eating, etc.). Thereare several sampling problems with this approach.
First, in order to make generalizations about how people are spending their time
the researcher needs a large representative sample. Sneaking up on people all over
town is tough way to spend your days. In addition, questions such as when, how
often, and where should you observe are often a concern. Many researchers have
overcome these problems by using nonrandom locations but randomly visiting
them at different times.
  Unobtrusive Observation:
Unobtrusive measures involves any method for studying behavior where individuals do
NOT know they are being observed (don't you hate to think that this could have happened
to you!). Here, there is not the concern that the observer may change the subject's
behavior. When conducting unobtrusive observations, issues of validity need to be
considered. Numerous observations of a representative sample need to take place in order
to generalize the findings. This is especially difficult when looking at a particular group.
Many groups posses unique characteristics which make them interesting studies. Hence,
often such findings are not strong in external validity. Also, replication is difficult when
using non-conventional measures (non-conventional meaning unobtrusive observation).
Observations of a very specific behaviors are difficult to replicate in studies especially if
the researcher is a group participant (we'll talk more about this later). The main problem
with unobtrusive measures, however, is ethical. Issues involving informed consent and
invasion of privacy are paramount here. An institutional review board may frown upon
your study if it is not really necessary for you not to inform your subject

Brand Name: TRAMADOL

CLASSIFICATIONS
Therapeutic:
Analgesics (centrally acting)

ACTIONS
Physiologic Mechanism

• Decreased pain.

Pharmacologic Mechanism

• Binds to mu-opioid receptors.

• Inhibits reuptake of serotonin and norepinephrine in the CNS.

INDICATION
• Moderate to moderately severe pain

NURSING CONSIDERATIONS
• Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.

• Assess BP & RR before and periodically during administration. Respiratory depression has not
occurred with recommended doses.

• Assess bowel function routinely. Prevention of constipation should be instituted with increased
intake of fluids and bulk and with laxatives to minimize constipating effects.
• Assess previous analgesic history. Tramadol is not recommended for patients dependent on
opioids or who have previously received opioids for more than 1 wk; may cause opioid
withdrawal symptoms.

• Prolonged use may lead to physical and psychological dependence and tolerance, although
these may be milder than with opioids. This should not prevent patient from receiving adequate
analgesia. Most patients who receive tramadol for pain d not develop psychological dependence.
If tolerance develops, changing to an opioid agonist may be required to relieve pain.
• Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined
aspirin 650mg/codeine 60 mg for acute postoperative pain.

• Monitor patient for seizures. May occur within recommended dose range. Risk increased with
higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao inhibitors), opioid
analgesics, or other durgs that decrese the seizure threshold.

• Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse
some, but not all, of the symptoms of overdose. Treatment should be symptomatic and
supportive. Maintain adequate respiratory exchange.

• Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.