KENYA METHODIST UNIVERSITY

SCHOOL OF MEDICINE AND HEALTH SCIENCES

DEPARTMENT OF NURSING

UNIT TITLE : REPRODUCTIVE HEALTH 1 AND 111

UNIT CODE: NRSG 242
REG NO: BSN-1-1357-3/2019
INSTRUCTOR: ROSELYNE NDIRETU
INDIVIDUAL CASE STUDY.

INTRODUCTION
Background of Embu County and Referral Hospital.
Embu County and Referral Hospital is government hospital. It started as a dispensary in
1924, then elevated to a health centre in 1935, then sub district hospital in 1941, it had a one
30 bed ward and the first medical officer of health was posted to the institution. Became
district hospital in 1960 and by 1984 it had a capacity of 166beds. A major expansion
program was started by the government in 1984 to upgrade the hospital to a provincial
general hospital. In 1985 the nyayo wards were completed (144 bed capacity). In 1987 the
kitchen and laundry were completed. In 1991 an eye unit which comprises an outpatient,
theatre and a 22-bed ward was completed. In 1993 a psychiatric unit with 20 beds was
completed. At the end of 1995 a maternity unit of 148 beds and 40 cots with an operation
theatre was completed. It was occupied on 22nd February 1996. This project was funded by
plan international Embu at an approximate cost of 42 million. The hospital is located in
Embu county, municipality ward in manyatta constituency. It serves as a Referral hospital for
the various counties and sub county hospitals such as manyatta, runyenjes, mbeere and other
counties in Eastern part of Kenya.There hospital is a Teaching Hospital for six learning
institutions. These institutions are Kenya Methodist University, Kenya Medical training
college [KMTC] Embu, KMTC Nakuru, Chuka University and Embu University.
Type: County hospital
County: Embu County
Owner: Ministry of health
Status: Operational institution
Constituency: Manyatta, Eastern Region
Location: Municipality
Sub location: Township
HOSPITAL VISION
An efficient and high-quality health care system that is accessible, equitable and affordable
for every Kenyan.
MISSION
To promote and participate in provision of integrated and high quality promotive, preventive,
curative and rehabilitative health care services to all Kenyans. Mandate, to formulate policies,
set standards, provide health services, create an enabling environment and regulate the
provision of health service delivery.
SERVICES OFFERED MCH DEPARTMENT AT EMBU LEVEL 5 HOSPITAL
i. Curative and diagnostic services.
ii. Child Health services.
iii. Family planning
iv. ANC
v. PMTCT
vi. Postnatal
vii. HTS/Comprehensive care services.
viii. TB clinic
ix. Cervical Screening
x. Laboratory Services

Activities that nurses and students are involved in

7.30am- duty staffs and students report on duty with duty. Preparation for the daily
routine is done and nurses together with students get ready to start offering services to
the clients. After that Students and staff are allocated to take care of various clients.
8:00am- Reporting to the stationed area and begin of daily routine
13:00pm- 14:00- lunch break for student and staffs.
16:30- Students and staff leave for various places Review is done and report is taken to
the management.
ABBREVIATIONS
ANC: Antenatal Clinic
APH: Antepartum Haemorrhage
BD: Twice per day
BP: Blood Pressure
CCF: Congestive Cardiac Failure
CSSD: Central Sterile Services Department
ENT: Ear, Nose and Throat
EDD: Expected Delivery Date
FHR: Foetal Heart Rate
HB: Haemoglobin
IM: Intramuscular
IV: Intravenous
IUFD: Intrauterine Foetal Death
IUGR: Intrauterine Growth Retardation
LBW: Low Birth Weight
LMP: Last Menstrual Period
PO: Per Oral
PPH: Postpartum haemorrhage
QID: Four times a day
TDS: Three times a day
VDRL: venereal disease research laboratory test
OD: Once a day

Justification of the case.

I chose this client because the client is at risk and also the cases of umblical hernias are rare
and they need immediate and thorough interventions. I therefore developed the interest of
taking this patient help me understand the theory behind it.

BACKGROUND DATA

NAME: RUTH WANGECHI

AGE: 25

MARITAL STATUS: MARRIED

OCCUPATION: HOUSEWIFE

EDUCATION LEVEL: CLASS 8

VILLAGE: KIAMBUTHI

GENDER: FEMALE

PARITY: 2+1

GRAVIDA: 4

TASK: A CASE STUDY OF A WOMAN WITH UMBILICAL HERNIA

Chief Complain

Ruth was diagnosed with hernia 2 years ago after she had a miscarriage that was due to the
hernia. Presently, the hernia had presented with back pains and abdominal swellings.

History of Present
On the day of hospital visit the patient had complains of back pains and abdominal swellings
which made her come for check-ups at our facility ,Embu Teaching and Referral Hospital.
Past medical history and surgical history.
She is a rhesus negative mother with 3 previous pregnancies, 2 being up to term while one
being a miscarriage due to the umbilical hernia complications.
Has no history of any surgery.
Past Obstetric history
Ruth Wangechi is a multi para and has a history of miscarriages.
Present Obstetric history/History of present Pregnancy
Ruth Wangechi is para 2+1, gravida 4.Her L.MP 20/07/2022 is and her E.D.D 27/04/2023.
Gestation is 26weeks.FH-?/40 FHR-regular 144b/min LIE-longitudinal, Presentation-
cephalic ,Position-LOA, Engagement 0/5
Gynaecological history
Ruth Wangechi started her menstrual flow at the age of 13years. Her menses were regular
and lasted for 4 days, in a cycle of 28 days each month. She reported no history of pain
during her menstrual period other than mild lower abdominal pain one day prior to start of
the menstrual flow. She had a history of miscarriage. She also has no history of STIs. She
reported to have been using an IUCD as her means of family planning for 3 years before it
was removed in October 2021 because of her desire to conceive.
Family history
She is married and she is also pregnant. She is married to one man of whom she is faithful.
She is a farmer at Embu. The family has no history of anaemia. She has no history of alcohol
or smoking. The family has a history of twins from her sister. The family also has a history of
TB from the husband’s side.
Physical examination
I conducted a physical examination on my patient to help me obtain data that would help
me make an accurate nursing diagnosis so as to be able to apply appropriate nursing
interventions.
Vital observations were as follows:
Weight 85.5kgs
Temperature 36. 5
Pulse rate 112beats per minute
Respirations 21breaths per minute
Blood pressure 131/78mmhg
Head to toe examination.
Head
On inspection the hair was equally distributed. It was clean and with a fine texture. She
had no rashes and no scars.
Eyes
On inspection the eyes were equal in shape, there was no discharge from the lachrymal
apparatus, and all the eyes could see both long and short distance. No cataracts, no squint.
The conjunctiva was slightly pale.
Ears
There was no discharge on inspection, no pain on palpation and had no hearing problems.
Nose
On inspection the nostrils were well separated by the septum, no swelling, no discharge, no
polyps. They were symmetrical and thus had good smelling sense.
Mouth
The mucous membrane was moist, no lesions, tongue not pale, no decayed teeth and all
teeth were present. No inflammation of the gums on inspection. She had no dentures. She
had no tonsillitis, no pain on the tonsils.
Neck
No lymph node swelling, no thyroid enlargement, palpable jugular vein and regular rhythm.
No bruise on jugular vein.
Chest
On inspection no swelling on right and left side, the respiratory rate was 22 breaths per min.
On dividing the breasts into four quadrants and palpating there are no lumps felt. On
pressing the areola for any discharge, there is no abnormal discharge except colostrum
which is normal because she is pregnant that is color less.
Arms
The arms were bilaterally equal, no deformities, and no clubbed nails. On palpation of a
wiped axilla, no swollen lymph nodes. She had a temperature of 36.7°c that was equally
distributed in both axilla and a blood pressure of 90/60 mmhg. No lesions on the arms, short
and clean nails. She had a slow capillary refill of 7seconds. Radial pulse present and regular.
Abdomen
On inspection it was gravid though there are some small swellings near around the
umbilicus and had no lesions . The abdomen had also linear nigra. On lateral palpation the
baby was felt to be lying longitudinal but on the right, that’s right occipito anterior. On
fundal palpation a hard mass was felt in the pubic area, that’s the head thus cephalic. On
auscultation using the fetoscope I listened the fetal heart rates that were regular. They were
138 beats per minute that were normal.
Back
There were no curves, no abnormal growths on palpation. There was also continuity of the
spine and no tenderness noted. Though she has complains of back pains.
Rectum
No prolapse, no tenderness, no swelling of the perineal area.
Lower limbs
The limbs were bilaterally equal, no deformities, no edema, no varicose veins, knee-jerk
reflex present. No pain in the knees when flexing and in the ankles when walking and
standing up.

INVESTIGATIONS AND FINDINGS

Granulocytes- 56.9
HB-13.6
Lymphocytes-31.9
MCV-64
Platelets-15.3
RBS 4.9

COLLABORATIVE MANAGEMENT:

Abdominal wall hernia repair with suture or mesh may cause pain in the last trimester of a
subsequent pregnancy. Hernia repair in conjunction with cesarean section appear as the
optimal treatment of a pregnant patient with a symptomatic abdominal wall hernia.
Therefore, hernioplasty is recommended during pregnancy, especially in early gestation.
Considering pain then management of pain on analgesics is also recommended.
Broad spectrum antibiotics should also be incorporated to reduce infections.

LITERATURE REVIEW

A hernia is an area of weakness or complete disruption of the fibromuscular tissues of the

body wall. In addition to the body wall, hernias can occur in the diaphragm, pelvic wall,
perineum, pelvic floor, and internal abdominal viscera (hernias through omental or
mesenteric defects, ligaments and folds).
Surgical repair of different types of hernia is the most common general surgical procedure
with more than 20 million hernioplasties performed each year. Abdominal wall hernias are
not common during pregnancy.
Hernias can be symptomless or have minimal symptoms, including slight discomfort or pain.
Such hernias are not life-threatening and should be controlled on regular basis. After
spontaneous delivery and uterine involution, they should be repaired on an elective basis.
It is of utmost importance for a clinician to diagnose emergent situations, which include
incarceration, strangulation and perforation caused by hernia because consultation with a
surgeon and emergency operation are mandatory.
There is still no consensus for irreducible hernia during pregnancy, but complications during
pregnancy outweigh elective operation. Therefore, hernioplasty is recommended during
pregnancy, especially in early gestation.
During pregnancy, a growing belly and baby means there’s more pressure inside your
stomach and this makes the stomach muscles become thinner and weaker as they stretch.
The pushing force and weaker muscles can cause umblical hernia.
If the hernia is small then it may be better to delay the surgery until after delivery or last
pregnancy.
If the hernia is symptomatic and seems to affect the patient’s quality of life, it may be better
to postpone the repair until the second trimester of after delivery if complications do not
occur.
Internal herniation should be suspected as a cause of the abdominal pain in pregnant
women who have undergone laparoscopic Roux-en-Y gastric bypass (LRYGB)
Pregnancy may be considered a significant risk factor for hernia recurrence.
The laparoscopic mesh repair should be offered whenever possible, whereas the open
approach may be preferred in complicated cases.
Pregnancy may be a significant risk factor for the hernia formation due to both hormonal
changes and increased intra-abdominal pressure by the enlargement of the gravid uterus.

RISK FACTORS OF HERNIA

AGE- infants especially those born preterm have a higher risk of an umblical hernia than adults

OBESITY- children and adults with obesity face a significantly higher risk of developing an umblical
hernia, compared with individuals of normal weight for their height and age.

COUGHING- having a cough for a long period of time can increase the risk of hernias, because the
force of coughing applies pressure on the abdominal wall.

MULTIPLE PREGNANCIES- when a woman is carrying more than one baby as part of pregnancy, the
risk of an umblical hernia is higher.

A CONGENITAL CONDITION that occurs during development in the womb and is present from birth.

SMOKING since this leads to wakening of the connective tissue.

HERNIA DIAGNOSIS
ABDOMINAL ULTRASOUND- which uses high frequency sound waves to create an image of the
structures of the body.

CT SCAN- this combines x-rays with computer technology to produce image.

MRI SCAN- uses combination of strong magnets and radio waves to make image.
ENDOSCOPY- which involves threading a small camera attached to a tube down your throat and into
your esophagus and stomach.

GASTROGRAFIN OR BARIUM X-RAY- uses a series of X-ray pictures of your digestive tract. The
pictures are recorded after you’ve finished drinking a liquid containing diatrizoate meglumine and
diatriazoate sodium or a liquid barium solution. Both show up well on the X-ray images.

Patient education
The patient should be cautious with everything she does to avoid worsening the condition.
She should avoid fatty foods including saturated of Trans fats foods such as red meat, high dairy
products foods because this foods leads to inflammation and an increase in weight that possess the
risk of increasing the problem of hernia.

The patient should avoid lifting heavy weights as lifting puts stress on the groin and can make it
worse.
When you must lift then don’t bend over and lift by using the legs not back if possible.

Eat high fiber foods and drink a lot of water as this helps in preventing constipation and straining
during bowel movements.

Maintain a healthy body weight to reduce pressure on the abdomen as obese persons has a lot of
pressure exerted on the lower abdomen which may worsen the condition.

To prevent acid reflux, avoid foods that may cause it such as spicy foods and tomato based foods.
Additionally, giving up on cigarettes also help.

Recommendations
Most umblical hernias may be repaired using an open approach with a peritoneal flat mesh.
A laparoscopic approach may be considered if the hernia defect is large or if the patient has
an increased risk of wound morbidity.

Umblical hernias are diagnosed using clinical examination and imaging tests e.g. ultrasound
is done in case of doubt in the findings.

For asymptomatic umblical hernias, a watchful waiting strategy can be considered.

Smoking cessation for 4-6 weeks for smokers and weight loss to BMI below 35kg/m2 before
elective umblical hernia repair.

Prophylactic antibiotics given as a single dose should be recommended when mesh is used
for umblical hernia repair.
To reduce recurrence rate, mesh is used for repair of umblical hernia and sutured repair can
be considered in shared decision making and for small hernia defects of less than 1cm.
Slowly resorbable or non-absorbable sutures are used for sutured repair of umblical hernia
as it is not advisable to use quickly absorbable sutures as they may be absorbed before the
wound is fully healed.
Flat permanent mesh is placed in the preperitoneal space for open umblical hernia repair.
The repair is based on patient and hernia characteristics and local resources and also patient
and surgeon preferences should also be taken into account.
Nursing care plan for 24hours
NAME: Ruth Wangechi AGE: 25YRS HOSPITAL NO.:0819/23 SEX: Female
MEDICAL DIAGNOSIS: UMBILICAL HERNIA IN PREGNANCY.

ASSESMENT DIAGNOSIS Goals Intervention

/Outcome
Patient verbalizes pain Acute pain related to 1.The patient 1.Administer the prescribed pain
on a scale of 7,patient is surgical repair will verbalize a reliever such as morphine
crying,patient is irritable. secondary to hernia as reduction of 2. Maintain the patient in a
evidenced by pain with a comfortable position.
irritability,verbalization scale of 4 out of
of pain,crying. 10.
2.The patient
will show
improvement
on mobility and
perform
physical activity
at a moderate
level.
Vomitin,Nausea,Dizziness Risk for fluid volume 1.Within 4 1.Assess the onset of
deficit related to post- hours of nursing symptoms,nausea,vomiting.Record
operative status intervention,the the quality,amount,presence of
secondary to hernia. patient will blood,bile, vomitus and odor.
experience 2.Obtain vital signs including apica
relief from pulse.
vomiting.
2.The patient
will show
clinical signs of
adequate
hydration.

CONCLUSION

Umbilical hernia is a common condition among infants but rare in pregnant women. There is
still no consensus about timing of surgery for an umbilical hernia in a woman who is already
pregnant. If the hernia is incarcerated or strangulated at the time of diagnosis an emergency
repair is inevitable. If the hernia is not complicated but symptomatic an elective repair
should be proposed.
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