Introduction

This chapter introduces you to a focused approach to the care of a patient in a day care unit. As this is a book about actual clinical placements, the focus is on what you can learn about specific patient care, and it brings together all the knowledge and skills you have learned in other sections of the book in order to make maximum use of learning in a day care unit placement.

Introduction to patient and clinical problem

Mr John Roberts, age 48, has been given an initial diagnosis by his GP as having an inguinal hernia. His medical history notes that he had been building an extension to his house which has required lifting heavy building materials. He has a visible swelling in his groin area.

Following a referral to a consultant surgeon at his local district general hospital, it has been decided that this problem needs to be addressed soon and that repair of this hernia can be undertaken as a day care patient.

Before we consider his perioperative care, it is important that you consider the diagnosis and the possible signs and symptoms Mr Roberts may be experiencing.

What is a hernia?

In broad terms, a hernia is a ‘protrusion of an organ or part of an organ through a weak point or aperture in the surrounding structures’ (Waugh & Grant 2010:321). According to Waugh & Grant (2010), there are seven different types of hernia affecting different parts of the body and with different causes. These are:

You will likely find a definition for an inguinal hernia similar to that from Waugh and Grant (2010:321): ‘The weak point is the inguinal canal, which contains the spermatic cord in the male and the round ligament in the female. It occurs more commonly in males than females’.

A similar definition from Kurzer et al (2007:318) states that an inguinal hernia is where part of the small bowel has protruded through the abdominal wall and causes ‘a swelling in the groin which appears on straining, lifting or standing’ and there may be ‘pain or discomfort in association with the swelling’.

In addition, access the NHS Choices website where you can see a video plus other information about the causes of hernia, possible outcomes and the procedures used to correct the problem:

http://www.nhs.uk/conditions/hernia/Pages/Introduction.aspx (accessed December 2011).

An excellent tool for decision making on appropriate treatment for a hernia is the NHS Choices Map of Medicine:

http://www.nhs.uk/Conditions/Hernia/Pages/MapofMedicinepage.aspx (accessed July 2011).

Kurzer et al (2007) state that whereas in the past, many hernias were treated with a ‘truss’ (a device that held a pad firmly against the deep inguinal canal and prevented the hernia coming out), it is normal today to undertake a surgical repair which aims to ‘eliminate the swelling, relieve discomfort and remove the risk of strangulation’ (2007:319).

One of the major complications of an untreated hernia is that known as a strangulated hernia, which is a surgical emergency due to the possible outcomes if left untreated. See Box 11.1 for an explanation and how it is treated.

Box 11.1 Strangulation of a hernia

This life-threatening complication presents with all the symptoms of intestinal obstruction, e.g. vomiting, severe abdominal pain, distension and absolute constipation. The patient rapidly becomes shocked, dehydrated and pyrexial. Diagnosis is made by history and clinical examination. A plain X-ray may identify the location and the associated distended loops of bowel. Rapid preparation for surgery is necessary and definitive therapy includes oxygen, opiate analgesics, IV correction of fluid and electrolyte balance, nasogastric aspiration and antibiotic administration. Surgery may well necessitate resection of the affected bowel and intensive nursing care will probably be required in the early postoperative period.

Care and management of the patient in the perioperative period

Your surgical placement may well be in a day care unit. You will have prepared yourself for this experience (see Chs 1–4) and made contact with the ward/unit and your mentor. On arrival at the unit and on meeting your mentor, you will discuss what the expectations are with regards to your practice assessment documents, as well as defining your placement learning pathway or ‘hub and spoke’ experiences (see Ch. 3).

Remember, you can learn and undertake a wide range of skills if your main placement is in a day care unit and, in particular, you will achieve competencies in all four

Activity

Read a physiology textbook and consider the anatomical structures involved in an inguinal hernia as well as the digestive system in general (e.g. see Kurzer et al 2007).

Review your understanding of a strangulated hernia and emergency admission procedures.

Mr Roberts does not have a strangulated hernia and has been admitted for repair of his inguinal hernia via laparoscopic surgery (see Kurzer et al (2007) for an excellent description of the repair procedure and choices).

of the Nursing and Midwifery Council (NMC) domains (NMC 2010). Prior experience and what you have to achieve at this specific point in your programme will determine which skills you will need to practice as well as what knowledge you need to acquire to care for a wide ranging group of patients admitted for day care surgery.

Day care surgery has increased over the past decade (Oakley 2010) and there are many advantages to it, in particular ‘avoiding unnecessary hospital stay … preference to have their aftercare at home rather than hospital, and minimal disruption of daily routine’ (2010:36).