Pre-operative and Post-operative Nursing Care: Hernia Repair

Introduction and Patient Overview

The patient in this case study is a 76-year-old individual weighing 99 kg, standing 153 cm tall, and smoking 25 cigarettes each day. The patient has been admitted to the ward and is scheduled for the repair of a right inguinal hernia. This study identifies information obtained during a nursing admission assessment and explains the importance of obtaining that information. It also discusses the purpose and necessity of collecting baseline data from the patient, as well as the ethico-legal responsibilities of the nurse during the pre-operative period.

Part B of the study addresses post-operative wound management. During a dressing change, a thick yellow discharge was noted oozing from the wound. Within this context, the study defines and explains the purpose of wound assessment, identifies and discusses the nursing interventions undertaken when assessing the wound and applying aseptic technique, and describes two causative factors of wound breakdown.

Baseline Data and Pre-operative Nursing Assessment

It is important that the nurse collect baseline data from the patient in order to effectively monitor the patient over the course of a surgical procedure, particularly with respect to data characterized by natural variability among individuals (Enrico, Lonner, & Moulton, 2008). The standard requirements for hospitals conducting pre-admission work vary; however, the nurse will inform the patient of the necessary information so that the patient can assist in preparing for surgery.

The nurse will question the patient about any changes in health status and will provide pre-operative instructions concerning medications and other relevant matters (Enrico, Lonner, & Moulton, 2008). Information collected will include current medications, general health condition, and results from blood work and other clinical laboratory tests.

The nurse must also ensure that the patient signs consent forms prior to surgery in order to protect the hospital from ethical or medical liability. All forms should be signed and witnessed with the date properly recorded. Finally, the nurse is responsible for explaining the possible risks and complications associated with the procedure, which may include bleeding, transfusion, infection, wound infection, dehiscence, pain, scarring of tissues, failure of the procedure, potential injury to surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death, or a prolonged stay in the Intensive Care Unit (ICU).

Burney et al. (1997), in "Core Outcomes Measures for Inguinal Hernia Repair," note that baseline data collection is important because "demands on the medical profession to develop performance measures and demonstrate cost-effectiveness make it imperative that a uniform approach to the measurement of outcomes for common conditions be adopted."

Sussman and Bates-Jensen (2007), in Wound Care: A Collaborative Practice Manual, report that wound assessment data are collected for five purposes: (1) examination of the severity (stage) of the lesion; (2) determination of the status of wound healing; (3) establishment of a baseline for the wound; (4) preparation of a plan of care; and (5) reporting of observed changes in the wound over time.

Assessment data enables clear communication among clinicians about the wound, provides continuity in the plan of care, and allows for evaluation of treatment modalities (Sussman & Bates-Jensen, 2007).

Post-operative Wound Management and Assessment

Wounds classified as red, yellow, or black are those that require examination for deep tissue involvement (Sussman & Bates-Jensen, 2007). The wound must be monitored throughout the healing process, as monitoring provides the means of checking the wound on a regular and frequent basis for signs and symptoms that should trigger a full reassessment, such as increased wound exudate or bruising of the adjacent or periwound skin. Monitoring also includes gross evaluation for signs and symptoms of wound complications, such as erythema (change in color) of the periwound skin and the presence of pus, which is indicative of infection (Sussman & Bates-Jensen, 2007). Progress toward healing — including granulation tissue growth (indicated by red color) and re-epithelialization (new skin formation) — should also be noted.

The aseptic technique of wound care is "the method by which microbial contamination is prevented during invasive procedures or care of breaches in the skin's integrity" (ICNA, 2003, as cited in Calderdale and Huddersfield NHS Foundation Trust, 2008). There are two types of aseptic techniques: (1) medical and (2) surgical (Calderdale and Huddersfield NHS Foundation Trust, 2008).

The aim of the medical aseptic technique is to reduce the number of organisms present and to prevent their spread within the hospital ward and other treatment areas. The surgical aseptic technique is described as a "strict process" that encompasses procedures geared toward the elimination of micro-organisms from an area, carried out by nurses and other healthcare workers (Calderdale and Huddersfield NHS Foundation Trust, 2008).

Various causative factors contribute to wound breakdown or the spread of infection. These include: (1) infectious agents such as bacteria, viruses, fungi, or parasites; (2) a reservoir that supports the infectious agent, allowing it to survive and multiply; (3) a portal of exit that allows the infectious agent to leave the reservoir; (4) a mode of spread, including direct and indirect contact or airborne droplets; (5) a portal of entry into a new host; and (6) a susceptible host (Calderdale and Huddersfield NHS Foundation Trust, 2008).