Hiatal Hernia
Hiatal Hernia
Hiatal Hernia
Davao City
In Partial Fulfillment of
BY:
CHRISTINE M. PADASDAO
April 7, 2021
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TABLE OF CONTENTS
Page Number
I. INTRODUCTION ……………………………………………………………2
II. OBJECTIVES ………………………………………………………….……3
III. ANATOMY AND PHYSIOLOGY ………………………………………...4
IV. PATHOPHYSIOLOGY
A. ETIOLOGY……………………………………………………………..6
B. SYMPTOMATOLOGY ………………………………………………..9
C. DISEASE PROCESS ………………………………………………..12
D. NARRATIVE ………………………………………………………….17
V. MEDICAL MANAGEMENT ………………………………………………19
VI. SURGICAL MANAGEMENT ……………………………………………47
VII. NURSING MANAGEMENT …………………………………………….48
A. NURSING CARE PLAN
VIII. PROGNOSIS ……………………………………………………………49
IX. DISCHARGE PLANNING ……………………………………………….50
X. RELATED NURSING THEORY …………………………………………54
XI. REVIEW OF RELATED STUDIES/LITERATURE ……………………55
XII. REFERENCES …………………………………………………………..57
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I. INTRODUCTION
Gastrointestinal/Metabolism Nursing is a specialty within the field of nursing that
gives importance to the mechanism of processes involved in metabolism as well as its
regulatory factors, the diagnostics procedures done, presentation of the different
metabolic disorders, and its pathophysiology. Moreover, it also involves the systematic
way of management of the different conditions and the nursing care to be rendered to
the patient.
Hiatal Hernia is a condition wherein the opening of the diaphragm through which
the esophagus passes becomes enlarged, and part of the upper stomach moves up into
the lower portion of the thorax. A hiatal hernia occurs more often in women than in men.
There are two main types of Hiatal hernias: sliding and paraesophageal. This causes
pyrosis, regurgitation, and dysphagia, but many patients are symptomatic. The patients
may present with vague symptoms of intermittent epigastric pain or fullness after eating.
Large Hiatal hernias may lead to intolerance to food, nausea, and vomiting. This
condition is typically confirmed by x-ray studies; barium swallow;
esophagogastroduodenoscopy (EGD) and managed through conservative nursing
interventions and surgery (Brunner & Suddarth, 2018).
We believe that by this rotation, our group will enhance our medical-surgical
knowledge about hiatal hernia condition and its types, pathophysiology, and
symptomatology. The case analysis will be a ground for future research on hiatal hernia
more specifically on its prevalence starting locally and envisioning into the wide-scale
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study. For us, honing our skill in handling patients with this disease allows us to be
equipped in the future for when we are being exposed again to this type of illness, we
will deliver quality and efficient care to the clients involved. It is in our most genuine
principle that through research there will be a strengthening of the theoretical
foundations concerning maladaptive nursing.
II. OBJECTIVES
Within four weeks of Gastrointestinal and Metabolism nursing rotation, the
student nurses will be able to construct a comprehensive case study on hiatal hernia to
understand the pathology of the disorder and appreciate the study’s contribution to
nursing education, practice, and research which the student nurses can utilize in
providing competent and quality nursing care to patients with this disorder.
The esophagus runs from the pharynx through the diaphragm to the stomach.
About 25 cm (10 inches) long, it is essentially a passageway that conducts food (by
peristalsis) to the stomach. The walls of the alimentary canal organs from the
esophagus to the large intestine are made up of the same four tissue layers or tunics
namely the mucosa (innermost layer), submucosa (found beneath the mucosa),
muscularis externa (inner circular layer and outer longitudinal layer of smooth muscle
cells), and serosa which is further subdivided into visceral peritoneum, parietal
peritoneum, and mesentery.
The C-shaped stomach is on the left side of the abdominal cavity, nearly hidden
by the liver and the diaphragm. The cardial region or cardia surrounds the
cardioesophageal sphincter, through which food enters the stomach from the
esophagus. The fundus is the expanded part of the stomach lateral to the cardiac region.
The body is the midportion of the stomach; in the body, the convex lateral surface is the
greater curvature, and its concave medial surface is the lesser curvature. As it narrows
inferiorly, the body becomes the pyloric antrum and then the funnel-shaped pylorus, the
terminal part of the stomach. The pylorus is continuous with the small intestine through
the pyloric sphincter, or pyloric valve. The stomach varies from 15 to 25 cm (6-10 inches)
in length, but its diameter and volume depend on how much food it contains. When it is
full, it can hold about 4 liters of food and when it’s empty, it collapses inward on itself,
and its mucosa is thrown into large folds named rugae.
The lesser omentum, a double layer of peritoneum, extends from the liver to the
lesser curvature of the stomach. The greater omentum, another extension of the
peritoneum, drapes downward and covers the abdominal organs like a lacy apron
before attaching to the body wall. It is riddled with fat, which helps to insulate, cushion,
and protect the abdominal organs. It also has large collections of lymphoid follicles
containing macrophages and defensive cells of the immune system. The stomach acts
as a temporary “storage tank” for food as well as a site for food breakdown. Besides the
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usual longitudinal and circular muscle layers, its wall contains a third, obliquely arranged
layers in the muscularis externa. This arrangement allows the stomach not only to move
food along the gastrointestinal tract, but also to churn, mix, and pummel the food,
physically breaking it down into smaller fragments. In addition, the chemical breakdown
of proteins begins in the stomach (Marieb & Kelly, 2018).
IV. PATHOPHYSIOLOGY
A. ETIOLOGY
PREDISPOSING RATIONALE
FACTORS
B. SYMPTOMATOLOGY
SYMPTOMS RATIONALE
PRECIPITATING FACTORS
PREDISPOSING FACTORS Obesity
Age (50 or older) Straining
Pregnancy
Genetics (Ehlers Danlos syndrome) Heavy lifting
Smoking
Sex (female) Cough
Trauma
Surgery
Ascites
Chronic esophagitis
A
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Substernal Postprandial
chest pain fullness
Compromises the integrity of the diaphragmatic
opening (hiatus)
DIAGNOSTIC TOOLS
Physical Assessment: DIAGNOSTIC TOOLS
PQRST pain assessment Pressure overcomes muscle strength Physical Assessment
Alteration in BP, HR, RR Belching and bloating may
Grimaced face, irritability may be observed
be noted Uncomfortable feeling of
Factors that alleviate pain Tear of phrenoesophageal ligament fullness after eating as
Nursing Diagnosis: verbalized by the client
Acute pain related to tissue
injury and increased intra-
abdominal pressure
MANAGEMENT
Lower portion of the Greater curvature of Nursing
esophagus slips the stomach slips Avoid carbonated drinks
MANAGEMENT through the hiatus through and beer.
Medical Eat and drink slowly
Provide pharmacologic pain Get moving. It may help
management as ordered (MILD-
nonopioid analgesics; MODERATE-
to take a short walk after
opioid, or a combination of opioid Upper portion of the eating
C
and nonopioid; SEVERE - opioid is stomach follows
administered and titrated in ATC
scheduled doses until the pain is
relieved
Nursing
Teach the use of nonpharmacologic B
techniques before, after, and if
possible, during painful activities.
Reduce or eliminate factors that
precipitate or increase the pain
experience
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B C Heartburn,
Regurgitation
Injury
Backflow of gastric MANAGEMENT
materials to the Medical
Scar formation esophagus Administer medications as
ordered (antacids, H2RAs and
proton pump inhibitors)
Nursing
Avoid tight-fitting clothing and
D Gastric acid irritates the foods that trigger heartburn
esophageal lining Avoid lying down after a meal.
Wait at least three hours.
Elevate the head of bed.
Avoid large meals. Instead eat
many small meals throughout
the day.
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D Occult
Dysphagia
bleeding,
anemia
DIAGNOSTIC TOOLS
Physical Assessment
Decrease obstruction Decrease DIAGNOSTIC TOOLS
Unable to swallow Incarcerated
Physical assessment
Bringing food back up functioning hernia flexibility
Black-tarry or even
(regurgitation)
maroon stool
Coughing or gagging
Low blood pressure,
when swallowing Decrease Irregular heartbeats,
Medical Decrease diaphragmatic Decrease Shortness of breath
X-ray with a contrast digestion expansion capacity Pale skin
material (barium X-ray),
Fatigue, weakness
endoscopy, Fiber-optic
Medical
endoscopic evaluation of
Complete blood count
swallowing (FEES), malnutrition Decrease (CBC)
imaging scans
respiratory Fecal occult blood test
effort Capsule endoscopy
Imaging tests
MANAGEMENT Weight
Medical loss
Administer medications MANAGEMENT
as ordered (antacids, Medical
H2RAs and proton pump IV fluids, blood transfusion
inhibitors) Nursing
Surgical Encourage oral fluid intake of
E MANAGEMENT
Laparoscopic Nissen at least 2L per day if not
DIAGNOSTIC TOOLS Medical
fundoplication (LNF) contraindicated
Physical Assessment Enteral feedings, protein
Nursing supplements
Monitor intake and output
a lack of growth and low regularly
Try eating smaller, body weight Nursing
more-frequent meals. loss of fat, muscle mass, Provide good oral hygiene and
Be sure to cut food into dentition
and body tissue
Provide companionship during
smaller pieces, chew Medical
mealtime.
food thoroughly and Serum electrolytes, CBC,
Provide a pleasant
eat more slowly. serum albumin
environment.
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MEDICAL MANAGEMENT
IV fluids, enteral feeding, blood transfusion for
replacement
Proton pump inhibitors and H2 blockers antagonists to Respiratory Chronic Strangulated
reduce stomach acid production complications regurgitation hiatal hernia
Antacids to help neutralize stomach acid or reflux
Analgesics to relieve pain
SURGICAL MANAGEMENT
Laparoscopic Nissen fundoplication (LNF) blood being
NURSING MANAGEMENT stopped from
Teach the use of nonpharmacologic techniques before, flowing freely to the
after, and if possible, during painful activities. Barrett’s Recurrent tissue
Reduce or eliminate factors that precipitate or increase esophagus aspiration
the pain experience
Avoid carbonated drinks and beer.
Eat and drink slowly Esophageal Respiratory Tissue death
Get moving. It may help to take a short walk after eating cancer tract infections and gangrene
Avoid lying down after a meal. Wait at least three hours.
Elevate the head of bed.
Avoid large meals. Instead eat many small meals
throughout the day.
DEATH
PROGNOSIS
Most people with hiatal hernias have few, if any, symptoms.
PROGNOSIS
More bothersome symptoms usually are controlled with
medications which includes the medications mentioned If left untreated, hiatal hernia will progress and cause a
above. Thus, with prompt treatment and patient’s compliance, lot of complications that may lead to death. In this case,
hiatal hernia would have a good prognosis. it will have a poor prognosis.
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D.NARRATIVE
Normally, the esophagus passes through an opening called the
diaphragmatic hiatus, in order to reach the stomach which is below the
diaphragm. In cases of hiatal hernia, a junction of the stomach goes beyond the
hiatus. This may be because of the risk factors associated with it that includes
people 50 years or older, Ehlers Danlos syndrome, and women, which
predisposes to hiatal hernia. While obesity, straining, pregnancy, heavy lifting,
smoking, cough, trauma, surgery, ascites, and chronic esophagitis are
precipitating factors for hiatal hernia that causes the increased pressure in the
abdominal cavity. Due to this pressure, an upward movement towards the
diaphragm may occur, thus reaching the diaphragmatic opening or also called
the hiatus.
This in turn, compromises the integrity of the diaphragmatic opening. With
the continuous increase in pressure, the muscle strength and tone decreases.
This causes the tearing of the phrenoesophageal ligament, which is a fibrous
layer of connective tissue that maintains the lower esophageal sphincter within
the abdominal cavity. This may lead to two possible occurrence which are as
follows: a)lower portion of the esophagus slips through the hiatus then upper
portion of the stomach follows that causes substernal chest pain, which is a
condition called sliding hiatal hernia; and b) greater curvature of the stomach
slips through causing the feeling of fullness after eating, which is a condition
known as a rolling hiatal hernia or paraesophageal hernia. If both of these occur
at the same time, it is called a mixed hiatal hernia. These types can lead to a
stricture or narrowing due to continuous increase in pressure, that may cause
injury to the surrounding tissues, then lead to scar formation. Also, lower
esophageal sphincter relaxation and reduced esophageal sphincter pressure
may occur due to the herniation. This may lead to the backflow of gastric
materials to the esophagus causing heartburn and regurgitation of foods and
fluids, that can irritate the esophageal lining. This will also explain the scar
formation that may occur.
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Doctors throughout
the procedure.
● Administering IV
drips.
during the
examination.
● Inform him that he’ll
be placed in various
positions on a tilting
radiograph table
and that
radiographs will be
taken.
● If gastric reflux is
suspected, withhold
antacids, histamine-
2 (H2) blockers, and
proton pump
inhibitors, as
ordered.
● Just before the
procedure, instruct
the patient to put a
hospital gown
without snap
closures and to
remove jewelry,
dentures, hairpins,
and other
radiopaque objects
from the radiograph
field.
● Check the patient
history for
contraindications to
the barium swallow,
such as intestinal
obstruction and
pregnancy.
Radiation may have
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teratogenic effects
● Regarding the
patient's risk for
bleeding, the patient
should be instructed
to avoid taking
natural products and
medications with
known
anticoagulant,
antiplatelet, or
thrombolytic
properties or to
reduce dosage, as
ordered, prior to the
procedure. The
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number of days to
withhold medication
is dependent on the
type of
anticoagulant.
Protocols may vary
among facilities.
B. LABORATORY TEST
Intra-procedure
1. Identify the patient
2. Inform the patient
that he/she will
experience
discomfort from the
needle puncture and
the pressure of the
Tourniquet.
Post-procedure
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1. Observe the
venipuncture site for
bleeding or
hematoma
formation.
2. Apply pressure at
the site of the
venipuncture
because bleeding
may occur.
3. If hematoma
develops, apply
warm compress
4. Evaluate the results
in relation to the
patient’s symptoms
and other tests
performed.
C. PHARMACOLOGICAL MANAGEMENT
1. Histamine 2 receptor antagonist
Drug Photo
Pregnancy Category B
Drug Photo
Pregnancy Category B
Nursing 1. Inform the patient about the purpose of the drug, and its
Interventions side effects.
2. Instruct patient to immediately report signs and
symptoms such as dizziness, nausea, vomiting,
drowsiness, headache,
3. Instruct client to take cimetidine before or after meals
4. To reduce the risk of dizziness, instruct patient to get up
slowly when rising from a sitting or lying position
5. Avoid taking other medications within 2 hours before or
2 hours after you take cimetidine.
6. Inform clients to avoid smoking. Cigarette smoking
decreases the drug's effectiveness
7. Instruct the client to drink plenty of water to replace fluid
loss.
8. Instruct the client to take with meals or at bedtime. To
prevent heartburn from foods or beverages, take
cimetidine within 30 minutes before eating or drinking.
Take this medicine with a full glass of water.
9. If the client drinks alcohol, instruct the client to avoid
drinking alcohol.
10. Report signs of an allergic reaction hives, difficult
breathing, swelling in your face or throat.
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Drug Photo
Pregnancy Category C
Contraindications ● Hypersensitivity
● Orally disintegrating tablets contain aspartame and
should not be used in patients with phenylketonuria
● Congenital long QT syndrome
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necrolysis.
3. Instruct client to avoid hazardous activities
R: Dizziness may occur.
4. Instruct clients to avoid alcohol, salicylates, NSAIDs.
R: These may cause GI irritation.
5. Report severe diarrhea.
R: Drug may need to be discontinued.
6. Monitor serum magnesium prior to and periodically
during therapy.
R: May cause hypomagnesemia.
7. Temporarily stop esomeprazole at least 14 days before
assessing chromogranin A (CgA) levels and consider
repeating the test if initial CgA levels are high.
R: May cause false positive results in diagnostic investigations
for neuroendocrine tumors due to 36 increase serum CgA
levels secondary to drug-induced decreased gastric acidity.
8. Inspect and palpate the abdomen.
R: To determine potential underlying medical conditions.
9. Assess for changes in bowel elimination and GI upset.
R: To identify possible adverse effects.
10. Assess respiratory status, including respiratory rate and
rhythm; note evidence of cough, hoarseness, and
epistaxis.
R: To monitor for potential adverse effects of the drugs.
3. Antacids
Drug Photo
Pregnancy Category C
Drug Photo
Classification Antacid
Pregnancy Category C
4. Antiemetics
Drug Photo
Nursing 1. Inform the patient about the purpose of the drug, and its
Interventions side effects.
2. Instruct patient to immediately report signs and
symptoms such as dizziness, drowsiness, headache
3. Instruct clients to take drugs exactly as prescribed.
4. To reduce the risk of dizziness, instruct patients to get
up slowly when rising from a sitting or lying position.
5. If the client drinks alcohol, instruct the client to avoid
drinking alcohol. It will make you feel more sleepy.
6. Advise patients to avoid driving, other hazardous
activities until stabilized on this medication; drowsiness
or dizziness may occur.
7. Tell the patient to take Metoclopramide 30 minutes
before the meal.
5. Analgesics
Drug Photo
Pediatrix, Tylenol
Classification Analgesic/Antipyretic
7. Avoid alcohol.
8. Monitor CBC, liver, and renal functions.
9. Assess for fecal occult blood and nephritis.
10. Avoid using OTC drugs with Acetaminophen.
6. Antiulcers
Drug Photo
Mode of Action Reduced gastric acid secretion and decreases gastric acidity.
Esomeprazole works by binding irreversibly to the H+/K+
ATPase in the proton pump. Because the proton pump is the
final pathway for secretion of hydrochloric acid by the parietal
cells in the stomach, its inhibition dramatically decreases the
secretion of hydrochloric acid into the stomach and alters
gastric pH.
Symptomatic GERD
● Adults: 20 mg or 24.65 mg (strontium) P.O. daily for 4
weeks. If symptoms are unresolved, may continue
treatment for 4 more weeks.
● Children and adolescents ages 12-17: 20 mg P.O. once
daily for up to 4 weeks.
● Children ages 1-11: 10 mg P.O. once daily up to 8
weeks.
Erosive esophagitis due to antacid-mediated GERD only
● Infants ages 1-11 months weighing more than 7.5 to 12
kg: 10 mg P.O. once daily for up to 6 weeks.
● Infants ages 1 to 11 months weighing 3 to 5 kg: 2.5 mg
P.O. once daily for up to 6 weeks.
Short-term treatment (up to 10 days) of GERD in patients
with a history of erosive esophagitis who can’t take drugs
orally.
● Adults: reconstitute 20 or 40 mg with 5 mL of D5W,
NSS, or lactated Ringer injection and give by I.V. bolus
over 3 minutes. Or, further dilute to a total volume of 50
mL and give I.V. over 10-30 minutes. Switch patient to
oral therapy as soon as tolerated.
● Children ages 1-17 weighing 55 kg or more: 20 mg I.V.
infusion once daily over 10-30 minutes.
● Children ages 1-17 weighing less than 55 kg: 10 mg I.V.
infusion once daily over 10-30 minutes.
● Children ages 1 month to younger than 1 year: 0.5
mg/kg I.V. infusion once daily over 10-30 minutes.
To reduce the risk of gastric ulcers in patients receiving
continuous NSAID therapy.
● Adults: 20 or 40 mg or 24.65 or 49.3 mg (strontium)
P.O. once daily for up to 6 months.
Long-term treatment of pathologic hypersecretory
conditions, including Zollinger-Ellison syndrome.
● Adults: 40 mg or 49.3 mg (strontium) P.O. b.i.d. Adjust
dosage based on patient response.
To eliminate Helicobacter pylori
● Adults: 40 mg (magnesium) or 49.3 mg (strontium) P.O.
daily 1,000 mg amoxicillin P.O. b.i.d. And 500 mg for
clarithromycin P.O. b.i.d. Given together for 10 days to
reduce duodenal recurrence.
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Drug-herb:
● Red clover. My increased estrogen effects. Discourage
use together.
● St John’s Wort: may decrease effects of drug.
Discourage use together.
Drug-food:
● Grapefruit, grapefruit juice. May increase risk of adverse
effects. Discourage together.
○ Avoid: fatty foods, cola, coffee, tea, chocolate, alcohol (may cause
decrease LES pressure)
○ Upright position before and after eating (1-2 hrs.). Do not eat at
least 3 hours before bedtime to prevent nightmare reflux
○ No evening snacks - the burning sensation in the chest (heartburn)
usually after eating, which might be worse at night.
○ Reduce weight - Losing weight puts less pressure on the abdominal
and chest area, where the stomach and esophagus lay underneath.
● Relieve Pain
○ Antacids - Antacids that neutralize stomach acid. Antacids, such
as Mylanta, Rolaids, and Tums, may provide quick relief. Overuse
of some antacids can cause side effects, such as diarrhea or
sometimes kidney problems.
● Promote Lifestyle Changes
○ Elevate the head of the bed 6-12 in. for sleep. Raising the level of
your head helps gravity keep your stomach’s contents in the
stomach.
○ Avoid factors that increase intra-abdominal pressure such as:
■ Use of constrictive clothing
■ Straining - heavy lifting
■ Bedding, stooping
■ Coughing
○ Avoid smoking (causes a rapid and significant drop in LES pressure)
IX. PROGNOSIS
X. DISCHARGE PLANNING
health better than a simple medical cure. She believes that a holistic approach to
health care is central to the practice of caring in nursing.
According to Watson, the core of the Theory of Caring is that “humans
cannot be treated as objects and that humans cannot be separated from self,
other, nature, and the larger workforce.” Her theory encompasses the whole
world of nursing; with the emphasis placed on the interpersonal process between
the caregiver and care recipient. The theory is focused on “the centrality of
human caring and on the caring-to-caring transpersonal relationship and its
healing potential for both the one who is caring and the one who is being cared
for.”
In relation to the client’s condition, Watson’s theory is applicable since the
client needs assistance and care to cope up with its condition and this will boost
the coping mechanism of the patient to overcome and achieve good wellness. A
need of special approach is given in order for us nurses to render the care our
patient needs.
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