7. Diaphragmatic (hiatal) hernia: protrusion of part of stomach through diaphragm and into thoracic cavity. Types: sliding (most common); paraesophageal “rolling.”
   1. Pathophysiology: weakening of the musculature of the diaphragm, aggravated by increased intra-abdominal pressure-protrusion of the abdominal organs through the esophageal hiatus-reflux of gastric contents esophagitis.
   2. Risk factors:
      1. Congenital abnormality.
      2. Penetrating wound.
      3. Age (middle-aged or elderly).
      4. Women more than men.
      5. Obesity.
      6. Ascites.
      7. Pregnancy.
      8. History of constipation.
   3. Assessment:
      1. Subjective data:
         1. Pressure: substernal.
         2. Pain: epigastric, burning.
         3. Eructation, heartburn after eating.
         4. Dysphagia.
         5. Symptoms aggravated when recumbent.
      2. Objective data:
         1. Cough, dyspnea.
         2. Tachycardia, palpitations.
         3. Bleeding: hematemesis, melena, signs of anemia due to gastroesophageal irritation, ulceration, and bleeding.
         4. Diagnostic tests:
            1. Chest x-rays, showing protrusion of abdominal organs into thoracic cavity.
            2. Barium swallow (upper GI series) to show presence of hernia.
            3. Endoscopy
         5. Symptoms parallel those of gastroesophageal reflux disease (GERD).
   4. Analysis/nursing diagnosis:
      1. Pain related to irritation of lining of GI tract.
      2. Altered nutrition, less than body requirements, related to dysphagia.
      3. Sleep pattern disturbance related to increase in symptoms when recumbent.
      4. Risk for aspiration related to reflux of gastric contents.
      5. Activity intolerance related to dyspnea.
      6. Anxiety related to palpitations.
   5. Nursing care plan/implementation:
      1. Presurgical:
         1. Goal: promote relief of symptoms.
            1. Diet:
               1. Small, frequent feedings of soft, bland foods, to reduce abdominal pressure and reflux.
               2. Fluid when swallowing solids may push food into stomach; hot fluid may work best.
               3. Avoid eating 2 hours before bedtime.
               4. High-protein, low-fat foods to decrease heartburn.
            2. Positioning: head elevated to increase movement of food into stomach. Symptoms may decrease if head of bed at home is elevated on 8-inch blocks.
            3. Weight reduction to decrease abdominal pressure.
            4. Medications as ordered:
               1. 30 mL antacid 1 hour after meals and at bedtime.
               2. Avoid anticholinergic drugs, which decrease gastric emptying.
      2. Postsurgical:
         1. Goal: provide for postoperative safety needs.
            1. Respiratory: deep breathing, coughing, splint incision area.
            2. Nasogastric (NG) tube: check patency.
               1. Drainage: should be small amount.
               2. Color: dark brown 6-12 hours after surgery, changing to greenish yellow.
               3. Do not disturb tube placement to avoid traction on suture line.
            3. Position: initially head of bed elevated slightly, then semi-Fowler’s; turn side to side frequently, to prevent pressure on diaphragm.
            4. Maintain closed chest drainage if indicated.
            5. Check for return of bowel sounds.
         2. Goal: promote comfort and maintain nutrition.
            1. IVs for hydration and electrolytes.
            2. Initiate feeding through gastrostomy tube if present.
               1. Usually attached to intermittent, low suction after surgery.
               2. Aspirate gastric contents before feeding-delay if 75 mL or more is present; report these findings to physician.
               3. Feed in high Fowler’s or sitting position; keep head elevated for 30 min after eating.
               4. Warm feeding to room temperature; dilute with H₂O if too thick.
               5. Give 50mL, H₂O before feeding; 200-500 mL feeding by gravity over 10-15 minutes; follow with 50 mL H₂O
               6. Give frequent mouth care.
         3. Goal: health teaching.
            1. Avoid constricting clothing and activities that increase intra-abdominal pressure, e.g., lifting, bending, straining at stool.
            2. Weight reduction.
            3. Dietary needs: small, frequent, soft, bland meals; chew thoroughly; upright position for at least 1 hour after meals.
   6. Evaluation/outcome criteria:
      1. Relief from symptoms, comfortable.
      2. Receiving adequate, balanced nutrition.
      3. Describes dietary changes, recommended positioning, and activity limitations to prevent recurrence.