HIATAL HERNIA

A Case Study Presented to the

Faculty of the Nursing Department

San Pedro College

Davao City

MR. MARC JADE ADLAWAN, RN

In Partial Fulfillment of

The Requirements in NCM 216-RLE

GASTROINTESTINAL / METABOLISM NURSING ROTATION

BY:

JUNNESSA DALE LELIS, ST.N.

ALEXIS KHALYL MONTEJO, ST.N.

CHRISTINE M. PADASDAO

FIONA SOTITO, ST.N.

CLARISSA S. TORRES, ST.N.

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).

While statistics about hiatal hernia prevalence is unfortunately not well-published,

statistics show that 50% of adults will have some degree of hiatal hernia by age 60
according to Johns Hopkins’ Comprehensive Hernia Center and it also occurs in 15-
20% more in pregnancy. . Some patients with gastroesophageal reflux disease (GERD)
have been found to have hiatal hernia and in the Philippines, 11% to 15% of the
population have hiatal hernia. Moreover, hiatal hernia occurs 16.6% more frequently in
men (53.6%).

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.

Specifically, the student nurses aim to:

a. explain the anatomy and physiology of the affected system;
b. list the different precipitating and predisposing factors;
c. enumerate the signs and symptoms present in hiatal hernia;
d. trace the disease process of hiatal hernia through a schematic diagram;
e. narrate the pathophysiology of the disorder;
f. tabulate the diagnostic exams and laboratory tests;
g. Identify pharmacological management which includes H2 blockers, proton pump
inhibitors, antacids, antiemetics, and analgesics drug classification;
h. describe different surgical management and its nursing responsibilities;
i. formulate five nursing care plans;
j. outline nursing interventions to be rendered to patients with this disorder;
k. generate a prognosis in relation to hiatal hernia;
l. develop a discharge plan in relation to the case using the METHOD format;
m. discuss two related nursing theories;
n. summarize related works of literature or studies that are published not later than
5 years from the conduct of this study; and
o. cite the references used in alphabetical order using APA format.
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III. ANATOMY AND PHYSIOLOGY OF THE AFFECTED SYSTEM

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 diaphragm is a dome-shaped muscle. The organs in the thoracic cavity

abdominopelvic cavity obtaining the stomach, liver intestines, and other organs.
 5

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

Age (50 or older) The chances of having a hiatal hernia increase as

people get older. The diaphragmatic muscles naturally
become weaker and more flexible with advancing age.
With decreasing tissue elasticity, the gastric cardia may
not return to its normal position below the diaphragmatic
hiatus following a normal swallow. Loss of muscle tone
around the diaphragmatic opening also may make it
more patulous (Pawluszewicz, P. et al., 2018).

Genetics (Ehlers Danlos In general, a hiatal hernia is not believed to be genetic,

syndrome) but the most common hereditary condition that may be
associated with a hiatal hernia is Ehlers Danlos
syndrome. This is a connective tissue disease that has
a variety of clinical manifestations, including easy
bruising and overly flexible joints. A hiatal hernia may be
present as well. Thus, babies and young children can
have a hiatal hernia from birth (Moawad, H., 2020).

Sex (female) There is a theory that suggests a relationship

between increased intra-abdominal pressure during
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pregnancy and hernia, which is a probable explanation

for more frequent Hiatall hernias in women. Moreover,
women are believed to have more adipose tissues but
less activity, thus causing a decrease in muscle tone
(Pawluszewicz, P. et al., 2018).

PRECIPITATING FACTORS RATIONALE

Obesity Obesity is one of the biggest risk factors for hiatal

hernias. This may be due to increased pressure on
the diaphragm due to heavy weight (Moawad, H.,
2020).

Straining Exertion and muscle contraction when straining at

stool, due to constipation or diarrhea, may cause
an increase in intra-abdominal pressure. Thus, it
can increase the chances of having a hiatal hernia
due to excess pressure on the diaphragm
(Moawad, H., 2020).

Pregnancy During pregnancy, women develop increased

abdominal wall compliance to help pregnant
women adapt to the increased intra‐abdominal
pressure (IAP) caused by a growing fetus, fluid,
and tissue. The abdominal pressure and hormonal
changes of pregnancy can increase the chances of
a hiatal hernia (Moawad, H., 2020).

Heavy lifting It is believed that heavy lifting puts stress on the

diaphragmatic muscle, increasing the chances of
an enlarged hole that allows the stomach to
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protrude above the diaphragm (Moawad, H., 2020).

Smoking Smoking leads to COPD and other obstructive

diseases which force the diaphragm and other
muscles of respiration to work harder, leading to
their exhaustion. Thus, it weakens the muscles of
the diaphragm, allowing the stomach to protrude
above the diaphragm (Moawad, H., 2020).

Cough The abdominal pressure caused by coughing can

allow or cause the stomach to squeeze through the
diaphragm. Involuntary coughing such as that
evoked from the larynx triggers a coordinated
contraction of the thoracic, abdominal, and pelvic
muscles, which increases intra-abdominal pressure
(IAP), displaces the diaphragm upwards and
generates the expiratory force for cough and airway
clearance (Addington, W. et al, n.d.).

Trauma A traumatic injury can contribute to pressure on the

diaphragm, causing expansion of the opening in the
muscle (Moawad, H., 2020).

Surgery Previous surgery may precipitate to hiatal hernia as

scar formation due to surgery will decrease
vascularity in the area. Thus, there is decreased
blood circulation that may cause a decrease in the
muscle tone (RNSpeak, 2018).

Ascites Ascites is defined as an accumulation of fluid in the

abdominal cavity. This accumulated fluid can cause
elevated intra-abdominal pressure that may
precipitate to hiatal hernia (Stoppler, M., 2019).
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Chronic esophagitis Conditions, such as chronic esophagitis may cause

shortening of the esophagus, causing fibrosis of the
longitudinal muscles and thus precipitating the
hiatal hernia (Pawluszewicz, P. et al., 2018).

B. SYMPTOMATOLOGY

SYMPTOMS RATIONALE

Reflux, heartburn HH causes an anatomical and physiological

interference in the normal anti-reflux barrier with
several mechanisms: it reduces LES length and
pressure, impairs the augmenting effects of the
diaphragmatic crus, is associated with decreased
esophageal peristalsis, increases the cross-
sectional area of the esophagogastric junction
(EGJ), and acts as a reservoir allowing reflux from
the hernial sac into the esophagus during
swallowing. All these mechanisms lead to:
reduction in LES competence; increase in the
frequency of the acid-associated TLESRs; and
impairment of esophageal clearance (Torresan et
al., 2016)

Postprandial fullness The most common cause of a hiatal hernia is an

increase in pressure in the abdominal cavity
(Cleveland Clinic 2020). Dysphagia and
postprandial fullness occur as a result of
esophageal compression by a progressively
expanding herniating stomach.
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Substernal chest pain The chest pain commonly occurs postprandially

(after eating) and is substernal (behind the breast
bone) in location, giving rise to concern that the
chest pain is cardiac in origin
(Memorialhermann.org). At times, a hiatal hernia
causes chest pain or upper abdominal pain when
the stomach becomes trapped above the
diaphragm through the narrow esophageal hiatus
(Simic, 2020)

Dysphagia Hiatal hernias can cause obstruction and delay in

emptying of the lower part of the esophagus and
the stomach, resulting in dysphagia
(Memorialhermann.org). The existence of a hiatal
hernia may also lead to symptoms of dysphagia, by
the effect of compression of the esophageal hiatus
at the level of the diaphragm and the creation of a
mechanical obstacle to the normal discharge
(Reflux Centre, 2020). Chronic reflux of stomach
acids into your esophagus can irritate your throat.
In severe cases, it can cause dysphagia (Roth,
2018)

Occult bleeding The gastrointestinal bleeding associated with Hiatal

hernias can result from gastric ischemia in cases of
strangulation or acute secondary gastric volvulus.
Another etiology of gastric bleeding unique to
Hiatal hernias is ulcerations of the gastric mucosa
known as Cameron lesions. These lesions present
as linear ulcerations in the gastric mucosa in the
fundus or body of the stomach.
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The bleeding from Cameron lesions can present as

an acute upper gastrointestinal hemorrhage in
patients with a hiatal hernia. More frequently, the
blood loss associated with hiatal hernia can be
occult and present as iron deficiency anemia. The
prevalence of Cameron lesions ranges from 1.9–
9.2% in patients with iron deficiency anemia
(Goodwin, 2020).

Regurgitation Foods can remain in the hiatal hernia and return

back into the mouth. Type II and Type III hiatal
hernia can result in mechanical obstruction of the
lower part of the esophagus, causing regurgitation
of the food into the mouth after eating. This can be
associated with a bitter taste in the mouth in
patients with reflux disease. Memorialhermann.org
Regurgitation is the perception of the flow of
refluxed gastric content into the mouth or
hypopharynx (Goodwin, 2020).

Anemia Anemia is the most common laboratory finding in

patients with paraesophageal (type II) hiatal hernia
and results from damage and ulceration to the
lining of the stomach due to compression of the
stomach at the level of esophageal hiatus
(Memorialhermann.org)

Weight loss Often patients complain of postprandial fullness in

the chest or epigastrium which may limit oral
nutrition and lead to subsequent weight loss
(Goodwin, 2020).
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SCHEMATIC DIAGRAM

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

Increased pressure in the

abdominal cavity

Upward movement of pressure

Reaches the diaphragmatic

opening

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

SLIDING HIATAL ROLLING HIATAL

HERNIA HERNIA DIAGNOSTIC TOOLS
Physical assessment
 Nausea, vomiting
 Burning sensation in the
MIXED HIATAL chest
HERNIA  Sour taste in the mouth
 Gagging or chocking
Medical
 X-ray, endoscopy,
ambulatory acid probe test,
esophageal motility testing
Nursing Diagnosis
 Risk for aspiration r/t
Stricture LES relaxation and reduced esophageal compromise
esophageal sphincter pressure affecting the lower
esophageal sphincter

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.
 15

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.
 16

If treated If not treated

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.
 17

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.
 18

These can also lead to more complications such as decrease functioning

of the surrounding organs that may cause delay in gastric emptying or a delay in
digestion, which when not managed, may cause malnutrition. This explains the
weight loss and dysphagia that may happen on patients with hiatal hernia. It can
also lead to incarcerated hernia, which means that it cannot be easily returned to
its original placement causing obstruction. Due to the obstruction, occult bleeding
and even anemia may occur. With an obstructed esophagus or stomach,
decrease diaphragmatic expansion that often leads to decrease respiratory
capacity may occur. Moreover, decrease flexibility of the esophagus and
diaphragm may occur causing decrease capacity to function.
Most people with hiatal hernias have few, if any, symptoms. More
bothersome symptoms usually are controlled with medications which includes the
medications mentioned above, surgical management and the nursing
interventions to be carried out. Thus, with prompt treatment and patient’s
compliance, hiatal hernia would have a good prognosis. On the other hand, if left
untreated, hiatal hernia will progress and cause a lot of complications that may
lead to death. These may include respiratory complications due to decrease
respiratory capacity; chronic regurgitation or reflux that may lead to Barrett’s
esophagus that may also precipitate to esophageal cancer or recurrent aspiration
that may cause respiratory tract infections; and strangulated hernia that is
caused by incarceration, that may lead to blood being stopped from flowing freely
to the tissue thus causing tissue death and gangrene. Furthermore, the blocked
circulation may lead to chronic anemia that may lead to shock. All these
complications may lead to the death of the patient if left untreated. In this case, it
will have a poor prognosis.
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VI. MEDICAL MANAGEMENT

A. DIAGNOSTIC EXAMS

TEST INTERPRETATION AND NURSING

SIGNIFICANCE RESPONSIBILITIES

ENDOSCOPY ● An endoscopy is a ● Answering patient

procedure in which questions and
the inside of the addressing their
upper digestive concerns.
system is viewed ● Observing patient
with an endoscope vital signs.
(a long, thin, flexible ● Sedating patients
instrument about 1/2 before procedures.
inch in diameter). ● Recovering patients
after procedures.
● Administering the
necessary
medication to
patients.
● Keeping the patient
informed throughout
the duration of the
procedure.
● Completing all
necessary
documentation
including patient
notes and discharge
documents.
● Preparing the
instruments,
equipment, and
supplies for the
procedure.
● Cleaning and
sterilizing equipment
before use.
● Providing
assistance to
 20

Doctors throughout
the procedure.
● Administering IV
drips.

BARIUM SWALLOW ● A barium swallow ● Explain to the

involves drinking a patient that this test
special liquid, then evaluates the
taking X-rays to help function of the
see problems in the pharynx and
esophagus (such as esophagus.
swallowing ● Instruct the patient
disorders) and the to fast after midnight
stomach (such as before the test.
ulcers and tumors).
It also shows how
● If the patient is an
infant, delay the
big the hiatal hernia
feeding to ensure
is and if there is
complete digestion
twisting of the
of the barium.
stomach as a result
of the hernia. ● Explain that the test
takes approximately
30 minutes.
● Describe the
milkshake
consistency and
chalky taste of the
barium preparation
the patient will
ingest; although it’s
flavored, it may be
unpleasant to
swallow.
● Tell him he’ll first
receive a thick
mixture and then a
thin one and that he
must drink 12 to 14
oz (355 to 414 ml)
 21

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
 22

teratogenic effects

ESOPHAGEAL ● Esophageal ● There are no activity

MANOMETRY restrictions unless
manometry
measures the by medical direction.
strength and muscle Under medical
coordination of your direction, the patient
esophagus when should withhold
you swallow. medications for 24
hr before the study.
Instruct the patient
to fast and restrict
fluids for 6 hr prior
to the procedure to
reduce the risk of
aspiration related to
nausea and
vomiting. The
patient may be
required to be NPO
after midnight.

● 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
 23

number of days to
withhold medication
is dependent on the
type of
anticoagulant.
Protocols may vary
among facilities.

● Ensure that barium

studies were
performed more
than 4 days before
the esophageal
manometry (EM).

GASTRIC EMPTYING ● Gastric emptying ● There are no activity

STUDIES or medication
studies examine
how fast food leaves restrictions unless
the stomach. by medical direction.
Results from this Instruct the patient
test are especially to restrict food and
important in patients fluids for 8 hr before
who have nausea the scan. Inquire
and vomiting. There about allergic
could be other reactions to eggs.
causes of nausea No other
and vomiting radionuclide scans
besides a hiatal or procedures using
hernia. barium contrast
medium should be
scheduled within 24
to 48 hr before this
procedure.
Protocols may vary
among facilities.
 24

B. LABORATORY TEST

TEST DEFINITION NURSING

RESPONSIBILITIES

Complete Blood Count ● The complete blood Pre-procedure

(CBC) count (CBC) is a 1. Identify the patient.
group of tests that 2. Explain the
evaluate the cells procedure to the
that circulate in the patient.
blood, including red 3. Obtain a history of
blood cells (RBCs), known allergens.
white blood cells 4. Obtain results of
(WBCs), and tests previously.
platelets (PLTs). 5. Obtain a list of
The CBC can medications the
evaluate your overall patient is taking.
health and detect a 6. Note any recent
variety of diseases procedures that can
and conditions, such interfere with the
as infections, result.
anemia, and 7. Inform the patient
leukemia. and the watcher that
● In hiatal hernia there is no fluid,
patients, CBC is food, or medication
done to check for restrictions unless
anemia due to blood contraindicated on
loss the patient’s diet.

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
 25

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.

Stool test ● A series of tests 1. Assess the patient’s

done on a stool level of comfort.
(feces) sample. Collecting stool
● Involves the specimens may
collection and produce a feeling of
analysis of fecal embarrassment and
matter to diagnose discomfort to the
the presence or patient.
absence of a 2. Encourage the
medical condition. patient to urinate.
Allow the patient to
urinate before
collecting to avoid
contaminating the
stool with urine.
3. Instruct patient to do
handwashing. Allow
the patient to
thoroughly clean his
 26

or her hands and

perianal area.

C. PHARMACOLOGICAL MANAGEMENT
1. Histamine 2 receptor antagonist

Drug Photo

Generic Name Ranitidine

Brand Name Apo-Ranitidine, GenRanitidine, Novo-Ranitidine,

Nu-Ranit, Zantac

Classification Histamine-2 receptor antagonists

Pregnancy Category B

Mode of Action Inhibits histamine at H2 receptor site in the gastric parietal

cells, which inhibits gastric acid secretion

Dose and Route Erosive esophagitis

● Adult: PO 150 mg qid for up to 12 wk
● Child >1mo: PO 5-10 mg/kg/day in 2-3 divided doses
Duodenal ulcer
● Adult: PO 150 mg bid or 300 mg/day after pm meal or at
bedtime, maintenance 150 mg at bedtime
● Infant and child: PO 2-4 mg/kg bid, max 300 mg/day
Zollinger-Ellison syndrome
● Adult: PO 150 mg bid, may increase if needed
Gastric ulcer
● Adult: PO 150 mg bid 3 6 wk, then 150 mg at bedtime
Infant/child: PO 2-4 mg/kg bid, max 300 mg/ day

Indications To prevent duodenal and gastric ulcers

 27

Contraindications Hypersensitivity Precautions: Pregnancy B,

breastfeeding, child,12 yr, renal/hepatic disease

Side effects Skin Rash, Constipation, Diarrhea, Dizziness,

Drowsiness, Headache, Nausea, Stomach
Cramps.

Adverse Effects ● CNS: Headache, sleeplessness, dizziness, confusion,

agitation, depression; hallucinations (geriatric)
● CV: Tachycardia, bradycardia, premature ventricular
contractions
● EENT: Blurred vision, increased ocular pressure
● GI: Constipation, abdominal pain, diarrhea, nausea,
vomiting, hepatotoxicity GU: Impotence, acute interstitial
nephritis (rare)
● INTEG: Urticaria, rash, fever
● RESP: Pneumonia
● SYST: Anaphylaxis (rare)

Drug Interactions Adefovir, pramipexole, procainamide, trospium, triazolam,

memantine, saquinavir: increased effect of each product
Diazepam, metoclopramide: decreased absorption of ranitidine
Ketoconazole: decreased effect of ketoconazole NIFEdipine,
ext rel products: increased GI obstruction risk

Nursing 1. Advise patients to avoid driving, other hazardous

Interventions activities until stabilized on this medication; drowsiness
or dizziness may occur.
2. Inform patient that smoking decreases the effectiveness
of the product; that smoking cessation should be
considered
3. Instruct patients that the product must be continued for
prescribed time to be effective and taken exactly as
prescribed; doses should not be doubled; a missed
dose should be taken when remembered up to 1 hr
before the next dose.
4. Advise patient to report bruising, fatigue, malaise; blood
dyscrasias may occur
5. Inform patient to report diarrhea, black tarry stools, sore
throat, rash, dizziness, confusion, or delirium to
prescriber immediately
 28

6. Teach patients to take a once-daily dose before

bedtime.
7. Inform patients that healing of an ulcer may require 4 to
8 weeks of therapy.
8. Tell the patient to stop taking ranitidine and contact
prescriber if she has trouble swallowing, vomits blood,
or passes black or bloody stools.

Drug Photo

Generic Name Cimetidine

Brand Name Tagamet

Classification Histamine-2 receptor antagonists

Pregnancy Category B

Mode of Action The H2-receptor antagonist cimetidine competitively blocks

histamine from stimulating the H2-receptors located on the
gastric parietal cells (these cells are responsible for
hydrochloric acid secretion and secretion of the intrinsic
factor). The effect results in reducing the volume of gastric acid
secretion from stimuli, including histamine, food, caffeine, and
insulin.

Dose and Route Route: PO

● Dose for duodenal ulcers range from 800 to 1600 mg to
be taken at bedtime or 300 mg 4 times a day at meal
times and bedtime, or 400 mg twice a day for 4-6
weeks.
● For active gastric ulcers, 800 mg at bedtime or 300 mg
4 times a day at meal times and bedtime for up to 8
weeks.
● Dose for GERD is 800 mg twice a day or 400 mg 4
 29

times a day for 12 weeks.

● Heartburn, indigestion or sour stomach may be treated
with 200 mg once or twice daily and may be
administered up to 30 minutes before ingestion of food
or beverages that may cause heartburn.

Indications ● Short-term treatment of active duodenal ulcer or benign

gastric ulcer.
● Treatment of pathological hypersecretory conditions
such as Zollinger-Ellison syndrome (blocking the
overproduction of hydrochloric acid that is associated
with these conditions).
● Treatment of erosive gastroesophageal reflux
(decreasing the acid being regurgitated into the
esophagus will promote healing and decrease pain).
● Relief of symptoms of heartburn, acid indigestion, and
sour stomach

Contraindications Contraindicated for patients known to have hypersensitivity

to the product.

Side effects ● Headache

● Dizziness
● Diarrhea
● Skin rash
● Drowsiness
● Nausea, vomiting.

Adverse Effects CNS: Dizziness, confusion, headache, depression, anxiety,

Hallucinations,
Cardio: cardiac arrest.
GI: Constipation, diarrhea, nausea, vomiting, dry mouth
Renal: Increased plasma creatinine

signs of an allergic reaction:

● hives, difficult breathing, swelling in your face or throat
severe skin reaction:
● fever, sore throat, burning in your eyes, skin pain, red or
purple skin rash that spreads and causes blistering and
peeling.
 30

Drug Interactions warfarin-type anticoagulants,

● phenytoin,
● propranolol,
● nifedipine,
● chlordiazepoxide,
● diazepam,
● certain tricyclic antidepressants,
● lidocaine,
● theophylline
● and metronidazole

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.
 31

2. Proton Pump Inhibitor

Drug Photo

Generic Name Omeprazole

Brand Name Losec, Prilosec, Prilosec OTC, Zegerid

Classification Proton Pump Inhibitor; Antisecretory

Pregnancy Category C

Mode of Action Suppresses gastric secretion by inhibiting hydrogen/potassium

ATPase enzyme system in gastric parietal cells; characterized
as gastric acid pump inhibitor because it blocks the final step
of acid production.

Dose and Route PO (Adults): 40 mg once daily in the morning with

clarithromycin for 2 wk, then 20 mg once daily for 2 wk or 20
mg twice daily with clarithromycin 500 mg twice daily and
amoxicillin 1000 mg twice daily for 10 days (if ulcer is present
at beginning of therapy, continue omeprazole 20 mg daily for
18 more days); has also been used with clarithromycin and
metronidazole.

Indications ● Duodenal and gastric ulcer.

● Gastroesophageal reflux disease including
● severe erosive esophagitis (4 to 8 wk
● treatment).
● Long term treatment of pathologic hypersecretory
conditions such as Zollinger Ellison syndrome, multiple
endocrine adenomas, and systemic mastocytosis.
● In combination with clarithromycin to treat 34 duodenal
ulcers associated with Helicobacter pylori.
● Dyspepsia occurring more than twice weekly

Contraindications ● Hypersensitivity
● Orally disintegrating tablets contain aspartame and
should not be used in patients with phenylketonuria
● Congenital long QT syndrome
 32

● Concurrent use of apomorphine

Side effects Frequent:

● Headache
Occasional:
● Diarrhea
● Abdominal pain
● Nausea
Rare:
● Dizziness
● Asthenia
● Vomiting
● Constipation
● Upper respiratory tract infection
● Back pain
● Rash
● Cough

Adverse Effects ● Pancreatitis

● Hepatotoxicity
● Interstitial nephritis occur rarely
● May increase risk of C. difficile infection

Drug Interactions Drug:

● Apomorphine may cause profound hypotension, altered
LOC. QT interval–prolonging medications (e.g.,
amiodarone, azithromycin, ciprofloxacin, haloperidol)
may increase risk of QT interval prolongation, torsades
de pointes.
Herbal:
● St. John‘s wort may decrease concentration.
Lab Values:
● May transiently increase serum bilirubin, ALT, AST

Nursing 1. Perform a physical examination to establish baseline

Interventions data before beginning therapy.
R: To determine the effectiveness of the therapy and to
evaluate for the occurrence of any adverse effects associated
with drug therapy.
2. Assess for rash periodically during therapy.
R: May cause Stevens-Johnson syndrome or toxic epidermal
 33

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

Generic Name Aluminum Hydroxide

Brand Name Alternagel, Alu-Cap, Alu-Tab, Alugel, Aluminet, Amphojel,

Basalgel, Dialume
 34

Pregnancy Category C

Classification Antacids, Antireflux Agents & Antiulcerants

Mode of Action Aluminium hydroxide neutralises HCl in the stomach resulting

in increased gastric pH and inhibition of pepsin activity.
Additionally, it reduces absorption of phosphate by binding
and forming insoluble complexes in the GI tract

Dose and Route Hyperphosphatemia in patients with chronic renal failure

● Adult: Up to 10 g daily in divided doses, adjusted to
individual patient’s requirement.
Antacid
● Adult: Doses of up to 1 g, given after meals and at
bedtime.

Indications ● Hyperphosphatemia in patients with chronic renal

failure
● Antacid

Contraindications Hypersensitivity to aluminum or its components

Side effects ● GI: Constipation, anorexia, fecal impaction

● META: Hypophosphatemia

Adverse Effects ● CNS: Encephalopathy

● GI: Constipation, intestinal obstruction, white-speckled
stool
● MS: Osteomalacia, osteoporosis
● Other: Aluminum accumulation in serum, bone, and
CNS; aluminum intoxication; electrolyte imbalances

Drug Interactions ● Absorption of tetracyclines, chlorpromazine, iron salts,

isoniazid, digoxin, or fluoroquinolones may be
decreased.
● Salicylate blood levels may be decreased.
● Quinidine, mexiletine, and amphetamine levels may be
increased if enough antacid is ingested such that urine
pH is increased

Nursing Interventions 1. Note number and consistency of stools. Constipation is

common and dose related. Intestinal obstruction from
 35

fecal concretions has been reported.

2. Not to use for prolonged periods for patients with low
serum phosphate or patients on low-sodium diets; to
shake liquid well
3. Hyperphosphatemia: to avoid phosphate foods (most
dairy products, eggs, fruits, carbonated beverages)
during product therapy
4. To notify prescriber of black tarry stools, which may
indicate bleeding
5. Tell patient to take drug 1 hour after meals and at
bedtime.
6. Caution patient not to take drug within 1 to 2 hours of
anti-infectives, H2 blockers, iron, corticosteroids, or
enteric-coated drugs.
7. Advise patient to take drug with water or fruit juice.
8. Instruct patient to report signs and symptoms of GI
bleeding and hypophosphatemia (appetite loss,
malaise, muscle weakness).
9. Recommend increased fiber and fluid intake and
regular physical activity to help ease constipation.
10. As appropriate, review all other significant and life-
threatening adverse reactions and interactions,
especially those related to the drugs, tests, and foods
mentioned above.

Drug Photo

Generic Name Calcium Carbonate

 36

Brand Name Caplets, Mallamint, Mylanta Lozenges, Nephro-Calci, Nu-Cal,

Os-Cal, Oysco, Oyst-Cal, Oystercal, Rolaids Calcium Rich,
Surpass, Surpass Extra Strength, Titralac, Tums, Tums E-X

Classification Antacid

Pregnancy Category C

Mode of Action Calcium carbonate acts as an antacid by neutralising gastric

acidity resulting in increased gastric and duodenal pH. It
inhibits proteolytic activity of pepsin if the pH is increased >4
and increases lower esophageal sphincter tone. Additionally, it
forms an insoluble complex with dietary phosphate, thereby
reducing phosphate absorption in patients with chronic kidney
disease.

Dose and Route Hyperphosphatemia in patients with chronic renal failure

● Adult: 3-7 g daily in divided doses. Adjust according to
the patient's serum phosphate level.
Hyperacidity
● Adult: 0.5-3 g as symptoms occur. Max: 7.5 g daily for
up to 2 weeks. Dosage may vary according to the
product being used.
● Child: 2-5 years 0.375-0.4 g as symptoms occur. Max:
1.5 g daily for up to 2 weeks; 6-11 years 0.75-0.8 g as
symptoms occur. Max: 3 g daily for up to 2 weeks; ≥12
years Same as adult dose. Dosage may vary according
to the product being used.
Hypocalcemia and calcium deficiency states
● Adult: 0.5-4 g daily in 1-3 divided doses. Dosage may
vary according to the product being used.
● Child: 6-10 years 500 mg daily; >10 years 1 g daily.
Dosage may vary according to the product being used.

Indications ● Hyperphosphatemia in patients with chronic renal

failure
● Hyperacidity
● Hypocalcemia and calcium deficiency states

Contraindications Hypercalcemia; Renal calculi; Ventricular fibrillation;

Concurrent use of calcium supplements (calcium acetate).
 37

Hypercalcemia and hypercalciuria (e.g., hyperparathyroidism,

vitamin D overdose, decalcifying tumors, bone metastases),
calcium loss due to immobilization, severe renal failure, renal
calculi, GI hemorrhage or obstruction, dehydration, digitalis
toxicity; hypochloremic alkalosis, ventricular fibrillation, cardiac
disease

Side effects Calcium carbonate: Milk-alkali syndrome (headache,

decreased appetite, nausea, vomiting, unusual fatigue).

Rare: Urinary urgency, painful urination.

Adverse Effects Hypercalcemia:

● Early signs: Constipation, headache, dry mouth,

increased thirst, irritability, decreased appetite, metallic
taste, fatigue, weakness, depression.
● Later signs: Confusion, drowsiness, hypertension,
photosensitivity, arrhythmias, nausea, vomiting, painful
urination.

Drug Interactions ● Atenolol, fluoroquinolones, tetracycline: decreased

bioavailability of these drugs
● Calcium channel blockers: decreased calcium effects
● Cardiac glycosides: increased risk of cardiac glycoside
toxicity
● Iron salts: decreased iron absorption
● Sodium polystyrene sulfonate: metabolic alkalosis
● Verapamil: reversal of verapamil effects

Nursing Interventions 1. Observe for S&S of hypercalcemia in patients receiving

frequent or high doses, or who have impaired renal
function (see Appendix F).
2. Monitor lab tests: Weekly serum and urine calcium in
patients receiving prolonged therapy and in patients
with renal dysfunction.
3. Do not take within 1–2 hrs of other oral medications,
fiber-containing foods.
4. Avoid excessive use of alcohol, tobacco, caffeine.
5. Do not continue this medication beyond 1–2 wk, since it
may cause acid rebound, which generally occurs after
repeated use for 1 or 2 wk and leads to chronic use. It
 38

is potentially dangerous to self-medicate. Do not take

antacids longer than 2 wk without medical supervision.
6. Do not use calcium carbonate repeatedly with foods
high in vitamin D (such as milk) or sodium bicarbonate,
as it may cause milkalkali syndrome: hypercalcemia,
distaste for food, headache, confusion, nausea,
vomiting, abdominal pain, metabolic alkalosis,
hypercalciuria, polyuria, soft tissue calcification
(calcinosis), hyperphosphatemia and renal
insufficiency. Predisposing factors include renal
dysfunction, dehydration, electrolyte imbalance, and
hypertension.
7. To increase fluids to 2 L unless contraindicated; to add
bulk to diet for constipation; to notify prescriber of
constipation
8. To avoid spinach, cereals, dairy products in large
amounts, other foods high in oxalates before taking the
product; may interfere with absorption of calcium
9. Keep patient in a recumbent position for 30 minutes
after parenteral administration to prevent dizziness
from hypotension
10. Instruct patient to take calcium carbonate tablets 1 to 2
hours after meals and other forms with meals
11. If a patient is taking an oral suspension, teach to shake
the bottle well before taking it to ensure that the liquid is
evenly mixed. Use the measuring spoon or cup
provided to measure the dose.
12. If a patient is taking an effervescent tablet, teach the
patient to dissolve the tablet in a glass of water and the
solution should be taken immediately after complete
dissolution.
13. If a patient is taking a chewable tablet, instruct the
patient that the tablet should be chewed and not
swallowed whole.
14. For better absorption, take Calcium carbonate with
food.
 39

4. Antiemetics

Drug Photo

Generic Name Metoclopramide

Brand Name Reglan, Clopra, Emex , Maxeran , Maxolon, Reglan

Classification Dopaminergic blocker

Mode of Action The antiemetic action of metoclopramide is due to its

antagonist activity at D2 receptors in the chemoreceptor trigger
zone in the central nervous system; this action prevents
nausea and vomiting triggered by most stimuli.

Dose and Route ● Adults—At first, 10 to 15 milligrams (mg) four times a

day, taken 30 minutes before symptoms are likely to
begin or before each meal and at bedtime, for 4 to 12
weeks. Your doctor may adjust your dose as needed.
However, the dose is usually not more than 60 mg per
day.
● Children—Use and dose must be determined by your
doctor.

Indications Used to treat the symptoms of slow stomach emptying

(gastroparesis) in patients with diabetes. It works by increasing
the movements or contractions of the stomach and intestines.
It relieves symptoms such as nausea, vomiting, heartburn, a
feeling of fullness after meals, and loss of appetite.

Contraindications Contraindicated in patients with pheochromocytoma because

the drug may cause a hypertensive crisis, probably due to
 40

release of catecholamines from the tumor. Such hypertensive

crises may be controlled by phentolamine.

Side effects Restlessness, drowsiness, lack of energy,dizziness,

headache, confusion, and sleep problems (insomnia).

Adverse Effects ● CNS Effects: Restlessness, drowsiness, fatigue,

Insomnia, headache, confusion, dizziness.
● Gastrointestinal: Nausea and bowel
disturbances,diarrhea.
● CV: Transient Hypertension

Drug Interactions Antipsychotic drugs, atovaquone, Dopamine agonists,

fosfomycin, MAO inhibitors. pramlintide, phenothiazines,
rivastigmine.

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

Generic Name Acetaminophen

Brand Name Biogesic, Abenol, ACET,

 41

Pediatrix, Tylenol

Classification Analgesic/Antipyretic

Mode of Action Thought to produce analgesia by inhibiting prostaglandin and

other substances that sensitize pain receptors. Drugs may
relieve fever through central action in the hypothalamic heat-
regulating center.

Dose and Route Intravenous

Fever, Mild to moderate pain
● Adult: 33-50 kg: 15 mg/kg 4-6 hourly if needed. Max: 3 g
daily. >50 kg: 1 g 4-6 hourly if needed. Max: 4 g daily.
Administer by infusion over 15 minutes.
● Child: Full-term neonates and children <10 kg: 7.5
mg/kg as a single dose, at least 4 hourly. Max: 30
mg/kg/day; 10-33 kg: 15 mg/kg as a single dose, at
least 4 hourly. Max: 2 g daily; 33-50 kg: 15 mg/kg as a
single dose, at least 4 hourly. Max: 3 g daily; >50 kg:
Same as adult dose.
Oral
Fever, Mild to moderate pain
● Adult: 0.5-1 g 4-6 hourly. Max: 4 g daily.
● Child: 1-2 months 30-60 mg 8 hourly. Max: 60
mg/kg/day; 3-<6 months 60 mg. 6 months to <2 years
120 mg; 2-<4 years 180 mg; 4-<6 years 240 mg; 6-<8
years 240 or 250 mg; 8-<10 years 360 or 375 mg; 10-
<12 years 480 or 500 mg; 12-16 years 480 or 750mg.
Administer 4-6 hourly if necessary. Max: 4 doses in 24
hours.

Indications Mild pain or fever; mild to moderate pain; mild to moderate

pain with adjunctive opioid analgesics; fever

Contraindications Patients hypersensitive to drug; IV form is contraindicated in

patients with severe hepatic impairment or severe active liver
disease

Side effects ● Frequent (30%–26%): Joint swelling/ discomfort,

peripheral edema, muscle spasm, musculoskeletal pain,
hypokalemia.
 42

● Occasional (19%–6%): Hot flashes, diarrhea, UTI,

cough, hypertension, urinary frequency, nocturia.
● Rare (less than 6%): Heartburn, upper respiratory tract
infection

Adverse Effects ● CNS: agitation (I.V.), anxiety, fatigue, headache,

insomnia, pyrexia
● CV: HTN, hypotension, peripheral edema, periorbital
edema, tachycardia (I.V>)
● GI: nausea, vomiting, abdominal pain, diarrhea,
constipation (I.V.)
● GU: oliguria (I.V.)

Drug Interactions ● Barbiturates, carbamazepine, hydantoins, rifampin,

sulfinpyrazone: High doses or long-term use of these
drugs may reduce therapeutic effects and enhance
hepatotoxic effects of acetaminophen. Avoid using them
together.
● Busulfan: May increase busulfan level. Monitor patients
closely.
● Cholestyramine resin: May decrease acetaminophen
absorption. Give at least 1 hour after acetaminophen or
consider therapy change.
● Warfarin: May increase hypoprothrombinemic effects
with long term use with high doses of acetaminophen.
Monitor INR closely.

Nursing 1. Do not exceed the recommended dosage.

Interventions 2. Consult a physician if needed for children less than 3
years old; if needed for longer than 10 days; if continued
fever, severe or recurrent pain occurs (possible serious
illness).
3. Avoid using multiple preparations containing
acetaminophen. Carefully check all OTC products.
4. Give drugs with food if GI upset occurs.
5. Discontinue drugs if hypersensitivity reactions occur.
6. Treatment of overdose: Monitor serum levels regularly,
N-acetylcysteine should be available as a specific
antidote; basic life support measures may be
necessary.
 43

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

Generic Name Esomeprazole

Brand Name Nexium

Classification Therapeutic class: Antiulcer drugs

Pharmacologic class: Proton pump inhibitor

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.

Dose and Route ● Capsules- 20 mg, 40 mg

● Powder for suspension: 2.5 mg, 5 mg, 10 mg, 20 mg
● Tablets: 20 mg

Indications GERD; to heal erosive esophagitis

● Adults: 20 or 40 mg or 24.75 or 49.3 mg (strontium)
P.O. daily for 4-8 weeks. Maintenance dose for healing
erosive esophagitis is 20 mg P.O. daily for up to 6
months.
● Children ages 1 to 11 weighing 20 kg or more: 10 or 20
m P.O. once daily for up to 8 weeks.
 44

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.
 45

Reduction of risk for rebleeding of gastric or duodenal

ulcers after therapeutic endoscopy.
● ADults: 80 m I.V. over 30 minutes, followed by
continuous infusion of 8 mg.hr for a total I.V. treatment
duration of 72 hours, followed by oral acid-suppressive
therapy
● Adjust-a-dose. In patients with mild to moderate hepatic
impairment 9Child-Pugh classes A & B), maximum
continuous infusion rate is 6 mg/hr. In patients with
severe hepatic impairment (Child Pugh class C),
maximum continuous infusion rate is 4 mg/hr.

Contraindications ● Contraindicated in patients hypersensitive to drug or

components of esomeprazole or omeprazole (a drug
similar to this one). There may be an increased risk of
osteoporosis-related hip, wrist, and spine fractures
associated with PPIs. Risk is increased in patients who
received high-dose and long-term (> 1 year) therapy.
The lowest dosage for the shortest duration should be
used.
● Use cautiously in patients receiving continuous NSAID
therapy who are at increased risk for gastric ulcers
(those age 60 and older and those with a history of
gastric ulcers).
● Drug-induced decreases in gastric-acidity may increase
serum chromogranin A (CgA) level, possibly causing
false-positive results in diagnostic investigations for
neuroendocrine tumors. Temporarily stop esomeprazole
at least 14 days before assessing CgA level; consider
repeating the test if initial CgA level is high.
● If cutaneous lupus or SLE occurs, discontinue the drug.

Side effects ● Skin: Blistering, peeling, or loosening of the skin,

bloating, chills,
● GI: constipation
● Respiratory: cough
● Urinary: darkened urine

Adverse Effects ● CNS: headache, dizziness

● GI: abdominal pain, constipation, diarrhea, dry mouth,
 46

flatulence, nausea, vomiting

● Skin: Pruritus

Drug Interactions Drug-Drug:

● Anastrozole. May interfere with anastrozole
effectiveness. Avoid use together.
● Carbamazepine, fosphenytoin, phenobarbital,
phenytoin, rifampin: May decrease effectiveness of
estrogen therapy. Monitor patients.
● Clarithromycin, erythromycin, itraconazole,
ketoconazole, ritonavir. May increase estrogen plasma
levels and side effects. Monitor patients.
● Corticosteroids. May increase corticosteroid effects.
Monitor patients.

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.

Nursing 1. Monitor patients for rash or signs and symptoms of

Interventions hypersensitivity. Monitor GI symptoms for improvement
or worsening.
2. Monitor magnesium level before treatment and
periodically during treatment. Monitor patient for signs
and symptoms of low magnesium level, such as
abnormal HR or heart rhythm, palpitations, muscle
spasms, tremor, and seizures. In children, abnormal HR
may present as fatigue, upset stomach, dizziness, and
light-headedness.
3. Instruct patient to take drug exactly as prescribed.
4. Tell patient to take drug at least 1 hour before a meal.
5. Advise patient that antacids can be used while taking
drug unless otherwise directed by the prescriber.
6. Warn patient not to chew or crush drug pellets because
 47

this inactivates the drug.

7. Tell patient who has difficulty to inform prescriber of
worsening signs and symptoms, pain diarrhea that
doesn’t improve.
8. Instruct patient to alert prescriber if rash or other signs
and symptoms of allergy occur.
9. Warn patient to immediately report symptoms of low
magnesium level, such as involuntary muscle
movements or seizures.
10. Monitor for S&S of adverse CNS effects (vertigo,
agitation, depression) especially in severely ill patients.

VII. SURGICAL MANAGEMENT

Manage Definition Rationale Procedure Nursing

ment Responsibilities

Laparos Fundoplication is a Patients with 1. Five small 1. Assess the

copic minimally invasive symptoms that incisions level of
Nissen form of surgery are not are made in consciousnes
fundopli that strengthens completely the s of the
cation the LES by controlled by abdomen patient after
(LNF) suturing the fundus PPI therapy where a surgery.
of the stomach can be camera and 2. Inspect
around the considered for working incision site
esophagus and surgery; surgical for irritation
anchoring it below surgery can instruments and redness.
the diaphragm. also be are placed. Monitor for
considered in 2. The any signs of
patients with esophagus infection
well-controlled is mobilized 3. Provide pain
GERD who and the medication
desire opening in and a stool
definitive, one- the softener to
time treatment diaphragm help avoid
(crural constipation.
opening) is 4. Instruct
identified. patients to
 48

3. The crural advance their

opening is diet slowly, to
then closed. start with a
4. The fundus clear liquid
(upper part diet, advance
of the to full liquids,
stomach) is and then soft
then foods before
wrapped returning to a
around the normal diet.
lower 5. Instruct to
portion of avoid tight
the clothing
esophagus. around the
5. Fundoplicati incision sites
on is or fabrics
formed by which may
suturing the irritate the
stomach skin.
around the 6. Teach how to
esophagus. keep the
incision clean
with soap and
water in the
shower.

VIII. NURSING MANAGEMENT

● Modify Diet
○ High CHON diet to enhance LES pressure
○ SFF (4-6) and minimize the amount of liquid to prevent overfilling
the stomach and putting pressure on the esophageal sphincter.
○ Eat slowly and chew food properly this reduces the risk of choking
on food and swallowing of air and stimulates the production of
saliva, which is alkaline and may help neutralize any acid that
refluxes from the stomach.
 49

○ 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

Most hiatal hernia prognosis is excellent, if it has bothersome symptoms it

is usually controlled with medications or surgery which may give long-term relief
from acid reflux. The success of hiatal hernia surgery can be measured by the
relief of symptoms, complications, and need for reoperation. Patients who have
undergone surgery have a 90% reduction of symptoms at 10 years.
 50

If left untreated, complications can arise such as a strangulated hiatal

hernia. Hernias tend to get worse or larger if not addressed adequately, mild
symptoms can turn into serious ones and possibly spiraling into serious
underestimated complications. In some cases, as hernias can become larger,
they become more susceptible to incarceration and strangulation. The latter
usually involves blood being stopped from flowing freely to the tissue, which can
lead to tissue death and gangrene. Such an event can lead to parts of organs
dying or rupturing, both of which will usually require emergency surgery.
Attempting to treat a strangulated hernia can be much riskier and complicated
than treating a regular hernia; additionally, recovery can take much longer and
the risk of recurrence is higher. Untreated hernias may not only keep increasing
in size but may also become harder to manage, more uncomfortable, more
painful, and in worst-case scenarios, life-threatening.

X. DISCHARGE PLANNING

HEALTH TEACHINGS RATIONALE

MEDICATION 1. The patient should a. Reporting of side effects

follow the doctor’s may help evade
prescribed dose and situations that are life-
dosage of the drug. threatening and
2. The family and reporting a decrease of
patient should be effectivity may help
told to contact the adjust medication
healthcare provider if therapy
they feel the drug b. Drugs can be
does not benefit the dangerous, though,
patient and has side even when they're
effects. meant to improve our
3. Maintain a list of the health. Taking them
medications, correctly and
supplements, and understanding the right
herbs that the patient way to administer them
has taken. Include can reduce the risks.
the numbers and c. To prevent any drug
 51

when they take overdose that may

them, and why. endanger the client‘s
4. For follow-up wellness. Educate the
appointments, carry client so that he/she
the list or the pill may have an idea about
bottles. In the event the process of her/his
of an emergency, recovery.
bring the drug list d. Having lists aid clients in
remembering
medications and when
to take them for proper
guidance.

EXERCISE 1. Encourage on weight a. To minimize abdominal

reduction regimen pressure from excess
2. Encourage deep fats
breathing exercise b. This helps relax muscles
every time feeling on tension during
nauseated and or forceful backing of
gagging gastric materials
3. Do some regular low c. To promote active
intensity workouts lifestyle and mood
such as stretching, elevation
walking, and passive - Yoga can also alleviate
range of motion, pain and discomfort
such as arm circling, caused by a hiatal
leg raises, yoga. hernia. Yoga poses like
4. Advised to rest the chair pose helps
whenever needed. strengthen the
diaphragm and stomach
muscles.
d. To avoid over-
exhaustion.
- While stress doesn't
necessarily cause acid
reflux, an increasing
body of evidence has
shown that stress can
impact the way in which
our body reacts to reflux
 52

symptoms. So, rather

than tying yourself in a
knot, trying sitting
calming, and engaging
in deep breathing
exercises or meditation.
Find someplace quiet
where you can sit
comfortably until the
symptoms pass.

TREATMENT 1. Elevate the head of a. To prevent the reflux of

your bed 6 inches stomach contents into
(about 15 the esophagus
centimeters) b. Helps control reflux and
2. Instruct to remain in causes less irritation
upright position at from reflux action into
least 2 hours after esophagus.
meals; avoiding c. Smoking doesn't cause
eating 3 hours acid reflux, and it can
before bedtime. affect gastric motility
3. Avoid smoking and how food moves
through the esophagus.
Smoking can also dull
the responsiveness of
your LES and promote
dysphagia (swallowing
difficult). These effects
are long-lasting and may
become permanent in
heavy smokers, turning
even a small hernia into
a source of ongoing
grief.

HYGIENE 1. Maintain good and a. To promote cleanliness

proper personal and maintain the
hygiene. integrity of skin, nails,
2. Avoid unnecessary etc.
infections b. To keep healthy and
 53

avoid additional stress

brought about by
another unnecessary
infection.

OUT-PATIENT CARE 1. Instruct the client to a. To avoid or prevent

seek medical serious complications.
consultation for b. It is important to follow
observed check-ups so that the
unusualities physician can monitor
2. Attend a follow-up the disease's
check progression and have
3. scheduled by the better treatment.
Physician

DIET 1. Avoid foods that a. To prevent heartburn

trigger heartburn, b. Small and frequent
such as fatty or fried meals are easier to
foods, tomato sauce, digest. Helps prevent
alcohol, chocolate, reflux.
mint, garlic, onion, c. Not only contributes to
and caffeine weight loss, but it can
2. Encourage small also help normalize
frequent meals of bowel function and
high calories and relieve constipation that
high protein foods. contributes to herniation.
3. Encourage a low- High-fiber foods are an
fat, high-fiber diet. effective means of relief
4. Proper hydration d. Namely drinking no less
than eight glasses of
water per day, can
further reduce the risk of
constipation while
diluting concentrations
of acid in the stomach
 54

XI. RELATED NURSING THEORY

COMFORT THEORY by KATHARINE KOLCABA

The Theory of Comfort considers patients
to be individuals, families, institutions, or
communities in need of health care. The
environment is any aspect of the patient, family,
or institutional surroundings that can be
manipulated by a nurse or loved one in order to
enhance comfort. Health is considered to be
optimal functioning in the patient, as defined by
the patient, group, family, or community.

In the model, nursing is described as the

process of assessing the patient’s comfort needs, developing and implementing
appropriate nursing care plans, and evaluating the patient’s comfort after the
care plans have been carried out. Nursing includes the intentional assessment of
comfort needs, the design of comfort measures to address those needs, and the
reassessment of comfort levels after implementation. Assessment can be
objectives, such as the observation of wound healing, or subjective, such as
asking the patient if he or she is comfortable.

THEORY OF HUMAN CARING by JEAN WATSON

The nursing model states that nursing

is concerned with promoting health,
preventing illness, caring for the sick, and
restoring health. It focuses on health
promotion, as well as the treatment of
diseases. According to Watson, caring is
central to nursing practice and promotes
 55

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.

XII. REVIEW OF RELATED LITERATURE

This chapter consists of studies regarding Hiatal Hernia. These presented

studies will further deepen understanding of the said disease. They will support
and justify the proponents' case by giving out more related information that is
timely and with valid references.
According to Mayo Clinic. (2021). A hiatal hernia occurs when the upper
part of your stomach bulges through the large muscle separating your abdomen
and chest. In a hiatal hernia, the stomach pushes up through that opening and
into your chest. But a large hiatal hernia can allow food and acid to back up into
your esophagus, leading to heartburn. If you experience signs and symptoms,
such as recurrent heartburn and acid reflux, you may need medication or surgery.
Medications If you experience heartburn and acid reflux, your doctor may
recommend: Antacids that neutralize stomach acid. Surgery Sometimes, a hiatal
hernia requires surgery. Surgery is generally used for people who are not helped
 56

by medications to relieve heartburn and acid reflux or have complications such

as severe inflammation or narrowing of the esophagus. Surgery to repair a hiatal
hernia may involve pulling your stomach down into your abdomen and making
the opening in your diaphragm smaller or reconstructing an esophageal sphincter.
In some cases, hiatal hernia surgery is combined with weight-loss surgery, such
as a sleeve gastrectomy. Your surgeon inserts a tiny camera and special surgical
tools through several small incisions in your abdomen in laparoscopic surgery.
As stated by Dunn, C., Patel, T., Bildzukewicz, N., Henning, J., Lipham, J.
(2020), Hiatal hernias are common in the western population, with an estimated
prevalence of 15% to 20%. Since there is wide variability in the symptomatology
and severity of Hiatal hernias, it is important to understand when repair of these
hernias is indicated. The current literature body is constantly expanding, with new
evidence for and against the aggressive repair of these hernias appearing every
month. This review will synthesize the most recent body of knowledge to clarify
which Hiatal hernias should be repaired and which should be observed. Although
the literature is complex and occasionally conflicting, trends emerge when the
entire picture is viewed from a broad perspective. For type II-IV Hiatal hernias,
the literature also supports repair of those hernias which are symptomatic. For
asymptomatic hernias, the literature is conflicting. Finally, additional population-
based studies are required to determine the true incidence and ideal
management of asymptomatic Hiatal hernias of all types.
 57

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