Congenital Diaphragmatic Hernia

PEDIATRIC NURSING

1. CONGENITAL DIAPHRAGMATIC HERNIA PEDIATRIC NURSING P.THIRUNAGALINGA PANDIYAN M.Sc.,(N ) School of Nursing, Madurai Medical College, Madurai

2. Introduction The diaphragm is a dome-shaped muscular barrier between the chest and abdominal cavities . It separates heart and lungs from abdominal organs (stomach, intestines, spleen, and liver). A diaphragmatic hernia occurs when one or more of abdominal organs move upward into chest through a defect (opening) in the diaphragm.

3. DIAPHRAGM

4. DEFINITION A hernia is an abnormal protrusion of an organ into the cavity CDH is the herniation of abdominal contents into thoracic cavity due to developmental defect in diaphragm. The herniation occurs through posterolateral foramen of bochdalek on left side. It is most common in females. Incidence : one in every 3,000 to 4,000 live births.

5. CONGENITAL DIAPHRAGMATIC HERNIA NORMAL CDH

6. Embryology and Etiology The wide, flat muscle that separates the chest and abdominal cavities is called the diaphragm. The diaphragm forms when a fetus is at 8 weeks’ gestation. When it does not form completely, There is a hole in the diaphragm The hole allows the contents of the abdomen (stomach, intestine, liver, spleen, and kidneys) to go up into the fetal chest.

7. TYPES Hernia through the Foramen of Bochdalek This is the most common type . The defect is always on the left side . It results from the failure of the pleuro peritoneal canal to close which normally occurs between 6 and 8 weeks of gestation. This type involves an opening on the back side of the diaphragm. The stomach, intestines and liver or spleen usually move up into the chest cavity.

8. TYPES Hernia through the Foramen of Morgagni It is the rare and usually occurs on right side . It occurs in the anterior portion of the diaphragm through the defects secondary to a developmental failure of the retrosternal segment of the septum transversum. The liver or intestines may move up into the chest cavity .

9. TYPES

10. CLINICAL MANIFESTATION Infants frequently exhibit a scaphoid abdomen, barrel-shaped chest, and signs of respiratory distress (retractions, cyanosis, grunting respirations). In left-sided posterolateral hernia, auscultation of the lungs reveals poor air entry on the left, with a shift of cardiac sounds over the right chest. In severe defects, signs of pneumothorax (poor air entry, poor perfusion )

11. CLINICAL MANIFESTATION Abnormal chest movements Difficulty breathing Blue discoloration to the skin (cyanosis) Absent breath sounds on one side of the chest Bowel sounds in chest A “ half-empty” feeling abdomen Tachycardia (rapid heart rate)

12. DIAGNOSTIC EVALUATION CDH is often discovered during a routine prenatal ultrasound around the 20th week of the pregnancy. The ultrasound may show abdominal organs (intestines, stomach, and liver) in the chest cavity Abdominal x-ray Arterial blood gas – test used to measure the amount of oxygen in the blood Echocardiogram – a type of ultrasound that takes images of the heart using sound waves.

13. MANAGEMENT SURGERY The intestines and other abdominal organs are moved from the chest cavity into their proper place in the abdominal cavity. The opening in the diaphragm is then closed .

14. MANAGEMENT

15. PREOPERATIVE CARE The infant should be placed on affected side to allow for expansion of lungs Place in semi fowlers position in order that the abdominal viscera may proceed by gravity into the abdominal cavity Keep the infant quiet and not to cry because as the infant cries and swallow air , the stomach and intestine distended Nasogastric tube insertion and intermittent suction in order to reduce the air in the stomach The neonate must be kept warm because chilling increases acidosis

16. POST OPERATIVE CARE A chest tube is may placed in the affected side so nurse maintain the functioning of chest tubes Frequent change of position Chest physiotherapy Observe for respiratory distress Provide close attention to acid base balance Maintain gastric decompression

17. POST OPERATIVE CARE Maintain thermoregulation Maintain cardiac output and peripheral perfusion Prevent infection Appropriate pain management Parent education regarding child care

18. NURSING DIAGNOSES Ineffective breathing pattern related to decreased lung expansion Pain related to surgical wound and drainage in situ Impaired skin integrity related to surgical incision Fluid volume deficit related to starvation