Section 2: Lesson plan details

Time Behavioural Content Teaching Learning AV aids

objective activities activities and
references
At the end of
the class student
will be able to:

5min Discuss the The esophagus is a fibromuscular tube, about 25 centimetres long in discussing Actively PPT, ref 2
anatomy and adults, which travels behind the trachea and heart, passes through listening
physiology of the diaphragm and empties into the uppermost region of the stomach.
the esophagus, During swallowing, the epiglottis tilts backwards to prevent food from
stomach and going down the larynx and lungs.
diaphragm

2 min State the Meaning : Explaining Listening and PPT

meaning of the questioning adding on Ref 1,3
term hiatus A hiatus hernia or hiatal hernia is the protrusion of the upper part of points
hernia the stomach into the chest through a tear or weakness in the diaphragm.
 List the types CLASSIFICATION OF HIATUS HERNIA Explaining Listening PPT, ref 2
3 min hiatus hernia there are 4 types according to Hill’s Classification: questioning
 Sliding hiatal hernia (type 1)
• The sliding type, as its name implies, occurs when the
junction between the stomach and esophagus slides up through
the esophageal hiatus during moments of increased pressure in
the abdominal cavity.
• When the pressure is relieved, the stomach falls back down
with gravity to its normal position.
• Approximately 90% of all hiatal hernias are the sliding type.
 Paraesophageal hiatal hernia(type 2)
• In paraesophageal hiatal there is no sliding up and down.
Stomach fundus rolls through diaphragm A portion of the
stomach remains stuck in the chest cavity.
• These hernias remain in the chest at all times.
• This type is less common.
Other Types of Hiatal Hernia
 Type 3: Combination of Type 1 and Type 2
 Type 4: Abdominal organ (eg colon or spleen) +/- stomach herniate
into chest cavity

List the causes

and risk factors Describing and
5 min of hiatus hernia questioning understanding, Ref 1, 2
RISK FACTORS: answering PPT
  Age - Aging: Overall, the chances of having a hiatal hernia
increase as you get older. The diaphragmatic muscles naturally
become weaker and more flexible with advancing age, and, as
you get older, you are more likely to experience the risk
factors for hiatal hernia. Exceptions include congenital (from
birth) and hereditary hiatal hernia, which develops at an early
age.
 Obesity: Obesity is one of the biggest risk factors for hiatal
hernia. This may be due to increased pressure on the
diaphragm due to heavy weight.
 Heavily 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 protrude above the
diaphragm.
 Coughing: The abdominal pressure caused by coughing can
allow or cause the stomach to squeeze through the diaphragm.
 Straining: Straining may increase the chances of having a
hiatal hernia due to excess pressure on the diaphragm. This
includes straining for a bowel movement.
 Pregnancy: The abdominal pressure and hormonal changes of
pregnancy can increase the chances of a hiatal hernia.
 Smoking: Smoking weakens the muscles of the diaphragm,
allowing the stomach to protrude above the diaphragm.

ETIOLOGICAL FACTORS:

 Idiopathic
 Increased pressure within the abdomen caused by:
o Heavy lifting or bending over.
o Frequent or hard coughing.
o Hard sneezing.
 o Pregnancy and delivery.
o Vomiting.
o Constipation.
 Congenital/hereditary: Ehlers Danlos syndrome
 Traumatic
 infection/infestation
 autoimmune
 neoplastic (benign and malignant)
 Male gender
 Obesity
 Weight lifting, straining
 Cystic fibrosis and chronic lung infections
Describe the  Previous abdominal surgery
pathophysiolog  Collagen disorders. Lecturing
5 min y of hiatus Actively PPT
hernia PATHOPHYSIOLOGY: listening Ref 1, 2

Due to etiological factors advanced age, congenital factor weakening of

the muscle of the diaphragm

High intra-abdominal pressure from pregnancy, constipation, ascites,

and obesity

causing some parts of the esophagus and/or stomach to pass through

protrusion of the greater curvature of the stomach through the

diaphragmatic defect

Discuss the Paraesophageal hernia

signs and Discussing
5 min symptoms of CLINICAL MANIFESTATION: Actively Chalkboard
hiatus hernia. listening Ref 4
  Usually asymptomatic due to normal GE junction
 Pressure sensation in lower chest, dysphagia
 Nausea and vomiting
 Heartburn
 Regurgitation of food or liquids into the mouth
 Backflow of stomach acid into the esophagus (acid reflux)
 Difficulty swallowing
 Chest or abdominal pain
 Shortness of breath
 Vomiting of blood or passing of black stools, which may
indicate gastrointestinal bleeding
 Belching or hiccuping shortly after eating
 A stinging sensation in the throat
 A sour or bitter taste in the mouth
 Bad breath
 sweating,
 raspy voice
 sore throat
Discuss the
diagnostic explaining
5 min evaluation for HISTORY AND PHYSICAL EXAMINATION: Actively ref 1, 2
hiatus hernia listening PPT
. Blood test:
. Barium Swallow: VERY helpful in establishing diagnosis; Shows
anatomy & size of hernia, orientation of stomach, and location of GEJ
• CXR: Retrocardiac air bubble (air-fluid level in posterior
mediastinum); however, CXR may be normal
• CT scan/MRI: Stomach is partially or completely intrathoracic +/-
herniation of other intra-abdominal organs into chest
 • Esophageal manometry: Double hump configuration on manometry;
pH may be abnormal as well
• Upper Endoscopy: Helps to rule out other esophageal /gastric
pathologies; Retroflexion maneuver can be used to detect
paraesophageal hernias
• Ambulatory pH testing: Helps in planning appropriate intervention
and to establish a baseline of acid reflux for follow-up
. Gastric emptying studies examine how fast food leaves the stomach.
Results from this test are especially important in patients who have
nausea and vomiting. There could be other causes of the nausea and
vomiting besides a hiatal hernia.

. 24-48h esophageal pH monitoring to quantify reflux

. Gastroscopy with biopsy to rule out cancer and esophagitis

Enumerate the Explaining

management Active ref 1, 2
10 min and treatment MEDICAL MANAGEMENT: listening PPT
modalities of  Antacids
hiatus hernia  H2 receptor antagonists e.g. Cimetidine
 Proton pump inhibitors e.g. Omeprazole
nizatidine (Axid ) and ranitidine (Zantac).
 Prokinetic agents e.g. Metoclopramide
 Antibiotic- Erythromycin can help empty the stomach

Licorice
Licorice, derived from the licorice root, has long been used to treat
heartburn and other gastrointestinal symptoms

SURGICAL MANAGEMENT:
Anti-reflux surgery
Nissen Fundoplication

Nissen fundoplication is newer technique performed laparoscopically.

The aim of the surgery is to tightly wrap the upper part of the stomach
(called the fundus) around the esophagus and secure it in place with
stitches or staples so that it's held upright and supported. If performed
correctly, fundoplication can realign the LES into a position where it
functions normally.
Open repair

Your surgeon will make 1 large surgical cut in your belly.

A tube may be inserted into your stomach through the abdomen to keep
the stomach wall in place. This tube will be taken out in about a week.
Laparoscopic repair

Your surgeon will make 3 to 5 small cuts in your belly. A thin tube with
a tiny camera on the end is inserted through one of these cuts. Explaining
Surgical tools are inserted through the other cuts. The laparoscope is Actively Ref 3
connected to a video monitor in the operating room. answering PPT
Endoluminal fundoplication
Endoluminal fundoplication is a newer procedure, and it’s the least
invasive option. No incisions will be made. Instead, your surgeon will
insert an endoscope, which has a lighted camera, through your mouth
and down into the esophagus. Then they’ll place small clips at the point
 where the stomach meets the esophagus. These clips can help prevent
stomach acid and food from backing up into the esophagus.

Gastropexy: Suturing the stomach to anterior abdominal wall

PEG (Percutaneous endoscopic gastrostomy): Usually in

elderly patients at high surgical risk.
Discuss the Explaining,
nursing discussing Actively PPT
7 min diagnosis and listening Ref 3
intervention for NURSING MANAGEMENT:
hiatus hernia
patient. Imbalanced Nutrition: Less Than Body Requirements May be
related to inability to intake enough food because of reflux evidenced
by abdominal pain or discomfort.
Desired Outcome: Patient will ingest daily nutritional
requirements in accordance to his activity level and metabolic
needs.
Nursing intervention:
 Accurately measure the patient’s weight and height.
 Obtain a nutritional history.
 Encourage small frequent meals of high calories and high
protein foods.
 Instruct to remain in upright position at least 2 hours after
meals; avoiding eating 3 hours before bedtime.
 Instruct patient to eat slowly and masticate foods well.
  Esophageal pH monitoring

Acute Pain related to gastroesophageal reflux coughing,

aspiration, irritated esophageal mucosa, irritated oral cavity from
reflux evidenced by heartburn atypical chest pain
Desired Outcomes
Client will report pain is relieved.
Intervention:
 Assess for heartburn.
 Carefully assess pain location and discern pain from
GERD With hiatus hernia and angina pectoris.
 Give comfortable position
 Provide analgesic as per doctors order.
Risk for Aspiration: related to esophageal compromise affecting
the lower esophageal sphincter, impaired swallowing.

Desired Outcomes

 Client will mantain patent airway

Nursing intervention:
  Assess for pulmonary symptoms resulting from reflux of gastric
content.
 Assess for nocturnal regurgitation.
 Assess patient’s ability to swallow and the presence of gag reflex.
Have the patient swallow a sip of water.
 Avoid placing patient in supineposition, have the patient sit
upright after meals.
 Instruct patient to avoid highly seasoned food, acidic juices,
alcoholic drinks, bedtime snacks, and foods high in fat.
 Elevate HOB while in bed.
 Avoid nasogastric intubation for more than five (5) days.
 Instruct the patient to chew food thoroughly and eat slowly.
 If the patient has dysphagia, put the patient on NPO and notify
physician.
Enlist the
complication of explaining
5 min hiatus hernia Actively PPT
listening Ref 5
COMPLICATION:

Esophageal Compression
Compression of the esophagus can occur as the hernia presses against
the wall of the feeding tube. When this happens, food can get stuck in
the esophagus, causing chest pain after eating and difficulty swallowing
(dysphagia). While esophageal compression is not considered a medical
emergency, it may require medications to alleviate or prevent the
worsening of symptoms.
Incarcerated Hiatal Hernia
Incarceration occurs when the herniated portion of the stomach
becomes trapped during the hiatus. In some cases, the symptoms of
incarceration may be chronic but minimal (mostly a sensation of chest
pressure as food passes through the upper digestive tract). In others, it
can cause obstruction or impede blood circulation. Incarceration itself
is not a medical emergency unless a severe obstruction occurs.
Volvulus
Volvulus is when a herniated stomach twists more 180 degrees, causing
severe gastric obstruction. While it can occur with hiatal hernia, it can
also occur without it and is very uncommon. Symptoms may include
dysphagia, chest pain after eating, belching, and vomiting.
Strangulation
Strangulation describes the cutting off the blood supply to the stomach,
either due to volvulus or incarceration. This, too, is considered a
medical emergency as the blockage can result in rapid cell death
(necrosis) and organ damage.
Symptoms include a sudden, sharp chest pain; fever; fatigue; bloating;
vomiting; an inability to pass gas; constipation; warmth or redness over
the herniation; rapid heart rate; and bloody or tarry stools (due to
gastrointestinal bleeding). If not treated immediately, strangulation can
lead to gangrene, shock, and death.
Intrathoracic Stomach
 An intrathoracic stomach is a rare condition in which the stomach slips
entirely into the chest cavity. Oddly, not all cases cause symptoms. The
most common signs are a shortness of breath (dyspnea) and a feeling of
chest fullness and pressure. Other symptoms can include vomiting,
retching, dysphagia, gastrointestinal bleeding, and aspiration
pneumonia (caused when food is coughed up into the lungs).

discuss the
prevention of Lecture method
hiatus hernia Actively PPT
2 min listening Ref 5
This dynamic is, perhaps, best illustrated by a 2014 study from the
National Food and Nutrition Institute in Poland which evaluated the
association between acid reflux and common food triggers in 513 adults
with gastroesophageal reflux disease (GERD).
What they found was that there was as much as a two- to three-fold
increase in the risk of symptoms when people ate the following types
of foods:

Fatty foods
Sugary foods
Spicy foods
Fried foods
Peppermint tea
Fruit juices
Sour foods
Fresh fruit
Alcohol

While the study didn't take into the account certain common food
triggers, like citrus or caffeine, the figures more or less reflect the
experience of the typical person with GERD.
Life style modification:
 Alcohol should also be avoided
 Instruct to raise both arms, fully extended towards the ceiling
prior to eating.
 Always sit up straight in a chair while eating.
 Eat smaller, more frequent meals.
 Take smaller bites and chew longer.
 Sit upright for at least an hour after eating.
 Avoid eating three hours before bedtime.
 Weight Loss
 Reducing your body mass index (BMI) from above 30 (obese)
to below 25 (normal) can half your risk of acid reflux.
 A low-fat, high-fiber diet is key to both weight loss and the
normalization of your digestive function.
 Drinking at least eight glasses of water per day can further
relieve constipation
 Take a reasoned approach to exercise.
 Everyday Living
 When it comes to hiatal hernia symptoms, self-care can go a
long way in reducing them and preventing them from returning.
Work to turn these suggestions into habits:
 Relax.
 Loosen your belt and remove tight clothing.
 Take a fiber supplement.
 Elevate the head of your bed 4 to 8 inches.
 Avoid heavy lifting.
 stop smoking.
Assess the
motor system
10 min

Examining and Redemonstrati

demonstration on and clearing
doubts
Demonstratio
n
Ref 1& 2
Assess the
sensory system
10 min

Examining and Redemonstrati

demonstrating on

Describe the
diagnostic
studies

Demonstratio
n
Ref 1& 2
5 mins
Discussion Discussion

Clearing
Doubts

Discussion
Ref 1& 2