NCM 109 RLE – CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)

BSN 2 - NH
ENHANCEMENT CLASS ON CARDIOTOCOGRAPHY (CTG)

TEACHING LEARNING GUIDE

RLE GROUP H3
Justin Angelo B. Perreras
Luke Nathan C. Ranan
Wendybelle M. Rubin
Alfonso Joaquin C. Santos
Princess Mae A. Segovia
Nathaniel L. Setier
Ammarah D. Sidic
Janelle Dennese Q. Tare
Sofia Cris T. Vitor
Maria Lea Anthoinette Q. Yema
TOPIC: Cardiotocography (CTG)
Target Audience (Age Group): Adults (20 to 45 years old), especially pregnant women

GOAL AND CONTENT OUTLINE METHOD OF TIME RESOURCES METHOD OF

OBJECTIVES INSTRUCTION ALLOTMENT EVALUATION
By the end of this 30 I. Introduction I. Lecture Projected Learning Formative
minute session, the client a. What is Discussion Introduction of Resources Assessment:
will be able to: Cardiotocogr ● In order to the Topic ● Microsoft
1. Define aphy? enhance Powerpoint Oral during
Cardiotocography everyone's ● 1-minute Presentation discussion to
2. Gain sufficient II. Purpose and thinking, evaluate the
knowledge on the Necessity of learning, Group Online attentiveness of the
purpose of CTG problem-solvin Presentation Articles/Studies students.
Cardiotocograph, g skills, or 1. Does the
how it operates, III. External vs. understanding ● 15 References: CTG creat an
and when it is Internal CTG of patient care, minutes image? T or F
required the group will Alfirevic, Z., Gyte, G. 2. What does
3. Comprehend how IV. Advantages and have the Question and
M., Cuthbert, A., & CTG Detect?
a CTG is Disadvantages opportunity to Answer/Clarificat 3. Is CTG
performed during of using CTG discuss with ions Devane, D., (2017). harmful?
pregnancy the clinical Continuous
4. Distinguish V. Before, During, instructor the ● 5 cardiotocography
between external and After the possibility of minutes
(CTG) as a form of
and internal CTG Procedure having an
monitoring a. Equipment open-ended, Closing electronic fetal Summative
5. Demonstrate used in CTG collaborative monitoring (EFM) Assessment:
his/her b. Procedure dialogue of ● 1 minute
for fetal assessment
understanding on ideas between during labour. The 5-Item Oral Quiz
how to read VI. Reading/Interpr the clinical 1. How does a
interpret a CTG eting CTG Data instructor and Cochrane database cardiotocogra
student of systematic ph function?
VII. Conclusion nurses. reviews, (3), 2. It is required
CD006066. for the mother
to wear during
https://doi.org/10.1 external CTG
002/14651858.CD0 during
06066.pub3 monitoring
process to
Bellani, P. S. (2022). restrict the
mother’s
What is
movement
cardiotocography 3. The
(CTG) and why do I monitoring of
need it? what is
particularly
https://www.babyc
beneficial for
enter.in/x1045384/ high-risk
what-is-cardiotocog pregnancies?
raphy-ctg-and-why- 4. When is
internal CTG
do-i-need-it
used?
Davies, H. (n.d.). 5. What are the
potential risk
Cardiotocography associated
(CTG). with internal
https://www.ebme. CTG?
co.uk/articles/clinic
al-engineering/cardi
otocography-ctg
Potter, L. (2022, July

6). How to

Read a CTG |

CTG
 Interpretatio

n. Geeky

Medics.

https://geek

ymedics.com

/how-to-rea

d-a-ctg/

University of
Rochester Medical
Center (URMC).
(2023). External and
internal heart rate
monitoring of the
fetus.
https://www.urmc.r
ochester.edu/encycl
opedia/content.asp
x?contenttypeid=92
&contentid=P07776
Willacy, D. H. (2021,
June 28).
Cardiotocography.
Baby Heartbeat
Monitor. labour and
Delivery.
Patient.info.
Retrieved February
12, 2023, from
https://patient.info/
pregnancy/cardioto
cography
 Research/Written Output Portion:
INTRODUCTION
[ LEY ]
A cardiotocograph (CTG) is a type of Doppler that measures the fetal heartbeat through sound waves without creating an image. It is a
simple, painless, and non-invasive test conducted during pregnancy to assess the well-being of the baby. The procedure is also referred to as a
"non-stress test (NST)" as the baby is not under any stress or strain during the test. During the examination, the doctor listens to the baby's
heartbeat while the baby is at rest and while it is active. A baby's heart rate typically ranges from 120 to 160 beats per minute and increases
during movement, so monitoring the heart rate response to the baby's movements is an indirect way of determining if the baby is receiving
enough oxygen from the placenta (Bellani, 2022). Monitoring of the fetal heart rate is particularly beneficial for high-risk pregnancy
circumstances, including cases of diabetes, elevated blood pressure, and issues related to fetal growth (URMC, 2023).

Purpose and Necessity of CTG (When is it needed?) [LEY]

The purpose of a cardiotocograph is to assess the well-being of a fetus and allowing early detection of foetal distress by to monitoring the
heartbeat of a fetus as well as uterine contractions. Performing a CTG is common and frequent in high-risk pregnancies with symptoms such as
pre-eclampsia, Polyhydramnios/Oligohydramnios. It is also indicated when the following occurs:
● The baby is coming early or seems smaller than expected.
● The mother having high blood pressure.
● The mother having a high temperature (fever).
● The mother have an infection.
● The mother pass fresh blood whilst in labour.
● The mother is expecting more than one baby (twins or more).
● The baby has opened its bowels (passed meconium) into the amniotic fluid.
● The midwife thinks there may be a problem, having listened with a Pinard® or Doppler® machine.
 ● If the mother’s membranes have ruptured more than 24 hours before your labour starts.
● If the baby is in an unusual position.
● Mother having labour speeded up with Syntocinon® or need an epidural for pain relief.
● If the mother has an epidural for pain relief during labour, CTG may be used for half an hour after an epidural has been put in, or after
top-ups for the epidural.

External vs. Internal Cardiotocography [JANELLE]

The cardiac activity of the fetus and the uterine contractions of the mother can be meticulously documented through the use of a
cardiotocograph. This apparatus functions by employing a Doppler ultrasound transducer to monitor the fetal heart rate and a pressure
transducer to track the uterine contractions, which are then linked to a recording device. The method of utilizing this technology is referred to
as external cardiotocography (external CTG) and is typically performed continuously during labor, although it may also be utilized intermittently
(intermittent CTG). To facilitate external CTG, the mother is required to wear an abdominal belt during the monitoring process, which restricts
her mobility (Alfirevic et al., 2017). This ultrasound transducer will then transmit the sounds of the fetal heart to a computer, where the rate
and pattern of the fetal heart are displayed on the screen and recorded onto specialized graph paper.
An alternative means of monitoring the fetal heart rate is internal CTG, in which an electrode is attached directly to the presenting part of the
fetus, usually the head. This form of continuous monitoring necessitates a ruptured amniotic sac, either naturally or artificially, and the
attachment of a scalp electrode (clip) to the head of the fetus. This method also restricts the mother's mobility. However, internal monitoring
provides a more precise and stable transmission of the fetal heart rate compared to external monitoring, as external factors such as movement
do not interfere with it. This method of monitoring may be employed when external monitoring of the fetal heart rate is insufficient or when
closer observation is necessary (URMC, 2023).

Advantages and Disadvantages of using CTG [WENDY]

According to Alfirevic et al. (2017), the utilization of cardiotocography (CTG) as a method of monitoring fetal and uterine activity during labor
offers several potential advantages, including the ability to measure a greater number of parameters related to fetal heart rate (FHR) patterns,
and the production of a continuous physical record of FHR and uterine activity that can be reviewed at any point during or after labor. This
record may prove beneficial in clinical audits, counseling parents following adverse outcomes, and medico-legal situations.
However, the use of CTG also presents certain disadvantages and risks, including the difficulty in standardizing FHR patterns due to their
complexity, and the restriction of mobility and the inability to use various methods of comfort, control, and coping strategies, such as massage,
different positions, or water immersion, during labor. The potential risks associated with internal monitoring include infection or bruising of the
fetal scalp or other part of the body. Additionally, internal fetal heart rate monitoring is contraindicated for women with active herpes lesions
on the cervix or vagina, as this increases the likelihood of transmitting the infection to the fetus (URMC, 2023).

What to do before, during, and after the procedure? [wendy]

EQUIPMENT:
For the equipments used include the fetal monitor/cardiotocograph transducer for sensing uterine contractions, transducer for sensing fetal
heart rate as well as the belt used to attach the transducer to the abdomen of the mother.
External
In the external CTG of a patient, an elastic belt is placed around the mother’s abdomen. Two round flat plates, the size of a tennis ball is placed
in contact with the skin. One plate is used to measure the fetal heart rate while the other plate measures the on the abdomen. Through this we
are able to measure the strength of contractions as well as its duration. A jelly may be placed on the skin to aid in receiving a stronger signal.
The belt is connected to a machine that interprets the signal from the plates. A beating or pulsing sound produced by the machine is used to
identify the fetal heart rate. A print out is provided to show the fetal heart rate over a certain period of time, as well as the heart rate changes
with the contractions. When CTG is done during labour the patient may be asked to press a button on the machine everytime the baby moves.
Internal
When External monitoring yields no results Internal monitoring is the next option for CTG. An electrode, a small thin device, is inserted
vaginally and neck of the womb, which is open during labour, and place on the scalp of the infant. It records the fetal heart rate. For situations
where twins are present, the electrode only reads the infant’s heart rate closest to the neck of the womb. If infant is in breech presentation,
Internal monitoring will not work.

How can you read/interpret CTG data? [LUKE and NAT]

As stated by Dr. Lewis Potter, a physician in Newcastle (UK) and the founder of Geeky Medics, to interpret a CTG you need a structured method
of assessing its various characteristics. The most popular structure can be remembered using the acronym DR C BRAVADO:
● DR: Define risk
● C: Contractions
● BRa: Baseline rate
● V: Variability
 ● A: Accelerations
● D: Decelerations
● O: Overall impression
First, is DEFINING RISK.
When performing CTG interpretation, you first need to determine if the pregnancy is high or low risk. This is important as it gives more context
to the CTG reading (e.g. if the pregnancy categorised as high-risk, the threshold for intervention may be lower). Some reasons a pregnancy may
be considered high risk are shown below.
Maternal Medical Illness: Gestational Diabetes
Obstetric Complications: Multiple gestation, Pre-eclampsia
Other Risk Factors: Absence of prenatal care, Smoking, Drug Abuse
CONTRACTIONS.
Next, you need to record the number of contractions present in a 10-minute period.

Each big square on the example CTG chart below is equal to one minute, so look at how many contractions occurred within 10 big squares.

Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity.

Assess contractions for the following:

● Duration: How long do the contractions last?
● Intensity: How strong are the contractions (assessed using palpation)?
BASELINE RATE OF THE FETAL HEART.
The baseline rate is the average heart rate of the fetus within a 10-minute window.
Look at the CTG and assess what the average heart rate has been over the last 10 minutes, ignoring any accelerations or decelerations.
A normal fetal heart rate is between 110-160 bpm.
In some cases, we can assess greater or less than to that of the normal fetal heart rate.
First is what we call Fetal Tachycardia. Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm.
Causes of fetal tachycardia include:
● Fetal hypoxia
● Chorioamnionitis
● Hyperthyroidism
● Fetal or maternal anaemia
● Fetal tachyarrhythmia
And then we have Fetal Bradycardia. Fetal bradycardia is defined as a baseline heart rate of less than 110 bpm.
It is common to have a baseline heart rate of between 100-120 bpm in the following situations:
● Postdate gestation
● Occiput posterior or transverse presentations
Severe prolonged bradycardia (less than 80 bpm for more than 3 minutes) indicates severe hypoxia.
The third characteristic is VARIABILITY.
Baseline variability refers to the variation of fetal heart rate from one beat to the next.
Variability occurs as a result of the interaction between the nervous system, chemoreceptors, baroreceptors and cardiac responsiveness.
It is, therefore, a good indicator of how healthy a fetus is at that particular moment in time, as a healthy fetus will constantly be adapting its
heart rate in response to changes in its environment.
Normal variability indicates an intact neurological system in the fetus.
Normal variability is between 5-25 bpm.
To calculate variability you need to assess how much the peaks and troughs of the heart rate deviate from the baseline rate (in bpm).
Next is, ACCELERATIONS.
Accelerations are an abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.
The presence of accelerations is reassuring.
Accelerations occurring alongside uterine contractions is a sign of a healthy fetus.
The absence of accelerations with an otherwise normal CTG is of uncertain significance.
Then, there comes DECELERATIONS also.
Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.
The fetal heart rate is controlled by the autonomic and somatic nervous system. In response to hypoxic stress, the fetus reduces its heart rate
to preserve myocardial oxygenation and perfusion. Unlike an adult, a fetus cannot increase its respiration depth and rate. This reduction in
heart rate to reduce myocardial demand is referred to as a deceleration.

There are a number of different types of decelerations, each with varying significance. The following are Early Deceleration, Variable
Deceleration, Late Deceleration, Prolonged Deceleration, & Sinusoidal Pattern.
Last but not least, is OVERALL IMPRESSION.
Once you have assessed all aspects of the CTG you need to determine your overall impression.
The overall impression can be described as either reassuring, suspicious or abnormal.
Overall impression is determined by how many of the CTG features were either reassuring, non-reassuring or abnormal.
Conclusion [janelle]
Cardiotocography (CTG) is a frequently used technique of fetal monitoring to evaluate the well-being of the fetus during pregnancy and in labor.
The surveillance technique depends on the analysis of characteristic fetal heart rate patterns and uterine contractions. The machine used to
perform the monitoring is called a cardiotocograph, more commonly known as an Electronic Fetal Monitor (EFM). Cardiotocography (CTG) is a
technical method for recording (graphy) the fetal heartbeat using ultrasound (cardio) and the uterine contractions (toco) during pregnancy,
typically in the third trimester.

References:
Alfirevic, Z., Gyte, G. M., Cuthbert, A., & Devane, D., (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM)
for fetal assessment during labour. The Cochrane database of systematic reviews, (3), CD006066.
https://doi.org/10.1002/14651858.CD006066.pub3
Bellani, P. S. (2022). What is cardiotocography (CTG) and why do I need it?
https://www.babycenter.in/x1045384/what-is-cardiotocography-ctg-and-why-do-i-need-it
Davies, H. (n.d.). Cardiotocography (CTG). https://www.ebme.co.uk/articles/clinical-engineering/cardiotocography-ctg
Potter, L. (2022, July 6). How to Read a CTG | CTG Interpretation. Geeky Medics. https://geekymedics.com/how-to-read-a-ctg/

University of Rochester Medical Center (URMC). (2023). External and internal heart rate monitoring of the fetus.
https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=92&contentid=P07776
Willacy, D. H. (2021, June 28). Cardiotocography. Baby Heartbeat Monitor. labour and Delivery. Patient.info. Retrieved February 12, 2023, from
https://patient.info/pregnancy/cardiotocography
 Xavier University-Ateneo de Cagayan

COLLEGE OF NURSING
4th Flr, Faber Hall
73 Corrales Avenue, Cagayan de Oro

A CONCEPT MAP OF A PATIENT WITH DIAPHRAGMATIC HERNIA

In partial fulfillment of the requirements of NCM 109 Care of Mother, Child, at Risk or with Problems
(Acute and Chronic)

Submitted By:
Perreras, Justin Angelo B.
Ranan, Luke Nathan C.
Rubin, Wendybelle M.
Santos, Alfonso Joaquin C.
Segovia, Princess Mae A.
Sidic, Ammarah D.
Setier, Nathaniel L.
Tare, Janelle Dennese Q.
Vitor, Sofia Cris T.
Yema, Maria Lea Anthoinette Q.

Submitted to:
Ma’am Joie Oliveros RN, MN

March 8, 2023
 DIAPHRAGMATIC HERNIA

A defect where there is a hole in the diaphragm, or the large muscle that separates the chest from the abdomen.
Organs in the abdomen such as intestines, stomach, and liver can move through the hole in the diaphragm and upwards
into a baby's chest.

PREDISPOSING FACTORS

Predisposing factors are factors or conditions that make a person more susceptible or vulnerable to a particular
disease or health condition. These factors can include genetic, environmental, and lifestyle factors.

● Age. A maternal age of 35 and above can cause diaphragmatic hernia due to improper development of the fetus.
● Genetics. The development of the fetus is affected by genetics when there is/are abnormalities in the
chromosomes or genetics (specify). This can lead to diaphragmatic hernia.
● Race. The maternal Caucasian race is more prone to Congenital Diaphragmatic Hernia. (Why?) walay
explanation why bai (pag put nlng mog study or something like data nga most caucasian prone ani)
https://www.ajog.org/article/S0002-9378(11)01868-0/fulltext#:~:text=Risk%20factors%20for%20the%20developm
ent,CI%3A%201.05%2D1.79). Nara ang study
● Gender. The male fetal gender is more prone to the Congenital diaphragmatic hernia when compared to the
female fetal gender. This may be caused by the abnormalities in the baby’s gene (unsay abnormalities sa male?
Na wla sa female?). Might be Chromosomal but science is unsure why mas prominent sa male - sir isearch nlang
aHAHAHA possible questions rni ni maam ahahah
● Lifestyle factors. Penetrating/blunt injuries may be cause by lifestyle factors such as accidents due to
motorcycles or firearms. (ngano naa nis predisposing oy)

Identifying and understanding predisposing factors is important for preventing and managing diseases and health
conditions.

PRECIPITATING FACTORS

For the congenital diaphragmatic hernia, specific maternal medical conditions such as pregestational diabetes
and hypertension, as well as smoking and alcohol consumption are significantly associated with congenital
diaphragmatic hernia. For the acquired diaphragmatic hernia, factors such as blunt or penetrating trauma result in the
rupture of the diaphragm and herniation of abdominal content. These are important modifiable risk factors to consider
with regard to efforts seeking to impact the incidence of CDH.

DISEASE PROCESS (cess)

Starting with the predisposing process, these would include factors such as genetic predisposition, family history,
maternal age greater than 35, male fetal gender, and maternal Caucasian race. And with the precipitating factors, these
would include pregestational diabetes, smoking and alcohol use during pregnancy, and blunt/penetrating trauma.
 In the condition, Congenital Diaphragmatic Hernia, the diaphragm does not develop properly. In Acquired
Diaphragmatic Hernia, there is a rupture of the diaphragm due to blunt or penetrating trauma. Both of these lead to
herniation, a process where organs move from the abdomen upwards into the chest. This then compresses the lungs,
causing the impairment of the development and function of the lungs. The breathing pattern of the individual is then
altered due to herniation.

In conjunction, diaphragmatic hernia is a defect where there is a hole in the diaphragm, or the large muscle that
separates the chest from the abdomen. Symptoms that may persist when having diaphragmatic hernia would include:
respiratory distress, cardiac issues, gastrointestinal problems, delayed growth & development, recurrence, and
pulmonary hypertension.

SIGNS AND SYMPTOMS

A diaphragmatic hernia is a rare defect. The diaphragm is not fully developed when it occurs since the baby is
still growing within the womb. With that, the severity of symptoms with a diaphragmatic hernia might vary depending on
its size, cause, and the organs involved. The following are a few of the more common symptoms:

● Difficulty breathing,
● Blue discoloration of the skin (Cyanosis),
● Rapid heart rate (Tachycardia),
● Bowel sounds in the chest area,
● Diminished or absent breath sounds.

After the infant is born, severe breathing problems or difficulty breathing usually begin to develop. This is partly
because the lung tissue is crowded and the diaphragm muscle moves poorly. Blood vessels and lung tissue that are still
developing can also lead to breathing and oxygenation problems. Also, the infant may be cyanotic with intercostal or
subcostal retractions. It is when the baby's body doesn’t receive enough oxygen from the lungs, it can make his/her skin
appear blue. Next is tachycardia or rapid heart rate wherein the baby's heart may pump more rapidly than usual in an
effort to deliver oxygen-rich blood to his body. Moreover, over the involved hemithorax, bowel sounds (and an absence of
breath sounds) may be heard. Bowel sounds in the chest area occur when the intestines move up into the chest cavity. At
birth, breath sounds are a common symptom in the case of a diaphragmatic hernia and are usually absent on the
affected side of the chest cavity because at least one of the lobes of the lungs on that side cannot expand completely
(and may not have fully formed). The breath sounds on the affected side will be absent or very difficult to hear. Rarely do
newborns with diaphragmatic hernia show no noticeable symptoms much at. Small hernias that don't manifest any
noticeable symptoms may not be found until later in childhood or even adulthood. Generally, this defect involves signs
and symptoms of causing breathing difficulties for the baby at birth which has no known prevention and genetic
counseling may be helpful for couples who have a family history of this condition. Although, prenatal care should be
received early in pregnancy and on a frequent basis to help detect issues before birth. This enables appropriate prenatal,
perinatal, and postpartum planning and care.

COMPLICATIONS
 Complications of diaphragmatic hernia can depend on various factors such as the size and location of the hernia,
the organs involved, and the age and overall health of the affected individual.

Here are some potential complications of diaphragmatic hernia:

1. Respiratory distress. In congenital diaphragmatic hernia, the displacement of abdominal organs can put
pressure on the lungs, leading to respiratory distress and difficulty breathing. This can result in low levels of
oxygen in the blood and can be life-threatening.

2. Gastrointestinal problems. The displacement of abdominal organs can also affect the functioning of the
digestive system, causing symptoms such as nausea, vomiting, or bowel obstruction.

3. Cardiac issues. Congenital diaphragmatic hernia can also affect the heart, causing abnormalities in the
development of the heart and blood vessels.

4. Delayed growth and development. Children with congenital diaphragmatic hernia may experience delayed
growth and development due to the strain on the body from the hernia and the treatment required to manage it.

5. Recurrence. After surgical repair, there is a risk of recurrence of the diaphragmatic hernia.

6. Pulmonary hypertension. Some individuals with congenital diaphragmatic hernia may develop pulmonary
hypertension, a condition where high blood pressure in the lungs can cause damage to the heart and lungs.

Prompt diagnosis and treatment of diaphragmatic hernia can help to prevent serious complications and improve
outcomes.

LABORATORY & DIAGNOSTIC TESTS/EXAMS:

Throughout pregnancy, there are screening tests to look for some birth anomalies and other problems. Usually, a
diaphragmatic hernia can be diagnosed by a doctor before the baby is even born. Diaphragmatic hernia might carry out
any of the subsequent procedures following delivery by the doctor and can usually be diagnosed with the tests listed
below:

● Ultrasound. Doctors use an ultrasound to create a picture of the diaphragm and lungs to look for abnormalities.
In some cases, ultrasounds during pregnancy do not show the diaphragmatic hernia. However, once the baby is
born, doctors may diagnose the condition after noticing that the baby has trouble breathing.

● Chest X-ray. A chest x-ray can show that organs normally in the abdomen are in the chest, and the lungs may
appear smaller than usual or pushed to one side. After delivery, diagnosis is by chest x-ray showing the stomach
and intestine protruding into the chest. In a large defect, there are numerous air-filled loops of intestine filling the
hemithorax and contralateral displacement of the heart and mediastinal structures. If the x-ray is taken
 immediately after delivery before the neonate has swallowed air, the abdominal contents appear as an opaque
airless mass in the hemithorax.

● Computed Tomography (CT scan). It allows for direct viewing of the abdominal organs.

● Magnetic Resonance Imaging (MRI). It is utilized for a more focused assessment of organs in a fetus.

● Arterial Blood Gas Test (ABG). An arterial blood gas test measures the acidity (pH) and the levels of oxygen
and carbon dioxide in the blood drawn from a sample blood from an artery. This examination measures how well
your lungs can deliver oxygen to the blood and expel carbon dioxide from the body. By doing so, it helps
diagnose certain conditions like Diaphragmatic Hernia.

MEDICAL INTERVENTIONS

The medical interventions for diaphragmatic hernia depend on the type and severity of the hernia and the overall
health of the patient. Here are some possible interventions:

1. Stabilization and respiratory support: In cases of congenital diaphragmatic hernia, the first step is to stabilize
the patient and provide respiratory support. This may involve oxygen therapy, mechanical ventilation, or
extracorporeal membrane oxygenation (ECMO) until surgical repair can be performed.

2. Surgical repair: The primary treatment for diaphragmatic hernia is surgical repair, which involves closing the
defect in the diaphragm and repositioning any displaced organs. The timing of surgery depends on various
factors, including the patient's overall health, the severity of the hernia, and the availability of specialized surgical
care.

3. Medications: Medications may be used to manage symptoms of diaphragmatic hernia, such as pain, nausea, or
respiratory distress. In some cases, medications may also be used to reduce pulmonary hypertension, a potential
complication of congenital diaphragmatic hernia.

4. Nutritional support: Patients with diaphragmatic hernia may require specialized nutritional support, such as tube
feeding or intravenous (IV) nutrition, to ensure adequate nutrient intake and support healing after surgery.

5. Monitoring and follow-up: After surgical repair, patients require close monitoring to ensure adequate healing
and to detect any potential complications, such as infection or recurrence of the hernia. Follow-up care may
involve imaging tests, such as X-rays or ultrasounds, to assess healing and monitor for recurrence.

Overall, the medical interventions for diaphragmatic hernia aim to stabilize the patient, repair the hernia, manage
symptoms and complications, and promote recovery and healing. The specific interventions used depend on the
individual patient's needs and circumstances.
PHARMACOLOGIC MANAGEMENT

Pharmacologic management for diaphragmatic hernia depends on the specific symptoms and complications that
the patient is experiencing. Here are some possible medications that may be used:

1. Analgesics: Pain medications may be used to manage pain after surgical repair of diaphragmatic hernia. These
may include nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids.

2. Antiemetics: Patients with diaphragmatic hernia may experience nausea and vomiting, particularly after surgery.
Antiemetic medications, such as ondansetron or promethazine, may be used to manage these symptoms.

3. Respiratory support medications: Patients with congenital diaphragmatic hernia may require medications to
support respiratory function. These may include bronchodilators, corticosteroids, or surfactant replacement
therapy.

4. Proton pump inhibitors (PPIs): Patients with diaphragmatic hernia may be at increased risk of
gastroesophageal reflux disease (GERD) due to the displacement of abdominal organs. PPIs, such as
omeprazole or pantoprazole, may be used to reduce acid production and prevent GERD.

5. Pulmonary hypertension medications: Some patients with congenital diaphragmatic hernia may develop
pulmonary hypertension, a condition where high blood pressure in the lungs can cause damage to the heart and
lungs. Medications used to treat pulmonary hypertension may include sildenafil, bosentan, or prostacyclin
analogs.

It is important to note that medication management for diaphragmatic hernia should be individualized based on the
patient's specific needs and circumstances. The medications used, dosages, and duration of treatment may vary
depending on various factors, such as the patient's age, overall health, and other medical conditions.

NURSING CONSIDERATIONS

Nursing considerations for diaphragmatic hernia can vary depending on the type and severity of the hernia, the age and
overall health of the patient, and the treatment plan recommended by the healthcare provider. However, here are some
general nursing considerations:

1. Respiratory support: In cases of congenital diaphragmatic hernia, respiratory support may be necessary to help
the patient breathe until surgical repair can be performed. This may include oxygen therapy, mechanical
ventilation, or extracorporeal membrane oxygenation (ECMO).

2. Monitoring vital signs: It is important to monitor the patient's vital signs, including heart rate, blood pressure,
respiratory rate, and oxygen saturation levels.

3. Assessing pain: Patients with diaphragmatic hernia may experience pain or discomfort, particularly after surgical
repair. Nurses should assess and manage pain appropriately, using pain medication as prescribed.
 4. Monitoring fluid and electrolyte balance: Patients with diaphragmatic hernia may be at risk of dehydration or
electrolyte imbalances due to vomiting, bowel obstruction, or other gastrointestinal symptoms. Nurses should
monitor intake and output, electrolyte levels, and fluid status, and take appropriate measures to maintain fluid and
electrolyte balance.

5. Education and support: Nurses should provide education and support to the patient and their family about the
condition, treatment plan, and potential complications. This may include teaching about proper nutrition, activity
restrictions, and signs of complications that require immediate medical attention.

6. Preventing infection: Patients who undergo surgical repair for diaphragmatic hernia are at risk of developing
infection. Nurses should monitor for signs of infection, such as fever or wound drainage, and follow appropriate
infection prevention protocols, such as hand hygiene and sterile technique during dressing changes.

Overall, the nursing care for a patient with diaphragmatic hernia should be individualized and based on the patient's
unique needs and treatment plan.

Nursing Diagnosis:

● Risk for ineffective gas exchange related to displaced bowel

● Risk for imbalanced nutrition, less than body requirements, related to NPO status

Healthcare Management/Nursing Interventions:

● Surgery includes repair of the diaphragm and replacement of the herniated intestine and organs back into the
abdomen, possibly requiring both thoracic and abdominal incisions.
● At birth, the infant is immediately endotracheally intubated and then gently ventilated with low-pressure,
high-frequency, low-intensity oxygen to aid breathing.
● A nasogastric tube or a gastrostomy tube will be iCarDiffid further respiratory difficulty.
● Keep the infant NPO to prevent the bowel from filling and becoming distended.
● After surgery, to prevent pressure on the suture line in the diaphragm by a full stomach and bowel, nutrition will
be supplied with TPN.
● When oral feedings are started, be certain to burp the infant frequently during and after feedings to reduce the
amount of swallowed air and limit bowel pressure against the diaphragm.
CONCEPT MAP

References:

diaphragmatic hernia - Symptoms and causes - Mayo Clinic. (2021b, February 23). Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/hiatal-hernia/symptoms-causes/syc-20373379
Eades, S., & Eades, S. (2020, February 7). Diaphragmatic hernia: causes, symptoms, treatment.
Medical Society. https://imedicalsociety.org/diaphragmatic-hernia/

Facts about Diaphragmatic Hernia | CDC. (2019, December 4). Centers for Disease Control and
Prevention. https://www.cdc.gov/ncbddd/birthdefects/diaphragmatichernia.html

Khalid, R. (2017, June 7). Diaphragmatic Hernia. Healthline.

https://www.healthline.com/health/diaphragmatic-hernia

McAteer JP, Hecht A, De Roos AJ, Goldin AB. Maternal medical and behavioral risk factors for
congenital diaphragmatic hernia. J Pediatr Surg. 2014 Jan;49(1):34-8; discussion 38. doi:
10.1016/j.jpedsurg.2013.09.025. Epub 2013 Oct 5. PMID: 24439577.

Pillitteri, A., & Silbert-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the Childbearing and
Childrearing Family) (8th ed.). Wolters Kluwer.

Spellar, K. (2022, December 3). Diaphragmatic Hernia. StatPearls - NCBI Bookshelf.

https://www.ncbi.nlm.nih.gov/books/NBK536952/