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