Content created by Kim Matthews, RN.
Overview: Hiatal Hernia
This content is intended as a Quick Reference for hiatal hernia and will cover an overview as well as nursing considerations utilizing the nursing process.
Hiatal Hernia Etiology and Epidemiology
Hiatal hernia is a condition where part of the stomach, the lower part of the esophagus, or other organs move through an opening in the diaphragm and up into the chest.
The diaphragm, which assists in respiration, has a small opening that allows the esophagus to pass through to connect to the stomach. This opening is called the hiatus. The gastroesophageal junction (GEJ) is where the esophagus connects to the stomach and is located below the diaphragm.
When the stomach passes through the hiatus and moves into the chest, the lower esophageal sphincter is compromised and allows gastric contents to back up into the esophagus leading to gastroesophageal reflux disease (GERD). This is the leading cause of GERD (Smith & Shahjehan, 2021)
More than half of the population has a hiatal hernia, though most are symptom free (Baiu & Lau, 2019). There is also an increased prevalence in women.
Hiatal hernias are divided into four types:
- Type I or sliding hernia occurs when the GEJ is displaced up towards the hiatus.
- Type II or paraesophageal hernia occurs when part of the stomach moves into the mediastinum parallel to the esophagus.
- Type III is both a sliding and paraesophageal hernia. The GEJ and a portion of the stomach is displaced into the mediastinum.
- Type IV occurs when the stomach, as well as additional organs such as the spleen, colon, or small intestine, herniate into the chest.
Hiatal hernias can be acquired or congenital. They are more common in older adults due to the loss of elasticity that occurs with age that may cause the stomach not to return below the diaphragm after swallowing. Increased intraabdominal pressure predisposes an individual to a hernia.
This may be caused from:
- Obesity
- Chronic constipation
- Pregnancy
- COPD
Other conditions that can increase an individual’s risk of a hiatal hernia include:
- Age
- Trauma
- Previous surgeries
- Genetics
Hiatal Hernia Diagnosis
The diagnosis is through history and physical examination. Symptoms of a hiatal hernia include:
- Heartburn
- Reflux
- Nausea
- Vomiting
- Bloating
- Coughing
- Shortness of breath
- Feeling of food getting stuck in the chest
- Unexplained abdominal or chest pain
If the bowel or stomach twists, the blood supply is lost and is considered a medical emergency. When this occurs, symptoms become more severe such as:
- Severe vomiting
- Chest pain
- Palpitations
- Tachycardia
- Severe abdominal pain
- Lack of bowel movements
- Shortness of breath
Several tests can assist in the diagnosis of a hiatal hernia.
Some of these tests include:
- pH test that measures the acid levels in the esophagus
- Barium swallow
- Gastric emptying studies
- Endoscopy
- Esophageal manometry rules out motility disorders
- Esophagography
Sometimes a hiatal hernia is diagnosed incidentally through CT, chest X-ray, or MRI.
Hiatal Hernia Management
Treatment for hiatal hernias depends on the type and the severity of symptoms. Initial conservative treatment of symptoms involves the use of proton pump inhibitors.
Other conservative treatment includes lifestyle changes such as:
- Eating small frequent meals
- Sleeping with the head elevated
- Losing weight
- Smoking cessation
- Avoiding eating 3 hours before lying down
- Avoiding acidic foods
- Avoiding fried foods
When conservative treatments are not effective or an individual has symptoms for a long time, there are surgical options. The operations can usually be minimally invasive. The most common surgical intervention is the Nissen fundoplication which involves wrapping the GEJ using the fundus of the stomach. The wrap is then attached to the esophagus and hiatus.
When esophageal motility is poor a partial fundoplication is performed. The two most common types of these procedures are the Dor procedure and the Toupet procedure.
Hiatal Hernia Nursing Care Plan & Considerations
Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for hiatal hernia are listed below.
Assessment
Assess signs and symptoms such as:
- Pain
- Nausea/vomiting
- Coughing
- Difficulty breathing or shortness of air
- Bloating
- Reflux
Hiatal Hernia Nursing Diagnosis/Risk For
Nursing diagnosis for individuals with a hiatal hernia may include:
- Acute pain related to GERD as evidence by verbalization of pain
- Risk for aspiration related to impaired swallowing as evidence by increased intragastric pressure, depressed gag and cough reflex
- Altered nutrition less than body requirements related to the inability to take in enough food due to reflux as evidence by weight loss or inadequate food intake
Interventions
Common nursing interventions may include:
- Encourage small frequent meals as tolerated
- Administer medication as ordered such as proton pump inhibitors or antinausea medications
- Measure individual’s height and weight
- Encourage individuals to sit upright at least 2 hours after meals
- Assess the location of pain
- Assess pulmonary status for symptoms resulting from reflux
- Assess ability to swallow
- Encourage head elevation when sleeping
Expected Outcomes
- Shows no signs of aspiration
- Achieves adequate caloric and nutritional intake
- Verbalizes feelings of increased comfort
- Demonstrates effective coping
Individual/Caregiver Education
- Condition, treatment, and expected outcomes
- Sleeping with the head of the bed elevated
- Frequent, small meals
- Smoking cessation
- Weight loss
- Low fat and low acidic foods
- Follow-up with healthcare provider
- Notify healthcare provider or seek immediate medical care for: difficulty swallowing, inability to consume food or water, or uncontrolled pain
Additional Information
Content Release Date
4/1/2022
Content Expiration
12/31/2025
Content Contributor
The content was created by Kim Matthews, RN.
Ms. Matthews obtained a nursing degree from Western Kentucky University in 1998. Ms. Matthews possesses over 20 years of nursing experience, with over 17 of those in the Skilled Nursing industry. Ms. Matthews has extensive experience in MDS, restorative nursing programs, and nursing management. Ms. Matthews is currently a Post-Acute Care Content writer and subject matter expert for MDS.
References
- Baiu, I., & Lau, J. (2019). What is a paraesophageal hernia? JAMA, 322(21), 2146. https://jamanetwork.com/journals/jama/fullarticle/2756292
- Smith, R., & Shahjehan, R. (2021). Hiatal hernia. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK562200/