Nursing Plan for Emergency
Diaphragmatic Hernia Repair
By Sarra Borne Lord
A 2 year-old, male German Shepherd admitted for
hit by car with resulting diaphragmatic hernia
requiring surgical repair.
Actual Problems Potential Problems
Diaphragmatic Hernia
Translocation of abdominal organs
into thoracic cavity. Dyspnea from
pressure on the lungs. Lung
laceration or bruising.
Pneumothorax. Hemothorax. Pain.
Surgical intervention on
compromised patient
Administering anesthesia to critically
ill patient.
Balanced anesthesia plan
Potential head trauma from accident.
Respiratory depression.
Nursing Plan
Evaluate patient for signs of
additional trauma.
Patient needs to be stabilized and
treated for shock before surgery
initiated.
Stabilize patient as best as possible
prior to anesthesia and surgery.
Administer supplemental oxygen
and keep as calm as possible.
Place large gauge peripheral
catheters in both front limbs. Run
pre-anesthetic panel including
CBC with hematocrit, coagulation
panel (PT/PTT), and chemistry
w/electrolytes to assess major
organ function. Be ready to
address any abnormalities during
anesthesia. Start intravenous
fluids as ordered. Give preanesthetic sedation/analgesia as
directed.
Avoid acepromazine in patients
with head trauma to prevent
increased intracranial pressure
during anesthesia. Avoid using
buprenorphine or butorphanol if
mu receptor opioids will be used
intra- or postoperatively as they
will decrease the effectiveness.
Anesthetic induction
Myocardial bruising. Respiratory
depression. Head trauma.
Hydromorphone, morphine or
oxymorphone are good analgesic
agents however they may cause
vomiting which should be avoided
when the stomach or intestines are
in the thoracic cavity. Methadone
provides good analgesia and is less
likely to cause vomiting. Fentanyl
is an excellent analgesic agent but
is better suited to either a quick
induction combined with a
benzodiazepine or as an ingredient
in an analgesic CRI either alone or
with lidocaine and ketamine
because the duration of effect
from a single injection lasts only
20-30 minutes.
If patient has myocardial bruising
it may be safest to induce
anesthesia with etomidate and
diazepam or midazolam.
Otherwise ketamine and a
benzodiazepine or propofol may
be used for induction. The
veterinarian will choose the drugs
in the anesthetic plan but the
nursing staff should be aware of
the drugs and their potential side
effects.
To prevent regurgitation and
aspiration in a patient with
diaphragmatic hernia, the patient
should be kept in a sternal
position with its head up until the
endotracheal tube is placed and
the cuff is inflated.
Check settings on ventilator
before attaching patient. Should
be set for 12 breaths per minute,
with pressure less than 20 cmH2O.
Monitor depth of anesthesia, heart
rate, SP02, blood pressure,
temperature and CO2. Adjust
anesthesia as necessary. If blood
pressure drops administer fluid
bolus or Hetastarch as ordered.
Surgical repair of diaphragmatic
hernia
Blood loss, increased respiratory
depression due to anesthesia,
decreased blood pressure.
Post-surgical considerations
Pain, discomfort, respiratory
depression, decreased oxygenation,
decreased body temperature postsurgical.
Place patient in dorsal
recumbency with the head and
thorax slightly elevated unless
otherwise directed by the surgeon.
Clip and scrub wide surgical
margins allowing scrub adequate
contact time with skin. Continue
monitoring ventilator, depth of
anesthesia, heart rate, SPO2,
blood pressure, temperature and
CO2. Provide heat support.
Additional analgesia using FLK
(fentanyl, lidocaine, ketamine)
CRI should be initiated before
patient is recovered from
anesthesia. Blood gas analysis
during surgery if available to
monitor arterial oxygenation.
Chest (thoracostomy) tube will be
placed. Drain air and fluid from
chest as ordered. Ventilator
support should continue at a
decreased rate until spontaneous
breathing resumes. Patient should
be positioned with the
forequarters elevated during
recovery.
Provide oxygen support via O2
cage or nasal cannula after
surgery. Monitor SPO2 with
pulse oximeter to ensure patient is
adequately oxygenating. Continue
providing heat support and
monitor temperature every 30
minutes until maintaining on own.
Aspirate chest tube every hour to
monitor fluid/air output. If
aspirated fluid is bloody check
PCVof fluid. Continue analgesic
CRI post-surgery. Observe and
monitor for dysphoria, patient
may require further sedation until
fully recovered from anesthesia.
Once recovered observed for signs
of pain including depression,
Hospitalization of critical patient
aggression or guarding. Adjust
level of analgesia as necessary.
Continue fluids as ordered.
Continue chest tube care. Assist
outside for eliminations when
patient is able. Check cage to
ensure environment is clean and
comfortable. Change/supplement
bedding as needed. Monitor for
bleeding, check surgical site for
integrity. Keep surgical site clean
and dry. Hand feed patient a
small meal when allowed. Cold
pack incision every 4-6 hours for
the first 3 days. Soft e-collar as
needed to prevent self-trauma.
Provide owner updates, and set up
a visitation schedule.
Monitor vital signs on hospitalized
patients frequently, intensive
monitoring will decrease as
patient stabilizes and is nearing
discharge:
Monitor:
Pulse q 1-6 h
Continuous ECG monitoring or
telemetry for at least 24 hours
after surgery.
Respiratory rate, effort and
pattern q 1-6 hr
MM/CRT q 1-6 hr
Blood pressure q 1-6 hr (per
orders)
Level of consciousness q 1 hr
Fluid rate q 1 hr
TVI q 6-12 hrs
IV catheter (flush/palpate) q 4-6
hr
Temperature q 2-12 hr
Body weight q 12 hr
Eliminations q 2-4 hr
Notify veterinarian of any
significant changes or trends.
Continue chest tube care hourly
until the amount of air or fluid
being drained decreases. Intervals
may be between 1 – 4 hours as
needed. Volume of fluid and air
recovered should always be
recorded. Fluid should have color
and consistency noted as well.
The dressing covering the chest
tube should be replaced at least
every 12 hours. Dressing changes
should use sterile technique.
Local anesthetics (lidocaine,
bupivacaine) may be instilled into
the chest tube to reduce pain
caused by the presence of the tube.
Continue to provide analgesia as
ordered. Intravenous CRI will
eventually be changed to bolus
injections and then to oral
medications. Notify veterinarian
if patient seems excessively painful
or depressed, as may be changing
routes or doses too quickly for
patient’s needs.
If patient is not willing to get up to
eliminate outside an indwelling
urinary catheter may be placed.
Catheter care requires wiping
with dilute nolvalsan or betadine
twice daily, and the emptying of
the collection bag at least every 4
hours. Volume and color should
be recorded.
Antibiotics should be
administered as directed.
Monitor appetite and water
consumption. Encourage patient
to eat frequent small meals of a
highly digestible diet. Warm food
to make more enticing. Hand feed
as needed. May syringe feed to
supplement intake if patient
allows. Offer boiled chicken if no
interest in canned food. Water
bowl should be washed and
refreshed every 4-6 hours. Notify
veterinarian for further
instructions if patient refuses to
eat or drink for more than 6-12
hours.
Patient discharge from hospital
At home care
Provide daily updates on patient
condition to owner. Arrange
visitations if patient is not unduly
stressed by visits.
Give detailed instructions to
owner on care of incision sites,
allowed exercise, and diet.
Educate them on signs of pain or
discomfort and what to do.
Ensure they are able to administer
medications as ordered. Ensure
the owner is aware of how the
surgical site should look, and what
to do if complications occur.
Make sure they have
appointments for rechecks and
suture removal. Educate owner
on importance of following
instructions as their pet is
recovering from major surgery.
Send e-collar home to keep pet
from self-trauma to incision area.
Make sure owners have phone
numbers for 24 hour emergency
care available.