Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse’s first action should be to:
Remove the tube.
Deflate the esophageal portion of the tube.
Determine whether the tube is obstructing the airway.
Increase the oxygen flow rate.
The Correct Answer and Explanation is:
Correct Answer: Determine whether the tube is obstructing the airway.
Explanation:
The Sengstaken-Blakemore (SB) tube is a specialized medical device used to control bleeding from esophageal varices, typically in clients with liver cirrhosis. It consists of three lumens: one for gastric balloon inflation, one for esophageal balloon inflation, and one for gastric aspiration. The esophageal balloon applies direct pressure on varices to reduce or stop bleeding, but incorrect positioning or overinflation can lead to serious airway obstruction—a life-threatening emergency.
When a client exhibits difficulty breathing 30 minutes after insertion, the first priority is airway assessment. According to the ABC (Airway, Breathing, Circulation) priority framework in nursing, ensuring a patent airway is critical. The most appropriate initial action is to determine whether the tube is obstructing the airway. This means assessing for signs such as stridor, cyanosis, decreased oxygen saturation, or visible misplacement of the tube into the trachea.
Removing the tube immediately is not the first action, because it may cause aspiration of blood or worsen esophageal bleeding. It should only be done if obstruction is confirmed and airway compromise is severe.
Deflating the esophageal balloon may eventually be needed if the balloon is the cause of the obstruction, but this action should come after confirming the source of the breathing difficulty.
Increasing the oxygen flow rate does not address the underlying cause of the client’s respiratory distress. If the airway is obstructed, no amount of supplemental oxygen will help.
Summary:
When a client with an SB tube has breathing difficulty, the first nursing action should be to assess if the tube is obstructing the airway. Acting according to ABC priorities ensures the nurse quickly identifies and addresses potentially life-threatening conditions. Further interventions depend on what the assessment reveals.