A nurse is caring for a client who has bleeding esophageal varices and is being treated with a Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?
A.
Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis.
B.
Keep the head of the bed flat at all times to prevent the development of shock.
C.
Maintain constant observation while the balloons are inflated.
D.
Suction the tube every 2 hr and as needed to maintain patency.
The Correct Answer and Explanation is:
The correct answer is C. Maintain constant observation while the balloons are inflated.
Explanation:
A Sengstaken-Blakemore tube is a specialized medical device used to manage bleeding esophageal varices, which are dilated veins in the esophagus that can rupture and cause severe hemorrhage. This tube has multiple lumens and two inflatable balloons: one in the stomach (gastric balloon) and one in the esophagus (esophageal balloon). The primary purpose of these balloons is to apply direct pressure on the varices, thereby controlling the bleeding.
Maintaining constant observation (Answer C) is crucial because the tube and inflated balloons can lead to several complications that require immediate attention. These complications include balloon displacement, airway obstruction, aspiration, and tissue necrosis due to prolonged pressure. If the tube dislodges or the balloons overinflate, it could obstruct the airway or worsen bleeding, both of which are life-threatening situations. Therefore, continuous monitoring allows the nurse to identify and address these complications promptly.
Incorrect Options:
- A. Deflate the balloons for 5 min every 2 hr to prevent tissue necrosis: While it is true that prolonged pressure from the balloons can lead to tissue necrosis, deflating the balloons periodically is not the standard practice. This is because deflation could lead to a rebleed, which is potentially more dangerous. The protocol for balloon deflation, if necessary, should be determined by the healthcare provider and is based on the client’s specific condition.
- B. Keep the head of the bed flat at all times to prevent the development of shock: This option is incorrect because keeping the head of the bed flat can increase the risk of aspiration, especially if the client vomits or has an unsecured airway. The head of the bed is typically elevated to reduce this risk. Elevating the head also reduces pressure on the diaphragm, which is beneficial in maintaining respiratory function.
- D. Suction the tube every 2 hr and as needed to maintain patency: While suctioning might be necessary, it is not a routine action that is performed every 2 hours. Over-suctioning can irritate the mucosa and lead to additional bleeding. Suctioning should be done as needed, based on the client’s condition and assessment findings.
In conclusion, constant observation is essential when managing a client with a Sengstaken-Blakemore tube because it allows the nurse to quickly identify and address any complications that arise, ensuring the safety and well-being of the client.