A nurse is caring for a client who was admited with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?
A.
Provide frequent oral and nares care
B.
Keep the client in a supine position
C.
Ambulate the client four times per day
D.
Encourage the client to consume clear liquids
The Correct Answer and Explanation is:
Correct Answer: A. Provide frequent oral and nares care
Explanation:
Bleeding Esophageal Varices and Sengstaken-Blakemore Tube:
Bleeding esophageal varices are a serious complication often associated with liver cirrhosis. They occur when dilated veins in the esophagus rupture, leading to life-threatening hemorrhage. To control the bleeding, a Sengstaken-Blakemore tube is often used. This tube has balloons that are inflated in the esophagus and stomach to apply pressure to the varices and stop the bleeding. While this intervention is potentially life-saving, it requires vigilant nursing care to prevent complications.
Answer Analysis:
- Option A: Provide frequent oral and nares care (Correct)
This is the most appropriate nursing action. The Sengstaken-Blakemore tube can cause significant discomfort and dryness in the mouth and nares due to its presence and the associated inability of the client to swallow normally. Oral and nasal care are essential to maintain mucosal integrity, prevent infections, and ensure the client’s comfort. Regular care helps prevent complications such as mucosal ulceration and can reduce the risk of pneumonia, a common risk when oral secretions are not managed properly. - Option B: Keep the client in a supine position (Incorrect)
Keeping a client in a supine position can increase the risk of aspiration, especially if the balloon dislodges and causes secretions or stomach contents to enter the lungs. Instead, the client should be positioned in a semi-Fowler’s or Fowler’s position to reduce this risk. The semi-upright position helps to protect the airway and decreases the risk of aspiration, which is a critical concern in clients with esophageal varices and a Sengstaken-Blakemore tube. - Option C: Ambulate the client four times per day (Incorrect)
Ambulating a client with a Sengstaken-Blakemore tube is not appropriate due to the risk of dislodgement and the potential for increased pressure that could exacerbate bleeding. Clients with this type of tube are typically kept on strict bed rest until the tube is removed to prevent any movement that might compromise the balloon’s position. - Option D: Encourage the client to consume clear liquids (Incorrect)
Clients with a Sengstaken-Blakemore tube are usually not allowed to eat or drink because of the risk of aspiration and further bleeding. The tube occupies the esophagus, making swallowing nearly impossible, and ingestion of liquids could lead to serious complications. Instead, the client’s nutritional needs are typically managed through intravenous fluids or total parenteral nutrition (TPN) while the tube is in place.
In conclusion, the primary focus of care for a client with bleeding esophageal varices managed by a Sengstaken-Blakemore tube includes maintaining airway protection, ensuring tube patency, and providing comfort measures such as frequent oral and nasal care. This care helps prevent complications, ensures patient safety, and improves overall outcomes.