Question

A client with cirrhosis and bleeding esophageal varices has a SengstakenBlakemore tube in place. Which nurse's assessment finding is the priority? A. Wheezing on chest auscultation. B. Blood pressure elevation by \(20 \mathrm{~mm} / \mathrm{Hg}\) - C. Blood noted in the lumen that is in the stomach. D. The label is missing from one of the three tube lumens.

Short answer

A. Wheezing on chest auscultation B. Blood pressure elevation by 20 mm Hg C. Blood noted in the lumen that is in the stomach D. The label is missing from one of the three tube lumens Answer: A. Wheezing on chest auscultation Explanation: Wheezing on chest auscultation could indicate respiratory distress and may lead to severe complications such as airway obstruction from the migration of the gastric balloon. This should be assessed and addressed urgently to avoid a life-threatening situation.

Step-by-step solution

Understand the purpose of the Sengstaken-Blakemore tube

A Sengstaken-Blakemore tube is a medical device used to treat bleeding esophageal varices, a life-threatening complication of cirrhosis. The tube consists of three lumens, one each for gastric aspiration to decompress the stomach, esophageal aspiration, and the inflation of a gastric balloon to apply pressure to the bleeding varices.

Assess each option and its relevance

A. Wheezing on chest auscultation: This may indicate respiratory distress or complications, such as pneumonia or aspiration. It should always be a concern, but it may not be directly related to the Sengstaken-Blakemore tube or the patient's primary issue. B. Blood pressure elevation by \(20 \mathrm{~mm} \mathrm{Hg}\): An increase in blood pressure is a concern, but it may not be directly related to the client's bleeding esophageal varices or the Sengstaken-Blakemore tube. C. Blood noted in the lumen that is in the stomach: This may indicate that the Sengstaken-Blakemore tube is not fully effective in controlling the bleeding of esophageal varices. This is an important finding, but there might be an even more important sign to consider as a priority. D. The label is missing from one of the three tube lumens: This could create confusion about which lumen is being used for which purpose, which might result in improper inflation of the balloon or aspiration. It is crucial to correctly identify each lumen to ensure the safety and effectiveness of the treatment.

Determine the priority assessment finding

Considering the implications of each finding and their relevance to the client's condition and the purpose of the Sengstaken-Blakemore tube, the priority assessment finding would be: A. Wheezing on chest auscultation This is because it could indicate respiratory distress and may lead to severe complications. Respiratory issues could be a direct result of the Sengstaken-Blakemore tube if the gastric balloon migrates upward and obstructs the airway. So, this finding should be assessed and addressed urgently to avoid a life-threatening situation.