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.

Key concepts

Sengstaken-Blakemore tube

The Sengstaken-Blakemore tube is a critical medical device often used in emergency settings to manage life-threatening bleeding esophageal varices, which can occur due to complications of liver cirrhosis. It's a specialized tube that performs multiple functions due to its three distinct lumens:

• One lumen is dedicated to gastric aspiration, which helps in decompressing the stomach.
• Another is for esophageal aspiration, which aids in removing secretions or blood, potentially preventing complications such as aspiration pneumonia.
• The third lumen is used for the inflation of a gastric balloon. This applies pressure directly to the varices, effectively controlling bleeding by tamponading the vessels within the esophagus and preventing further blood loss.

The proper labeling of each lumen is paramount as it ensures the right interventions are applied. Incorrect use can complicate the patient's condition or lead to ineffective management of their bleeding.

Bleeding Esophageal Varices

Bleeding esophageal varices are dilated veins in the esophagus, which can rupture and lead to significant blood loss. These are most commonly a result of portal hypertension due to cirrhosis of the liver. The liver damage from cirrhosis causes increased pressure in the portal vein, leading to the development of these fragile veins. Knowing how to quickly and effectively manage bleeding esophageal varices is essential for nursing professionals.

• The primary objective is to stop the bleeding. The Sengstaken-Blakemore tube is used to apply direct pressure on the bleeding varices, effectively reducing or halting the blood loss.
• Nurses must be vigilant for signs of rebleeding or ineffective pressure control, such as blood present in the gastric lumen indicated during gastric aspiration.

Immediate medical intervention is vital, as severe blood loss from these varices can lead to hypovolemic shock, a life-threatening emergency.

Cirrhosis Complications

Cirrhosis is a chronic liver condition characterized by scarring and poor liver function. A significant complication of cirrhosis is portal hypertension, which can lead to the development of esophageal varices. Other related complications include:

• Ascites, or fluid accumulation in the abdominal cavity.
• Hepatic encephalopathy, leading to confusion and altered mental status due to toxin accumulation in the brain.
• Hepatorenal syndrome, a serious condition where the kidneys begin to fail due to advanced liver disease.

Understanding the broad spectrum of cirrhosis complications is crucial for nurses. This knowledge aids in anticipating potential issues, like bleeding esophageal varices, and ensuring timely interventions.

Nursing Assessment Priority

In any clinical setting, particularly involving complex devices like the Sengstaken-Blakemore tube, nursing assessment priorities are crucial for patient safety. The initial priority is to ensure airway patency and avoid respiratory distress. Wheezing or respiratory changes should be promptly addressed, as these could indicate inadvertent airway obstruction by the tube's balloon. Other priority assessments might include:

• Monitoring for signs of inadequate hemostatic control, such as blood in the gastric lumen, suggesting continued bleeding.
• Ensuring that tube lumens are correctly identified and labeled to avoid mismanagement of the device.
• Keeping a close watch on vital signs, particularly blood pressure and heart rate, to identify potential signs of hypovolemic shock.

Proper and diligent nursing assessment ensures interventions are timely and efficient, ultimately safeguarding the patient's health.