The physician has left orders to deflate a client's Sengstaken-Blakemore tube, used to stop esophageal bleeding, for 5 minutes every 12 hours to prevent esophageal erosion. Two hours following second re-inflation, the client suddenly becomes severely dyspneic and dusky. The nurse should:
A)Call a code blue (cardiac arrest)
B)Deflate the balloons
C)Decrease the traction on the tube where it enters the nose
D)Irrigate the tube with ice-cold saline to facilitate movement of the balloons into the stomach

Question

Quizplus · Accepted Answer

Symptoms of severe respiratory distress indicate that the tube has dislodged and is obstructing the airway. Reestablishing an airway is the first priority: Deflate the balloons using a syringe. Following deflation, the doctor should be notified to assess the client's condition and determine ongoing medical therapy. A code blue would be called only after establishing the airway. Traction on the Sengstaken-Blakemore tube should be increased or decreased only by the attending physician. Iced saline is no longer used for irrigation during active bleeding and this problem is respiratory, not hemorrhagic.

The Physician Has Left Orders to Deflate a Client's Sengstaken-Blakemore