A nurse is caring for a client with a history of cirrhosis w… | 마이메르시 MyMerci
Adult Health
문제

A nurse is caring for a client with a history of cirrhosis who presents with hematemesis and melena. Endoscopy confirms bleeding esophageal varices. Which nursing intervention should be the priority?

해설
For acute bleeding esophageal varices, priority is preparing for Sengstaken-Blakemore tube insertion to achieve immediate mechanical hemostasis. Other options do not directly control life-threatening hemorrhage.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for a patient with cirrhosis experiencing acute, life-threatening hemorrhage from esophageal varices. The core theme is managing an airway/breathing/circulation (ABC) emergency. Esophageal varices are dilated, fragile veins in the lower esophagus that rupture due to portal hypertension. Bleeding is massive and can quickly lead to hypovolemic shock and death. The priority is to stop the bleeding immediately.

Answer Rationale: Key Point! The Sengstaken-Blakemore tube is a specialized device used for tamponade—applying direct pressure to the bleeding varices. It is a critical, immediate intervention for uncontrolled hemorrhage when endoscopic therapy fails or is unavailable. Preparing for its insertion is the priority because it directly addresses the life-threatening problem. The nurse must gather the equipment, ensure informed consent, and prepare for assisting with the procedure, which is a high-priority, time-sensitive action.

Distractor Analysis:
Watch out for confusion! Option ①: Proton pump inhibitors (PPIs) like pantoprazole are often administered to reduce the risk of re-bleeding from gastric mucosal lesions or ulcers, but they do not control active variceal hemorrhage. This is a supportive, not a priority, intervention.
Option ②: Positioning a patient with active upper GI bleeding in the Trendelenburg position (head down) is contraindicated. This position can increase intracranial pressure and, more critically, increase the risk of aspiration of blood. The correct position is semi-Fowler's or lateral to protect the airway.
Option ④: Encouraging any oral intake, including ice chips, is contraindicated during active upper GI bleeding. The patient should be NPO (nothing by mouth) to prevent further irritation, nausea, vomiting, and aspiration risk. Oral ice chips do not promote significant vasoconstriction in this context.

Related Concepts: The management of bleeding varices follows a stepwise approach: Resuscitation (IV fluids, blood products) → Pharmacologic therapy (octreotide, vasopressin) → Endoscopic intervention (band ligation, sclerotherapy) → Balloon tamponade (Sengstaken-Blakemore tube) → Definitive procedures (TIPS - Transjugular Intrahepatic Portosystemic Shunt). The nurse's role spans all phases, with airway protection and preparation for invasive procedures being paramount.
Concept Summary
ConceptKey Points
PathophysiologyCirrhosis → Portal Hypertension → Portosystemic Collateral Veins (Varices) form → Rupture → Massive Hemorrhage.
Priority Nursing FocusABCs: Airway protection (risk of aspiration), Breathing, Circulation (fluid resuscitation, prepare for blood transfusion).
Immediate InterventionsLarge-bore IV access (e.g., 16-18 gauge), Type & Crossmatch, Administer octreotide, Prepare for endoscopic or tamponade procedures.
Contraindicated ActionsTrendelenburg position, Oral intake, Nasogastric tube insertion with caution (can dislodge clots).

Side-by-Side Comparison!
Intervention for Bleeding VaricesPurpose & MechanismNursing Role
Pharmacologic (Octreotide)Vasoconstricts splanchnic arteries, reducing portal pressure. First-line medical therapy.Administer IV infusion, monitor for side effects (hyperglycemia, abdominal pain).
Endoscopic Band LigationPrimary definitive treatment. Places rubber bands over varices to strangulate them.Pre-procedure consent & prep, post-procedure monitor for complications (perforation, re-bleeding).
Balloon Tamponade (S-B Tube)Temporary emergency measure. Inflates gastric & esophageal balloons to compress bleeding vessels.Priority prep. Post-insertion: secure tube, monitor balloon pressures, keep scissors at bedside to cut tube if needed for emergency deflation.

Anatomy, Physiology & Pharmacology Points • Portal System: Veins from the GI tract, spleen, pancreas → Portal Vein → Liver. In cirrhosis, scar tissue blocks flow, causing portal hypertension. • Variceal Locations: Esophageal (most common), gastric, rectal (hemorrhoids). • Drugs: Octreotide (somatostatin analog) reduces portal blood flow. Vasopressin causes systemic vasoconstriction (use with nitroglycerin to reduce cardiac side effects).
Memory Tips • ABCs for Varices: Airway (protect!), Bleeding (stop it!), Cirrhosis (the cause). • S-B Tube: Think "Stop Bleeding" or "Save the patient, Balloon now!" • Position: Remember "Head Up, Not Down" to prevent aspiration.
High-Frequency NCLEX Topics Bleeding esophageal varices is a classic High Yield emergency scenario. The NCLEX loves to test: 1) Priority action (often tamponade prep or airway), 2) Correct patient positioning, 3) Understanding contraindications (like Trendelenburg), and 4) Medication knowledge (octreotide).
Watch Out for Question Variations! • Instead of "priority intervention," the question may ask: "Which finding requires immediate action?" (Answer: Signs of hypovolemic shock or aspiration). • It may shift to post-procedure care: "After Sengstaken-Blakemore tube insertion, which action is essential?" (Answer: Keep scissors at the bedside for emergency deflation if the balloon migrates and obstructs the airway). • It could combine with lab values: "The client's hemoglobin is 7.2 g/dL. Which order should the nurse implement first?" (Answer: Administer packed red blood cells per protocol—supporting circulation is priority after securing the airway/bleeding).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the Emergency Department. Mr. Johnson, a 58-year-old with a history of alcoholic cirrhosis, is brought in by ambulance. He is pale, diaphoretic, and anxious. He has vomited a large amount of bright red blood, and his blood pressure is 88/50 mmHg with a heart rate of 128 bpm. The physician confirms bleeding esophageal varices via endoscopy and states, "We need to place a Blakemore tube, stat."

Nursing Intervention Strategy: 1. Assessment & Immediate Actions: Continuously monitor vital signs and oxygen saturation. Apply oxygen via nasal cannula. Place the patient in a semi-Fowler's position and turn his head to the side to prevent aspiration. Establish two large-bore IV lines (16-gauge or larger) and begin rapid infusion of isotonic crystalloids (e.g., Normal Saline) as ordered, while awaiting blood products. 2. Preparation for Procedure: This is your priority. Gather the Sengstaken-Blakemore tube kit, lubricant, syringes for balloon inflation, suction equipment, and a pair of scissors to keep at the head of the bed. Assist the physician with insertion, ensuring the patient is sedated as ordered. Once placed, secure the tube to the patient's face with tape and to the traction system (often a football helmet or similar device) per protocol. 3. Post-Procedure & Monitoring: Confirm balloon placement and inflation pressures with an X-ray. Connect the gastric lumen to low intermittent suction. Never irrigate or clamp the lumens without a specific order. Monitor for re-bleeding (hematemesis, melena, worsening vital signs) and for complications like aspiration or esophageal necrosis from excessive balloon pressure.
Nursing Procedure & Medication Flow • Procedure: Assisting with S-B Tube Insertion 1. Explain the procedure to the sedated patient/family. 2. Position patient semi-Fowler's. 3. Check balloon integrity by inflating with air underwater. 4. Lubricate tube. 5. Assist physician with insertion. 6. Inflate gastric balloon first with prescribed volume (e.g., 250-300 mL air). 7. Pull back gently until resistance is felt at gastroesophageal junction. 8. Inflate esophageal balloon to prescribed pressure (typically 25-45 mmHg). 9. Secure tube to traction device. 10. Label all lumens clearly. • Medication: Octreotide IV - Action: Reduces splanchnic blood flow and portal pressure. - Dosing: Bolus (50-100 mcg IV), then continuous infusion (25-50 mcg/hr). - Nursing Point: Use an infusion pump. Monitor blood glucose (can cause hyper- or hypoglycemia).
A Word from Your Senior Nurse "In a bleeding varices crisis, your calm, prepared demeanor is as vital as any medication. The sight of massive hematemesis can be frightening, but your brain must click into 'ABCs and procedure prep' mode. Remember, that S-B tube is a temporary bridge to more definitive treatment. Your vigilant monitoring for re-bleeding and airway compromise makes you the patient's frontline guardian. On the NCLEX and in practice, thinking 'what will kill this patient first?' guides you to the correct priority every time."

핵심 개념

  • Portal Hypertension — Increased blood pressure in the portal venous system, often due to liver cirrhosis, leading to complications like varices and ascites.
  • Sengstaken-Blakemore Tube — A multi-lumen tube with esophageal and gastric balloons used for temporary tamponade to control bleeding from esophageal varices.
  • Octreotide — A somatostatin analog used as a vasoactive drug to reduce portal pressure and blood flow in acute variceal bleeding.
  • Hematemesis — Vomiting of blood, which can be bright red (fresh) or coffee-ground (digested), indicating upper gastrointestinal bleeding.
  • Balloon Tamponade — A therapeutic procedure using inflated balloons to apply direct pressure on bleeding blood vessels, such as esophageal varices, to achieve hemostasis.

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