# 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?

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## 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?

## 보기

1. Administer prescribed proton pump inhibitors to reduce gastric acid production
2. Position the client in Trendelenburg position to improve venous return
3. Prepare for insertion of a Sengstaken-Blakemore tube **✔ 정답**
4. Encourage oral intake of ice chips to promote vasoconstriction

**정답: 3**

## 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

Understanding the Clinical Scenario

The client with cirrhosis is experiencing an acute episode of hematemesis (vomiting blood) and melena (dark, tarry stools), and endoscopy has confirmed the source is bleeding esophageal varices. This is a life-threatening complication of portal hypertension. The immediate priority is to control the active hemorrhage and prevent hemodynamic collapse.

Analysis of the Priority Intervention

The correct priority nursing intervention is to prepare for insertion of a Sengstaken-Blakemore tube (SBT). While endoscopic variceal ligation is the first-line definitive treatment, the SBT is a critical salvage therapy used to achieve temporary mechanical hemostasis when bleeding is massive and uncontrolled, or when definitive interventions like endoscopy are not immediately available or successful [2,3]. The device works by using an inflated gastric balloon to anchor the tube against the gastroesophageal junction and an esophageal balloon to directly compress the ruptured varices, thereby tamponading the bleeding [3]. In a situation where a patient is actively hemorrhaging from confirmed varices, preparing for this temporizing measure is the nurse's immediate focus to stabilize the patient for further procedures.

Why the Other Options are Incorrect

- Option 1: Administering a proton pump inhibitor (PPI) is an adjunctive therapy, not a priority intervention for active variceal hemorrhage. While PPIs may be used after endoscopic treatment to prevent ulcer-related rebleeding, they do not stop the mechanical rupture of a varix and will not control the acute, life-threatening blood loss.

- Option 2: Positioning the client in Trendelenburg position is contraindicated. This position can increase pressure on the esophageal and gastric varices from abdominal contents, potentially worsening the hemorrhage. It also increases intracranial pressure and the risk of aspiration, which is already high due to hematemesis.

- Option 4: Encouraging oral intake of ice chips is an outdated and potentially harmful practice. A patient with active hematemesis and potential for emergent airway management or endoscopic intervention should be kept strictly NPO (nothing by mouth). Ice chips do not provide clinically significant vasoconstriction to stop variceal bleeding and increase the risk of aspiration.

Deep Dive into the Sengstaken-Blakemore Tube

The SBT's role has shifted over time due to the widespread availability of endoscopy and procedures like the transjugular intrahepatic portosystemic shunt (TIPS) [1,3]. However, it remains a high-acuity, low-frequency procedure that is essential for a nurse to understand. Its use is now largely confined to a "bridge" therapy—a temporary measure to control catastrophic bleeding until a more definitive procedure can be performed or the patient can be transferred to a higher level of care [1,2]. Because its use is declining, many providers have limited experience with it, making simulation-based training crucial for maintaining competency in this life-saving intervention [2,4]. The nurse's responsibilities during preparation and insertion include gathering the specialized tube, preparing for balloon inflation, and critically, having scissors at the bedside at all times to cut the tube and rapidly deflate the balloons if they migrate and obstruct the airway. The high risk of complications, such as esophageal rupture or airway obstruction, underscores why this is a temporary salvage technique, not a first-line treatment [3].References (research sources)

- [3]Decline of the Sengstaken-Blakemore tube: A review of shifting practices in gastrointestinal hemorrhage management.Research articleKogilathota Jagirdhar GS, Okafor CC, Hussain M, Elmati PR, Ghumman A, Shah M, Surani S. (2025) · DOI: 10.5492/wjccm.v14.i3.101856

## 임상 시나리오

Sengstaken-Blakemore Tube ManagementSalvage therapy for uncontrolled variceal hemorrhage
The Sengstaken-Blakemore tube is a temporary salvage device for life-threatening esophageal variceal bleeding when endoscopy fails or is unavailable. It achieves hemostasis through direct mechanical compression via an inflated esophageal balloon and a gastric balloon that anchors the tube at the gastroesophageal junction.

Before insertion, ensure the airway is protected with a cuffed endotracheal tube to prevent aspiration. Verify balloon patency and document inflation volumes. Apply low intermittent suction to the gastric port to assess for ongoing bleeding.

CautionScissors must be kept at the bedside at all times. If the tube migrates and causes airway obstruction, immediately cut all lumens and remove the tube. Esophageal balloon pressure must be monitored and deflated periodically to prevent pressure necrosis.

## 핵심 개념

- **Sengstaken-Blakemore Tube** — A medical device with gastric and esophageal balloons used for temporary mechanical compression of bleeding esophageal varices when endoscopic therapy fails or is unavailable.
- **Hematemesis** — Vomiting of blood, often indicating an acute upper gastrointestinal bleed, which can be bright red or have a coffee-ground appearance.
- **Melena** — The passage of black, tarry stools containing digested blood, typically indicating a bleed originating from the upper gastrointestinal tract.
- **Portal Hypertension** — Elevated blood pressure within the portal venous system, a common complication of cirrhosis that leads to the development of collateral vessels like esophageal varices.
- **Variceal Hemorrhage** — Life-threatening bleeding from dilated submucosal veins in the distal esophagus or proximal stomach, a direct consequence of portal hypertension.

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