# Situation: A 64-year-old man who has smoked for 40 years and drinks alcohol daily is admitted for esophagectomy with gastric pull-up for squamous cell carcinoma of the esophagus. After surgery the nurse keeps the head of his bed at 30 degrees or higher at all times, even during sleep. What is the MAIN reason?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630371  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 64-year-old man who has smoked for 40 years and drinks alcohol daily is admitted for esophagectomy with gastric pull-up for squamous cell carcinoma of the esophagus.

After surgery the nurse keeps the head of his bed at 30 degrees or higher at all times, even during sleep. What is the MAIN reason?

## 보기

1. Gravity helps his chest tube drain more completely
2. It reduces tension on the suture line in his neck
3. His stomach now lies in the chest with no valve **✔ 정답**
4. It prevents pressure injury over his sacral area

**정답: 3**

## 해설

In esophagectomy with gastric pull-up, the stomach is brought into the chest and the lower esophageal sphincter is removed. Nothing stops gastric contents from flowing back toward the mouth, so the client stays upright at least 30 degrees at all times to prevent reflux and aspiration.

## 심화 해설

The main reason for the upright position
In esophagectomy with gastric pull-up, the stomach is brought up into the chest and joined to the remaining esophagus, and the lower esophageal sphincter is removed. Nothing now prevents gastric contents from flowing back toward the mouth. Keeping the head of the bed at 30 degrees or higher at all times, even during sleep, prevents reflux and aspiration.

How the anatomy has changed
Normally the lower esophageal sphincter and the position of the stomach below the diaphragm work together to keep gastric contents in the abdomen. After this surgery, the stomach lies in the chest with no valve, and the pressure inside the chest is lower than in the abdomen, which also favors reflux. Lying flat lets gastric fluid, bile, and food pass upward to the throat, and the client may inhale them, causing aspiration pneumonia, one of the most serious complications after esophagectomy. This risk is lifelong, not just postoperative.

| Option | Assessment |
| --- | --- |
| Gravity helps chest tube drainage | Chest drainage relies on keeping the unit below chest level, not on the head of the bed |
| Reduces tension on the neck suture line | The upright position is not used to relieve tension on the anastomosis |
| Stomach now in the chest with no valve | Correct: prevents reflux and aspiration |
| Prevents sacral pressure injury | Raising the head of the bed increases shear on the sacrum |

Why the other reasons are wrong
Watch out! These distractors sound plausible because the client does have a chest tube, a neck anastomosis, and a risk of pressure injury. However, chest tube drainage depends on the drainage system being below the chest, not on bed position. The upright position does not reduce tension on the suture line. And raising the head of the bed actually increases shear and pressure on the sacrum, so the nurse protects the skin with repositioning and pressure-relieving surfaces while keeping the client upright.

Related postoperative care
The nurse keeps the nasogastric tube secure and does not reposition it without an order, because it lies across the new anastomosis. Later, as eating resumes, the client takes small, frequent meals, sits upright during and for some time after meals, avoids eating close to bedtime, and sleeps with the head elevated at home. The nurse monitors for signs of aspiration and of an anastomotic leak, such as fever, tachycardia, or neck redness and drainage.

Exam takeaway
Key point! After esophagectomy with gastric pull-up, the client stays at least 30 degrees upright at all times because the stomach is in the chest without a sphincter. The goal is to prevent reflux and aspiration, a lifelong risk.

## 임상 시나리오

Positioning After EsophagectomyWhy the head of the bed stays raised
With gastric pull-up, the stomach lies in the chest and the lower esophageal sphincter is removed, so gastric contents can flow back toward the mouth.

Keep the head of the bed at least 30 degrees at all times, including sleep, to prevent reflux and aspiration.

Do not reposition the NG tube without an order; it lies across the new anastomosis. Protect the sacrum from shear with turning and pressure relief.

CautionAspiration risk is lifelong. Teach small meals, staying upright after eating, avoiding late meals, and sleeping with the head elevated.

## 핵심 개념

- **Esophagectomy** — Surgical removal of part or all of the esophagus, usually for cancer.
- **Gastric pull-up** — Reconstruction in which the stomach is brought into the chest to replace the esophagus.
- **Lower esophageal sphincter** — The muscular valve that normally prevents gastric reflux into the esophagus.
- **Aspiration pneumonia** — Lung infection caused by inhaling gastric contents, food, or fluid.
- **Anastomosis** — A surgical connection between two hollow structures, such as esophagus and stomach.

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