The nurse is caring for a patient with a Sengstaken-Blakemore tube. Which assessment finding should the nurse immediately report for follow-up?
1. left lower leg swollen and reddened
2. absent bowel sounds to lower-left quadrant
3. decreased level of consciousness
4. 3 cm darkened area on left heel
Correct Answer: 3
The Sengstaken-Blakemore tube has two balloons, which are used to tamponade the esophageal bleeding. One balloon is in the stomach and the other is in the esophagus, and if the tube migrates, the airway can be obstructed. Decreased level of consciousness may indicate hypoxia and is the priority for follow-up. A swollen and reddened lower leg may indicate a venous thrombus. Absent bowel sounds may indicate ileus. A darkened area on the left heel may indicate a pressure ulcer. While all of these are potentially serious problems, the possibility of hypoxia is the priority for follow-up.
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