A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?
a. Instruct the patient to cough every hour.
b. Monitor the patient for shortness of breath.
c. Verify the position of the balloon every 4 hours.
d. Deflate the gastric balloon if the patient reports nausea.
b. Monitor the patient for shortness of breath.
The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.
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