A nurse is performing gastric lavage on a client using a large-bore NG tube. Which of the following actions should the nurse take?
A.
Position the client on the right side.
B.
Instill 1000 mL of sterile saline.
C.
Withdraw fluid until it is clear.
D.
Connect the NG tube to high continuous suction.
The Correct Answer and Explanation is:
The correct answer is A. Position the client on the right side.
Explanation:
Gastric lavage is a procedure performed to clear the contents of the stomach, often in cases of poisoning, drug overdose, or to prepare the stomach for certain medical procedures. The procedure involves inserting a large-bore nasogastric (NG) tube into the stomach and then instilling and aspirating fluid to flush out the stomach contents.
Positioning the Client:
- Positioning the client on the right side is crucial during gastric lavage because it facilitates the drainage of the stomach contents by utilizing gravity. The right lateral decubitus position allows the stomach contents to move more effectively toward the pylorus, aiding in the lavage process. This positioning helps prevent aspiration of gastric contents, especially if the client is unconscious or has a decreased level of consciousness.
Sterile Saline Instillation:
- While it’s necessary to instill fluid during gastric lavage, the volume of fluid used should be based on specific protocols or physician orders. Typically, smaller amounts of normal saline (around 200-300 mL) are instilled in intervals, not 1000 mL all at once. The fluid should be instilled in controlled amounts to prevent excessive distension of the stomach, which could lead to complications like gastric rupture or aspiration.
Withdrawing Fluid:
- The goal of gastric lavage is to remove toxic substances from the stomach. However, withdrawing fluid until it is completely clear is not typically the endpoint. The lavage continues until the retrieved fluid is relatively clear, but not necessarily crystal clear. Some residual gastric contents may remain.
Suction Setting:
- High continuous suction should not be used because it can cause gastric mucosal injury and lead to significant fluid and electrolyte imbalances. Instead, intermittent suction or gravity drainage is preferred to safely remove the gastric contents without damaging the stomach lining.
Conclusion:
In summary, positioning the client on the right side is the safest and most appropriate action for the nurse to take when performing gastric lavage. This positioning optimizes the effectiveness of the lavage by using gravity to aid in the removal of gastric contents and reduces the risk of complications such as aspiration. Other actions, such as using excessive fluid volumes or high continuous suction, can lead to adverse outcomes and are generally not recommended.