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lavage(la-vazh') [Fr. lavage, a washing]
bronchopulmonary lavageBronchoalveolar lavage.
colonic lavageColonic irrigation.
The following equipment is needed: plastic large-lumen nasogastric tube; water-soluble lubricant; disposable irrigation set with bulb syringe; adhesive tape or other device; clamp, safety pins, and rubber band; gloves and stethoscope; tissues; glass of water with straw; emesis basin; container for aspirant; at least 500 to 1000 ml of prescribed irrigating solution; and any specified antidote.
Physical restraints are applied only if prescribed and required. The patient's clothing is removed and a hospital gown put on. If conscious and cooperative, the patient is placed in the high Fowler's position (head elevated 80 to 90°), and the chest is covered with a water-impermeable bib or drape. If unconscious, the patient is positioned to prevent aspiration of stomach contents; suction equipment is provided, and the airway is protected.
The distance for tube insertion is measured by placing the tip of the tube at the tip of the patient's nose and extending the tube to the earlobe and then to the xiphoid process. The length of tubing that will remain outside the patient after insertion is marked on the tube. Nostril patency is checked and the nostril with the least obstruction is selected. While the patient or an assistant holds the emesis basin, the nurse lubricates the tip of the tube and inserts it. A downward and backward motion aids passage through the back of the nose and down into the nasopharynx, thus avoiding producing a gag reflex. The patient is instructed to dry-swallow during this phase of passage. The tube should not be forced. If obstruction is met, the tube is removed, the patient permitted to rest briefly, the tube relubricated, and the procedure attempted again. If the tube cannot be passed without traumatizing the mucosa, the physician is notified.
When the tube is in the nasopharynx, the patient is instructed to flex the neck slightly to bring the head forward. A sip of water (if permitted) is given to the patient, and the patient is encouraged to swallow the tube. Rotating the tube toward the opposite nostril often helps direct toward the esophagus and away from the trachea. Placing the nondominant hand on the nose to secure the tube, the practitioner advances it with the dominant hand as the patient swallows.
The back of the throat is periodically inspected for any evidence of coiled tubing, esp. if the patient is gagging or uncomfortable, or unconscious. When the tube has been passed, placement is verified by aspirating gastric contents with the bulb syringe. The tube is then secured to the nostrils with adhesive tape or another securing device according to protocol.
CAUTION!Gastric lavage should never be performed on a patient who has ingested corrosive acids or alkalis. It also should never be performed on patients who cannot protect their own airways unless they are already intubated.
The irrigation fluid is instilled, and care is taken to prevent the entrance of air. A Y connector can be attached to the nasogastric tube, with one tubing exiting to the bulb syringe or irrigant container and the other to a drainage set. The return line is clamped, and the solution, usually 500 ml or more, instilled to distend the stomach and expose all areas to the solution. The large volume also dilutes harmful liquids and thins or dissolves other materials.
The patient is monitored throughout for retching. If retching occurs, the flow is stopped, suction is applied to the bulb syringe, or the drainage line is opened to remove some of the instilled fluid. The stomach is then drained, and the procedure is repeated as necessary to cleanse and empty the stomach of harmful materials and irrigant. Alternatively, 150 to 200 ml may be removed and the same amount added on an alternating basis. The process is repeated until a total of 1000 ml has been employed and drained. An activated charcoal slurry is then instilled as appropriate and prescribed.
A specimen of the aspirant is sent to the laboratory for analysis as directed. The tube may remain in place, attached to intermittent low suction, or be removed immediately after the procedure.
For removal, the tube is clamped securely. Any securing devices are removed, and the tube is rotated gently to ensure that it moves freely and then is gently but steadily pulled out of the nose and coiled. The patient is handed tissues to wipe the eyes and blow the nose and is assisted with oral hygiene. A fresh gown or linens are provided as necessary.
After the procedure, the tube and prescribed suction are maintained as necessary, drainage is documented, comfort measures (oral misting, anesthetic throat sprays) are provided, and the patient is assessed and treated for any complications of lavage or of the toxic exposure.