The nurse should begin each entry in the clinical record with the date and time of the entry. If possible, document the type of substance ingested, when the ingestion occurred, and how much substance was ingested. The nurse should obtain and record preprocedure vital signs (VS) and level of consciousness (LOC). The date and time of lavage; the size and type of nasogastric tube used; the volume and type of irrigant solution; the method used to verify correct tube placement; and the amount of drained gastric contents, including the color and
consistency of drainage, should be recorded by the nurse. The amount of irrigant solution instilled and gastric contents drained should be documented on the intake and output record sheet. The nurse should note whether drainage was sent to the laboratory for analysis as well as any drugs instilled through the tube. The patient’s VS should be assessed and recorded every 15 minutes on a frequent VS assessment sheet, and LOC should be assessed and recorded on a Glasgow Coma Scale sheet until the patient is stable. (See
“Intake and output,” pages 210 to 212; “Level of consciousness, changes in,” pages 237 to 239; and “Vital signs, frequent,” page 430.) Document the time that the tube was removed and how the patient tolerated the procedure. The nurse should provide and document patient education and emotional support given.
