DIRECTORATE OF NURSING AFFAIRS

GENERAL NURSING PROCEDURES

ESOPHAGO-GASTROESOPHAGO-GASTRO-DUODENOSCOPY ASSISTING IN ENDOSCOPY PROCEDURES

DEFINITION Esophago-Gastro-Duodenoscopy is the direct visualization of the mucosa of the esophagus, stomach and duodenum using a flexible fiberoptic scope. PURPOSE 1. 2. 3. 4. 5. To diagnose lesions such as gastric or duodenal ulcers and neoplasms and obtain specimen for cytological studies or biopsy To locate and study sources of upper gastrointestinal bleeding To study upper gastrointestinal motility and identify strictures and obstructions To diagnose hiatal hernias and esophageal and gastric varices To perform therapeutic procedures

EQUIPMENT 1. 2. Light source Endoscope tray or trolley Fiberoptic endoscope Accessories: Camera Biopsy forceps Cytology brush Cleaning brush Water bottle and connecting tube Sterile distilled water Suction equipment Resuscitation equipment Mouth guard Drugs: local anaesthesia Sedation Antispasmodic Syringes and needles Alcohol swabs Scalp vein set Adhesive tape Lubricant K-Y jelly Disposable gloves Disposable gowns Disposable masks Histology specimen containers Cytology fixative, slides with carriers Histology / Cytology request form
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3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

SECTION 9 ENDOSCOPY: ASSISTING IN ENDOSCOPY PROCEDURE

DIRECTORATE OF NURSING AFFAIRS

GENERAL NURSING PROCEDURES

PROCEDURE
SN Action Rationale

1. 2. 3.

Check physicians order, progress notes and nursing care plan. Identify the patient. Prepare the patient emotionally and physically for the procedure.

To obtain specific instructions and/or information. To ensure that the right procedure is performed to the right patient. Nursing support is offered by explaining procedures mechanics, providing opportunities for the patient to ask questions, allowing him to verbalize his feelings and giving expert physical care. To allay fears and gain patients confidence and cooperation. To ensure that patient is ready for the procedure. To ensure that all relevant information is available for endoscopy team This procedure requires patients to fast for at least 8 hours before endoscopy of upper gastrointestinal tract To decreases anxiety and promotes muscle relaxation To decreases pain and induces sedation To produces amnesic effect, diminishes recall of events during procedure Provides baseline data for comparison with postprocedure measurements Procedure is contraindicated in patients with severe upper gastrointestinal bleeding because viewing lens may get covered with blood clots, preventing visualization. Esophageal diverticulum is a contraindication to endoscopy because scope can easily fall into diverticulum and perforate its wall.

4.

Ensure that procedure has been fully explained by the physician and that consent has been signed by the patient. Check that patient has undergone preprocedure preparations: Verify that patient has been fasting. Administer pre-procedure medication if prescribed. Ensure that blood analysis has been done and results is available for the medical team Ensure that endoscopy referral form is available in the chart

5.

6.

Assess patient Obtain vital signs Determine gastro-intestinal bleeding, observe character of emesis, stool, nasogastric tube drainage Verify that patient does not have esophageal diverticulum

SECTION 9 ENDOSCOPY: ASSISTING IN ENDOSCOPY PROCEDURE

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DIRECTORATE OF NURSING AFFAIRS

GENERAL NURSING PROCEDURES

SN

Action

Rationale

7.

Assist the patient in an appropriate position (left lateral position) Unexpected change of position can cause accidental perforation of oesophagus, stomach, and dueodenum. Ensure privacy Wash and dry hands (refer to Hand Washing procedure). Don gloves Place the mouth guard firmly between the patient teeth. Reassure the patient during the procedure and relay to the physician any expression or complaints of pain. The long-term effect of sedation can last as long as 24 hours. Warnings about amnesia, possible self-injury, dangers of alcohol, driving and working must be emphasized before discharging the patient.

To ensure a safe and effective positioning for the procedure and promote patients comfort

8. 9. 10. 11. 12.

To avoid unnecessary embarrassment to the patient during the procedure. To prevent cross-infection To reduce transmission of microorganisms To prevent damage to the endoscope To promote comfort Tenderness and pain may be experienced by the patient with history of abdominal surgery where procedure may have to be terminated in order not risk any perforation.

13.

Disinfection of scope and accessories is done To prevent cross-infection before starting and between procedures.

Physicians responsibilities a. b. c. d. Wash and dry Hands. Spray nasopharynx with local anaesthetic (usually xylocaine). Apply gown, mask, goggles, and gloves Attach distal end of endoscope to light source.

Rationale Reduces transmission of microorganisms Early application of anaesthetic allows for optimal effect of anaesthesia Adheres to guidelines for body fluid precautions. Provides for direct visualization of gastrointestinal tract

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DIRECTORATE OF NURSING AFFAIRS

GENERAL NURSING PROCEDURES

Physicians responsibilities e. f. g. Slowly pass endoscope into mouth, esophagus, stomach, duodenum. Insufflate air through endoscope into upper gastro-intestinal tract. Examine or perform biopsy of structures

Rationale Provides visualization of structures Distends gastrointestinal structures for better visualization Provides data from which physician makes diagnosis.
Rationale

SN

Action

14. 15.

The nurse lubricate the endoscope with a lubricant jelly using sterile gauze piece. The light source, suction pump, and the camera are connected to endoscope and switched on. The nurse must remember that the endoscopist is engrossed with technical aspects of the procedure and the nurse is responsible for the monitoring of patients condition. Pathology : The nurse should provide the biopsy forceps and assist in the collection of histology specimens. He/she should careful record specimens obtained and completes Laboratory Forms. Photography When required, the findings must be recorded in a video-cassette with patients name, hospital number, age and sex. Assist patient through procedure. Anticipate needs and promote comfort. Tell patient what is happening Suction if patient begins to vomit or accumulate saliva.

To prevent irritation of the mucosa

16.

17.

18.

19.

Patient is unable to speak after tube is passed into throat. Reassures patient about procedure and how long it will last. Prevents aspiration of gastric contents or oral secretions.

20.

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DIRECTORATE OF NURSING AFFAIRS

GENERAL NURSING PROCEDURES

SN

Action

Rationale

21.

At the end of the procedure : Assist the physician to remove the endoscope. Assit patient to comfortable position. Wash and dry hands. Dispose of equipment Monitor vital signs according to Physicians order and hospital Policy Observe for pain Evaluate emesis or aspirate for frank or occult blood Assess for return of gag reflex Ask patient to state post-procedure dietary and activity limitations Record the procedure in the appropriate documents. Notes: procedure, duration, patients tolerance, collection and disposition of specimen. Report onset bleeding, abdominal pain, dyspnoea, and vital signs change to the physician. Report to nurse in charge: duration of procedure, patients tolerance, change in vital signs and condition.

Change in vital signs can indicate new bleeding in GI tract Sudden abdominal pain can indicate rupture of abdominal organs Indicates gastrointestinal bleeding Determines when effects of anaesthetic have disappeared. To evaluate learning Provides documentation of procedure in patients record.

22.

May require emergency treatment Enables prompt medical follow-up for unexpected out-comes

Nursing Alert Have the following ready . Reversal ( antidote) drug . Oropharyngeal suction equipment . Emergency resuscitation equipment

FOLLOW-UP ACTIVITIES . Do not allow the patient to eat or drink anything until the tracheobronchial anaesthesia has worn off and gag reflex returns ( 2 to 4 hours ). . Monitor vital signs according to physicians order and hospital policy. . Provide oral hygiene when gag reflex returns. . Provide for delivery of specimens to appropriate laboratory.

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DIRECTORATE OF NURSING AFFAIRS

GENERAL NURSING PROCEDURES

SPECIAL CONSIDERATIONS . Promay be contraindicated in patient unable to fully cooperate. . Vital signs are especially crucial in patient who have had GI bleeding. . If patient is actively bleeding, stomach should be lavaged and aspirated clear of clots before procedure is attempted. . Lidocaine is frequently used to inactivate gag reflex. . If endoscopy of the upper GI tract is emergency and patient has had something to eat or drink, be sure physician is informed first. . Meperidine may also be used as relaxation agent. Decision to use diazepam or meperidine is usually physicians preference. . Midazolam (versed) is routinely used in the Ministry of Health hospitals. The endoscopy unit keeps cardiac monitor, oxygen, suction equipment, and resuscitation equipment on hand since midazolam may cause serious respiratory depression. . Know in advance if specimens are to be immediately delivered to Laboratory and have person available to transport specimen. . Initially after procedure, patient may experience internal bleeding without visible signs of blood loss. TEACHING CONSIDERATIONS . Inform patient of procedure medication and anticipated effects. . Explain method for endoscope insertion. . Explain that patient will be unable to speak when the endoscope is positioned in the esophagus. . Make sure patient knows not to eat or drink until gag reflex returns. Before return of gag reflex, patient could aspirate and develop pneumonia. . Inform the patient that insertion of endoscope into mouth may cause feeling of inability to breathe. Assure patient that suffocation will not occur. . Explain that patient may be hoarse or have sore throat after procedure. Ice chips or anaesthetic lozenges can be given after gag reflex returns.

SECTION 9 ENDOSCOPY: ASSISTING IN ENDOSCOPY PROCEDURE

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