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Want to Dabble?GI Have a Palette of Tips and Tricks Designed to

Improve your practice

Margaret Hauser-Ullman ADN RN CGRNLynn Miller BSN RN CGRN

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Objectives

• Discuss strategies employed in pre-procedure assessment to anticipate complex cases

• Discuss methods and techniques to help ensure a thorough endoscopic exam

• Identify signs and symptoms related to GI procedure complications

• Discuss strategies employed in pre-procedure assessment to anticipate complex cases

• Discuss methods and techniques to help ensure a thorough endoscopic exam

• Identify signs and symptoms related to GI procedure complications

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Plan Ahead!!A. Patient History Review

Sedation Considerations

• OSA - SNAP BANG-CENTRAL SLEEP APNEA

• MORBID OBESITY

• AGE > 80 WITH CO-MORBIDITIES

• CHRONIC NARCOTIC/OPIOD DEPENDANCE

• HIV positive and taking Ritonavir

• ETOH USE (MALES 3 PER DAY, FEMALES 2 DRINKS PER DAY)

• HX OF DRUG ABUSE -? Urine drug screen

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SEDATION CONSIDERATIONS continued..

• HX OF FAILED SEDATION - ? HOW MUCH IS TOO MUCH

• EXTREME ANXIETY

• AIRWAY CONCERNS/ISSUES. HX OF PRIOR NECK SURGERY, CHEMO, RADIATION,ORAL CANCER, RHEUM ARTHRITIS

• SEVERE CO-MORBIDITIES - CONSIDER MAC FOR KNOWN ADMISSIONS FOR CHF, IMPAIRED PULM FUNCTION, HOME O2, RECENT CARDIAC ISCHEMIC EVENT (WITH LAST 12 MONTHS), DECOMPENSATED CIRRHOSIS, ESRD ON DIALYSIS

• IMMUNOCOMPROMISED

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H & P / ADDITIONAL CHART REVIEW AND REASON FOR UPPER EXAM

• SYMPTOMS : DYSPHAGIA - Location/type, globus choking, halitosis, regurgitation

• SYMPTOMS: ODYNOPHAGIA (Possible tumor, Hx immunocompromised, HIV, CMV is most common, Herpes simplex, candida?) - anticipate brushings

• SYMPTOMS: GERD, ABDOMINAL PAIN, HB, N & V, REFLUX

• OTHER CONDITIONS: ANEMIA, HX OF CONSTIPATION, NSAID USE, MELENA-anticipate H Pylori - (clo or bx), GASTRIC CANCERS, ULCERS, GASTROPARESIS (consider longer NPO solids prior to procedure - > 8 hours-Consider clear or full liquids only - day prior)

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H & P / ADDITIONAL CHART REVIEW AND REASON FOR LOWER EXAM

• REVIEW PRIOR PROCEDURES-“DIFFICULT COLON”, TORTUOUS, FLUORO USED? POSITION CHANGES? ABDOMINAL PRESSURE APPLIED AND WHERE ? COMFORT, ADEQUATE PREP, SCOPE CHANGE DURING PROCEDURES (190’S YEAH!)

• IBD PTS MAY BE MORE UNCOMFORTABLE

• HX OF POOR PREP - REASONS - REMEDY PRIOR TO PREP

• HX OF DIFFICULT POLYP REMOVAL (BEHIND FOLD, TATTOOED) LOCATION OF FLAT POLYP IN PAST

• PENDULOUS ABD, DIVERTICULOSIS(SEVERE- CONSIDER PEDS), HX ABD SURGERIES(adhesions), ENDOMETRIOSIS

• HX OF KNOWN AAA - RISK/BENEFIT - COLONOSCOPE LOOP AND/OR ABDOMINAL PRESSURE

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MEDICAL HISTORY-OTHER

Medication Considerations

• COAGULOPATHY (VON WILLIBRANDS (DDAVP) ADRENAL INSUFFICIENCY (STRESS DOSE OF STEROIDS NEEDED)

• HIV positive and taking Ritonavir

• Chronic Opiods/narcotic use

• Phentermine-need to hold for 2 weeks

• ANTICOAGULANTS (REFER TO CHART)

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B. INFORMATION FROM SCHEDULERSB. INFORMATION FROM SCHEDULERS

• CORRECT PATIENT

• CORRECT EXAM

• CORRECT INDICATIONS

• CORRECT PATIENT CONTACT INFORMATION

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C. INPATIENT REPORT FROM RN’SCALL AHEAD!!

• ETA

• PREP STATUS-ANY DIFFICULTIES?

• NPO STATUS

• NPO STATUS - PTS WITH FEEDING TUBES

• CONSENT

• ADMINISTERED MEDICATIONS (continue BP meds)

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C. INPATIENT REPORT FROM RN’SCALL AHEAD!. CONT…

• GENERAL REPORT - VS, ASSESSMENT, ANY ABERRANCE'S, MOBILITY STATUS

• PATIENT GOWN

• REMOVABLE ITEMS - ENCOURAGE LEAVING ITEMS IN ROOM - LESS IS MORE

• DOCUMENT ANY ITEM THAT COMES WITH PT (JEWELRY, DENTURES, ETC)

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D. PRE CALL PATIENT INTERVIEW

• OPEN ENDED QUESTIONS

• REVIEW PREP INSTRUCTIONS (TIMING, REMIND NPO STATUS)

• STRESS DIET CHANGES

• PUSH FLUIDS!!!!!

• TYPES AND APPROPRIATENESS OF PREPS (BEST PREP FOR CONSTIPATION, AVOID MIRALAX PREP FOR RENAL PTS) (SEE CHART)

• GOLYTELY, SUPREP, MOVIPREP, PREPOPIK, MIRALAX/GATORADE

• PREPS FOR ALTERED ANATOMY (ILEOSTOMY) - CLEAR LIQUIDS

• DIABETIC MEDICATIONS

• DIURETICS

• ANTICOAGULANTS (SEE CHART)

• TRANSPORTATION HOME

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Objective # 2: Discuss Methods and Techniques to help ensure a thorough endoscopic exam

A. Anticipate Needed Equipment

• EXPIRATION DATES - CHECK ALL EQUIPMENT - INCLUDING ITEMS THAT ARE REPROCESSED (I.E. DILATORS)

• DEVELOP SYSTEM/SCHEDULE TO ACCOMPLISH THIS - DELEGATE STAFF

• INVENTORY - SYSTEM TO ENSURE PAR LEVELS ARE MAINTAINED AND NEEDED EQUIPMENT IS ALWAYS AVAILABLE

• COLLABORATE WITH GI TECH TO ENSURE HE/SHE IS PREPARED

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A. ANTICIPATE EQUIPMENT….CONT

EGD

• ALTERED ANATOMY (gastric bypass, sleeve) Balloon dilators

• TORTUOUS ESOPHAGUS (kyphosis, elderly, arthritis, hx cervical fusion) -Consider pediatric upper or nasal scope

• HIATAL HERNIA/PARAESOPHAGEAL HERNIA (consider NG if sx with paraesophageal hernia - may develop volvulus)

• DYSPHAGIA - Possible EoE or stricture (dilators, bx forceps)

• CAUSTIC INJURIES - Strictures - dilators

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A. ANTICIPATE EQUIPMENT….CONT

EGD cont.

• Foreign Body/bezoars - Assemble Tool box - Roth Retrieval net, snares, overtube, rat tooth, alligator

• Zenkers diverticuli - occurs with dysfunctional UES - anticipate difficult intubation - suction (oral and nasal) neutral neck position

• Achalasia - Balloon dilators - 80-85% cure rate

• Gastroparesis - (diabetic, opiods, other pharmacological, autoimmune) Gastric lavage kit (code blue) - HOB elevated or dependent ??

• Pyloric Stenosis - dilators - balloon -

• GIB - melena, anemia - sclerotherapy (ethanolamine oleate, morrhuate sodium), cautery, APC, epi, clips

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A. ANTICIPATE EQUIPMENT….CONT

EGD cont.

• GERD sx - bx forceps, CLO, pH equipment (Bravo monitoring)

• Bravo - check expiration dates, check fluid in capsule

• Capsule endoscopy/Agile - check expiration dates

• Hx ETOH abuse or Cirrhosis - possible varices - anticipate banding/sclerotherapy

• Odynophagia - Brushings (saline, brush, sterile scissors) KOH Test for Candida albicans - potassium hydroxide- quick, inexpensive fungal test for definitive Candida dx

• Malignancies - stents/fluoro, EMR equipment

• Fistulas - Esophageal/bronchial - stents

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A. ANTICIPATE EQUIPMENT….CONT

Colonoscopy

• Altered anatomy/resection - colectomy - ostomy (extra supplies, RN do not discard!)- pouches

• Diarrhea, CIBH - bx forceps, aspirate

• Colonic Strictures - colonic balloons, gastrografin, fluoro

• Past colonoscopy reports - diverticulosis, adhesions, abdominal surgeries, endometriosis, position changes

• Was fluoro needed in past? Available?

• Abdominal pressure applied in past - where?

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Sigmoid loop-

dipping into thepelvic region

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N - Loop

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Preventing the scope from entering the pelvic region

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Preventing scope from entering the

diaphragm

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Right hand protectingthe spleen

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Protecting the alpha loop from

reforming

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Right hand blocking and protecting the hepatic

flexure

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Left hand - sigmoid loop

Right hand-blocking and protecting hepatic flexure

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Left hand blocking sigmoid loop

Right hand blocking and protecting the spleen

A. ANTICIPATE EQUIPMENT….CONT

Colonoscopy

• Polypectomy Equipment - loop, snares & bx forceps - hot & cold, cautery & APC unit, Lift supplies for flat polyps (saline, Eleview or Spot ink)

• Lower GIB - Cautery, clips, epi, needle supplies, high volume irrigation

• Colon decompression : Kit - foley bag & secure device or tape, tincture of benzoine, CHUX, flush supplies

• Flexible sigmoidoscopy - Complete prep if cautery is anticipated

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https://www.youtube.com/watch?v=5uect4jRbGg

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A. ANTICIPATE EQUIPMENT….CONTPEG

• Pre procedure antibiotics - weight based

• PEG KIT - Pull (?push?).

• Surgical scrub kit/sterile towels, sterile gloves

• Education materials -

• Notify wound ostomy nurse, who sets up home care?

http://www.med.umich.edu/1libr/Surgery/OralSurgery/PegTubeGuidelines-postop-OMFS.pdf

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Objective # 3: Review signs and symptoms of complications post procedure

• Post polypectomy bleed

• Post dilation bleed

• Post EGD bleed - ulcers, etc

• PEG - buried bumper

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Objective # 3: Review signs and symptoms of complications post procedure

• Perforation

• Incarcerated hernia

• Stent migration

• Valsalva Retinopathy

• Infection after colon/egd rare?

• Traveling after polypectomy - window of risk for bleed

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Review signs and symptoms of complications post procedure

• Sinus irritation - O2 administration

• Traveling after polypectomy - window of risk for bleed

• Listen to your patients……

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• Looping and Abdominal Pressure: A Visual Guide to a Successful Colonoscopy- Prechel, James A. AA, GTS; Sedlack, Robert E. MD; Harreld, Frank A.; Sederquest, Melissa M.Gastroenterology

Nursing: July/August 2015 - Volume 38 - Issue 4 - p 289–294

• SGNA Gastroenterology Nursing - Core Curriculum

• SGNA Website -GI Nurse Sedation

• Bowel preparation before colonoscopySaltzman, John R. et al.Gastrointestinal Endoscopy , Volume 81 , Issue 4 , 781 - 794

• PEG CARE INSTRUCTIONS : Disclaimer: This document contains information and/or instructional materials developed by the University of Michigan Health System (UMHS) for the typical patient with your condition. It may include links to online content that was not created by UMHS and for which UMHS does not assume responsibility. It does not replace medical advice from your health care provider because your experience may differ from that of the typical patient. Talk to your health care provider if you have any questions about this document, your condition or your treatment plan. Author: Erin Larowe Reviewers: Brent Ward, DDS, MD Patient Education by University of Michigan Health System is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. Last Revised 3/2016

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• Eleview: This excerpt is part of the ASGE: The American Society for Gastrointestinal Endoscopy Tech Talk Series, held in August 2017. ASGE Tech Talks cover new and existing technology, techniques, and tools used by endoscopists in routine clinical practice. - ASGE Tech talk - Dr. Douglas Rex on Eleview

• References: “The management of antithrombotic agents for patients undergoing GI endoscopy” Vol 83, No.1: 2016 Gastrointestinal Endoscopy

• “Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures” N ENGL J MED 368:22 May 30, 2013

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