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Safe & Effective Abdominal Pressure During Colonoscopy:

Forearm Versus Open Hand Technique

Presented By:St. James Healthcare Education Collaborative

With The Support Of:Susan DePasquale, Barbara Dudden & Bonita Becker

GI Endoscopy - Surgical Services Department

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Safe & Effective Abdominal Pressure

Purpose & Methods:

purpose is to help the scope around the colon

start abdominal pressure with patient positioned on their left side [although some endoscopists will occasionally request to reposition patient from their left to supine, right side or prone if not successful with scope advancement in the typical left side position]

scope progression through the colon (as visualized on the video monitor screen) means effective pressure is being provided

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Safe & Effective Abdominal Pressure

Purpose & Methods:

provide external abdominal pressure around the area of the scope to assist scope movement through the colon and decrease scope looping within the colon

think about the size of the “scope head” and how to provide “splinting” around the scope to help direct its movement

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Safe & Effective Abdominal PressureTechnician needs to be aware of the following during colonoscopy: where the scope is located in the colon

physician effort to reduce a loop by pulling back / repositioning scope (to allow technician to provide adequate counter pressure)

best place to start external abdominal pressure is the sigmoid area (a common place for loop formation)

how to apply external pressure and reposition hand(s) around other areas of the colon if sigmoid pressure is not effective

signs of patient discomfort during abdominal counter pressure and scope advancement

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Safe & Effective Abdominal PressureSeveral key factors are crucial to keep in mind when applying

abdominal pressure during colonoscopy:

awareness of the amount of abdominal pressure exerted to avoid injury to technician or patient

open hand technique and increased risk of wrist injury to technician

good body mechanics and positioning to ensure optimal comfort for technician

forearm techniques which allows the technician to provide effective and safe abdominal pressure while reducing the risk of injury to technician or patient

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Safe & Effective Abdominal Pressure SCENARIO 1: OPEN HAND TECHNIQUE

Technique: technician’s hands equally applies counter pressure to the left upper and lower abdomen - sigmoid and splenic flexure of the colon

Ergonomic Issue:arrow indicates areas of possible injury to the technician

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Safe & Effective Abdominal Pressure

Technique:technician’s hand covers onlythe left lower abdomen - sigmoid portion of the colon.

Ergonomic Issue: arrow indicates area of possible injury to the technician.

SCENARIO 2: OPEN HAND TECHNIQUE

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Safe & Effective Abdominal Pressure

Technique: “Prechel pressure” is where the technician’s left forearm rolls into the patient with left hand under pelvic bone while right hand pulls the patient forward; allowing patient’s own weight to act as counter pressure.

Ergonomic Issue:potential strain from ineffective use of patient’s own weight.

SCENARIO 3: SINGLE FOREARM TECHNIQUE

hand over sigmoid / midline colon

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Safe & Effective Abdominal PressureSCENARIO 4: TWO-FOREARM TECHNIQUE

Technique:Technician’s left forearm in Open Hand Technique, right hand under splenic flexure below diaphragm (fingers extended, knuckles down, or fisted).

Ergonomic Issue:Potential strain if not performed with another person rolling the patient onto the technician’s forearm to apply counter pressure. hands over sigmoid, midline, splenic

flexure, and mid-transverse colon

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Safe & Effective Abdominal Pressure “It is advantageous for one to know the most effective muscle group

in order to apply pressure correctly and safely. Communication amongst the team is also imperative to provide any compromise

and consensus necessary on patient positioning, i.e., how the table height is set, if others will be available to assist with pressure,

where everyone will stand, duration of pressure before a moment of release is needed, what are appropriate forces for pressure

applied, if an additional monitor can be available, and an appropriate height stepstool. When pressure is needed to assist with movement of the scope or looping, the assistant applying pressure needs to be able to stand in a posture that allows the body to assist with the technique. This is one that maintains the back in a neutral spine posture and allows the knees and hips at

least a slight bend to be more fluid in the stance”.

Cynthia Edgelow, MSN, RN, CGRN; Ray Hucke, MPH, OT; and Jim Prechel, GI Tech. Mayo Clinic, Scottsdale, Ariz.

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Safe & Effective Abdominal Pressure

Most pressures, when applied with good body mechanics and positioning, should be sufficient for 3-5 minutes.

When longer periods of applying abdominal pressure are needed there should be communication between the technician and endoscopist to provide a moment to relax the pressure.

Fatigue or discomfort to the arms should be communicated by the technician so that another person may take over or help with directing the patient’s weight onto the forearms.

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Safe & Effective Abdominal Pressure

The technician needs to be aware of their own height, arm lengths, and muscle strengths while applying abdominal pressure.

Work with the various techniques of applying abdominal pressure to find the postures and position most effective to splint the scope,

reduce looping, provide comfort to the patient, and protect technicians supporting the endoscopist during colonoscopy.

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Safe & Effective Abdominal PressureFor the comfort of the patient and protecting sensitive soft tissue: Be aware of point of pressure (increases with a smaller surface area

where abdominal pressure is applied)

Splint to assist with reducing scope looping, applying pressure over as broad an area as possible to stabilize tissue around the scope

along with downward pressure against the abdomen

External abdominal pressure during colonoscopy does not need to be exceptionally forceful (with possibly the exception of patients with obesity or large abdominal girth)

Duration of the abdominal pressure applied may be determined by the speed of the procedure – be aware of length of time

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Safe & Effective Abdominal PressureBe aware of pinpoint force being directed to a precise focal point:

Similar to wound care management, localized and prolonged abdominal pressure during colonoscopy are discouraged

If colonoscopy pressures are applied for longer duration be aware of patient discomfort and the potential injury to the patient due to pressure being applied using fingertips, elbows, or fists

Possibly less assistance in loop reduction and direction of motion can occur with external smaller pressure areas because of colon flexibility and layers pressed against the abdomen

Pressure over a broad spectrum is preferred because it allows pressure to be displaced evenly

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Safe & Effective Abdominal Pressure

References:

James A. Prechel & Ray Hucke (2009). Safe and Effective Abdominal Pressure During Colonoscopy. Gastroenterology Nursing. Vol. 32; No. 1. Jan/Feb 2009; pp. 27 – 30.

Cynthia Edgelow, Ray Hucke, MPH, OT & Jim Prechel, GTS (2007). The Importance of Positioning During Colonoscopy.

ENDONURSE.