Endoscopy Learning Module N12 CSUS 2008

Endoscopy Learning Module N12 CSUS 2008
School of Nursing By B. Millar RN, BSN, MSNc Click here to begin 1

LEARNING OBJECTIVES After completing the module, you should be able to: Implement nursing responsibilities for preparing patient for Upper endoscopy (EGD) in the context of patient teaching Employ adaptive responses to alleviate patient anxiety and knowledge deficit in endoscopic procedures Describe therapeutic treatment goals for upper endoscopy and list one major complication Continue

LEARNING OBJECTIVES (CONT)
After completing the module, you should be able to: Implement nursing responsibilities for preparing patient for Colonoscopy in the context of patient teaching Explain rationale for Endoscopic Retrograde Cholangiopancreatography (ERCP) given correlating pre-operative diagnosis Identify signs and symptoms for at least one complication of ERCP Continue

What is GI Endoscopy? A therapeutic and diagnostic gastroenterological procedure that allows for direct visualization of the lumen of the GI tract. The idea here is that we are looking into the GI tract, and the endoscope can do two things: Therapeutic means it can give treatment of some sort, in an effort to fix something. Diagnostic means that visualizing the GI tract can give valuable information that may help with the diagnosis, or take samples that will help a diagnosis. Continue

The GI Endoscope Gastroscope: Colonoscope: Flexible
103cm long 11mm diameter Colonoscope: 180cm long 13mm diameter Flexible Channel for biopsy, air, water, suction Not a sterile Procedure 103 cm is actually about 40.5” or 3.4feet (2.54 cm=1inch) 11mm (10mm=1cm) is only a little over a cm 180 cm is about 70” or almost 6 feet! 13 mm is still only about half an inch! Channel for biopsy, air, water, suction=balloon demonstration Why isn’t this a sterile procedure? Can a scope going into the gut ever be a sterile procedure? Continue 5

Why isn’t this a sterile procedure?
Click on correct answer.. A. It is a sterile procedure (trick question)! B. The GI tract is not sterile. Continue->

A. Incorrect. It is not a sterile procedure because the GI tract is not sterile. The scope enters the body through the mouth, which is not a sterile area of the body. Back to question

B. Correct! It cannot be a sterile procedure because the scope enters the body through the mouth, which is not sterile at all. Back to question

What can Endoscopy do? Visualizes upper and lower GI tract
Diagnostic treatment Therapeutic treatment Continue-> 9

The GI Endoscopy Suite Continue->

Diagnostic Treatment In GI Endoscopy
Therapy intended to confirm or rule out a diagnosis. GI Endoscopy does this by: Gross visualization during the procedure and/or Biopsy: taking a specimen (piece of tissue) to study the cells (Cytology) or tissue for disease (Hystopathology) Continue-> Back

Therapeutic Treatment in GI Endoscopy:
1.Treat bleeding by Hemostasis: hem(=blood) + stasis(=standing still): “to stop bleeding” 2.Treat problems of nutrition or dysphagia (difficulty swallowing) by placement of a Gastrostomy or Jejunostomy Tube 3.Foreign body removal-removing something foreign to the body from the GI tract 4.Gastric or Colon polypectomy-removal of a polyp 5.Stricture Dilatation-tearing open a stricture in the esophagus 6. Obtain tissue sample for diagnosis continue back

Endoscopy Procedures “Table of Contents”
EGD: Esophagogastroduodenoscopy COLONOSCOPY ERCP: Endoscopic Retrograde Cholangiopancreatography 13

Esophagogastroduodenoscopy
EGD = Esophago (esophagus) Gastro (stomach) Duoden (duodenum) Oscopy (to examine) back Continue 14

Most Common Indications for EGD
Acute or Chronic GI Bleed Removal of ingested foreign object Dysphagia or odynophagia or dyspepsia Xray/CT Scan showing lesion Continue 15

Removal of foreign object
back

Dysphagia or odynophagia or dyspepsia
Difficulty swallowing (dysphagia), painful swallowing (odynophagia), or dyspepsia can cause malnutrition over time, and usually requires supplementing nutrition through a feeding tube. Continue

Feeding Tube PEG tube (Percutaneous Endoscopic Gastrostomy tube) or a PEJ tube (Percutaneous Endoscopic Jejunostomy tube) Back

Xray/CT Scan showing lesion
back

Less Common Indications for EGD
Suspected esophageal stenosis(narrowing) Suspected hiatal hernia Persistent esophageal reflux Obstructive lesions Caustic ingestion Chronic abdominal pain Persistent unexplained vomiting Continue

Diagnostic Treatment: Biopsy
Continue

Therapeutic Treatments
For Hemorrhage/Bleeding Gastrosomy or Jejunostomy Tube Placement Foreign body removal Gastric polypectomy, mucosal resection Stricture Dilatation Hemostasis : Hemo (blood)+ stasis (standing still) Electrocoagulation or Electrocautery refers to the use of heat applied to the tissue or vessel to create coagulation Continue 22

GI Bleeding/Hemorrhage
back

What causes GI Bleeding?
Gastric, esophageal or duodenal ULCERS (80% of all peptic ulcers are duodenal) ulceration Continue 24

GI Bleeding visualized by Endoscopy
If the GI bleed is active and profuse, it is difficult to find the site of the bleeding through all that blood! The body has formed a clot over the site of the previously bleeding ulcer. Continue

Other causes of GI Bleeding..
Esophageal Varices Mallory-Weiss Syndrome which causes a Mallory-Weiss Tear Erosive gastritis, esophagitis, duodenitis (think: erosive inflammation) AVMs (arteriovenous malformations) Tumor Continue

Esophageal Varices Dilated esophageal veins from portal HTN and cirrhosis. Once dilated, pressure builds up and bleeding occurs. Varices (bulging vein) Back

Mallory-Weiss Tear A tear in esophagus or gastroesopha-geal junction caused by severe retching, vomiting, or coughing and is usually associated with alcoholism. Back

Erosive Gastritis/Esophagitis
Inflammation and erosion of the stomach (Gastritis) or esophagus (Esophagitis) Endoscopy View of erosive gastritis (also known as watermelon stomach) Back

Arteriovenous Malformations (AVMs)
AVMs: dilated blood vessels in the submucosa -Also called angiodysplagias Back

Tumors Benign or Malignant
95% of all stomach cancers are adenocarcinoma Back

How does Endoscopy achieve Hemostasis?
Hemostasis=Heme(blood)+stasis(stand still) Electrocoagulation/Electrocautery Injection Therapy Laser Therapy Ligation/Banding Clipping All of these therapies are wired through an endoscope, and come out at the tip to perform their function. Electrocoagulation (same as electrocautery): heat is applied to the tissue or vessel creating coagulation. Injection Therapy: a solution is injected into the vessel or surrounding tissue Laser Therapy: A laser beam is applied directly at the site, a vessel or tissue Ligation/Banding: A band (small rubber-band, or o-ring) is applied to a bulging esophageal varix to impede flow Clipping: A clip is used to pinch the tissue together, thereby “pinching off” the vessel Continue->

What is electrocoagulation?
Heat is applied through direct heat heater probe or non-touch heat argon plasma coagulation to tissues. The heat coagulates the proteins in the tissue, thereby causing a burn (or seal) over the tissue. This effectively “seals” a bleeding vessel. Back

Electrocoagulation/electrocautery
Heater Probe: Probe that applies heat to the tissue Argon Plasma Coagulation (APC) The Probe comes out through the tip of the scope “Argon Plasma + Heat”is sprayed onto tissue, causing coagulation Electrocoagulation/electrocautery is the application of heat (electric current) to the tissue, causing coagulation of proteins and resulting in HEMOSTASIS. Back 34 34

Injection Therapy Injection Therapy: nonvariceal bleed
hypertonic saline + epinephrine (vasoconstrictor), or just saline, is injected into the vessel that is bleeding Sclerotherapy: variceal bleed (varices) Chemical Injected into bleeding site or varix (varix is the singular form of varices) Back The endoscope has a channel, called the biopsy channel. It allows wires and catheters to be pushed into the scope, which then comes out at the tip of the scope. For injection therapy, a needle will end up at the tip of the scope, which is then inserted into the tissue around the vessel. The syringe containing the saline or a mix of saline and epinephrine is connected to the needle, but it sits outside of the scope. Injecting solution from the syringe pushes the medication through the catheter, to the needle, and then into the target tissue. It is usually used in conjunction with electrocoagulation therapy to stop the bleed. The endoscope has a channel, called the biopsy channel. It allows wires and catheters to be pushed into the scope, which then comes out at the tip of the scope. Sclerotherapy is used for a varix (singular form of varices, which is a bulging vein along the esophagus, caused by cirrhosis or liver disease). For sclerotherapy, a needle will end up at the tip of the scope, which is then inserted into the tissue around the vessel. The syringe containing medication (sclerosing agent) is connected to the needle, but it sits outside of the scope. Injecting solution from the syringe pushes the medication through the catheter, to the needle, and then into the target tissue. The chemical will seal off the bleeding varix by “hardening” or “sclerosing” it. 35

Laser Therapy Photocoagulation-laser coagulates tissue
Photovaporization-laser vaporizes tissue Laser can reach 1-4mm tissue depth Laser Beam Tissue Laser Endoscope Tissue layers Back 36

Ligation or Banding Rubber bands or O-rings ligate the varix
the Band around a varix Back 37

Clipping Clipping involves actual titanium clips which are used to pinch the vessel and surrounding tissue closed. A clip Clips after deployment The clips should, and usually do, fall off after approximately 3 days. Back

Nursing Responsibilities
Pre-procedure Consent Teaching/Reduce Anxiety Patent IV (large gauge > 20) Oxygen Pre-medicate if indicated Good Oral Care prior to procedure NPO!!! (teaching is VERY important here) Remove dentures A 38 year old female is admitted to the hospital for weakness, melena, and an episode of hematemesis. She says she hasn’t eaten anything in almost two days, and is starving. You are to prepare your client for an EGD and explain that she cannot have anything to eat or drink. The nurse knows the reason for this is because: In order for the bleeding site to be visualized, the stomach must be empty b)If there is food or water in the client’s stomach, there is an increased risk of aspiration c)If the client eats or drinks, she is at greater risk for burn injury during the procedure d)Food will increase the likelihood of greater trauma to the tear in her esophagus Choose one of the following: 1) All the above 2) Only a, b, and d 3) Only a & b 4) Only a What is the best way to reduce the client’s anxiety about the procedure: Apply Oxygen by nasal cannula to prevent her from hyperventilating Tell the MD so an order for a medication with anti-anxiety effects can be ordered. Place a large bore IV in her arm and explain that it is important in case an emergency happens. Discuss the procedure in clear language and answer her questions to help reduce her anxiety. Continue-> 39

Consent You must spell it out completely (not EGD!) it must read: Esophagogastroduodenoscopy You must include the possible adjunct procedures involved (ie. Treatment to bleeding site, procedural sedation, etc) on the consent form. If the MD has not discussed the procedure with the patient, can you obtain a signed consent? Answer Back

No As an advocate for your patient, you must make sure the MD has discussed the procedure with the patient, AND the patient has no further questions for the MD, prior to obtaining the signature. Back

Teaching Teaching will not only inform your patient about what the procedure is, and what to expect, but it may also reduce anxiety, which most patients experience when they are about to participate in an unfamiliar procedure. In GI Endoscopy, patients will usually receive conscious sedation, which also needs to be explained to the patient. Back

Patent IV Patients should ALWAYS have a patent IV, but this needs to be confirmed prior to any procedure. Patients are given sedation and analgesia, as well as fluid resuscitation, blood products, and possible rescue medications, as well as the possibility of treatment for cardiac or respiratory arrest during the procedure. Make sure the IV is patent by flushing it with saline, if it is a saline lock. Back

Oxygen Patients receiving conscious sedation should always have appropriate O2 monitoring. In addition, make sure there is Oxygen and equipment nearby and available. REMEMBER: Conscious sedation MAY affect respiration, ventilation and oxygenation. Back

Good Oral Care Good general practice- especially prior to procedure
Back

NPO The stomach must be completely empty in order to:
1) visualize the interior appropriately 2) prevent aspiration of gastric contents Visualization is key to a successful endoscopic procedure. Back

Remove dentures Dentures should be removed because they may become loose during the procedure. Dentures should be marked clearly, and in a safe place at all times, to ensure that they do not get lost during a hospital admission. Back

Question #1 A 38 year old female is admitted to the hospital for weakness, melena, and an episode of hematemesis. She says she hasn’t eaten anything in almost two days, and is starving. The nurse prepares the client for an EGD and explains that she cannot have anything to eat or drink. The nurse knows the reason for this is because: Continue->

Choose all that apply: A)In order for the bleeding site to be visualized, the stomach must be empty B)If there is food or water in the client’s stomach, there is an increased risk of aspiration C)If the client eats or drinks, she is at greater risk for burn injury during the procedure <-Back to question Continue->

Back to Answers_(there is more than one correct response)
Correct! Visualization is the key to a successful endoscopy procedure! Back to Answers_(there is more than one correct response)

Back to Answers-(there is more than one correct response)
Correct! The patient is at risk for aspirating stomach contents because: 1. The patient will be sedated. 2. The gag reflux may be stimulated, and may cause the patient to vomit any stomach contents. 3. The airway may not be protected. Back to Answers-(there is more than one correct response)

C. Incorrect. There is no greater risk for burn injury (from use of electrocautery) because of food in stomach. Back to Answers

Question #2 Your client tells you she is scared and does not want to have the endoscopy procedure because she is afraid of surgery. The nurse knows the best way to reduce her anxiety is to: Continue

Choose all that apply… A) Apply Oxygen to prevent her from hyperventilating. B) Call the doctor, request anti-anxiety medication for the patient. C) Place a large bore IV in her arm and explain that it is important in case an emergency happens. D) Discuss the procedure in clear language and answer her questions to help reduce her anxiety. Continue

A. Incorrect. Oxygen will not prevent a person from hyperventilating, or reduce anxiety. Back to Answers

B. Incorrect. This may help eventually, but the patient does not appear to understand that an EGD is not surgery, it is a procedure. She may need further teaching, first. Back to Answers

C. Incorrect. Although it is important to have a patent IV, this may not serve to reduce a patients’ anxiety. Back to Answers

D. Correct! Discussing the procedure and answering her questions will help to reduce her anxiety about the procedure. Back to Answers

Complications Respiratory depression or arrest
Perforation of esophagus, stomach or duodenum Hemorrhage related to trauma or perforation Pulmonary aspiration of blood, secretions or gastric contents Infection Sepsis Cardiac arrhythmia or arrest Vasovagal response Allergic reaction to topical anesthetic or IV meds Client reports diffuse pain in right upper abdomen, tender to palpation, low grade temp, and elevated BP Continue 59

Perforation One of the major complications of an EGD, although the incidence is rare, is a cut through the esophagus, stomach or duodenum. Usual signs and symptoms include neck, back, chest, shoulder, or abdominal pain, as well as tachycardia, diaphoresis, and hypotension. Back

Question #3 A client has just returned from an EGD to assess for a GI Bleed. The endoscopy found a large gastric ulcer which required electrocoagulation therapy. When assessing the client upon return from the procedure, he reports severe back and abdominal pain, and appears diaphoretic. The abdomen is distended, and he is tachycardic. Continue

Click here for the correct answer
The nurse knows that these assessment findings are most consistent with which potential complication of the GI procedure: A) Perforation B) Sepsis C) Infection D) Aspiration Click here for the correct answer

Perforation This is one of the major complications of an EGD, although the incidence is rare. It is a perforation of the submucosal layer of the lumen in the GI tract. Usual signs and symptoms include neck, back, chest, shoulder, or abdominal pain, as well as tachycardia, diaphoresis, and hypotension. Continue

Colonoscopy Endoscopic visualization of colon as far as the terminal ileum Continue 64

Indications for Colonoscopy
Outpatient: Colon Cancer Screening Inpatient: GI Bleeding/Anemia Cancer/tumors Arteriovenous Malformations (AVMs) Bleeding polyps Ulcerative Colitis Hemorrhoids Diverticulosis Colonic Ischemia Post Polypectomy Continue 65

Colon Cancer/Tumor Back

AVMs Arterial-Venous Malformations (AVMs)
Superficial blood vessels which are prone to bleeding Back

Bleeding Polyps Actively bleeding polyp
Polyps can bleed due to vascularity Back

Ulcerative Colitis Inflammation of the colon Back

Hemorrhoids Internal veins around anus that can bleed Back

Diverticulosis Diverticuli Back

Colonic Ischemia Area of ischemia Back

Post Polypectomy Bleed
Post Argon Plasma Coagulator to stop the bleeding Polyp Post polypectomy bleed Back

Polypectomy What’s a polyp? Polypectomy is the removal of a polyp
A lesion that protrudes from the mucosal layer of the GI lumen. Polypectomy is the removal of a polyp How is a polyp removed? Transection by a snare and a high frequency current Continue 74

Colon Polypectomy Polyp After Polypectomy Colon Cancer Continue 75

Colonoscopy Therapeutic Treatments: usually for bleeding cancers, AVMs, polyps Hemostasis is achieved by: Electrocoagulation (Electrocautery) Injection Therapy Polypectomy Clipping Foreign body removal Continue 76

Electrocoagulation/electrocautery
Heater Probe: Probe that applies heat to the tissue Argon Plasma Coagulation (APC) The Probe comes out through the tip of the scope “Argon Plasma + Heat”is sprayed onto tissue, causing coagulation Electrocoagulation/electrocautery is the application of heat (electric current) to the tissue, causing coagulation of proteins and resulting in HEMOSTASIS. Back 77 77

Clipping Clipping involves actual titanium clips which are used to pinch the vessel and surrounding tissue closed. Back

Pre-procedure Consent Administer bowel preparation!!!! NPO prior to procedure IDDM -consult with MD Patent IV, added IV fluids Oxygen, if indicated (make sure the tank is full) Pre-med antibiotics, if ordered Continue

Bowel Preparation Critical element in a successful colonoscopy!
Most common: Golytely (4 Liters) Less common: Phosphosoda (3oz) A primary factor in whether a colonoscopy is successful or not depends on how well the bowel is visualized. It is imperative for the bowel to be cleansed as thoroughly as possible prior to the procedure. Continue

Bowel Preparation A primary factor of a successful colonoscopy depends on how well the bowel is visualized. It is imperative for the bowel to be cleansed as thoroughly as possible prior to the procedure. Back

Complications Bleeding (up to 21 days post polypectomy)
Adverse reaction to sedation Transmural burns (Abd. Pain, leukocytosis, fever without free air) Bowel perforation: Emergency! Xray to OR Risk of explosion (due to hydrogen and methane in bowel) Ensure a good bowel Prep!) Good info, again focus and objective and question here. This is what we want them “smart in” so they can safely care for the patient and recognize a major problem developing early. Continue 82

Perforation of the Bowel
Early Signs and Symptoms: Fever, abdominal or rectal pain, abdominal distention, abdominal rigidity, increased HR, increased RR Late sign: Hypotension-impending shock! Perforation is confirmed by XRAY showing free air under the diaphram Back Continue

Question #4 The doctor has ordered a bowel preparation prior to a colonoscopy. The client is supposed to drink the 4 Liter bowel prep, and remain on clear liquids until midnight; at which time the client is then supposed to be NPO. Continue

A) visualize the inner lumen B) reduce methane gas in the colon
The nurse explains that a thorough preparation of the bowel is important to: A) visualize the inner lumen B) reduce methane gas in the colon C) find the source of bleeding D) all of the above Continue

A. A thorough preparation allows for visualization of the inner lumen. Stool may be difficult to flush away during the procedure and may prevent the endoscopist from accurately visualizing the colon. Back

B. Stool produces methane gas. Back

C. The source of bleeding may be a small area that has bled slowly over a long period of time, or a larger vessel. If the bowel preparation is thorough, there is a greater chance that the bleeding site is found during the colonoscopy. Back

Correct Answer: D In order to accomplish the goal of the procedure, it is important that the Colon is properly visualized. The best way to evaluate the preparation is to confirm that bowel movements prior to the procedure result in clear watery stools, and that the directions were followed for bowel preparation as ordered. Back

Endoscopic Retrograde Cholangiopancreatography
ERCP Continue 90

Most Common Indications for ERCP
Gallstone Pancreatitis Pancreatic malignancy Obstruction of the CBD or in biliary system Choledocholithiasis Chole=bile +docho=duct +lithos=stone +iasis=condition Biliary Tract disorders include: cholethiasis, choledocholithiasis, cholangitis, cholecystitis, sphincter of Oddi disease(SGNA, 2003) Continue 91

Goals of an ERCP To investigate the obstruction of bile in the common bile duct (CBD)-(diagnostic) To evaluate the condition of the obstruction and obtain cytology brushing for further diagnosis-(diagnostic) for possible pancreatic cancer To evaluate for pancreatitis To clear the CBD of its obstruction by removing the stones-(therapeutic) To create a passage for bile to drain if obstruction cannot be removed, or if reobstruction is suspected-(therapeutic) To evaluate jaundice or abnormal CT caused by biliary disease. Continue

2 Types of Gallstones Cholesterol Stone: made up of bile that is supersaturated with cholesterol or with a reduced bile-salt secretion. Cholesterol stones make up 75% of all stones Pigment Stones: made up of bilirubin polymers, calcium salts, and fatty acids. How do they form? When the bile is supersaturated, it forms crystal nucleates that cluster together in the form of “stones” in the gallbladder. Cholesterol Stone is made up of cholesterol, calcium salts, bile acids, fatty acids, protein and phospholipids Continue

Treatments by ERCP Endoscopic Retrograde Cholangiopancreatography with… Sphincterotomy or Papillotomy Lithotripsy Cytology Balloon Dilatation Stent placement Endoscopic (done by endoscopy methods: scope)+ Retrograde (going against the flow, refers to the fact that the procedure involves entering the bile duct in the opposite direction of flow)+ Cholangio (refers to the biliary system) +Pancrea (refers to the pancreas) +graphy (refers to visualize or to “write”) Sphincterotomy or Papillotomy: refers to cutting the Sphincter of Oddi or the Papilla of Vater Lithotripsy: breaking/crushing the stone Cytology/biopsy: a brushing of the cells are taken from the duct and sent to the lab for a pathology/cytology(cells) report. Balloon Dilatation: Uses a balloon to push open the narrow duct from the inside of the duct Stent placement: A stent is left in the bile duct to maintain its patency Something to remember: an ERCP procedure can involve one or more of these treatments. Continue 94

ERCP = Endoscopic Retrograde Cholangiopancreatography
Endoscopic (done by endoscopy methods: scope)+ Retrograde (going against the flow, refers to the fact that the procedure involves entering the bile duct in the opposite direction of flow)+ Cholangio (refers to the biliary system) +Pancreat (refers to the pancreas) +ography (refers to visualization ) Continue

Sphincterotomy (also called Papillotomy)
Bile drains into the duodenum by way of the sphincter of Oddi. This outlet is too small to allow for a stone to pass through. A small cut is made into the opening (ampulla) of the sphincter, in order to allow the stone to pass through. When possible, a sphincterotomy is performed during an ERCP. But this is only the first step in the procedure. Back

Lithotripsy Crushing of gallstones by using a mechanical lithotripter. Lithotripsy can also be done by focussed shock waves, but during ERCP, it is most commonly done mechanically. Back

Cytology A cytology brush is passed through the endoscope and into the bile duct in order to obtain cells for microscopic examination Back

Balloon Dilatation A balloon is used to expand a narrowed area within the bile duct that could be contributing to the obstruction. The cause for the narrowing is further evaluated using a cytology brush. Back

Stent Placement A flexible or metal mesh stent is placed within the CBD to allow for bile flow through the endoscope. A flexible stent is removed 6-8 weeks later through endoscopy. If an additional stent needs to be replaced, it must be done under fluoroscopy in an ERCP. A mesh stent adheres to the inner lumen of the common bile duct and cannot be removed once in place. This is most often used for palliative measures, once a diagnosis of pancreatic CA is confirmed. Back

PRE-PROCEDURE: Know the patient’s PTT, make sure the MD is aware of the most recent PTT, especially if elevated NPO (IDDM) Pain Control Patent IV Teaching/reduce anxiety Pre-medicate Continue 101

Elevated PTT? If the patient has an elevated PTT, they are at increased risk of bleeding. ERCP usually requires that a sphincterotomy is performed. Back

Why NPO? The patient must be NPO prior to the procedure because
Conscious sedation will be given Pt will be in a Prone position They may be unable to protect their airway The Pt will be at risk for aspiration! Back

Pain Control? Patients with suspected biliary disease or obstruction or pancreatitis generally have abdominal pain. Consider medicating patient for pain so they can tolerate the prone position required for the procedure. Communicating this to the endoscopy team performing the procedure is important. Additional analgesia and sedation will be given during the procedure. Back

Patent IV? When sending a patient to a procedure, ALWAYS confirm they have a patent IV. If IV is infusing-check the site and confirm good placement and infusion without swelling or redness. If Saline lock, flush with Saline and confirm patency prior to sending patient for procedure. Procedure is delayed if IV is not patent. Back

Teaching to reduce anxiety?
Educating and informing the patient (and family) of the procedure and what to expect may be the most effective way to reduce fear and anxiety. The patient will be in a prone position with their head to one side during the procedure. Conscious sedation is used They are monitored for O2, HR,RR,BP and LOC throughout the procedure Procedure is done under XRAY(fluoroscopy) Back

Premedicate Often, an antibiotic prophylaxis is ordered in anticipation of preventing an infection when the sphincterotomy is done, or if there is biliary or pancreatic stasis. Confirm whether the patient is receiving a broad spectrum antibiotic and discuss with MD if no antibiotic is ordered. Gentamicin and/or Ampicillin are most commonly given Back

POST PROCEDURE: Assess your patient: vital signs, LOC, O2 Sat Maintain NPO status until gag reflex returns or further orders are written Observe for abdominal distention and signs of pancreatitis, including: chills, low-grade fever, pain, vomiting, tachycardia Observe patient for any adverse drug reactions Continue 108

Complications Most Common: Also observe for: Pancreatitis
Sepsis, biliary sepsis Also observe for: Cholangitis (infection in stagnant duct) Aspiration Bleeding Perforation Respiratory depression or arrest Cardiac arrythmia or arrest Continue 109

Pancreatitis Following an ERCP, 7% of cases result in Pancreatitis (SGNA, 2003) Signs and symptoms include: 1) pain in midepigastrium, left chest, shoulder and back 2) nausea and vomiting 3) low-grade fever 4) abdominal swelling and tenderness 5) shock, hypovolemia, hypotension, hypoxia 6) serum amylase, lipase greater than 3x normal Back

Sepsis Early Signs : Chills, fever, warm flushed skin, mild hypotension (increased Cardiac Output) Late Signs: Severe hypotension, tachycardia (appears similar to hypovolemic shock) Antibiotic prophylaxis in high risk patients may prevent complication of sepsis (bacteremia). Back

Question #5 A client returning from an ERCP procedure is drowsy, but easily arousable. The client appears warm, feverish with chills, and is mildly hypotensive. The nurse knows that these findings are consistent with what complication following an ERCP: A) Pneumonia B) Sepsis C) Hemorrhage D) Duodenal perforation Click here for correct answer Continue

Correct Answer: B Sepsis:
The patient is exhibiting early signs of sepsis following the ERCP. This is one of the common complications following an ERCP and early recognition is crucial. Back Continue

Click here for correct answer
Question #6 Which of the following statements best describes the goal of ERCP when the patient has a diagnosis of Choledocolithiasis? A) Sphincterotomy B) Dilatation of the bile duct C) Removal of gallstones in the bile duct D) Biopsy for cytology of the pancreatic duct Click here for correct answer

Correct Answer: C Choledocolithiasis is the appropriate medical terminology that refers to a stone in the common bile duct. Therefore, treatment goal would be removal of the stone, and therefore, the obstruction. Choledocholithiasis Chole=bile +docho=duct +lithos=stone +iasis=condition Back Continue

N12 Endoscopy Module click here to begin
Set aside up to 75 minutes to complete this module Please click on all the links for further information To complete in 3 sections, start from page titled “Table of Contents” and complete each procedure separately. Feel free to leave feedback regarding your learning experience at the end of the module!

Sources and Links 1) Gastroenterological nursing: a core curriculum. Coordinated by the Society of Gastroenterological Nurses and Associates (SGNA), Core Curriculum Committee. (2003) SGNA, Inc. Illinois. (3rd ed.) ERCP Colonoscopy Click here to watch a colonoscopy (5 minutes) More about Ulcerative Colitis Continue

Click here to leave feedback for the author of this module.
The End This module is part of a student research study. If you have completed the Pre-test, you are part of the research study. (Thank you!) So please complete the Post-test (in Assessments). Time required is 5 minutes or less (results do not affect your grade total) Click here to leave feedback for the author of this module.

Endoscopy Learning Module N12 CSUS 2008

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