Adult Nursing Care
Adult Nursing Care 323
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This 10 page Class Notes was uploaded by Allison Notetaker on Tuesday January 12, 2016. The Class Notes belongs to 323 at University of North Dakota taught by in Fall 2016. Since its upload, it has received 30 views. For similar materials see Adult Nursing Care II in Nursing and Health Sciences at University of North Dakota.
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Date Created: 01/12/16
Running head: ENDOSCOPY CENTER 1 Endoscopy Center Allie Simon University of North Dakota ENDOSCOPY CENTER 2 For my clinical offsite experience I observed at the Altru endoscopy center. At this center they do various endoscopic procedures such as: gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy. During my observation time at the clinic I was saw two gastroscopies and four colonoscopies. Though I saw multiples of the same procedure each one was unique because of the patients having them. The Procedure Endoscopy as a whole is the visualization of the gastrointestinal tract through the use of an endoscope (Ignatavicius & Workman, 2016). An esophagogastroduodenoscopy, also known as a gastroscopy or EGD is the visual exam of the esophagus, stomach and duodenum (Ignatavicius & Workman, 2016). A colonoscopy is an endoscopic exam of the entire large intestine and is considered the gold standard in detecting colon cancer (Ignatavicius & Workman, 2016). Medications For all the procedures that I observed the medications given were the same. All were given running IV Lactated Ringers during the admitting process. Once in the procedure room with the doctor present the nurse gave the patient fentanyl and versed. They were given fentanyl for pain control/relief and versed as a sedative. One of the greatest risks associated with endoscopy is sedation, which is why the sedation must be altered for each person and their response to it (Deas & Sinsel, 2014). Initially each patient got 100 mcg of Fentanyl and 2 mg of Versed. The dosage from there depended on the patient and what the physician decided to order for them. ENDOSCOPY CENTER 3 Monitoring During the procedure the patients are hooked up to an EKG monitor to watch their heart rhythm and their vitals are taken every three minutes by the automatic vitals machine that measures heart rate, blood pressure, oxygen saturation and respiratory rate. During the procedure it is also standard that the patient receives oxygen per nasal cannula. The patients do not have any labs done before or after their procedures. Personnel During each procedure there was a registered nurse (RN), a surgical technician, a surgical resident and the gastrointestinal doctor present. State and CMS inspectors require an RN to be present in the room in addition to the RN who is administering the sedation (Deas & Sinsel, 2014). However, the American Society for Gastrointestinal Endoscopy says that “the RN should monitor the patient and he or she can simultaneously preform other tasks” (Deas & Sinsel, 2014). The procedures I observed did not meet this requirement because only one RN was in each procedure room and they provided the sedation as well as monitored the patient’s vitals and overall condition during the procedure. I think that the facility should work to have two RNs in each procedure room in order to better care for the patient in a safe manner. Infection Control One of the major challenges with endoscopy is maintaining proper cleaning between procedures to prevent transmission of bacteria and other contaminants (Ignatavicius &Workman, 2016). Endoscopic procedure rooms are now beginning to be held to the same level of sterile conditions that operating rooms are held to (Deas & Sinsel, 2014). Though the equipment and ENDOSCOPY CENTER 4 water used for the procedure were sterile the room was not sterile and neither the surgeon nor doctor wore sterile gloves, even though they both did parts of each procedure. Though maintaining a sterile procedure room would be more expensive and less efficient I feel that overall it would be worth it because of lower infection rates and other complications for the patients. Observed Procedures The first procedure I observed was a colonoscopy on a 60 year old woman. She was having the colonoscopy as a screening because it had been 10 years since she had her last one, which was in 2005. Her last colonoscopy had no abnormal findings. She had been in for her colonoscopy three days earlier, but her colon was still full so she was told to go through the bowel prep again for the procedure and have two days of clear liquids prior to the rescheduled colonoscopy. For the procedure she had an IV placed with running Lactated Ringers. Once the doctor entered the room he called for 2mcg of versed and 100mg of fentanyl. After about a minute passed he called for another 2mcg of versed, and then later another 2mcg versed. After she had been given the 6mcg of versed the doctor started with the procedure. However, the colon was still filled with stool so the doctor ended the procedure since he could not view the colon itself. The second procedure I observed was a gastroscopy on a woman who had swallowed a fish bone. She was having the gastroscopy to determine if the fish bone had caused any damage to the esophagus or if it was still in the esophagus. She was given 100mcg fentanyl and 2 mg versed to start, followed by another 4 mg versed in two equal doses before the procedure started. ENDOSCOPY CENTER 5 After laying on her left side the surgical tech put a bite block in the patient’s mouth and then the doctor started the procedure. No damage or remaining fish bone was found. Next I observed another colonoscopy, this time on a 63 year old woman. She was having the procedure as a screening because she had not had one in over 30 years, which is well beyond the recommended frequency. The patient was on both Ativan and Oxycodone at home for other conditions, which posed a problem for the procedure. Initially she was given 100mcg of fentanyl and 2mg versed, which showed to have no effect on her. The physician then ordered another 2mg versed which showed no effect; so he then ordered another 2mg versed. Once she had been given 6mg versed the doctor started with the procedure even though the patient was still pretty alert. The patient was so tolerant to the medications that she was alert and in a great deal of pain throughout the procedure. The doctor ordered another 100mcg of fentanyl for her, which still made little difference, due to her tolerance from continued opioid use. The doctor finally decided to stop the procedure because the patient was in too much pain and because he could not give her any more medication for it. The doctor’s recommendation for her was to get it done again, but to do it under anesthesia. The next procedure was on a patient having both a colonoscopy and a gastroscopy. The patient was having these procedures as screenings because he has a condition called MYH associated polyposis. He discovered he had this condition after his sister was found to have many polyps and colon cancer, and was eventually diagnosed with MYH. MYH associated polyposis is a unique recessive disorder that puts those with it at a risk for colorectal cancer development (Kwak & Chung, 2007). Since his first colonoscopy the patient has had a total of 18 polyps removed which is consistent with normal presentation of MYH, those with MYH associated ENDOSCOPY CENTER 6 polyposis typically present with 10100 adenomas polyps (Kwak & Chung, 2007). For the procedures I observed the doctor did the colonoscopy first after giving 100mcg fentanyl and a total of 6mg versed. During the colonoscopy the doctor removed a total of 12 polyps from his colon. The polyps were put into specimen jars for testing, but the doctor did not think that they looked cancerous. After the colonoscopy the patient was repositioned and given another 2 mg before starting the gastroscopy. Nothing abnormal was found during the gastroscopy. For those with MYH associated polyposis lifetime screenings by gastroscopy and colonoscopy are required every 612 months (Kwak & Chung, 2007). The patient I observed receives his screenings every 12 months. If there are too many polyps in the colon to control endoscopically, a colectomy should be considered (Kwak & Chung, 2007). The final procedure I observed was a colonoscopy on a 50 year old man. He was having the procedure as his first screening because he just turned 50. For average risk individuals screening for colorectal cancer should begin at age 50 because screening for colorectal cancer has been shown to improve survival and is recommended (ECRI, 2013). Prior to the procedure the doctor ordered 100 mcg of fentanyl and 2 mg of versed. He then ordered another 4 mg of versed in separate equal doses which were given before the procedure started. The patient was semialert and in visible discomfort about 510 minutes into the procedure, after the nurse noted this and told the doctor he ordered another 2 mg of versed. After the additional 2 mg were given the patient became bradycardic and hypotensive. His heart rate went down to 41, from his baseline, which was between 5760 and his blood pressure dropped to 69/46 from his baseline, which was 113/69. The nurse notified the doctor of these changes, to which he pulled out the scope a little and applied some suction in hopes to stop the vasovagal reaction the patient was ENDOSCOPY CENTER 7 having. The nurse also asked the tech to place a cold wet washcloth to the patient’s forehead. Once the patient’s vitals came back up the doctor ordered another 2 mg of versed for the patient. If the patient’s vitals had not come back up after the interventions provided by the doctor and nurse the doctor would have ordered for Atropine to be given to the patient to reverse the opioid’s effects. But since the vitals did come back up the doctor then continued with the procedure until he had finished visualizing the whole colon. No abnormalities were found. This patient was also recommended to have the procedure done under anesthesia next time he has it done, which will be in 10 years since no abnormals were found. Nursing Care Preprocedure For a gastroscopy teach the patient to remain NPO for 68 hours before the procedure, however usual drug therapy for current conditions can still be taken with anticoagulants, aspirin, and NSAIDs being an exception. These should be discontinued several days before the exam, unless necessary and discussed (Ignatavicius & Workman, 2016). For a colonoscopy the preparation is much more extensive. Teach the patient to maintain a clear liquid diet the day before the colonoscopy and to avoid red, orange or purple beverages. The patient should also be taught to drink plenty of sports drinks and water to replace the water and electrolytes that will be lost during the bowel prep. Teach the patient to take all of the bowel prep so that the bowel will be clear in order to visualize properly upon colonoscopy. To prevent nausea, teach the patient to drink the prep quickly. Patients must remain NPO besides water 46 hours before their procedure and should avoid anticoagulants, antiplatelet drugs and NSAIDs several days before the procedure (Ignatavicius & Workman, 2016). ENDOSCOPY CENTER 8 On the day of the procedure an IV line is placed for administration of fluids and for access of other medications during the procedure. Before the procedure begins EKG leads are placed on the patient in order to monitor the heart rhythm during the procedure. In the endoscopy suite the patient is placed in the left side lying position for both gastroscopy and colonoscopy. For a gastroscopy a bite block is placed in the patient’s mouth prior to the procedure. Intraprocedure During both gastroscopy and colonoscopy vitals must be taken every 3 minutes and continuously monitored. The vitals taken should be heart rate, pulse, blood pressure, respirations, and oxygen saturation; also it is essential to continuously monitor the patient for any pain. During the procedures I observed the nurse continuously monitored all of these vitals. Post Procedure After the procedure the patient is kept in the endoscopy suite until their vitals return to their baseline. Vitals are taken every 3 minutes until they leave the endoscopy suite. Once in the recovery area the patient’s vitals are taken very 15 minutes until they are deemed stable. The patient remains NPO after the procedure until their gag reflex returns (Ignatavicius & Workman, 2016). Once the patient releases gas either through burping or flatus, they are permitted to have fluids and will most likely be discharged shortly. Once discharged the patient will need to be driven home by someone else because they will not be able to due to the sedation. Conclusion ENDOSCOPY CENTER 9 Overall I enjoyed my offsite experience greatly. It was interesting and a great learning opportunity. It was especially educational because of all the abnormal cases that I observed. The nurse that I shadowed was also very helpful in explaining the procedures and things that went along with them to me. The rooms were not quite up to the newest standards of being sterile and they did not have separate RNs for sedation and other patient care. Despite these deviations from the recommendations I feel that the care given to the patients by the nurses was very good. The nurses were extremely attentive to the patients and advocated for them even when the doctor was not in agreement with them, it made me proud that I am going into such a caring profession. ENDOSCOPY CENTER 10 References Deas, Jr.T., & Sinsel, L. (2014). Ensuring patient safety and optimizing efficiency during gastrointestional endoscopy. Association of Perioperative Registered Nurses Journal. 99(3), 396,406. doi:10.1016/j.aorn.2013.10.022 ECRI. (2013). Cancer Screening. Retrieved from: guidelines.gov Kwak, E., & Chung, D. (2007). Hereditary colorectal cancer syndromes: an overview. Clinical Colorectal Cancer, 6(5), 340344. doi: 10.3816/CCC.2007.n.002 Ignatavicius, D., & Workman, M. (2016). Medical surgical nursing: Patient centered collaborative care (8 ed.). (pp. 10951096). St. Louis: Elsevier.
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