ESOPHAGOGASTRODUODENOSCOPY (EGD)
▪ Temporary loss of the gag reflex is expected; after the
patient’s gag reflex has returned, lozenges, saline gargle,
▪ It is also called EGD or Upper Endoscopy. and oral analgesic agents may be offered to relieve minor
throat discomfort.
▪ It is a procedure that allows the doctor to examine the
inside of the esophagus, stomach and duodenum. ▪ Patients who were sedated for the procedure must remain in
bed until fully alert.
▪ A thin flexible, lighted tube, called an endoscope, is guided
into the mouth and throat, then into the esophagus, stomach ▪ After moderate sedation, the patient must be transported
and duodenum. The endoscope allows the doctor to view home with a family member or friend if the procedure was
the inside this area of the body, as well as to insert performed on an outpatient basis. Someone should stay
instruments through a scope for the removal of sample with the patient until the morning after the procedure.
tissue for biopsy (if necessary). Because of sedation, many patients will not remember post
procedure instructions. For this reason, discharge and
follow-up instructions are provided to the person
accompanying the patient home, as well as to the patient.
▪ Many endoscopy suites have a program in which a nurse
telephones the patient the morning after the procedure to
find out if the patient has any concerns or questions related
to the procedure.
Preparing for the procedure: COLONOSCOPY
7 days before: ▪ It is an exam used to look for changes such as swollen
▪ Advise patient to stop taking iron, aspirin or irritated tissues, polyps or cancer in the large intestine
anti-coagulants. (colon) and rectum.
5 days before: ▪ During a colonoscopy, a long, flexible tube called
▪ Advise to stop taking non-steroidal anti-inflammatories colonoscope, is inserted into the rectum. A tiny video
(e.g. Advil, Celebrex) camera at the tip of the tube allows the doctor to view the
inside of the entire colon.
1 day before
▪ Advise patient not to eat any solid food after midnight, the ▪ If necessary, polyps or other types of abnormal tissue can
night before the procedure. be removed through the scope during a colonoscopy. Tissue
samples (biopsies) can be taken also.
Day of the procedure:
▪ Nothing to eat or drink at least 8 hours before the
procedure.
▪ Medication can be taken 4 hours before examination with
little sips of water. Do not take any antacids or Carafate
before the procedure
Nursing Intervention Purpose:
- Investigate intestinal signs and symptoms
▪ Before the introduction of the endoscope, the patient is
- Screen for colon cancer
given a local anesthetic gargle or spray. Midazolam - Look for more polyps
(Versed), a sedative that provides moderate sedation with - Treatment purposes such as placing a stent or removing an
loss of the gag reflex and relieves anxiety during the object in your colon
procedure, is administered.
Nursing Interventions:
▪ Atropine may be administered to reduce secretions.
▪ Adequate colon cleansing provides optimal visualization
▪ Glucagon may be administered to relax smooth muscle. and decreases the time needed for the procedure.
▪ Cleansing of the colon can be accomplished in various
▪ The patient is positioned in the left lateral position to
ways. The physician may prescribe a laxative for two
facilitate clearance of pulmonary secretions and provide nights before the examination and a Fleet’s or saline enema
smooth entry of the scope. until the return is clear the morning of the test.
▪ The patient maintains a clear liquid diet starting at noon the
day before the procedure. Then the patient ingests the
lavage solution orally at intervals over 3 to 4 hours. If
▪ After gastroscopy, assessment includes: necessary, the nurse can give the solution through a feeding
tube if the patient cannot swallow. Patients with a
o level of consciousness colostomy can receive this same bowel preparation.
o vital signs, oxygen saturation
o pain level
o monitoring for signs of perforation (pain, ▪ A sodium phosphate tablet (OsmoPrep, Visicol) can be
bleeding, unusual difficulty of swallowing and used for colon cleansing prior to colonoscopy. Dosing
rapidly elevated temperature. consists of 32 tablets: 20 tablets (4 tablets every 15
minutes) with 8 ounces of any clear liquid (water, any clear
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NCM [Link] JGBJ2023
carbonated beverage, or juice) on the evening prior to the Normal 500-1000ml Distends 15 mins. Fluid and
examination, and 12 tablets (taken in the same manner) on Saline intestine, Electrolyte
the morning of the examination. (Isotonic) increases Imbalance,
peristalsis Sodium
, soften retention
▪ With the use of lavage solutions, bowel cleansing is fast
stool
(rectal effluent is clear in about 4 hours) and is tolerated Soap Suds 500-1000ml Distends 10-15 Rectal
fairly well by most patients. (concentrate intestine, mins. mucosa
at irritates irritation or
▪ Side effects of the electrolyte solutions include nausea, 3-5ml/1,000 intestinal damage
ml) mucosa,
bloating, cramps or abdominal fullness, fluid and softens
electrolyte imbalance, and hypothermia (patients are often stool
told to drink the preparation as cold as possible to make it
Oil 150-200ml Lubricate 30mins. Sodium
more palatable).
(mineral, s stool retention
olive or and
▪ The side effects are especially problematic for older adults, cottonseed intestinal
and sometimes they have difficulty ingesting the required oil) mucosa
volume of solution.
Assessment:
▪ Monitoring older patients after a bowel preparation is
▪ Ask the patient when he or she had the last bowel
especially important because their physiologic ability to
movement.
compensate for fluid loss is diminished.
▪ Assess the patient’s abdomen, including auscultating of
▪ Many older adults take multiple medications each day; bowel sounds, and palpating for tenderness and/or
firmness.
therefore, the nurse’s knowledge of their daily medication
regimen can prompt assessment for and prevention of ▪ Assess the rectal area for any fissures, hemorrhoids, sores
potential problems and early detection of physiologic or rectal tears. If any of these are present, take added care
changes. while inserting the tube.
▪ Assess the result of the patient’s laboratory work,
▪ Additionally, the nurse advises the patient with diabetes to specifically the platelet count and white blood cell (WBC)
consult with his or her primary provider about medication count.
adjustment to prevent hyperglycemia or hypoglycemia
resulting from the dietary modifications required in ▪ Assess for dizziness, lightheadedness, diaphoresis, and
preparing for the test. clammy skin.
Equipment:
▪ The nurse also instructs all patients, especially older adults,
to maintain adequate fluid, electrolyte, and caloric intake ▪ Enema solution as ordered
while undergoing bowel cleansing.
▪ Disposable enema set, which includes a solution container
▪ Special precautions must be taken for some patients. and tubing
Implantable defibrillators and pacemakers are at high risk ▪ Water-soluble lubricant
for malfunction if electrosurgical procedures (i.e.,
polypectomy) are performed in conjunction with ▪ IV pole
colonoscopy.
▪ Waterproof pad
▪ A cardiologist should be consulted before the test is
▪ Bath Blanket
performed, and the defibrillator should be turned off. These
patients require careful cardiac monitoring during the ▪ Bedpan and toilet tissue
procedure.
▪ Disposable Gloves
ENEMA
● Enema Administration is a technique used to stimulate ▪ Paper towel
stool evacuation.
● It is a liquid treatment most commonly used to relieve ▪ Washcloth, skin cleanser and towel
severe constipation.
● The process helps push waste out of the rectum when the Nursing Diagnosis:
patient cannot do on their own.
● Other types of enemas are administered to clean out the Determine the related factors for the nursing diagnoses based on the
colon and better detect colon cancer and polyps. patient’s current status. Appropriate nursing diagnoses may include:
ADMINISTERING A LARGE-VOLUME CLEANSING ▪ Acute Pain
ENEMA
▪ Constipation
Commonly Used Enema Solutions
▪ Risk for Constipation
Time to
Adverse Outcome Identification and Planning
Solution Amount Action Take
Effects The expected outcome to be met when administering a cleansing
Effect
Tap Water 500-1000ml Distends 15 mins. Fluid and enema is that:
(hypotonic intestine, Electrolyte ▪ the patient expels feces.
) increases Imbalance,
peristalsis Water ▪ The patient verbalizes decreased discomfort; abdominal
, soften Intoxication distention is absent
stool
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NCM [Link] JGBJ2023
▪ The patient remains free of any evidence of trauma to the
rectal mucosa or other adverse effects. 14. If resistance is met while inserting the tube, permit a small
amount of solution to enter, withdraw tube slightly and then
Implementation continue to insert it. Do not force entry of tube. Ask the
patient to take several deep breaths.
Procedure:
1. Verify the order for the enema. Gather equipment. 15. Introduce solution slowly over a period of 5-10 minutes.
Hold tubing all the time that solution is being instilled.
2. Perform hand hygiene and put on PPE, if indicated. Assess for dizziness, light-headedness, nausea, diaphoresis
and clammy skin during administration. If the patient
3. Identify the patient. experiences any of these symptoms, stop the procedure
immediately, monitor the patient’s heart rate and blood
4. Explain the procedure to the patient and provide the pressure, and notify the primary care provider.
rationale to why the tube is needed. Discuss the associated
discomforts that may be experienced and possible 16. Clamp tubing or lower container if the patient has the urge
interventions that may allay this discomfort. Answer any to defecate or cramping occurs. Instruct the patient to take
questions, as needed. small, fast breaths or to pant.
5. Assemble equipment on overbed table within reach. 17. After the solution has been given, clamp tubing and remove
tube. Have paper towel ready to receive tube as it
6. Close the curtain around the bed and close the door to the withdrawn.
room, if possible. Discuss where the patient will defecate.
Have a bedpan, commode or nearby bathroom ready for 18. Return the patient to a comfortable position. Encourage the
use. patient to hold the solution until the urge to defecate is
strong, usually in about 5 to 10 minutes. Make sure the
7. Warm the enema solution in amount ordered, and check linens under the patient are dry. Remove your gloves and
temperature with a bath thermometer, if available, warm to ensure that the patient is covered.
room temperature or slightly higher and test on inner wrist.
If tap water is used, adjust temperature as it flows from the
19. Raise side rails. Lower bed height and adjust head of bed to
faucet.
a comfortable position.
20. Remove additional PPE, if used. Perform hand hygiene.
21. When patient has a strong urge to defecate, place him or
her in a sitting position on a bedpan or assist to commode
or bathroom. Offer toilet tissues, if not the patient’s reach.
Stay with the patient or have call bell readily accessible.
8. Add enema solution to container. Release clamp and allow
fluid to progress through the tube before reclamping.
22. Remind patient not to flush the commode before you
9. Adjust the bed to a comfortable working height, usually inspect results of enema.
elbow height of the nurse. Position the patient on the left
side (Sim’s position), as dictated by patient comfort and 23. Put on gloves and assist patient, if necessary, with cleaning
condition. Fold top linen back just enough to allow access anal area. Offer washcloths, skin cleanser, and water for
to the patient’s rectal area. Drape the patient with the blank handwashing. Remove gloves.
blanket, as necessary, to maintain privacy and warmth.
Place a waterproof pad under the patient’s hip. 24. Leave the patient clean and comfortable. Care for
equipment properly.
10. Put on gloves.
25. Perform hand hygiene.
11. Elevate solution so that it is no higher than 18 inches
(45cm) above level of anus. Plan to give the solutions
slowly over a period of 5-10mins. Hang the container on an
IV pole or hold it at the proper height. Evaluation
The expected outcome is met when:
12. Generously lubricate end of rectal tube 2 to 3 inches (5 to 7 ▪ The patient expels feces
cm). A disposable enema set may have pre-lubricated rectal
tube. ▪ The patient verbalizes decreased discomfort; abdominal
distention is absent
13. Lift buttock to expose anus. Ask patient to take several
deep breaths. Slowly and gently insert the enema tube 3 to ▪ The patient remains free of evidence of trauma to the rectal
4 inches (7 to 10cm) for an adult. Direct it at an angle mucosa or other adverse effect.
pointing toward the umbilicus, not the bladder.
Documentation
Document the following;
▪ the amount and type of enema solution used;
▪ amount, consistency, and color of stool;
▪ pain assessment rating; assessment of perineal area for any
irritation, tears or bleeding;
▪ the patient’s reaction to the procedure
Sample:
800 ml Warm tap water enema given via rectum. Large amount of
soft brown stool returned. No irritation, tears, or bleeding noted in
perineal area. Patient complained of “stomach cramping” relieved
when enema was released. Rates pain as 0 after evacuation of enema
ADMINISTERING RETENTION ENEMA
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Purpose: 13. Instruct the patient to retain enema solution for at least
30minutes or as indicated.
▪ Relieving constipation or fecal impaction
▪ preventing involuntary escape of fecal material during 14. Remove gloves. Return the patient to a comfortable
position. Make sure the linens under the patient are dry.
surgical procedures
Ensure that the patient is covered.
▪ Promoting visualization of the intestinal tract by
radiographic or instrument examination 15. Raise side rail. Lower bed height and adjust head of bed to
a comfortable position.
▪ Helping to establish regular bowel function during a bowel
training program 16. Remove additional PPE, if used. Perform hand hygiene.
Implementation 17. When the patient has a strong urge to dispel the solution,
Procedure: place him or her in a sitting position on a bedpan or assist
1. Verify the order for the enema. Gather equipment. to commode or bathroom. Stay with patient or have call
bell readily accessible.
2. Perform hand hygiene and put on PPE, if indicated.
18. Remind the patient not to flush the toilet or empty the
3. Identify the patient. commode before you inspect the results of the enema, if
used for bowel evacuation. Record character of stool, as
4. Explain the procedure to the patient and provide the appropriate, and patient’s reaction to enema.
rationale to why the tube is needed. Discuss the associated
discomforts that may be experienced and possible 19. Put on gloves and assist the patient, if necessary, with
interventions that may allay this discomfort. Answer any cleaning of anal area. Offer washcloths, skin cleanser, and
questions, as needed. water for handwashing. Remove gloves.
5. Assemble equipment on an overbed table within reach. 20. Leave the patient clean and comfortable. Care for
equipment properly.
6. Close the curtain around the bed and close the door to the
room, if possible. Discuss where the patient will defecate.
21. Perform hand hygiene.
Have a bedpan, commode or nearby bathroom ready for
use.
Evaluation
7. Adjust the bed to a comfortable working height, usually
elbow height of the nurse. Position the patient on the left The expected outcome is met when:
side (Sim’s position), as dictated by patient comfort and
condition. Fold top linen back just enough to allow access ▪ The patient expels feces without evidence of trauma to the
to the patient’s rectal area. Drape the patient with the blank rectal mucosa
blanket, as necessary, to maintain privacy and warmth.
▪ The patient verbalizes decreased discomfort;
Place a waterproof pad under the patient’s hip.
▪ The patient demonstrates signs and symptoms indicative of
8. Put on gloves.
a resolving infection.
9. Remove the cap of prepackaged enema solution. Apply a
Documentation
generously amount of lubricant to the tube.
Document the following;
10. Lift the buttock to expose anus. Ask the patient to take ▪ the amount and type of enema solution used;
several deep breaths. Slowly and gently insert the rectal
tube 3 to 4 inches (7 to 10cm) for an adult pointing toward ▪ length of time retained by the patient;
the umbilicus, not bladder. Do not force entry of the tube.
▪ amount, consistency, and color of stool;
▪ pain assessment rating; assessment of perineal area for any
irritation, tears or bleeding;
▪ the patient’s reaction to the procedure
Sample Documentation:
100-mL Fleet enema given via rectum. Large amount of soft, brown
stool returned. No irritation, tears, or bleeding noted in perineal area.
Patient states “stomach fullness” relieved when enema was released.
Reports pain as 2/10 rating scale after enema evacuated.
11. Compress the container with your hands. Roll the end up
on itself, toward the rectal tip. Administer all the solution in
the container. Assess for dizziness, light-headedness, Enema Nursing Procedure
nausea, diaphoresis, and clammy skin during [Link]
administration. If the patient experiences any of these
symptoms, stop the procedure immediately, monitor the
patient’s heart rate and blood pressure, and notify the
primary care provider.
12. Remove the container while keeping it compressed, Have
paper towel ready to receive tube as it withdrawn.
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