Topic 2: Preparation and care client for diagnostic procedure

1. Topic 2: Preparation and care client for diagnostic procedure Prepared by: Noor Mariana Sharif, RN Victoria international college

2. Learning objective At the end of the course, the student be able to: • Identify the appropriate diagnostic procedure to determining the status of GIT • Describe the indication each diagnostic procedure determining the status of GIT • Explain health information and procedure teaching to patients and significant others. • Describe preparation needed before, during and after procedure • Identify abnormal finding that may indicate impaired in GIT function. • Explain instruction about post procedure care and activity restrictions.

3. Oral Gastroduodenoscopy (Esophagogastroduodenoscopy) / OGDS • Rectal Examination • Sigmoidoscopy, Colonoscopy And Biopsy • Abdominal paracentasis • Barium Meal And Barium Enema • Endoscopic Retrograde Cholangio-Pancreatography • Ultrasound • Oesophageal Ballon Tamponade • Cholecystography • Choleangiogram • Ultra sonography • Computed tomography (CT scan) • Liver Biopsy • Fractional test meal

4. EsophagogastroduodenoscopyDefinition • OGDS/ endoscopies/gastroscopy • (OGDS) is a procedure during which a small flexible endoscope is introduced through the mouth (or with smaller caliber endoscopes, through the nose) and advanced through the pharynx, esophagus, stomach, and duodenum • It considered a minimally invasive procedure.

5. Indication • Diagnostic evaluation for signs or symptoms suggestive of upper GI disease (eg, dyspepsia, dysphagia, noncardiac chest pain, recurrent emesis) • Investigation for upper GI cancer in high-risk settings (eg, Barrett esophagus)

6. Indication • Biopsy for known or suggested upper GI disease (eg, malabsorption syndromes, neoplasms, infections) • Therapeutic intervention (eg, retrieval of foreign bodies, control of hemorrhage, dilatation or stenting of stricture, ablation(removal) of neoplasms, gastrostomy placement)

7. Contraindication • Possible perforation, medically unstable patients, or unwilling patients. • Relative contraindications include anticoagulation, pharyngeal diverticulum, or head and neck surgery.

8. Complication • Aspiration pneumonia • Bleeding • Perforation • Cardiopulmonary problem

9. Equipment • Endoscope • Stack - light source - insufflators - suction • Instruments - biopsy forceps - snares - injecting needles

12. Before procedure • Keep patient NBM (nil by mouth) • Obtain consent from the patient (risk for bleeding and perforation) • Take blood for investigation - complete blood cell count, blood cross matching, coagulation studies, BUSE, electrocardiogram, and chest radiographs. • Take vital sign for baseline

14. During procedure • Placed patient in the left lateral position. • Administer topical and/or intravenous sedation to minimize gagging and to facilitate the procedure. • Place a bite block (mouth guard) to prevent damage to the endoscope and to ease its passage through the mouth.

15. Under direct vision, the endoscope will passed through the pharynx, esophagus, stomach and duodenum. • Liquid and particulate matter can be aspirated through the suction channel. • The procedure and findings will be documented with pictures or a video system. Biopsy specimens can be obtained by passing forceps and taking small mucosal samples for histology studies. • The procedure may last @ 5-30 minutes

17. After procedure • Close monitoring of vital sign for 1 – 2 hours, or until the sedative or analgesia has worn off. • Keep patient nil by mouth until the local anesthetic has worn off (in the throat) and the gag reflex has returned (after two to four hours) • Patient may complaint of hoarseness and a mild sore throat - drink cool fluids or gargle to relieve the soreness

19. Rectal examination

20. Definition • Rectal examination consists of visual inspection of the perianal skin, digital palpation of the rectum, and assessment of neuromuscular function of the perineum.

21. Indication May be used to diagnosed: • Rectal tumors • Prostatic disorders and benign prostatic hyperplasia • Appendicitis • Piles • Anyabnormalities

22. Indication • for the estimation of the tonicity of the anal sphincter • in females, for gynecological palpations of internal organs • for examination of the hardness and color of the feces (eg. in cases of constipation, and fecal impaction); • prior to a colonoscopy or proctoscopy. • to evaluate hemorrhoids • In newborns to exclude imperforate anus

23. Before the procedure • Provide privacy (is a very embarrassing examination) • Advice patient to take a deep breath during the actual insertion of the finger into the rectum.

24. During the procedure • Put patient in left lateral position with the buttocks near the edge of the bedside. Keep the right knee and hip in slight flexion.

25. During the procedure • Put patient in well lit room, with total privacy. • A chaperon is needed if the patient is female • Using a gloved hand, the examiner inspects the buttocks for fistulous tracts, the skin tags of hemorrhoids, excoriations, blood, and rectal prolapsed. • Next, using a generous amount of lubrication, the gloved index finger is inserted gently into the rectum.

26. Sigmoidoscopy, Colonoscopy And Biopsy Definitions • Colonoscopy is the endoscopic examination of the colon and the distal part of the small bowel • Sigmoidoscopy is the medical examination of the large intestine from the rectum up to the sigmoid • A biopsy is a removal of tissue to determine the presence or extent of a disease.

27. Indication COLONOSCOPY: • Rectal bleeding • Iron deficiency anaemia • Cancer follow-up • Polyp follow-up • Abdominal pain • Abnormal bowel habit

28. SIGMOIDOSCOPY: • Symptoms that suggest anorectal pathology, including colorectal neoplasia • Prior to anorectal procedures • To obtain biopsy of any bowel condition • To assess the true height (distance from anal verge) of rectal cancers • Conservative treatment of sigmoid volvulus • During anterior resection of rectum to gauge the lower resection margin

29. Before procedure Stop • Aspirin and drugs for arthritis (ibuprofen, naproxen, etc.) A week before the procedure to prevent intestinal bleeding • Iron pills, because it may cause constipation – difficult for colon cleansing • Barium swallow or enema, because barium can cover intestinal mucosa thus hiding it from doctor’s view  • Anticoagulants – to prevent risk of bleeding • Insulin should not be taken during fasting

30. Bowel preparation • Low residue diet2-3 days pre operatively • Administration of glycol-electrolyte solution (Go-LYTELY) x 2 bottles / Foltran / fleet solution @ 1 day pre op (evening). • Clear fluids only after administration of Go-LYTELY • Bowel washout @ morning of operation day (if necessary)

31. During procedure • Lie on left lateral • Sedation will be given if necessary • Doctor will administer the colonoscope through your anus into the colon and advance it toward the end of the colon. • If necessary, doctor will perform a biopsy, stop the bleeding or remove the polyp. • Investigation lasts about 30-45 minutes

32. After procedure • Rest for 1 – 2 hours • Patient may experience some cramping or bloating (due to inflated air during the procedure) for the next day or 1-2 days • Biopsy results will be ready in a week

34. Definition • Abdominal paracentesis is a bed side clinical procedure in which needle is inserted into peritoneal cavity ndascitic fluid is removed. TYPES:- 1)diagnostic small quantity of fluid is removed for testing. 2) therapeutic:>5 litres of fluid is removed to reduce intraabdominal pressure and relieve the asso. Symptms like dyspnoea, abdominal pain

35. Indication • For evaluation of new onset ascites. • Testing of ascitic fluid. • For evaluation of pt with ascitis who has signs of clinical deterioration like fever,abd.pain,hepaticencephalopathy,decreased renal function n metabolic acidosis. • Paracentesis can identify unexpected diagnosis such as chylous, hemorrhagic or eosinophilia ascites useful to know etiology n antibiotic susceptibility.

36. Patient preparation: • Explain the procedure & Obtain Consent • No fasting before Procedure EQUIPMENT & STAFF Clinician & Assistant Bottles should be labelled for tests prior doing paracentesis Bacterial culture is done in pts

37. Choice of needle : • DIAGNOSTIC: 1.5 Inch, 22 Gauge needle For Obese :3.5 Inch, 22 Gauge spinal needle • THERAPEUTIC: 15/ 16 Gauge needle to speed up the removal. • KIMBERLY – CLARK QUICK TAP PARACENTESIS TRAY CONTAINS CADWELL NEEDLE which has a sharp inner trocar & blunt outer metal cannula with side holes to permit withdrawal of fluid if end hole is occluded by bowel/ Omentum

38. Position: • Mostly Supine • Head may be elevated • Knee elbow position for removal of minimal fluid in dependent area

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