FINE NEEDLE ASPIRATION BIOPSY/CYTOLOGY – Technique, Equipment Needed, Procedure, Variation in Technique and Indications

Fine needle aspiration biopsy cytology (FNAB/FNAC) diagnosis has important applications in surgical practice.

TECHNIQUE

Anesthesia: usually anesthesia is not required, sometimes local anesthesia/general anesthesia may be required for image intensification, e.g. renal and vertebral puncture.

EQUIPMENT NEEDED

• A 20 ml syringe
• Long needle for deep aspiration (spleen, liver or kidney)
• Stronger needle (1-1.2 mm diameter) with trocar for skeletal puncture
• Fine (23 and 26 gauge) needles for small breast cyst or for the puncture of abdominal organs

PROCEDURE

• Explain the procedure to the patient
• Cleanse the skin with an antiseptic solution and drape
• Insert the needle delicately into the lesion by an oblique tract, perceiving the tissue texture on entry and the piston and keep it steady. With suction in place pass the needle gently through the lesion in three or four directions. Then release the piston gently to release the suction, and withdraw the needle
• Apply pressure over the puncture site with a cotton wool ‘ball’ for 5 minutes
• Detach the needle from the syringe and draw the air into the syringe; contents of the needle bore are blown onto dry and clean microscopic slide
• Lightly spread the tissue juice and tumor fragments with the needle point as for bone marrow
• Staining

Immediate air-drying by waving the slide. This may be improved by hot air from hair-dryer or hot light bulb. Then the smear is fixed in methanol for 5 minutes and stained with Romanovsky stain

Immediate wet fixation of smears with ethanol and staining by Papanicolaou or hematoxylin and eosin ( H and E)

When immediate diagnosis is required preoperatively, dick quick staining method is valuable

VARIATION IN TECHNIQUE

• For splenic, hepatic and abdominal puncture, the clotting factors must be normal and local anesthesia employed. Aspiration is performed swiftly, with the patient holding breath after deep inspiration
• For skeletal puncture, it is not necessary to penetrate cortex. Primary and secondary bone tumor tissues may lie periosteally. A glancing aspiration on a skeletal surface frequently gives cells

INDICATIONS

• Breast

Carcinoma breast to confirm the diagnosis

Treatment of breast cyst

Inflammatory breast lesion

Impalpable mammographic abnormality

• Lymph node: lymphadenopathy
• Salivary swellings
• Thyroid swelling (goiter)
• For liver pathology in place of the needle biopsy
• Abdominal and retroperitoneal mass
• Pancreas: to distinguish carcinoma from chronic pancratitis, FNAB/C may be done preoperative as a guided procedure using endoscopic retrograde cholangiopancratography (ERCP), ultrasound or angiography
• Soft tissue lesion, e.g. soft tissue sarcoma
• Bone tumors
• Prostatic lesion
• Testicular lesion
• Cervical cysts, e.g. thyroglossal, branchial and desmoid cyst

Advantages: easy, simple and less painful technique. The patient’s compliance is more, so easily repeated. It is more convenient for a busy surgical practice and can be performed in the outpatient clinic.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY – Purpose, Indications, Client Preparation, Procedure, Post-Procedural Care, Factor Affecting Diagnostic Results and Client Teaching

Endoscopic retrograde cholangiopancreatography (ERCP) is an imaging in which the biliary pancreatic ducts are examined endoscopically after contrast medium is injected into the duodenal papilla.

The purpose of this procedure is to identify the cause of a biliary obstruction, which could be stricture, cyst, stones, or tumor; jaundice is usually present. ERCP is performed following abdominal ultrasound, computed tomography, liver scanning and/or biliary tract X-ray studies to confirm or diagnose hepato-biliary or pancreatic disorders.

PURPOSE

• To detect biliary stones, strictures, cyst or tumor
• To identify biliary obstruction, such as stones or strictures
• To confirm a biliary or pancreatic disorders

INDICATIONS

• Biliary stones
• Biliary strictures, cyst or tumor
• Primary cholangitis
• Cirrhosis
• Pancreatic stones
• Stricture, cysts, or pseudocyst or tumor
• Chronic pancreatitis
• Pancreatic fibrosis or duodenal papilla tumors

CLIENT PREPARATION

• Obtain a client history of allergies to seafood, iodine and contrast dye. Report allergic findings
• Determine whether the anxiety level may interfere with the client’s ability to absorb information concerning the procedure
• Check that the consent form has been signed prior to premeditations
• Explain to the client that when the contrast medium is injected, there usually is a transient flushing sensation
• Be supportive of the client prior to and during the test procedure
• Explain to the client that when the contrast medium is injected, there usually is a transient flushing sensation.
• Be supportive of the client prior to and during the test procedure
• Monitor the vital signs during the test and compare them to baseline vital signs. An increase in the pulse rate could be due to atropine. Rupture within the gastrointestinal tract caused by endoscope perforation could cause shock
• Inform the client that the endoscope will not obstruct breathing
• Inform the client that atropine will make the mouth dry and the tongue feels large or swollen
• Inform the client that the test takes approximately 1 hour and that lying still on the X-ray table is important

PROCEDURE

• Food and fluids are restricted for at least 8 hours before the test
• The consent form should be signed prior to premeditation
• Obtain baseline vital signs. Have the client void
• Premedicate with mild narcotic or sedative. Atropine may be given prior to or after insertion of the endoscope. Atropine relaxes gastrointestinal motility and will cause dryness of mouth
• Local anesthetic is sprayed in back of throat (pharynx) to decrease the gag reflex prior to the insertion of the fiberoptic endoscope
• Secretion may be given intravenously to paralyze the duodenum. Contrast medium is injected after the endoscope is at the duodenal papilla and the catheter is in the pancreatic duct

POST-PROCEDURAL CARE

• Monitor vital signs. A rise in temperature might indicate (bacteremia or septicemia). Check respirations for respiratory distress resulting from anesthetic spray and/or the endoscope
• Check the skin color. Increased or decreased jaundice is an indicator of a disease process or the result of therapy
• Check the gag reflex before offering food or drink
• Check signs and symptoms of urinary retention caused by atropine

FACTOR AFFECTING DIAGNOSTIC RESULTS

Inability to cannulate biliary and/or pancreatic duct

CLIENT TEACHING

• Suggest warm saline gargle and/or lozenges to decrease throat discomfort
• Explain to the client that he or she has a sore throat for a few days after the rest. This is due to the endoscope

ESOPHAGOGASTRODUODENOSCOPY/ESOPHAGOGASTROSCOPY – Purpose, Client Problems, Client Preparation, Procedure and Post-Procedural Care

Esophagogastroscopy includes gastroscopy and esophagoscopy. If duodenoscopy is included with the endoscopic examination, the term is esophagogastroduodenoscopy. A flexible fiberoptic endoscope is used for direct visualization of the internal structures of the esophagus, stomach and duodenum. Biopsy forceps or a cytology brush can also be inserted through a channel of the endoscope. Suction can be applied for the removal of secretions and foreign bodies

This test is performed under local anesthesia or IV sedation (benzodiazepine or narcotics), in a gastroenterologist. This procedure can be done on an emergency basis for removal of foreign objects (a bone, a pin, etc) and for diagnostic purposes. The major complications that can occur from esophagogastroduodenoscopy are perforation and hemorrhage

PURPOSE

• To visualize the internal esophagus, stomach, and duodenum
• To obtain a cytological specimen
• To confirm the presence of gastrointestinal pathology

CLINICAL PROBLEMS

1. Esophageal

Description: esophagitis, hiatal hernia, esophageal stenosis, achalasia, esophageal neoplasm (benign or malignant tumors), esophageal varices, Mallory-Weiss tear

• Gastric

Description: gastritis, gastric neoplasm (benign or malignant), gastric ulcer (acute or chronic), gastric varices

• Duodenal (small intestinal)

Description: duodenitis, diverticula, duodenal ulcers, neoplasm (benign or malignant)

CLIENT PREPARATION

• Recognize that a gastroscopy for visualizing the esophageal, gastric and duodenal mucosa is actually an esophagogastroduodenoscopy. These names are frequently used interchangeably
• Explain the procedure to the client. Inform the client that instrument is flexible; the procedure will be done under local anesthesia (the throat will be sprayed) premedications will be given before the test and usually IV sedation is given with the test; dentures are jewelry should be removed; and food and fluids will be restricted for 8-12 hours before the test
• Check the client dentures, eyeglasses and jewelry is removed. Give a client a hospital gown
• Have the client void. Take vital signs
• Check the consent form has been signed before giving the client premedications. Once the sedative and the narcotic analgesic are given, the client should remain in bed with side up. Tell him or her that these medications will cause drowsiness
• Explain to the client that he or she may feel some pressure with the insertion of the endoscope and may feel some fullness in the stomach and intestine areas
• Be a good listener. Allow the client, time to ask questions and to express concerns or fear

PROCEDURE

• A consent should be signed
• The client should be on and NPO for 8-12 hours before the test. When this procedure is used during an emergency and NPO cannot be enforced, the client’s stomach is lavaged (suctioned) to prevent aspiration.
• The client may take prescribed medications at 6 am on the day of the rest. Check with laboratory or healthcare provider for any changes.
• A sedative/tranquilizer, a narcotic analgesic, and atropine may be given an hour before the test, or they can be titrated intravenously immediately prior to the procedure and during the procedure as needed
• A local anesthetic may be used
• Dentures, jewelry and clothing should be removed from the neck to the wrist
• Record baseline vital signs. The client should void before the procedure
• Specimen containers should be labeled with the client’s name, the date and the type of tissues
• Emergency drugs and equipment should be available for hypersensitivity to medications (premedication and anesthetic) and for severe laryngospasms
• The test takes approximately 1 hour or less
• The client should not drive self-home following the test because of possible after-effects of sedation

POST-PROCEDURAL CARE

• Check the gag reflexes offering food and fluids by asking the client to swallow or by touching the posterior pharynx with a cotton swab or tongue blade if the throat was sprayed with the anesthetic
• Monitor vital signs (blood pressure, pulse, respiration) as ordered
• Give the client throat lozenges or analgesics for throat discomfort. Inform the client that he or she may have flatus or burp-up gas, which is normal. This is caused by instillation of air during the procedure for visualization purposes
• Observe the client for possible complications
• Be supportive of the client and family

Complications: perforation in the gastrointestinal tract from the endoscope. Symptoms could include pain (epigastric, abdominal and back pain), dyspnea, fever, tachycardia and subcutaneous emphysema in the neck

Factors affecting diagnostic results: barium from a recent gastrointestinal images series can decrease visualization of the mucosa. This test should not be performed within 2 days after such tests. An X-ray film of the abdomen can be taken to see if barium is in the stomach or duodenum.

CHOLANGIOGRAPHY (INTRAVENOUS, PERCUTANEOUS, T-TUBE) – Description, Clinical Problem, Client Preparation and Procedure

DESCRIPTION

Intravenous (IV) cholangiography examines the biliary ducts (hepatic ducts within the liver, the common hepatic duct, the cystic duct, and the common bile duct) by radiographic and tomographic visualization. Often the gallbladder is not well-visualized.

The contrast substances, an iodine preparation such as iodipamide meglumine (cholografin) are injected intravenously. Approximately 15 minutes, X-rays are taken. IV cholangiography is a tedious and time consuming test, and reactions are more common with the IV contrast substances than with the oral agents.

Percutaneous cholangiography is indicated when biliary obstruction is suspected. The contrast substances are directly instilled into the biliary tree. The process is visualized by fluoroscopy and spot films are taken.

T-tube cholangiography is also known as postoperative cholangiography may be done 7-8 hours after a cholecystectomy to explore the common bile duct for patency of the duct and to see if any gallstones are left. During the operation, a T-shaped tube is placed in the common bile ducts to promote drainage. The contrast substances are injected into the T-tube. A stone or two could be missed during a cholecystectomy, causing occlusion of the duct.

• Normal findings: patient biliary ducts (absence of stones and strictures)

CLINICAL PROBLEM

Test

1. IV cholangiography

Indications: to detect stricture, stones, or tumor in the biliary system

• Percutaneous cholangiography

Indications: to detect obstruction of the biliary system caused from stones, cancer of pancreas

• T-tube cholangiography

Indications: to detect obstruction of the common bile duct from stones or stricture, fistula

CLIENT PREPARATION

• Explain the client the purpose and procedure for the IV cholangiography, percutaneous cholangiography or T-tube cholangiography
• Check with your institution to see if procedure differ and make modifications in your explanation to the client
• Explain the procedure step by step for the client, as requested. This can decrease high levels of anxiety
• Obtain a client history of allergies to sea food, iodine or X-ray dye. Report a history of allergies to these substances to the healthcare provider, and record in the client’s chart
• Permit the client to express his or her concerns. Answer questions, if possible
• Check that consent form has been signed by the client before giving a sedative and before the test
• Administer the pre-test orders (e.g. laxatives, sedatives, etc)
• Inform the client having IV cholangiography that the test may take several hours (up to 4 hours)
• Observe for signs and symptoms allergic reaction to contrast agents (e.g. nausea, vomiting, flushing, rash, urticaria, hypotension, slurred, thick speech and dyspnea)
• Check the infusion site for signs of phlebitis (e.g. pain, redness, and swelling). Apply warm compresses to the infusion site if symptoms are present, as ordered
• Check the vital signs as ordered following the percutaneous cholangiography

PROCEDURE

IV Cholangiography

• A consent form for IV cholangiography should be signed
• The client should be on NPO for 8 hours the test. Some radiologist encourages fat-free liquids before the test to prevent renal toxicity caused by the injected dye
• A laxative (e.g. citrate of magnesium or castor oil) maybe given the night before the test, and cleansing enema may be given in the morning. Keeping the gastrointestinal tract clear can prevent shadows in the X-ray films. Check with radiology department for the exact preparation needed
• A contrast agent, iodipamide meglumine (cholografin) is injected intravenously while the client is lying on a tilting X-ray are taken every 15-30 minutes until the common bile duct is visualized

Percutaneous Cholangiography

• A consent form for percutenous cholangiography should be signed
• The client should be on NPO for 8 hours before the test
• A laxative the night before and cleansing enema the morning of the test may be ordered
• Preoperative medications usually include sedatives/tranquilizers. An antibiotic may be ordered for 24-72 hours before the test for prophylactic purposes
• The client is placed on tiling table that rotates. The upper right quadrant of the abdomen is cleaned and draped. A local (skin) anesthetic is given
• The client should exhale and hold his or her breath while a needle is inserted with the guidance of fluoroscopy into the biliary tree. Bile is withdrawn, and the contrast substances are then injected. Spot films are taken
• A sterile dressing is applied to the punctured site

T-tube Cholangiography

• A consent form for T-tube cholangiography should signed
• The client should be on NPO for 8 hours before the test
• A cleansing enema may be ordered in the morning before the test
• The client lies on an X-ray table, and a contrast agent such as sodium diatrizoate (hypaque) is injected into the T-tube and an X-ray is taken 15 minutes later
• The T-tube may be removed after the procedure or it may be left in place

Factors affecting diagnostic results: obesity and gas or fecal material in the intestines can affect the clarity of the X-ray

Client education: instruct the client to remain in bed or 6 hours following percutaneous cholangiography

GASTRIC ANALYSIS – Basal Gastric Analysis (Tube), Stimulation Gastric Analysis (Tube), Tubeless Gastric Analysis, Normal Findings, Purpose, Clinical Problems, Client Preparation, Procedure, Tubeless Gastric Analysis and Factor Affecting Diagnostic Results

The gastric analysis test examines the acidity of the gastric secretions in the basal state (without stimulation) and the maximal secretory ability (with stimulation, i.e. with histamine phosphate, betazole hydrochloride (histalog) indicate a peptic ulcer (stomach or duodenal), and an absence of a HCl (achlorhydria) could indicate gastric atrophy (possibly caused by gastric malignancy) or pernicious anemia.

In addition, gastric contents can be collected for cytological examinations. Gastric analysis by tube (basal and stimulation) and tubeless gastric analysis (urine examination after a resin dye and stimulant are administered) are the methods used for evaluating gastric secretions.

BASAL GASTRIC ANALYSIS (TUBE)

Gastric secretions are aspirated through a nasogastric tube after a period of fasting. Specimens are obtained to evaluate the basal acidity of the gastric content first and the gastric stimulation test follows.

STIMULATION GASTRIC ANALYSIS (TUBE)

The stimulation test is usually a continuation of the basal gastric analysis. After samples of gastric secretions are obtained, a gastric stimulant (i.e. histalog or pentagastrin) is administered, and gastric contents are aspirated every 15 – 20 minutes until several samples are obtained.

TUBELESS GASTRIC ANALYSIS

This test is for screening purpose to detect the presence or absence of HCl; however, it will not indicate the amount of the free acid in the stomach. A gastric stimulant (caffeine, histalog) is given, and an hour later a resin dye (azuresin, diagnex blue) is taken orally by the client. The free HCl releases the dye from the resin base; the dye is absorbed by the gastrointestinal tract and is excreted in the urine. Absence of the dye in the urine after 2 hours is indicative of gastric achlorhydria. This test method saves the client discomfort of being intubated with nasogastric tub; however, it does lack accuracy.

NORMAL FINDINGS

• Fasting: 1.0-1.5 mEq/L/h
• Stimulation: 10-25 mEq/L/h
• Tubeless: detectable dyes in the urine

PURPOSE

• To evaluate gastric secretions
• To detect an increase or decrease of free HCl

CLINICAL PROBLEMS

Decreased Level

• Pernicious anemia
• Gastric malignancy (atrophy)
• Atrophic gastritis

Elevated Level

• Peptic ulcer (duodenal)
• Zollinger-Ellison syndrome

CLIENT PREPARATION

• Explain the purpose and procedure of the tube or tubeless gastric analysis test to the client. Check with the healthcare providers before you give your explanation to find out whether he or she will perform both basal and stimulation gastric analysis. List the steps of the test on paper for the client, if needed.
• Tell the client how the nasogastric tube is inserted (i.e. the tube is lubricated and passes through the nose or mouth) and that he or she will be asked to swallow or will be given sips of water as the tube is passed into the stomach. The end of the tube may be attached to low intermittent suction
• Notify the healthcare provider if the client is receiving the following categories of drugs; antacids, antispasmodics, anticholinergics, adrenergic blocker, cholinergics and steroids. Drugs from the above groups and a few others should be withheld for 24-48 hours before the gastric analysis. Drugs that cannot be withheld should be listed on the request slip.
• Monitor vital signs. Observe for possible side effects for use of stimulants (i.e. dizziness, flushing, tachycardia, headache and a lower systolic blood pressure)
• Label the specimens (gastric or urine) with the client’s name, the date, the time and the specimen’s number
• Be supportive of the client. Encourage the client to express his or her concerns or fear. Answer questions or refer to appropriate health professions

PROCEDURE

• The client should be on NPO for 8 hours to 12 hours prior to the test. Smoking should be restricted for hours
• Certain groups (i.e. anticholinergics, cholinergics, adrenergic blockers, antacid, and steroids) and alcohol and coffee should be restricted for atleast 24 hours before the test. It should be notes on the request slip if the drugs cannot be withheld.
• Baseline vital signs should be recorded
• Loose dentures should be removed
• A lubricated nasogastric tube is inserted through the nose or mouth
• A residual gastric specimen and four additional specimen taken 15 minutes apart should be aspirated and labeled with the client’s name, the time, and a specimen number. The nasogastric tube may be attached to low intermittent suction

Stimulation Test

A continuation of the basal gastric analysis

• A gastric stimulant is administered (i.e. betazole hydrochloride (histalog) or histamine phosphate intramuscularly; pentagastrin subcutaneously)
• Several gastric specimens are obtained over a period of 1-2 hours (histamine four 15-minute specimens in 1 hour and histalog eight 15-minute specimen in 2 hours). Specimens should be labeled with the client’s name, the date, the time, and specimen numbers.
• Vital signs should be monitored. Emergency drugs, such as epinephrine (adrenalin) should be available
• The test usually takes 2 and half hours for both parts (basal and stimulation)

TUBELESS GASTRIC ANALYSIS

• The client should be on NPO for 8-12 hours before the test
• The morning urine specimen is discarded
• Certain drugs are withheld for 48 hours before the test (i.e. antacids, quinine, iron, vitamin B complex), with the health care providers permission
• Give the client caffeine sodium benzoate 500 mg in a glass of water
• Collect a urine specimen 1 hour later. This is control urine specimen
• Give the client the resin dye agent (azuresin or diagnex blue) in a glass of water
• Collect a urine specimen 2 hours later. The urine may be colored blue or blue green for several days. Absence of color in the urine usually shows absence of HCl in the stomach

FACTORS AFFECTING DIAGNOSTIC RESULTS

• Incorrect labeling of specimens could affect test results
• Drugs: antacids, anticholinergics, and histamine blockers (cimetidine, ranitidine) could decrease HCl levels; antacids, electrolyte and iron preparations, vitamin B complex, and quinidine could fastly elevate the diagnex blue level
• Stress, smoking and sensory stimulation could increase HCl secretions

SIGMOIDOSCOPY – Definition, Purpose, Principle, General Instruction, Preliminary Assessment, Preparation of the Article, Preparation of the Patient, Procedure and After Care

DEFINITION

Sigmoidoscopy is defined as an examination of the distal sigmoid colon, rectum and anal canal

PURPOSE

• To diagnose malignant and benign neoplasm
• To detect hemorrhoids, polyps, fissures and fistula
• To detect abscesses within the anal canal and rectum
• Before the rectal surgery
• To evaluate rectal bleeding, acute or chronic diarrhea

PRINCIPLE

• Microorganism are found everywhere the nurse takes care to prevent the transference of microorganism
• A thorough knowledge about the anatomy and physiology of the GI tract
• Mental and physical preparation of the patient facilitates introduction of the tube
• Systematic ways of functioning may save time, energy, and material
• Any unfamiliar situation produces fear and anxiety

GENERAL INSTRUCTION

• Explain the procedure to the client and win his confidence and cooperation
• The client assumes a knee-chest position
• The client is instructed to eat a light evening meal prior to the examination
• The nurse should remain with client. Watch his general condition and monitor the vital signs and skin color
• Both doctor and nurse should follow strict aseptic technique
• Lubricate the instrument before introducing into the rectum
• Do not expose the patient unnecessarily

PRELIMINARY ASSESSMENT

• Identify the patient name, age, ward, bed number, sex and diagnosis
• Check doctors order for specific precautions
• Check the general condition of the patient
• Check for any lesions on the rectal area
• Check the consciousness and ability to follow instruction
• Assess the need for extra help
• Articles available in the unit

PREPARATION OF THE ARTICLE

• Sigmoidoscope
• Draping sheet
• Gloves
• Lubricant
• Cotton swabs
• Emesis basin
• Toilet tissue
• Biopsy forceps
• Suction machine
• Paper bag

PREPARATION OF THE PATIENT

• Explain the procedure to the client
• Provide privacy with curtains and adequate draping
• Cover the patient with sheet or bath blanket
• Remove the back rest and extra-pillows
• Place the mackintosh and towel under the patient
• Place the patient in a knee-chest position
• Keep all the article arranged on the bedside locker and check the article for good working condition
• Remove the bottom garments or raise it up above the waist level
• Fold back a small portion of the sheet or bath blanked to expose only the anal region

PROCEDURE

The client assumes a knee chest position and encourages him to relax, as much as possible and to take deep breathing. The physician usually first examines the rectum with gloved fingers. After that the sigmoidoscope is inserted into the anus to visualize the distal sigmoid colon and rectum. A flexible sigmoidoscope is also make it possible to visualize the descending colon and rectum. The examines may obtain specimen from suspicious looking access of anus

AFTER CARE

• The client is observed for signs of peforation, such as bleeding, liver, etc
• Label and send the specimen to the laboratory
• Allow the patient to take rest
• Replace all the articles
• Recording and reporting (time, data, patient responses to the procedure complication if any)

LIVER BIOPSY – Definition, Purpose, Indication, Contraindication, General Instruction, Preliminary Assessment, Preparation of Patient and Environment, Articles Needed, Procedure, After Care and Complication

DEFINITION

It is the removal of a bit of liver tissue particularly for histological examination.

PURPOSE

• Diagnostic pour pose
• Morphologic studies
• Biochemical studies
• Bacteriologic studies
• Immunologic studies
• To get information regarding progression of disease
• Response to therapy

INDICATION

• Cirrhosis of liver
• Hepatic malignancies
• Granulomas
• Reticuloendothelial disease, e.g. leukemia

CONTRAINDICATION

• Bleeding disorders e.g. thrombocytopenia
• Infection in liver, peritoneum, biliary
• Severe form of hepatocellular jaundice
• Gross ascites
• Suspected hemangioma of liver

Site: needle is inserted at eighth and ninth intercostal space

Position:

• Position the patient on the right side near to the edge of bed
• After procedure, position patient supine

GENERAL INSTRUCTION

• Aseptic technique to be followed
• Investigate clotting time, bleeding time and prothrombin time
• Explain the need of procedure in a simple way
• Watch for complications during and after the procedure
• Keep two units of blood available for emergency care
• After procedure, patient should take 24 hour strict bed rest

PRELIMINARY ASSESSMENT

• Check the doctors order for specific instructions
• Check age, sex, name and diagnosis of patient
• Check investigation report from laboratory
• Check patient’s ability to obey orders
• Check patient’s self-care ability
• Check if all articles are available in the unit

PREPARATION OF PATIENT AND ENVIRONMENT

• Explain the procedure to minimize fear and anxiety
• Provide privacy
• Position the patient
• Teach the patient breathing exclusive
• Vitamin K is injected to prevent hemorrhage
• Informed consent is obtained from the patient
• Shave the area and clean it with antiseptic agent
• Arrange articles at bedside
• Monitor vitals before, during and after the procedure
• Maintain NPO, hours before procedure

ARTICLES NEEDED

An unsterile tray:

• Solutions – surgical spirit, Tr. Benzoin, iodine
• Mackintosh with towel
• K-basin
• Paper bag
• Xylocaine 2%

Sterile Tray Containing the Following

• Formalin 10% solution in a container
• Sponge holding forceps
• Dissecting forceps
• Small 2 bowls to receive solutions
• Keep patient NPO for 4 hours
• Wash hands thoroughly
• Recording and reporting
• Documentation

COMPLICATION

• Pain due to irritation of liver cells
• Hemorrhage
• Damage to neighboring organs
• Peritonitis
• Infection to the needle site
• Shock
• Pneumothorax

INSERTION OF SENGSTAKEN-BLAKEMORE (SB) TUBE BALLOON TAMPONADE – Definition, Purpose, Equipment, Procedure and Post-Procedural Care

DEFINITION

Exerting pressure directly on bleeding sites in esophagus and stomach by using SB tube

PURPOSE

To arrest acute bleeding from esophageal varices and stomach

EQUIPMENT

• Sengstaken-Blakemore tube
• Curved artery forceps to be protected with rubber tubing, lubricant adhesive, tincture, benzoin, syringes, gloves, Vaseline gauze

PROCEDURE

• Explain procedure to patient and relatives
• Place the patient in supine position
• Pass SB tube through nose into stomach with balloons deflated
• After tube reaches stomach inflate gastric balloon with 100-300 ml of air and clamp lumen
• Pull out tube gently till balloon is held tightly against cardioesophageal junction
• Secure tube to face with adhesive after placing gauze around nostril
• Check for further hematemesis
• Inflate esophageal balloon (20-45 ml of air) and clamp
• Aspirate all blood from stomach, since blood products breakdown into ammonia which may precipitate hepatic coma
• Document time, procedure and amount of blood aspirated

POST-PROCEDURAL CARE

• Be aware of pressure exerted by inflated balloons
• Monitor vital signs every 15 minutes
• Reassure patient and relative
• As soon as bleeding has been controlled, transfuse whole blood to prevent hypovolemic shock
• Provide frequent mouth care
• Clean nostrils and lubricate
• Encourage passive exercises
• Administer antibiotics
• If gastric balloon ruptures, esophageal balloon is deflated at once and entire tube is removed
• Look for complications like rupture, erosion of esophagus, occlusion of airway by balloon and aspiration of secretions
• Document level of consciousness, time, whether gastric/esophageal balloon is inflated, amount of gastric aspiration and irrigation and vital signs

COLONOSCOPY – Definition, Purpose, Indication, Principle, General Instruction, Preliminary Assessment, Preparation of the Article, Preparation of the Patient, Procedure, After Care and Complication

DEFINITION

It is a diagnostic procedure which provides visualization of the lining of the large intestine with the help of flexible endoscope.

PURPOSE

Diagnostic Purposes

• To detect colon cancer or polyps
• To detect inflammation and disease of bowel

Therapeutic Purposes

• To remove the polyps
• Detection and prevention of colorectal cancer
• To treat bleeding or stricture

INDICATION

• Unexplained constipation/diarrhea
• Rectal bleeding, lower abdominal pain

PRINCIPLE

• A thorough knowledge about the anatomy and physiology of the GI tract
• Mental and physical preparation of the patient facilitates introduction of the tube
• Systematic way of functioning saves, time, energy and material
• Any unfamiliar situation procedure fear and anxiety

GENERAL INSTRUCTION

• Explain the procedure to the client to win his confidence and cooperation
• Limit the intake of fluids for 24 to 72 hours before the examination
• Fleet saline enema should be given until the return is clear
• Lavage solutions are used for effective cleansing of bowel
• Instruct the patient not to take routine medication when lavage solution is ingested
• Advise the diabetic patient to consult his/her physician about medication adjustment
• Instructing all the patients especially elderly to maintain adequate fluid, electrolyte and caloric intake
• NSAIDs must be discontinued before the test and for 2 weeks after the procedure
• The patients having cardiovascular disease require careful cardiac monitoring during the procedure
• Colonscopy cannot be performed if there is a suspected colon perforation, acute severe diverticulitis
• The patients taking heparin must consult physician for specific instruction

PRELIMINARY ASSESSMENT

• Identify the patient name, age, sex, diagnosis, ward and bed numbers
• Check the doctor’s order for specific precaution
• Check the general condition of the patient
• Check for any lesion on the rectal area
• Check the consciousness and ability to follow the instructions
• Check the articles available in the unit
• Check the purpose of the procedure
• Check the medical order for the collection of specimen

PREPARATION OF THE ARTICLE

• Colonoscope
• Draping sheet
• Lubricant
• Cotton swabs
• Gloves
• Emesis basin
• Toilet tissue paper
• Kidney tray and paper bag
• Biopsy forceps

PREPARATION OF THE PATIENT

• Explain the procedure to the patient
• Provide privacy with curtains
• Cover the patient with sheet or bath blanket
• The patient receivers NPO after midnight before the test
• Place the patient in a left lateral position
• Keep the entire article on the bedside and check the articles for good working condition
• Remove the bottom garments or raise it up above the waist level
• Get the written consent from the client

PROCEDURE

• The patient assumes left lateral position. Ask him to relax as much as possible. The client is usually given (IV) sedation with valium, Demerol. The lubricated colonoscope is inserted into the anus. A small amount of it is instilled to help the physician visualize the bowel lumen. When the colonoscope reaches the sigmoid junction, the client may move to the supine position making it easier to advance the colonoscope pass the splenic flexure. During the test, encourage the client to relax. Monitor the vital signs throughout the procedure watching for a vasovagal response reaching to hypotension and bradycardia

AFTER CARE

• Place the patient in a comfortable position
• Monitor the vital signs
• Assess for the signs of perforation
• Administer the IV fluids  with sedation
• Client may develop nausea which may dictated with IV antiemetic
• Recording and reporting (time, date, patient response, complication, if any)

COMPLICATION

• Bleeding
• Intestinal perforation

BARIUM MEAL – Purpose, Principles, General Instruction, Types, Preliminary Assessment, Preparation of the Articles, Preparation of the Patient, Procedure, After Care and Complication

The examination of upper GI tract under fluoroscopy after the client drinks BaSO₄

PURPOSE

• To detect or exclude any anatomic or functional changes of upper gastrointestinal sphincter
• To diagnose ulcer, varices, tumors, regional enteritis
• Malabsorption syndrome

PRINCIPLE

• Microorganisms are found everywhere. The nurse takes care to prevent the transfer of microorganism
• Any unfamiliar situation produces fear and anxiety
• Good body mechanics maintains the body alignment and prevents fatigue
• Systematic ways of functioning saves time, energy and material

GENERAL INSTRUCTION

• The client should be prepared both physically and psychologically for the procedure
• Instruct the patient not to take anything orally 8 hours prior to rest
• Ensure the patient to take low residual diet for two days
• Instruct patient not to smoke prior to test
• The nurse should remain with the client and watch his general condition
• Both doctor and nurse should follow strict aseptic technique
• X-ray should be taken in every fixed interval
• The nurse should assess the client allergy to BaSO₄ prior to procedure
• Give prescribed laxative in previous night

TYPES

• Double-contrast studies
• Enteroclysis

PRELIMINARY ASSESSMENT

• Check the diagnosis
• Check the abilities and limitations
• Check the consciousness and ability to follow dissection
• Any extra help needed
• Articles available in the patient unit

PREPARATION OF THE ARTICLES

A tray containing:

Mackintosh and towel

BaSO₄ suspension in a bottle

Ounce glass

Paper bag and kidney tray

X-ray machine

PREPARATION OF THE PATIENT

• Explain the procedure to the patient to win his confidence
• Transfer the patient to the X-ray department
• Change client’s garments with hospital dress
• Maintain the privacy of the client with screen and drapes
• Maintain the desired position
• Arrange all the articles near bedside

PROCEDURE

• Films are taken at first
• Patient is given BaSO₄ suspension to drink
• 1^st X-ray will be taken
• Series of X-rays are taken at prescribed timings

AFTER CARE

• Transfer the patient to ward
• Place the patient comfortably
• A laxative may be prescribed
• Instruct the client to take more oral fluids it help to pass the barium
• Monitor the stools for the passage of barium
• Stools will be appearing chalky while barium can cause  bowel obstruction

COMPLICATION

• Obstruction in the intestine or
• Impaction in the rectum