The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [440]
Fractured base of skull.
Metastatic adenocarcinoma.
Some head/neck tumours.
Symptoms that are functional in origin.
Legal and professional issues
Nurse endoscopists
In some centres nurse endoscopists work alongside medical endoscopists undertaking endoscopy. In 1995 the British Society of Gastroenterology supported the development of non-medical endoscopists. The nurse endoscopist must work within their own professional boundaries and complement the medical endoscopist teams (Smith and Watson 2005). It is essential that all practitioners are adequately trained in the administration of conscious sedation, aware of its side-effects and reversal agents. Clinical units must also limit the possibility of overdose, particularly with midazolam, as highlighted by the NPSA (2008).
Consent
It is essential that informed consent is obtained as previously discussed in this chapter prior to any investigation. This is important as conscious sedation may be utilized during this procedure.
Preprocedural considerations
Equipment
To conduct a gastroscopy, a flexible side- or end-viewing endoscope is required. The endoscope allows visualization of the oesophagus, stomach and proximal duodenum (Smith and Watson 2005). Access to resuscitation equipment is also essential if conscious sedation is going to be administered (BSG 2003).
Assessment and recording tools
A medical and nursing history and assessment must be taken to identify any care needs or concerns that may be significant, in particular, the patient’s current drug therapy, drug reactions or allergies, any organ dysfunctions such as cardiac and/or respiratory disease and previous or current illnesses. It is also important to be aware of any coagulopathies as samples of tissue or biopsy may need to be taken during the procedure. This can be pre-empted by reviewing blood results prior to the gastroscopy. A set of observations including temperature, pulse, blood pressure, respiration rate and oxygen saturations should also be taken to identify any preprocedural abnormalities and to provide a baseline. If the patient has diabetes, a blood glucose level should also be checked (BSG 2003, Smith and Watson 2005).
Pharmacological support
Prior to the procedure a local anaesthetic spray may be used on the back of the throat. In some cases conscious sedation may be administered. This technique involves the administration of a benzodiazepine such as midazolam in small doses prescribed by a medical practitioner. Doses must be titrated for elderly patients or those with co-morbidities such as cardiac or renal failure. Oxygen therapy should also be administered for patients at risk or those requiring sedation. Generally 2 litres per minute is adequate for most circumstances to maintain oxygen saturation levels and prevent hypoxaemia (BSG 2003).
Specific patient preparations
The patient must fast for at least 4 hours prior to the gastroscopy to ensure that the stomach is relatively empty. This increases the visual field for the endoscopist and also minimizes the risk of aspiration if the patient vomits. The nurse can also assist by getting the patient to lie on their left side on the trolley (Smith and Watson 2005). If a sedative is used it is essential that the patient is monitored with pulse oximetry and observed for any respiratory depression. Nursing staff can observe and record oxygen saturations and respiratory rate. ECG monitoring may only be required if a patient is at risk of cardiac instability during the procedure (BSG 2003).
Postprocedural considerations
Immediate care
Physiological monitoring must continue in the immediate recovery period. Supplemental oxygen and oxygen saturations may be required especially if a sedative has been used. The patient should avoid drinking or eating for an hour after the use of the throat spray to minimize the risk of aspiration. Once stable, awake and reviewed by the team, the patient may be discharged or transferred to another department.
Ongoing care
It is recommended that patients who have been sedated with an intravenous benzodiazepine