Standards of Nursing Care for ERCP Procedures
Standards of Nursing Care for ERCP procedures
System / Within Normal Limits (WNL)Neurological / Alert, awake, and oriented to time, place, and person. Memory and speech
normal. Pupils equal and reactive to light. Eyes track objects together. Face
Symmetrical. Gag and cough reflexes present. Movement of all four limbs
Symmetrical and purposeful. Extremity sensation intact without numbness or
paresthesia.
Cardiovascular/Peripheral Vascular / Apical pulse regular, NSR, S1S2 present. Skin warm, and dry with supple
turgor. Capillary refill < 3 sec. Radial, dorsalis pedis, and posterior tibial
pulses > +2 palpable. No edema.
Respiratory / Respirations regular, quiet, and non-labored. Lungs symmetrical and equally
aerated throughout all lobes. Breath sounds clear. Sputum thin, white, or
clear; small to moderate amount. ETT/trach site clear.
Gastrointestinal / Abdomen soft and flat or rounded. Bowel sounds present. Tolerates
prescribed diet.
Genitourinary / Voids independently. Urine is clear and yellow in color.
Musculoskeletal / Full ROM in all joints. Limb strength ≥ 4+ (movement against gravity and
some resistance). Supple muscle tone in all limbs. Pain free muscles and
joints. Balance maintained when sitting up in bed, chair, or standing.
Positions self independently while in bed. Ambulatory.
Integumentary / Skin warm, dry, and intact. Mucous membranes pink, moist, and intact.
Pressure points without erythema or breakdown. Braden score ≥ 16. Central
and peripheral line sites clear.
Wound/Incision / Edges well approximated and pink. Normal temperature and non tenderness in
surrounding tissue. Granulation tissue present.
Psychosocial / Patient/family able to communicate needs. Patient’s/family’s anxiety level
commensurate with patient’s medical condition.
Education / No barriers to teaching/learning. Patient/family ready to learn.
Patient/Procedure Assessment / Nursing Interventions / Desired Patient Outcomes / Documentation
ENVIRONMENT/SAFETY &
ADMISSION
*Prior to patient admission: Evaluate
Procedure room for functioning suction withYankauer tip, airway supplies (nasal, oral andface mask), oxygen (nasal cannula & non-rebreather set-up) & Ambu bag
Ensure monitoring equipment is working properly. / *Replace missing items as needed.
*Ensure availability of various sizes of oral/nasal airways/face masks, Ambu bag
*Location of emergency phone numbers/code blue button
*Location and integrity of emergency cart/emergencymedications / Have emergency drug box available, respiratory supplies ready for emergency use. / Prompt response to emergencies / Crash cart checklist
The exam table is clean and prepared for a procedure. / Radiology staff is responsible to clean and disinfect all x-ray and exam table surfaces with Sani-wipe clothes. All patient care items are disposable after use.
Endocscopic equipment is clean and prepared for a procedure. / Endoscopy supplies, such as the endoscope are cleaned and disinfected by the Endoscopy department. / Endoscopy records
PRE-PROCEDURE NURSING ASSESSMENT OF PATIENT
Use the Nursing Assessment to evaluate patient and document, including the following:
*Patient ID/allergy bracelet/falls precautionbracelet
*Preoperative history and medications
*Procedure(s)
*Patient lines, tubes, and drains (if any)
*Intake and output (if any)
*Blood product administration (if any) / *Identify yourself and identify and greet the patient
*Use 2 patient identifiers-source document (withMRN) with ID band upon admission
*Verify procedure and site, physician, and procedure date
*Establish a calm and reassuring environment on admission to reduce anxiety
*Verify the following: NPOrequirements, transportation with responsible adult (for out-patients, the patient must have a ride home), support person’s contact information, valuables
*Obtain/validate medical history to include allergies, previous anesthetic/sedation problems
*If patient is diabetic, obtain orders for BS and management.
*Abuse screening
*Suicide risk assessment
*Assess presence of Advanced Directive
*Identify level of understanding of procedure and obstacles to learning
*Contact interpreter or interpreter services whennecessary
*Identify and document nursing problems andinterventions
Check Surgical consent; blood consent (if indicated);H & P within 30 days of procedure with a 24hour update if needed; / *Satisfactory transfer of care from inpatient nursing care provider to Radiology RN (if applicable)
Patient has understanding of the plan for the procedure and is prepared. / *Apex Nursing Assessment
*Apex
Pre-Procedure:
The team suspends all other activities and participates in the Universal Protocol checklist. /
- Verify patient identity
- Verify procedure and site
- History and physical completed within last 30 days
- Interval update of H&P if more than 24 hours old
- Consent signed, dated, witnessed
- Results of lab pathology and radiology studies are present and matched to patient
- Required blood products, implants, devices and equipment are present and functioning
- Required specimens for blood bank obtained and sent
Radiation protection: /
- Patient’s of childbearing age will be screened for pregnancy. Gonadal shielding will be placed under the table pad per policy. ALARA will be used. All staff will wear lead protection.
Contrast precautions: /
- Patient’s will be screened for the risk of allergies. Pre-medication is given for patients with known allergies.
PROCEDURE NURSING ASSESSMENT
Patient positioning: Patient is to lie in the prone position, head facing right, supported with one pillow. / Support bony prominences with cushioning. The left arm should be straight and the right arm should be bent at the elbows for comfort. Some patients may be required to have right side elevated with a wedge pillow as directed by the physician. / Proper and safe positioning, prevent pressure ulcers, prevent falls.
Monitoring:
Monitor EKG, BP, O2 saturation, capnography, respirations, level of consciousness by anesthesia care / EKG lead placement should be placed away from area of interest. Non-invasive BP cuff should be placed opposite the arm with the IV, if possible. Capnography is to be monitored via bite block. Monitor vital signs and patient response to procedure continuously. / Anesthesia record
Bite Block: A bite block with capnography should be used for capnography monitoring. / If the patient has loose teeth, inform the physician. Remove dentures and partials before placing bite block. Note: use the bite block with large orificefor anesthesia cases, to accommodate the endotrachial tube and the endoscope. Use the small pink pediatric bite block for pediatric cases. / Prevent damage to endoscope, prevent damage to patient’s teeth.
Throat Preparation: Hurricaine®: 20% spray is used for temporary numbing of the back of the throat. / The spray is used for 1-2 spays no longer than of 30 seconds each. Multiple sprays or use longer than indicated duration is not recommended to prevent the risk of Methemoglobinemia. Have Methylene blue ready as an antidote. The dose is 1-2 mg/kg or 25-50 mg/m2 over 5-10 minutes. / The patient throat is adequately numbed. / Physician will document hurricaine spray.
Grounding pad: Used on all patients for ERCPs / A grounding pad should be placed on the lower back of the patient and removed at the end of the procedure. / Electrical safety
Positioning support:
Patients are on a narrow table and may be required to be in lateral position. / Wedge cushions and Velcro straps are used around the patient to ensure that the patient is safely and properly positioned for the procedure. As directed by the proceduralist, the position may be the left lateral position. / Positioning adequate for procedure, and prevents falls.
Airway management: Observe constantly for open and clear airway. / Suction is to be ready for suctioning of oral secretions at all times. Prompt assessment and intervention by a well-trained team and appropriate use of available equipment for monitoring and airway support are essential in preventing iatrogenic complications. Be prepared to use airway adjuncts whichinclude oropharyngeal airways (oral airway) and nasopharyngeal airways (nasal trumpet) in a variety of sizes. / Patient has open and clear airway.
Antibiotic Prophylaxis
The formal ASGE guidelines and the American Heart Association guidelines regard biliary endoscopy as a nonsterile procedure. / Patients who require antibiotic prophylaxis, such as those with prosthetic heart valve, should receive antibiotics. Patients with obstructed biliary or pancreatic duct should get antibiotics. The routine use of prophylactic antibiotics may help to decrease the incidence of cholangitis.
Scan medication orders to the pharmacy.Use Pyxis medication and vial – mate system. / Prevent infection. / Given and documented by anesthesia
Charlene Fong, RN 3/18/13