Queen Elizabeth Hospital. Endoscopy Unit.

Transcription

1 Queen Elizabeth Hospital. Endoscopy Unit. Student Nurse Information.

2 Welcome to the Queen Elizabeth Hospital Endoscopy Department. We hope that your placement will not only be educational, but also enjoyable. Your Mentor. On arrival in the department, you will be introduced to your mentor who will be responsible for your professional development during your allocation. Your mentor will show you around the department and ensure you are familiar with fire and cardiac arrest procedures. It may not always be possible to work with your mentor, but working with different staff will give you the opportunity to experience a different approach to care and give you a broader view of the department. The Department. The endoscopy department sees approximately 7,500 patients per year, the majority are outpatients, but an inpatient service is also provided. The endoscope is an expensive, complex piece of equipment with channels enabling the use of instruments to take biopsies or carry out therapeutic procedures. The endoscope is connected to a processor which supplies light and an air supply. The processor is able to transmit an image onto the monitor in much the same way as a TV camera transmits images. This is why many patients call the test having the camera. An endoscopy procedure can be described as either diagnostic (when a cause for a patients symptoms may be discovered) or therapeutic (where treatment can be administered to ease the patients problem/disease). The term endoscopy literally means to look in and see. It is a generic term and can describe a variety of procedures. It is a term which is widely used, therefore may cause some confusion. For that reason, it is preferable to use specific terminology, ie: Gastroscopy, Colonoscopy and Flexible Sigmoidoscopy, to accurately describe the area to be looked at. Organisation of the Unit. The endoscopy department is open from 8am until 8.45pm and is staffed with both full and part-time staff. Variable start and finish times are worked in the department. Please discuss this with your mentor. On your first morning, come at 8.30am. You can bring your uniform and bags to the department where we have changing facilities. Your mentor will show you where to keep your belongings. The department consists of three procedure rooms (rooms 1, 2 and 3) and there are 10 sessions in each room each week. You and your mentor will be allocated an area to work in for each session of duty.

3 Procedures Carried Out Within the Unit. GASTROSCOPY. Examination of the oesophagus, stomach and duodenum. COLONOSCOPY. Examination of the large bowel (colon). FLEXIBLE SIGMOIDOSCOPY. Examination of the sigmoid colon. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP). Examination of the biliary tree and pancreas under x-ray screening. BRONCHOSCOPY. Examination of the bronchial tubes and lungs. Patients are both day cases and inpatients and consist of elective procedures and emergencies. CYSTOSCOPY. Examination of the urethra and bladder. TRANS RECTAL ULTRS-SOUND SCAN (TRUSS). Ultrasound of prostate gland. PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG). PEG tubes are feeding tubes which are placed endoscopically to provide a feeding system with direct access to the stomach through the stomach wall and skin. Patients with swallowing difficulties, or those whose nutritional state needs to be supplemented, may require this procedure, either for short or long-term periods (see protocol for pre-procedure care for patients undergoing PEG insertion). Endoscopy Staff. The department consists of: Service Manager - Assessment, Diagnostics and Screening Assistant Service Manager - Assessment, Diagnostics and Screening Modern Matron - Assessment, Diagnostics and Screening Endoscopy Ward Manager Endoscopy Sisters Staff Nurses Pre-Assessment Nurses Health Care Assistant Admin & Clerical

4 Specialist Nurses Available For Expert Advice. Nurse Endoscopist Respiratory Nurse Urology Nurse Practitioner Colorectal Nurse Infection Control Nurse Nutrition Nurse Current Issues With in the Unit. The department has been a 1st wave pilot site, working with the governments Modernisation Agency. We have re-designed our service to improve booking systems and the quality of patient care. Patients are now pre-assessed prior to their endoscopic procedure to ensure patients are better prepared for their procedure and to ensure efficient discharge planning. The recent development of the National Bowel Screening programme has provided the department with the ability to update and develop all endoscopy practices in line with JAG (Joint Advisory Group) The department has been JAG accredited and is now a bowel screening site along with Sunderland and South Tyneside. Conclusion. The staff in endoscopy will be more than willing to help, so take advantage of these opportunities and use this handout as a checklist to gain the most from your placement in the department.

5 COMMONLY USED DRUGS IN ENDOSCOPY. Benzodiazepines. These possess useful properties and allow unpleasant procedures to be better tolerated. These include reducing anxiety, causing amnesia and drowsiness, they do not induce sleep. They have no analgesic effect, so opioids can be given in conjunction with them for pain relief. The main side effect is respiratory depression. Drugs include: Midazolam. The drug of choice in the majority of our procedures (gastroscopy, colonoscopy, PEG and ERCPs). The sedative effect for up to 24 hours. Midazolam has a faster recovery time than other benzodiazepines. It is given intra-venously (I.V.). Draw up 2 mgs per patient in a labelled syringe. Concentration is 1mg/1ml. The reversal drug is Flumazenil (Anexate). Opioids. These are used to relieve moderate to severe pain. The main side effects include nausea, vomiting, constipation, drowsiness, hypotension and respiratory depression. Drugs include: Pethidine. Given during colonoscopy and ERCP. It produces prompt short-lasting analgesia. It is given intra-venously (I.V.). Draw up 50mgs per patient in a labelled syringe. Concentration is 50mg/1ml. Reversal drug is Naloxone (Narcan). Reversal Drugs. Used as antagonists. Both Naloxone and Flumazenil have shorter half-life than the drugs they reverse and the patient is at risk of becoming re-sedated. Flumazenil (Anexate). Used to reverse benzodiazepines. It is short-acting and may need to be repeated. It is given intra-venously (I.V.). Draw up 500mcgs when required in a labelled syringe. Concentration is 500mcgs in 5ml. Naloxone (Narcan). Used to reverse opioid drugs. It is short-acting and may need to be repeated. It is given intra-venously (I.V.). Draw up 400mcgs when required in a labelled syringe. Concentration is 400mcg in 1ml. Antispasmodics. Used to relax the gut during therapeutic procedures and colonoscopy, by reducing peristalsis and spasms: Hyoscine Butylbromide (Buscopan). Side effects include bradycardia and tachycardia, therefore it should not be used for patients who have recently had a myocardial infarction (MI) or cardiac rhythm disturbances. It is given intra-venously (I.V.). Draw up 20mgs or 40mgs (depending on the dose required) in a labelled syringe. Concentration is 20mg in 1ml.

6 Glucagon. Inhibits gut mobility. It tends to be used when buscopan is contra-indicated. Caution must be used if given to diabetic patients, as it is a hyperglycaemic agent. It comes in a ready prepared hypo kit. The pack contains a syringe containing water and a vial of powder to be reconstituted. Inject the water into the vial then draw it up into a normal syringe so that the needle can be removed in order to give it intra-venously (I.V.). Concentration is 1mg in 1ml. Local Anaesthetics. Lidocaine Throat Spray (Xylocaine). Used for gastroscopy patients who do not want to be sedated. It works by numbing the mouth and throat. The loss of sensation may make swallowing difficult. Reassurance is given to patients that swallowing and breathing remain the same. This effect can last for up to 1½ hours and the patient is kept nil by mouth (NBM) for 1½ hours after their procedure.

7 PROCESSING BRUSHINGS FOR CYTOLOGY AND CANDIDA. Cytology. 1 X2 microscope slides. On rough area, details of patients name, hospital number and date of birth, written in pencil. 2 Brush the middle of each slide. 3 Fix by placing in slide container filled with fixing agent immediately. 4 Using wire-cutters, remove the brush and place the end of the brush in a small bottle which is pre-filled with alcohol and saline, labelled with patient s details. 5 Complete cytology form. Candida. 1 Repeat 1 and 2 as above. 2 DO NOT USE FIXING AGENT. 3 Place slides in labelled slide container. 4 Using wire-cutters, remove the brush and place the end in a universal container containing Normal Saline. 5 Complete microbiology form. MULTIPLE GASTROINTESTINAL BIOPSIES. At gastroscopy, place the biopsies in sequence, starting at the pointed end and as close as possible to the bottom edge of the filter paper strip (as below): Once the endoscopy has finished and all the biopsies have been taken (no more than eight should be put on a strip), place strip in a universal container with sufficient formalin. All the biopsies taken from a single patient should be kept in the same container. Attach the patients label to the container and the request form and send them both to the laboratory for processing. This procedure should not be used for large mucosal polyps which should be sent to the laboratory in a separate universal container with formalin. CLO Test for Helicobacter. They are put onto a specially prepared slide, the results can be read in approximately 1 hour. The slide is labelled and a request form is completed it is then sent to pathology where they will read and record the result. The result is then sent to the referring doctor and the patients G.P.

8 DIAGNOSTIC, SURGICAL AND THERAPEUTIC ENDOSCOPES RECOMMENDED IMMERSION TIMES. ENDOSCOPE DISINFECTION MEDIUM BEFORE LIST BETWEEN CASES END OF LIST ENT Scopes Gigasept PA 10 mins 10 mins 10 mins Bronchoscopes/Laryngoscopes Gigasept PA 15 mins 15 mins 15 mins TB patients require 15 mins post procedure Cystoscopes Gigasept PA 10 mins 10 mins 10 mins Gastroscopes/Colonoscopes/ Flexible Sigmoidoscopes Gigasept PA 10 mins 10 mins 10 mins Duodenoscopes Gigasept PA 10 mins 10 mins 10 mins Gigaspet should be changed every seven days OR every 50 cycles, whichever is first. To validate efficacy of the disinfection medium, the medium is tested daily with test strips for dilution. ALL SCOPES MUST BE DISINFECTED 3 HOURS PRIOR TO USE UNLESS THEY HAVE BEEN STORED IN A DRYING CABINET WHEN THEY CAN BE USED UP TO 72 HOURS AFTER PROCESSING.

9 KEY ELEMENTS. INTERPERSONAL SKILLS. LEARNING OPPORTUNITIES. RESOURCE/DEPARTMENT. PERSONNEL/DEPARTMENT. Use of the Telephone: Answering calls Making calls Ring back etc Bleep system Passing on messages Clerical staff / Ward staff Medical staff / Multi disciplinary team Ward clerk Use of the Computer to Obtain: Patient investigation results Patient information Internet access Clerical staff / Sister / Any staff member/ Ward clerk Talking to: Patients Relatives Doctors Other nurses, including specialist nurses Multi-disciplinary team referrals Ancillary staff Multi Disciplinary Team Managerial structure within the trust Registered nurses / Health Care Assistants Sister Doctors / Multi disciplinary team Observation of roles

10 KEY ELEMENTS. CLINICAL SKILLS RESOURCE/DEPARTMENT. LEARNING OPPORTUNITIES. PERSONNEL/DEPARTMENT. Patient Care: Skin care Pressure care prevention Recording of physiological observations BP TPR Blood glucose Maintaining accurate charts Giving medications Rectal Intravenous Intravenous infusions Cannulation/care of venflons Medical devices Administration of blood and blood product Aseptic techniques (PEG) Risk assessment Nutritional assessment Moving and handling Infection control Patient safety Checking equipment Consent Information Non-invasive radiology / Health Care Assistant Registered / Health Care Assistant / Doctor Ward staff / Diabetic Specialist Nurse Registered / Health Care Assistant / Pharmacist / Doctor / Infection Control Nurse / Electronics / Equipment Library Registered nurse / Doctor Registered nurse / Sister Registered nurse Registered nurse Registered nurse / Moving and handling link All Staff Registered nurse / Doctors All Staff Registered nurse / Radiographer

11 KEY ELEMENTS. CLINICAL SKILLS RESOURCE/DEPARTMENT. LEARNING OPPORTUNITIES. PERSONNEL/DEPARTMENT. Colorectal: Anatomy/ physiology Disorders Investigations Infections Treatment Drugs Role of Nurse Specialist Support mechanisms / Nurse Specialist / Doctors / books / computers Microbiology / infection control Pharmacist / / Nurse Specialist Nutrition: Naso-jejunal tube insertion Nutrition Nurse Specialist Support mechanisms / Nurse Specialist / Dietician / Nurse Specialist / Dietician Upper Gastro Intestinal: Anatomy/physiology Disorders Investigations Infections Treatment Drugs Role of Nurse Endoscopist Support mechanisms / Nurse Specialist / Doctors Journal articles / videos

12 KEY ELEMENTS. HEALTH DEVELOPMENT OPPORTUNITIES. LEARNING OPPORTUNITIES. RESOURCE/DEPARTMENT. PERSONNEL/DEPARTMENT. Healthy lifestyle in relation to: Smoking cessation Alcoholic liver disease Bowel disorders Cancer Obesity Diabetes Eating for a healthy heart Drug and alcohol abuse Promotion of exercise Healthy heart Patient information leaflets Specialist nurses Intranet Journals Policies and procedures Registered nurses

13 KEY ELEMENTS. MANAGEMENT OF CARE. LEARNING OPPORTUNITIES. RESOURCE/DEPARTMENT. PERSONNEL/DEPARTMENT. Nursing Process: Assessment Who assesses How is assessment carried out/open or closed questions What is assessed Where does it take place Planning Care plans Risk assessment tools Care pathways Multi-disciplinary plan/working Referrals to other agencies Specialist nurses / Pre-assessment Nurse Source of information Patient / Doctor / Registered nurse Registered nurse Multi disciplinary team Implementation/Evaluation: Multi Disciplinary Team Documentation Standards Protocols Policies Communication/relative/patient Time management Planning priorities Dealing with difficult situations Patient property Religious needs / Royal Marsden Handbook / Intranet / Doctor/ Nurse Specialist / Doctor / Sister General office / / Hospital chaplain

14 KEY ELEMENTS. ORGANISATION AND MANAGERIAL ISSUES RESOURCE/DEPARTMENT. LEARNING OPPORTUNITIES. PERSONNEL/DEPARTMENT. Managing a Team: Organisational skills Delegation skills Prioritising skills Time management Leadership Off duty Managing patient workload Quality Standards of care Implementing change Documentation / Nurse Managers / Doctors / All ward staff Sister Sister / Audit tools Clerical / Giving Information to: Staff Doctors Patients Relatives MDT members Other departments Sister / Nurse Manager Sister / / Doctor / Doctor s s / Doctors Resources Stock control Drugs Materials management Non stock Stationery Establishment/skill mix Budget control / Pharmacists / Supplies / Pharmacists / Supplies Sister / Supplies Sister / Ward clerk Sister Sister

15 KEY ELEMENTS. ORGANISATION AND MANAGERIAL ISSUES RESOURCE/DEPARTMENT. LEARNING OPPORTUNITIES. PERSONNEL/DEPARTMENT. Managing Risk: Policies and procedures Equipment safety checks Quality control Weekly environment checks Infection control Moving and handling Sister / / Intranet Sister / Works Department Sister Sister / Modern Matron Control of Infection Lead Moving and Handling Co-Ordinator Emergency Situations: Cardiac arrest Fast bleep system Violent incidents Fire Cardiac Arrest Team / / Switchboard / Security officer / Fire Officer Staff Developments: Clinical supervision Reflective practice

16 Service Manager Respiratory Nurse Electronics & Estates Modern Matron Diabetic Nurse Infection Medical Reps Control Urology Nurse Patient Information IT Nurse Endoscopist Nutritional Nurse Patient Support Groups Supplies Cancer Nurse Endoscopists Colorectal Team Modernisation Team Medical Secretaries Admin & Clerical Booking ENDOSCOPY Outpatients PIU MAU/MAA/SSU Other Wards Ward 11 Pre-assessment GP Practice Nurses X-ray Trust-wide Pre-assessment