Each patient an endoscopy nurse sees has his or her own particular needs. Some are more self-conscious and require an extra gown; some may require extra attention and education; and others may have physical needs such as maintenance medication, which can interfere with the meds administered before and during a colonoscopy.
But specific age groups — pediatric and geriatric — have additional needs. Sedation, bowel preps, and starting a line all require different treatment for many elderly patients. Communication may be impaired, due to hearing or vision impairment. Skin and veins may be more fragile and require a delicate touch. And facilities may vary in their recommendations for taking maintenance medications before undergoing an endoscopy procedure.
“I inservice my staff frequently on special needs of the older folks,” says Elizabeth Warren, RN, who is a nurse in the U.S. Army and works with Army surgeons. “These include pillows to support joint replacement limbs; small IV catheters for fragile veins that may easily shred; and blankets to maintain their body temperature. Watch for developing pressure areas,” she adds.
Warren observes that this patient group is very compliant with bowel prep instructions, so she merely recommends having them drink plenty of fluids, suggesting juices that are clear (apple, white grape, etc.).
“Plan ahead to get some sugar/calories in them),” she adds. “Our patients take their blood pressure, heart, and seizure medications with a sip of water (NPO after midnight). We encourage the diabetics to take no meds on the day of the scope. They may bring it with them and do a glucometer stick prior to coming to the hospital. On the prep day for colonoscopies, the insulin users use their glucometers if using half of their insulin dose. They need to be sure they intake calories. Most of my docs do not advise an insulin on prep day or on procedure day, and watch their blood sugar levels.”
Cheryl Lindstrom, RN, CGRN, works at two separate facilities, holding part-time jobs at each, one as a staff nurse at a freestanding ambulatory care same-day surgery/endoscopy center. The other job is at North Memorial Medical Center, where she works in a combination department of same-day surgery/admissions/endo/infusion center. “The same group of gastroenterologists (GIs) practice at both facilities,” she explains.
Although the physicians utilize the same sedatives and painkillers as with other patients, they do modify the doses in consideration of geriatric patients’ advanced age. “Our docs use fentanyl and Versed® pretty exclusively. They do differ in their starting doses, from 50 to 160 micrograms of fentanyl; and .5 mg to 1 mg of Versed. I personally think that the higher starting doses of fentanyl on these senior patients contribute to a lot of ‘fentanyl stiffies’ that cause the patient to go rigid on you. We use smaller-gauge IV catheters on our endo patients, often as small as 24. And we tend to use the top of the hand, as it’s convenient throughout the procedure for med bumps,” she adds.
Skin fragility is an issue, too. “We are using a self-adherent wrap to wrap around the insertion site after the catheter is removed,” adds Lindstrom. “The wrap sticks to itself, not the patient, and it is elastic, so you can create a bit of a pressure dressing with it, which is helpful if the patient bruises easily, has friable skin or is on Coumadin®. Cautery pads can be a skin care issue as well. At the ASC, they have Megadyne Mega 2000 pads, which are placed on the cart right under the sheet. They are a huge return electrode, and they have about an inch of gel cushion to them. There isn’t any pulling off of cautery pads, and the cushion helps pad boney butts.”
Lindstrom observes that a pre-assessment RN call is important in this patient group, because by calling as much as a week ahead of time, the nurses can go over medications to take and to stop taking prior to the procedure. “We will often tell them to take their blood pressure medications in the morning with a sip of water,” Lindstrom says. “They will often have to take less of their insulin that morning as well. We can find out about implantable cardioverter defibrillators (ICDs) and pacemakers with that preprocedure phone call. A huge issue for some of my patients is that they have to find a ride home and a responsible adult to stay with them for the first 12 hours. And if the patient lives alone, they hate having to inconvenience their friends or family. But it is a safety issue. We decided that if a patient shows up for a procedure without family present, we need to call and go over instructions with the responsible adult who will be assuming care. We have caught many patients without arranged supervision, and have had to keep them with us for 12 hours, or until they had an adult to stay with them.”
“Pre-procedure phone calls/triage is of utmost importance,” affirms K. Jane Malick, BSN, RN, CGRN, a senior nurse in the GI lab at the University of Pittsburgh Medical Center Presbyterian Hospital. “Calls conducted in a timely fashion enable the nurse to become more proactive in addressing the needs of our geriatric patient population. Nothing is more distressing than having an elderly patient arrive to the procedure unit not properly prepared or instructed about all aspects of his/her procedure. “During the pre-procedure phone call, the patients’ database (assessment form) is completed on the computer.
During this information-gathering process, the nurse can pick up on many issues/concerns regarding medications, allergies, ability to comprehend instructions as well as family support (transportation) issues. Concerns regarding which type of colonoscopy prep can be addressed at this time. Patients are advised to take all necessary medications: blood pressure medications, cardiac medications. Medication adjustments are made for those who are diabetic (i.e., half a dose of insulin/hold oral hypoglycemics, etc.). For those patients on Coumadin or Plavix®, phone calls are made to the patient’s primary care physician (PCP) or cardiologist regarding safe discontinuation of medications for endoscopic/colonoscopic procedures. We note patients who have pacemakers and/or automatic ICDs so that proper precautions can take place for procedures requiring electrocautery. For those patients with many co-morbid conditions, arrangements can be made ahead for procedures and sedation with monitored anesthesia care,” she says.
It is not only medical issues that must be considered — long term planning is necessary as well. “We have to ask all patients on admission if they have a living will, and if they don’t, we offer them the needed info,” she says. “The do-not-resuscitate (DNR) issue does come up, usually on our hospitalized clients. We need to address the issue prior to starting the case. We have a form that the physician signs after they have spoken to the family and patient that rescinds the DNR just for the procedure.”
Lindstrom tries to make the procedure easier for older clients by keeping a blanket warmer available, supplying blankets liberally. “I raise the head of the cart up a little, and also the knees when I can to help protect their joints. Often, they need extra pillows between their knees during the procedure to support their hips. I enjoy the time when I am waiting for the physician, and can get to know the person under the blanket a little better. I guess I try to treat them like I would want someone to treat one of my parents/grandparents — and that is with respect, caring, dignity and a little bit of humor,” she says.
“Once the geriatric patient arrives to the procedure area, every effort is made to include family members/caregivers in preparing the patient for the procedure: pre-procedure instruction, postprocedure written discharge instructions. All personal belongings are labeled with the patient’s name and stored in a secured locker. As part of the pre-procedure phone call, patients are advised not to wear expensive jewelry and not to have a lot of cash/valuables on them,” Malick states.
She observes that it is important for the nurse to be available to answer questions and provide reassurance about the procedure. “The nurse has the unique ability to explain these procedures in lay terms, including what to expect before, during and after the procedure,” she points out. “Every effort is made to make the patient’s stay comfortable and individualized. In my experience, there is nothing more appreciated than introducing yourself by name and profession, and providing the patient with a warm blanket. In the event of procedure delays, every effort is made to communicate these delays to the patient as well as the family member or caregiver.”
“The elderly have limited physiologic reserves,” say Gerrie Farley, RN, FNP, and Lynne Roberts-Jachim, RN, staff nurses in the endoscopy unit at St. Mary’s Health Care in Grand Rapids, Mich. “They are at a greater risk for apnea because their ventilatory response to hypoxia and hypercarbia are reduced."
Also, they add, “Medications circulate longer because of slower renal clearance and hepatic function. Longer intervals between medication doses are needed to see their peak effects." In addition, these patients have impaired thermoregulation and are more vulnerable to hypovolemia and hypothermia, add Farley and Jachim. “Consider that the elderly take longer to accomplish tasks,” they caution.
Some patients are asked to do their bowel preps at the facility rather than at home. The criteria for determining where the prep is done include the following: if the patient is over 70 years of age; if they have constipation, diabetes, renal disease, or mobility issues, as well as if they have a long drive from home or live alone.
Farley and Roberts-Jachim recommend making the patient’s prep easier by pouring their drinks for them, as arthritis may impair their dexterity. Place a clock nearby so they can easily see when it is time to drink the next glass, if they are taking a prep at the center instead of at home.
“Give a list of time intervals when they should drink, and give them a pen so they can keep track and cross off as they drink a glass,” the nurses add. “We use Reglan 10 mg p.o. prior to the prep to prevent nausea and to relax the GI tract. But we avoid this if the patient is on MAO inhibitors or lithium.”
The endoscopy unit at St. Mary’s provides special prep instructions for patients on dialysis. For a week before the procedure, they may not take aspirin, ibuprofen, arthritis medication, iron, or vitamins with iron. On the night before the procedure, they take two Dulcolax tablets. On the morning of the procedure, dialysis patients are asked to take their blood pressure, heart, or breathing medications, as well as prednisone, but insulin requires special instructions. Liquids for these patients to prevent dehydration are crucial. “Beginning with the pre-op phone call, I tell the patient to drink more liquids than usual to prevent dehydration,” says Mary-Ann Rich, RN, a nurse at Advance Surgery Center in San Jose, Calif. “I tell them that their medications are considered part of the clear liquid. They should not take the meds less than three hours before or three hours after the prep so that it won’t get flushed out. The morning of the procedure, they should not take their diabetic meds or water pills. If they take medications for their heart, blood pressure, brain, or lungs then they should take it with a small amount of water in the morning. (That includes antidepressants and medications for neuropathy.)” she says.
Rich is also concerned with skin fragility in this patient group. According to the Cleveland Clinic Health Information Center, skin changes as age advances. “The loss of the elastic tissue (elastin and collagen) in the skin with age causes the skin to become slack and hang loosely,” states the clinic.1 And skin becomes more transparent with age, because the epidermis thins. Skin also becomes more fragile, due to flattening of the area where the epidermis and dermis meet. And the skin is more easily bruised, because of thinner blood vessel walls.
“When taking the first blood pressure, I place Webril® on the arm to protect the skin from tears or bruises,” Rich says. “I also use Webril under the tourniquet before starting the IV. Tegaderm™ is the initial tape to hold the catheter in place and paper tape with the ends folded for easy-to-remove tabs. Even with the delicate tapes, I remove them carefully, holding the skin to prevent skin tears. While I am starting the IV, I teach them about treating skin tears at home and give them the package of Tegaderm so they can find it in the drug store,” she adds. Patients are asked to turn down the left side if they wear hearing aids, to prevent feedback once they are in the room. And patients with glasses are allowed to keep them until after they have inspected the procedure room. “Taking a patient’s sight away will increase their stress,” Rich says. “I run a pre-op rhythm strip and sometimes a 12-lead. At this point, comparing the heart rhythm and VS, I discuss the plan of sedation with the doctor. Many of the doctors are not great at cardiac issues and respect my opinion. If the patient has some significant cardiac problems, I place them on two liters of 02 N.C. in the pre-op area, telling the family member that I am helping to decrease the workload on the heart because just being at the center is stressful.”
Rich continues, “I do all my teaching before going into the room. I tell them that they may feel some cramping; that is the gas feeling and to just pass it. There is no odor since it is only room air that we pump in. I also tell them that for the rest of the day they need to keep their head above their heart, so no tying of shoes, and if they drop something on the floor, leave it — somebody else needs to pick it up. They should change positions slowly, and when getting out of bed, they should sit briefly before standing. Dancing is forbidden for the rest of the day!”
When giving the sedation medication, Rich gives 25 mcg of fentanyl and 0.5 mg of Versed, waiting a full minute, evaluating the VS before giving more. “Depending on how large the patient is, I have discussed ahead of time with the doctor a max dose,” she explains.
All of Rich’s patients are carefully watched when getting into the wheelchair for discharge. The family is instructed to support the patient even if they look stable. “Diet should be like recovering from a stomach virus,” she says. “Let the bowel rest for the day since it was very active. Fats, oils and red meats slow down the digestion and may make it harder to pass the gas. Keep up the liquids. At this time, I remind the family about daily liquid requirements and to increase them in the hot weather.”
Rich considers family education another important part of making the patient’s experience more pleasant. “I take every opportunity to teach families of any health concerns that may affect the patient,” she says. “I encourage the family members to talk about the events of history and see the wisdom that the patient has. To me, this bonding that I get in only a few minutes with the patient can heal families and bring back a forgotten respect.”