The Importance of Positioning During Colonoscopy

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As the nursing population continues to age, the focus on care of the healthcare provider in the workplace has become paramount. The challenge is how to provide optimal nursing care and yet maintain a focus on one’s own body. Ergonomics allow the allied health professional to optimize body functioning while assisting during endoscopy. Guidelines regarding general nursing care in endoscopy with a specific focus on effective body positioning during colonoscopy will be discussed.

Endoscopy Procedures

Colon cancer is the second leading cancer diagnosed in the United States today. The gold standard for diagnosis of colon cancer is the colonoscopy. Care in the endoscopy suite is typically provided by specially trained endoscopy nurses and technicians. The majority of patients being seen in an endoscopy department undergo moderate sedation. Because of the importance assigned to managing the patient who is receiving sedation and analgesia, a second nurse or associate is required to assist the physician with those procedures that are complicated either by the severity of the patient’s illness or the complex technical requirements associated with advanced diagnostic and therapeutic procedures.6, 7

As a result of this, many endoscopy units have both a registered nurse (RN) and a gastroenterology (GI) technician in each endoscopy room. The Society of Gastroenterology Nurses and Associates (SGNA), which is one of the governing bodies regulating endoscopic practice, highly recommends the use of a gastroenterology technician (GI tech) during endoscopy.

The role of the endoscopy technician is a relatively new healthcare position. Due to the tremendous increase in the demand for endoscopic procedures such as colonoscopy, the need for an endoscopy technician has developed. By definition, the GI technician refers to assistive personnel such as technicians, technologists, and assistants.6 The GI technician is an integral member of the endoscopy team, and provides support for the physician and RN throughout the endoscopy procedure. It is common knowledge to those who work in endoscopy that a well-trained technician is a valuable team member. More than one allied healthcare member in the endoscopy room allows for an increased focus on ergonomic functioning and support.

One’s Core

It is imperative when working in the endoscopy suite to focus on one’s core. The core of the body includes the hips, shoulders and torso. These areas are the center from which all movement is based. The torso is the pillar — the structural center of movement. Its alignment and function directly correlate to the health of our organs and the rest of our bodies.4 When providing patient care, allied health staff members must remember to take care of themselves!

Basic Patient Care During Endoscopy

Some of the challenges within the endoscopy setting while providing patient care include the height of the bed, placement of the monitor screens, IV tubing access, basic core body alignment, and the application of abdominal pressure during colonoscopy. The average colonoscopy takes approximately 30 minutes to complete. During this time, the allied health professional may be asked to move the patient into various positions. It is imperative that the patient begin in the middle of the bed so that when he is rolled onto his side, less reaching is required by the allied health staff. Historically, much of the literature regarding patient positioning is directly related to surgical positioning. Although surgical procedures are typically longer in nature, endoscopy procedures entail repetitive body movements by the assisting personnel. Any one position can be detrimental over an extended period of time.2

The height of the bed allows the staff members to utilize their core muscles to assist with transfers, etc. The use of a drawsheet is beneficial when it is placed under the patient during endoscopy. This allows for ease of movement of the sedated patient, especially during colonoscopy. During endoscopy, the table or bed height will usually be at the height for the physician completing the examination. If the endoscopist is tall, the bed may be set too high for the allied health member. If this is the case, a stepstool may be beneficial. If the endoscopist is shorter in stature, the bed may be too low for the allied health member. This would require the allied health member to widen his stance, lowering the core.

The perfect posture is truly the proper stance for optimal movement — shoulder blades pulled back and down, tummy drawn up, and in activating the transversus abdominis, all providing a straight line from the ears to the shoulders, the shoulders to the hips, the hips to the knees, and the knees to the ankles. If the elbow height is more than three inches to six inches above the table height, then this person will need to use a stance of placing one foot forward, or spreading the feet apart to reduce the height over the patient. This is often termed the “athletic position” and requires one to hold the shoulder blades back and down, with the tummy tight, legs slightly bent with the hips sitting back and down, and one’s weight forward on the middle of the feet.4

Allied health personnel are required to view the procedure monitor as well as the vital sign monitor throughout an endoscopy procedure. These monitors should be at a level and position that minimizes strain on the neck of the nurse or technician.

IV tubing may require extension tubing to decrease a reaching motion by the allied health provider while administering moderate sedation. There is a multitude of extension tubing devices available to lengthen the IV tubing and make it more accessible to the nurse.

Abdominal Pressure During Colonoscopy

The ability to provide abdominal pressure is a very important part of colonoscopy. Typically, the patient is placed on his left side during colonoscopy. The patient needs to be positioned within 10 to 20 inches of the person applying pressure to the abdomen. This will allow the arms to be in a more effective posture with the whole body more involved, not just the arms and back. The longer the duration of pressure or the more forceful the pressure, the closer the patient needs to be to the person applying abdominal pressure. Be mindful of the back posture by reducing forward reaching distance. In order to provide effective pressure, the assistant should know where the scope is located in the colon. In an attempt to minimize discomfort to the patient, it is important to have the physician reduce any loops before the assistant begins providing pressure. Oftentimes, the sigmoid area is an area where one might provide pressure. If the scope is not moving, the assistant may need to reposition the hand placement and have the physician continue trying to advance the scope.

When one is applying abdominal pressure, it is beneficial to be familiar with various techniques and how to use these most effectively to protect himself or herself, as well as the patient. It is advantageous for one to know the most effective muscle group in order to apply pressure correctly and safely. Communication amongst the team is also imperative to provide any compromise and consensus necessary on patient positioning, i.e., how the table height is set, if others will be available to assist with pressure, where everyone will stand, duration of pressure before a moment of release is needed, what are appropriate forces for pressure applied, if an additional monitor can be available, and an appropriate height stepstool. When pressure is needed to assist with movement of the scope or looping, the assistant applying pressure needs to be able to stand in a posture that allows the body to assist with the technique. This is one that maintains the back in a neutral spine posture and allows the knees and hips at least a slight bend to be more fluid in the stance.

When abdominal pressure is applied to the patient, or when using the patient’s weight, one should rest more on the forearms, not all on the wrists and hands. The person(s) performing this technique should be at a height that allows the forearm to push in slightly while pulling the patient forward with the opposite arm, or pushed onto the forearms when assisted by another staff member. With these techniques, the hands act more as an anchor, with the pressure against the patient being primarily on the forearms. When performing a two-forearm technique with the patient supine, allow two to three inches of height above the patient, with the elbows bent at 90 degrees and the forearms parallel to the patient’s torso. This will allow this staffer to include her own body weight to assist with maintaining this pressure, versus relying only on arm strength. Become familiar with the various hand positions and determine which one is most effective for a given technique, protection of the wrists and hands, and individual strengths.

Conclusion

Providing patient care during endoscopy and maintaining optimal body alignment is often a challenge. Endoscopy frequently is synonymous with sustained postures or positions that one is expected to maintain for an extended period of time. It is important to be aware of ergonomic opportunities that effectively protect oneself. One needs to know his/her own most effective muscle groups and align their core appropriately.

Assisting in an endoscopy procedure also often means standing in one place for a period of time. It is important to choose a posture that maintains the back with a neutral spine position and allows for the knees and hips to have a slight bend.

Remember, we do not all have the same heights, arm lengths and muscle strengths. Most allied health personnel take a passive approach to protecting their bodies during endoscopy, but the body has functional planes that allow for flexion, extension, and rotational movements.4 While it is very important to pay particular attention to patient positioning, it is equally important to focus on our own!

Cynthia Edgelow, MSN, RN, CGRN; Ray Hucke, MPH, OT; and Jim Prechel, GTS, work at the Mayo Clinic in Scottsdale, Ariz. Edgelow is nurse educator for the GI endoscopy department; Hucke is the ergonomics specialist at the facility, and Prechel is a GI tech in the GI endoscopy department.


References

  1. Hoshowsky, Victoria M. Surgical Positioning. Orthopedic nursing, September/ October 1998 p. 55-65.
  2. Metzler, Debbie, Harr, Jill. Positioning your Patient Properly. American Journal of Nursing, Volume 96(3), March 1996. p. 33-37.
  3. Prechel JA, Young, CJ, Hucke R, et al: The Importance of Abdominal Pressure During Colonoscopy, Gastroenterology Nursing, 28:232-238, 2005.
  4. Verstegen, Mark. Core Performance; the revolutionary workout program to transform your body and your life. Rodale Inc. USA 2004.
  5. Wikipedia Encyclopedia, “General Relativity”, 2007, http://en.wikipedia.org/ wiki/General_relativity.
  6. Society of Gastroenterology Nurses and Associates, Inc. (2003). Role delineation assistive personnel. [Position Statement]. Chicago: SGNA Board of directors.
  7. Society of Gastroenterology Nurses and Associates, Inc. (2003). Role delineation of the registered nurse in a staff position in gastroenterology and/or endoscopy. [Position Statement]. Chicago: SGNA Board of directors.
  8. Society of Gastroenterology Nurses and Associates, Inc. (2003). Guidelines for nursing care of the patient receiving sedation an analgesia in the gastrointestinal endoscopy setting. [Guideline]. Chicago: SGNA Board of directors.
  9. Society of Gastroenterology Nurses and Associates, Inc. (2003). Minimal Registered Nurse Staffing for Patient Care in the Gastrointestinal Endoscopy Unit. [Guideline]. Chicago: SGNA Board of directors.
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