By Sue Ohme, RN, BSN
One of the most well-known ethical principles that guides nursing care is non-maleficence, or the intent to do no harm. In a position statement for the Nursing Code of Ethics, the American Nurses Association states that “nonmaleficence in nursing requires the provision of safe, effective, high-quality care.” To act in our patients’ best interest, it is crucial that we have a thorough understanding of risks and benefits for the procedure being performed and do everything possible to minimize harm.
As nurses, we play a pivotal role in advocating for patient safety. In an endoscopy unit, our patients often come to us feeling vulnerable and nervous prior to a procedure. We can have a powerful impact on providing the best possible health outcomes by adhering to the ethical principles of beneficence and non-maleficence. The ANA refers to beneficence as promoting good and ensuring that the patient’s best interest is what drives care. We can achieve this by providing compassionate care and taking the time to listen to our patients, address their concerns, and provide education about the procedure or their condition.
To ensure patient safety during an endoscopic procedure, the nurse’s role encompasses a variety of checks and balances throughout the pre-procedure, intra-op, and recovery phases, making way for the opportunity to proactively mitigate risk at each stage. While training new staff members or learning a new role, nurses can often be found hyper-focusing on the required documentation portion of the electronic medical record, unintentionally ignoring the fundamentals of the procedure and the associated risks involved. Exploring each phase of care in greater detail can reveal areas that allow for improvement and reduced risk.
In preop, during patient intake, it is crucial to not only focus on the required screening questions, but also to assess your patient’s overall physiological status. This is especially true in situations where the nurse has a greater responsibility to the patient’s well-being, as with moderate sedation cases where anesthesia is not actively involved.
The Society of Gastroenterology Nurses and Associates (SGNA) has an incredibly informative website. The section titled “Practice Resources and GI Nurse Sedation” provides a wealth of information on nurse sedation during an endoscopic procedure. SGNA states that cardiopulmonary events related to sedation are the most frequent cause of GI endoscopy–related morbidity and mortality (SGNA, n.d.). In your preassessment of the patient, think about comorbidities and other risk factors that could impact your ability to adequately and safely sedate the patient for the procedure. The American Society of Anesthesiologists has a classification system that can help predict the perioperative risk based on a patient’s medical comorbidities.
|I||Normal healthy patient|
|II||Patient with mild systemic disease|
|III||Patient with severe systemic disease|
|IV||Patient with severe, constantly life-threatening disease|
|V||Moribund patient who is not expected to survive without operation|
|VI||Brain-dead patient (organ donor)|
*ASA Scoring Table: Scores assigned based on comorbidities in pre-sedation screening assessment.
SGNA recommends considering anesthesia involvement for patients with ASA scores of III or greater, along with patients who have difficult airways, are at a high risk for aspiration, and have reduced tolerance or paradoxical reactions to standard sedatives (SGNA, n.d.).
In the procedure room, the level of a nurse’s experience can have a profound impact on adverse events. A study done at the University of North Carolina found that if you do not have an experienced nurse in the procedure room during a colonoscopy, the risk of immediate procedural complication goes up tenfold. In addition to adverse events, this study also found that the presence of inexperienced nurses led to prolonged procedural times and decreased cecal intubation rates for screening colonoscopies (Dellon ES et al., 2009). Having an experienced nurse in the endoscopy suite can go a long way toward mitigating potential adverse outcomes.
Other considerations during a moderate sedation case include adding capnography monitoring, and making sure there is clear, two-way communication between the nurse and the endoscopist. Capnography measures carbon dioxide concentrations during respiration and can help to quickly detect hypoventilation before pulse oximetry indicates oxygen desaturation. This allows the nurse to initiate appropriate and timely interventions by recognizing potential problems earlier. Communication between the nurse and endoscopist is crucial to ensure patient safety and positive outcomes. The nurse should feel empowered to bring any potential concerns to the attention of the team.
Maintaining basic safety measures during the case allows the nurse to mitigate potential risks, especially when cautery is involved. Safe practices during electrocautery includes knowledge surrounding proper grounding pad placement, among other considerations. The Association of Perioperative Nurses states that patient skin injuries at the dispersive electrode site are the most frequently reported electrosurgical incidents (DiNobile, 2022). Grounding pads should be applied to a muscular, well vascularized area; optimum site for colonoscopies is the flank. The long end of the pad should face the surgical site that gives the current the largest possible area to spread out and be safely dispersed. The pad placement site should be smooth, clean, dry and free of scar tissue. Avoid placing the pad in a position that directs the surgical current path through a metal implant.
You also want to avoid placing the grounding pad over a tattoo which may contain metallic dyes that can cause burns. The AORN Perioperative Standards and Recommended Practices for Electrosurgery is a great resource for guidelines and further information regarding safe practices surrounding grounding pad placement. Remember, site selection by an experienced nurse or tech can play a pivotal role in burn prevention and patient safety.
Another consideration while intra-op is the application of abdominal pressure to reduce scope-looping and to assist the colonoscope with its advancement forward within the colon. To avoid potential complications such as perforation or bleeding, it is important to apply even pressure over as broad an area as possible, avoiding any pinpoint, forceful pressure that may be applied, such as when using the knuckles or elbow.
For example, the Prechel technique encourages using the flat surfaces of the caregiver’s forearm and the patient’s own weight to apply the splinting pressure needed to support cecal canulation, while the patient is in the left lateral position. An alternative option to using the forearm that has been found to be useful, especially on obese patients, is placing a positioning wedge under the patient’s abdomen and having the patient roll onto the wedge while rolling onto their left side; thereby applying uniform abdominal pressure throughout the procedure—increasing canulation success rates.
A recent study found that when compared to using no device, using a positioning wedge under the abdomen eliminated the need for abdominal pressure for two-thirds of obese colonoscopy patients (Fetzer, 2020). It is important to communicate with the recovery nurse if the case required a significant amount of abdominal pressure to reach the cecum, and to be aware of early signs and symptoms of perforation, which include severe nausea, abdominal pain and distention.
In recovery, post-sedation monitoring is essential to ensure the patient has returned to an acceptable level of functioning before being discharged home. Using a standardized scoring system—such as the Aldrete or Modified Aldrete score—will allow the nurse to determine if a patient is safe for discharge. This is the time to evaluate for potential procedural complications. By understanding what is happening in the procedure room as well as reviewing the patient’s pre-existing conditions, we can anticipate potential complications.
As nurses in a busy endoscopy unit, we are trusted with a range of roles and responsibilities that can often be daunting. By adhering to the ethical principles of beneficence and non-maleficence, we can provide patient-centric care that provides the best possible outcomes, while maintaining the trust and safety of the patients we serve.
Sue Ohme, RN, BSN, works at Swedish Medical Center, in Issaquah, Washington. She graduated from Pacific Lutheran University with her BSN in 2013. Immediately after nursing school, she worked in a community hospital’s progressive care unit, which allowed her to hone her cardiac and respiratory skills. Ohme has worked at Swedish Medical Center since 2015—first as an emergency room RN, then switching to endoscopy in 2021. She’s been cross-trained in ECT and PPACU and is an active member of her unit’s shared-leadership committee. Prior to nursing, Ohme graduated with a BS in biology and worked as a chemist.
- Asa Physical Status Classification System – American Society of … (2020, December 13). Retrieved March 13, 2023, from https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
- Dellon ES;Lippmann QK;Galanko JA;Sandler RS;Shaheen NJ; (2009, August). Effect of GI endoscopy nurse experience on screening colonoscopy outcomes. Gastrointestinal endoscopy. Retrieved March 12, 2023, from https://pubmed.ncbi.nlm.nih.gov/19500788/
- DiNobile, C. (2022, November 4). Take our electrosurgery safety quiz. Outpatient Surgery Magazine. Retrieved March 19, 2023, from https://www.aorn.org/outpatient-surgery/article/2009-February-take-our-electrosurgery-safety-quiz
- Fetzer, S. J. (2020). Application of a Positioning Wedge During Colonoscopy of Obese Patients to Mitigate Nurse Pain. AAOHN Journal, 68(7), 320–324. https://doi.org/10.1177/2165079920904743
- GI nurse sedation. SGNA. (n.d.). Retrieved March 12, 2023, from https://www.sgna.org/Practice-Resources/GI-Nurse-Sedation
- Why ethics in nursing matters: Ethical principles in nursing. ANA. (2023, February 17). Retrieved March 12, 2023, from https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/why-ethics-in-nursing-matters/