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Safe _ Effective Abdominal Pressure During Colonoscopy Forearm Versus Open Hand Technique

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					 Safe & Effective Abdominal
Pressure During Colonoscopy:
 Forearm Versus Open Hand
          Technique
                  Presented By:
   St. James Healthcare Education Collaborative

              With The Support Of:
Susan DePasquale, Barbara Dudden & Bonita Becker
   GI Endoscopy - Surgical Services Department



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Safe & Effective Abdominal Pressure
Purpose & Methods:

n   purpose is to help the scope around the colon

n   start abdominal pressure with patient positioned on their left side
    [although some endoscopists will occasionally request to reposition
    patient from their left to supine, right side or prone if not successful
    with scope advancement in the typical left side position]

n   scope progression through the colon (as visualized on the video
    monitor screen) means effective pressure is being provided



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Safe & Effective Abdominal Pressure
Purpose & Methods:

n   provide external abdominal pressure around the area of the scope
    to assist scope movement through the colon and decrease scope
    looping within the colon

n   think about the size of the “scope head” and how to provide
    “splinting” around the scope to help direct its movement




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    Safe & Effective Abdominal Pressure
Technician needs to be aware of the following during colonoscopy:
n where the scope is located in the colon


n   physician effort to reduce a loop by pulling back / repositioning
    scope (to allow technician to provide adequate counter pressure)

n   best place to start external abdominal pressure is the sigmoid area
    (a common place for loop formation)

n   how to apply external pressure and reposition hand(s) around other
    areas of the colon if sigmoid pressure is not effective

n   signs of patient discomfort during abdominal counter pressure and
    scope advancement

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Safe & Effective Abdominal Pressure
Several key factors are crucial to keep in mind when applying
  abdominal pressure during colonoscopy:

n   awareness of the amount of abdominal pressure exerted to avoid
    injury to technician or patient

n   open hand technique and increased risk of wrist injury to technician

n   good body mechanics and positioning to ensure optimal comfort for
    technician

n   forearm techniques which allows the technician to provide effective
    and safe abdominal pressure while reducing the risk of injury to
    technician or patient


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 Safe & Effective Abdominal Pressure
                 SCENARIO 1: OPEN HAND TECHNIQUE

Technique:
technician’s hands equally
applies counter pressure to the
left upper and lower abdomen -
sigmoid and splenic flexure of
the colon

Ergonomic Issue:
arrow indicates areas of
possible injury to the technician


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 Safe & Effective Abdominal Pressure
                SCENARIO 2: OPEN HAND TECHNIQUE


Technique:
technician’s hand covers only
the left lower abdomen - sigmoid
portion of the colon.

Ergonomic Issue:
arrow indicates area of possible
injury to the technician.




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 Safe & Effective Abdominal Pressure
               SCENARIO 3: SINGLE FOREARM TECHNIQUE
Technique:
“Prechel pressure” is where the
technician’s left forearm rolls
into the patient with left hand
under pelvic bone while right
hand pulls the patient forward;
allowing patient’s own weight to
act as counter pressure.

Ergonomic Issue:
potential strain from ineffective
use of patient’s own weight.
                                    hand over sigmoid / midline colon

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 Safe & Effective Abdominal Pressure
              SCENARIO 4: TWO-FOREARM TECHNIQUE
Technique:
Technician’s left forearm in Open
Hand Technique, right hand under
splenic flexure below diaphragm
(fingers extended, knuckles down,
or fisted).

Ergonomic Issue:
Potential strain if not performed
with another person rolling the
patient onto the technician’s
forearm to apply counter pressure.   hands over sigmoid, midline, splenic
                                      flexure, and mid-transverse colon

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Safe & Effective Abdominal Pressure
 “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”.

Cynthia Edgelow, MSN, RN, CGRN; Ray Hucke, MPH, OT; and Jim Prechel, GI Tech.
                           Mayo Clinic, Scottsdale, Ariz.


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    Safe & Effective Abdominal Pressure

n   Most pressures, when applied with good body mechanics and
    positioning, should be sufficient for 3-5 minutes.

n   When longer periods of applying abdominal pressure are needed
    there should be communication between the technician and
    endoscopist to provide a moment to relax the pressure.

n   Fatigue or discomfort to the arms should be communicated by the
    technician so that another person may take over or help with
    directing the patient’s weight onto the forearms.




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Safe & Effective Abdominal Pressure

n   The technician needs to be aware of their own height, arm
     lengths, and muscle strengths while applying abdominal pressure.

n   Work with the various techniques of applying abdominal pressure to
    find the postures and position most effective to splint the scope,
    reduce looping, provide comfort to the patient, and protect
    technicians supporting the endoscopist during colonoscopy.




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Safe & Effective Abdominal Pressure
For the comfort of the patient and protecting sensitive soft tissue:
n Be aware of point of pressure (increases with a smaller surface
  area where abdominal pressure is applied)

n   Splint to assist with reducing scope looping, applying pressure over
    as broad an area as possible to stabilize tissue around the scope
    along with downward pressure against the abdomen

n   External abdominal pressure during colonoscopy does not need to
    be exceptionally forceful (with possibly the exception of patients
    with obesity or large abdominal girth)

n   Duration of the abdominal pressure applied may be determined by
    the speed of the procedure – be aware of length of time


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Safe & Effective Abdominal Pressure
Be aware of pinpoint force being directed to a precise focal point:

n   Similar to wound care management, localized and prolonged abdominal
    pressure during colonoscopy are discouraged

n   If colonoscopy pressures are applied for longer duration be aware of
    patient discomfort and the potential injury to the patient due to pressure
    being applied using fingertips, elbows, or fists

n   Possibly less assistance in loop reduction and direction of motion can
    occur with external smaller pressure areas because of colon flexibility and
    layers pressed against the abdomen

n   Pressure over a broad spectrum is preferred because it allows pressure to
    be displaced evenly



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Safe & Effective Abdominal Pressure

References:

n   James A. Prechel & Ray Hucke (2009). Safe and Effective
    Abdominal Pressure During Colonoscopy. Gastroenterology
    Nursing. Vol. 32; No. 1. Jan/Feb 2009; pp. 27 – 30.

n    Cynthia Edgelow, Ray Hucke, MPH, OT & Jim Prechel, GTS
    (2007). The Importance of Positioning During Colonoscopy.
    ENDONURSE.



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