1. Colonoscopy
   • Purpose and indications
   • Patient preparation and bowel cleansing
   • Procedure and sedation
   • Nursing care before, during, and after
   • Complications such as bleeding and bowel perforation
   • Patient teaching and documentation
2. ERCP - Endoscopic Retrograde Cholangiopancreatography
   • Anatomy of the biliary and pancreatic ducts
   • Diagnostic and therapeutic uses, such as removal of bile-duct stones and stent placement
   • Pre-procedure preparation, consent, fasting, investigations, and allergy history
   • Post-procedure monitoring, especially for pancreatitis, bleeding, infection, and perforation
   • Nursing priorities and discharge instructions
3. Upper GI Endoscopy
   • Examination of the esophagus, stomach, and duodenum
   • Indications including upper-GI bleeding, dysphagia, ulcer disease, varices, and biopsy
   • Preparation, local anesthetic/sedation, positioning, and recovery care
   • Recognition of complications, including aspiration, bleeding, and perforation
   • Safe return to oral intake and patient education
4. Liver Biopsy
   • Purpose in diagnosing hepatitis, fibrosis, cirrhosis, fatty liver disease, tumors, and unexplained abnormal liver tests
   • Types: percutaneous, transjugular, and laparoscopic
   • Coagulation and platelet assessment before biopsy
   • Positioning, sterile assistance, post-biopsy observation, and pain management
   • Detection of internal bleeding, bile leak, pneumothorax, and shock

• Colonoscopy
• ERCP
• Upper GI endoscopy
• Liver biopsy

Colonoscopy: Full Nursing Note

1. Definition

• Rectum
• Sigmoid colon
• Descending colon
• Transverse colon
• Ascending colon
• Caecum
• Sometimes the terminal ileum

2. Anatomy Relevant to Colonoscopy

1. Anal canal
2. Rectum
3. Sigmoid colon
4. Descending colon
5. Splenic flexure
6. Transverse colon
7. Hepatic flexure
8. Ascending colon
9. Caecum
10. Terminal ileum, if indicated

3. Purposes and Indications

A. Diagnostic indications

• Rectal bleeding or blood in stool
• Iron-deficiency anemia
• Persistent change in bowel habits
• Chronic diarrhea or unexplained constipation
• Unexplained abdominal pain
• Unexplained weight loss
• Suspected colorectal cancer
• Suspected colon polyps
• Inflammatory bowel disease, such as ulcerative colitis or Crohn disease
• Diverticular disease
• Positive fecal occult blood test or FIT test
• Abnormal findings on CT colonography or barium study
• Screening for colorectal cancer in at-risk individuals
• Surveillance following prior polyps or colorectal cancer treatment

B. Therapeutic indications

• Remove polyps by polypectomy
• Take tissue samples for biopsy
• Control bleeding by injection, clipping, cautery, or other endoscopic methods
• Remove foreign bodies
• Decompress volvulus in selected cases
• Dilate a narrowed area of bowel, called a stricture
• Place a colonic stent in selected obstruction cases

4. Contraindications and Precautions

Absolute or major contraindications

• Known or suspected bowel perforation
• Acute peritonitis
• Toxic megacolon
• Fulminant colitis
• Severe acute diverticulitis
• Hemodynamic instability not corrected by resuscitation
• Patient refusal or inability to provide valid consent

Relative contraindications or situations requiring special caution

• Severe cardiopulmonary disease
• Recent myocardial infarction
• Severe arrhythmia
• Pregnancy, unless benefits outweigh risks
• Significant coagulopathy
• Severe thrombocytopenia
• Anticoagulant or antiplatelet drug use
• Poor bowel preparation
• Renal failure or electrolyte imbalance
• Frail older adults
• Severe dehydration

5. Equipment Used

• Video colonoscope
• Light source and monitor
• Suction apparatus
• Irrigation system
• Insufflation system, often carbon dioxide
• Biopsy forceps
• Polypectomy snare
• Injection needle
• Electrocautery equipment
• Hemostatic clips or other bleeding-control devices
• Specimen containers with labels and formalin, if ordered
• Lubricating jelly
• Personal protective equipment
• Oxygen supply
• Pulse oximeter
• Blood pressure monitor
• ECG monitor when indicated
• Emergency trolley with airway and resuscitation equipment

6. Pre-procedure Nursing Assessment

A. Verify patient identity and procedure

• Patient's full name and identification number
• Prescribed procedure: colonoscopy, with or without biopsy/polypectomy
• Indication for procedure
• Written informed consent
• Allergies, especially to medications, latex, and antiseptic agents
• Responsible adult available to accompany the patient home if sedation is planned

B. Take relevant history

• Previous colonoscopy and any previous complications
• Heart disease, hypertension, arrhythmias, heart failure, or previous MI
• Respiratory disease, sleep apnea, COPD, asthma
• Diabetes mellitus
• Kidney disease
• Liver disease
• Bleeding disorders
• Seizure disorder
• Pregnancy possibility
• Previous abdominal or pelvic surgery
• History of diverticulitis, bowel obstruction, inflammatory bowel disease, or colorectal surgery
• Current vomiting, fever, severe abdominal pain, or rectal bleeding

C. Medication assessment

• Anticoagulants: warfarin, heparin, apixaban, rivaroxaban, dabigatran
• Antiplatelets: aspirin, clopidogrel, ticagrelor
• Insulin and oral antidiabetic medicines
• Iron tablets, which may need to be stopped several days before depending on local protocol
• NSAIDs
• Antihypertensives
• Diuretics
• Opioids, which may worsen constipation and bowel-prep quality
• Sedatives or benzodiazepines

D. Baseline physical assessment

• Temperature
• Pulse
• Respiratory rate
• Blood pressure
• Oxygen saturation
• Pain score
• Level of consciousness
• Abdominal appearance, distension, tenderness, bowel sounds
• Presence of rectal bleeding, if any
• Hydration status
• Baseline mobility and fall risk

E. Investigations, if ordered or clinically indicated

• Complete blood count, especially hemoglobin and platelet count
• Coagulation profile: PT/INR, aPTT
• Serum electrolytes and renal function
• Blood glucose for patients with diabetes
• Pregnancy test for patients of childbearing potential, if indicated
• ECG for patients with significant cardiac history or according to local policy

7. Bowel Preparation

Purpose

Usual preparation components

1. Low-residue or low-fiber diet before the procedure
2. Clear-liquid diet on the day before or for the specified period
3. Laxative bowel preparation, commonly a polyethylene glycol electrolyte solution
4. Split-dose preparation, where part of the solution is taken the evening before and the remainder on the day of the examination, is commonly recommended because it improves bowel cleanliness
5. Adequate clear-fluid intake to reduce dehydration risk

Examples of permitted clear liquids

• Water
• Clear broth
• Clear apple juice
• Clear oral rehydration fluids
• Tea or coffee without milk/cream
• Clear gelatin without red or purple coloring

Avoid

• Milk and milk products
• Solid food during the prescribed clear-liquid period
• Alcohol
• Red, purple, or dark-colored liquids, if instructed, because they may resemble blood during examination
• Foods with seeds, nuts, whole grains, or high fiber during the preparation period, if restricted by local policy

Nursing responsibilities during bowel preparation

• Explain the reason for preparation clearly.
• Check that the patient understands the timing and method of taking the laxative.
• Encourage approved clear fluids to prevent dehydration.
• Assess for dizziness, weakness, nausea, vomiting, reduced urine output, or confusion.
• Monitor patients at increased risk of electrolyte imbalance, including older adults, renal disease patients, and those taking diuretics.
• Document stool output and whether the final stool becomes watery, clear, or yellow-tinged with minimal particles.
• Inform the provider if preparation is inadequate, the patient cannot tolerate it, or severe vomiting occurs.

8. Fasting Instructions

• Solid foods are stopped as instructed before the procedure.
• Clear liquids may be allowed until a specified time before sedation.
• The nurse must confirm the actual last oral intake and document it.
• If fasting requirements are not met, notify the endoscopy team because sedation or the procedure may need to be delayed.

9. Sedation and Analgesia

• No sedation in selected patients
• Minimal or moderate conscious sedation
• Deep sedation, often with propofol, administered by appropriately qualified personnel
• Rarely, general anesthesia

• Midazolam for anxiolysis and sedation
• Fentanyl for analgesia
• Propofol for deep sedation

Nursing responsibilities related to sedation

• Confirm fasting status.
• Obtain baseline vital signs and oxygen saturation.
• Ensure IV access is patent.
• Check allergies and previous sedation history.
• Ensure suction, oxygen, monitoring equipment, and emergency drugs are available.
• Confirm the patient has a responsible adult escort for discharge.

• Monitor level of consciousness.
• Monitor oxygen saturation continuously.
• Monitor pulse, respiratory rate, blood pressure, and ECG when required.
• Observe for airway obstruction, apnea, hypoventilation, hypotension, bradycardia, arrhythmia, and allergic reaction.
• Maintain patient dignity and safe positioning.
• Document medications, dose, route, time, and patient response.

10. Intra-procedure Nursing Care

Patient position

Nursing responsibilities

• Maintain privacy with appropriate draping.
• Assist the patient into a safe left lateral position.
• Apply monitoring devices.
• Administer oxygen as prescribed.
• Ensure IV access remains secure.
• Assist with scope and accessory handling according to role and policy.
• Assist with abdominal pressure or patient repositioning when requested.
• Observe for pain, pallor, diaphoresis, respiratory depression, cyanosis, or vasovagal symptoms.
• Label biopsy or polypectomy specimens correctly in the presence of the clinician, following local policy.
• Send specimens promptly to the laboratory.
• Record the procedure start and finish times, sedation medicines, vital signs, specimens, interventions, and patient tolerance.

Important procedural facts

• Air or carbon dioxide is used to open the bowel lumen for visualization.
• The patient may experience pressure, bloating, cramps, or the urge to pass stool.
• A digital rectal examination is commonly performed before introducing the colonoscope.
• Polyps may be sessile, meaning broad based, or pedunculated, meaning attached by a stalk. Many can be removed by snare polypectomy. Pfenninger and Fowler's Procedures for Primary Care, Third, p. 720.

11. Post-procedure Nursing Care

A. Immediate recovery

• Airway patency
• Respiratory rate and work of breathing
• Oxygen saturation
• Pulse and blood pressure
• Consciousness level
• Pain score
• Nausea and vomiting
• Abdominal pain, distension, and tenderness
• Rectal bleeding
• Ability to drink fluids, if permitted
• Ability to mobilize safely

B. Expected findings after uncomplicated colonoscopy

• Abdominal fullness or bloating
• Mild cramping
• Passage of gas
• A small amount of blood after biopsy or minor polyp removal, if specifically explained by the endoscopy team

C. Nutrition

• Resume oral intake only when the patient is awake and there is no vomiting or aspiration risk.
• Start with fluids, then light food if tolerated and permitted.
• Follow any special instructions after polypectomy or therapeutic procedures.

D. Mobility and safety

• Assist the patient on first ambulation because sedation may cause dizziness and poor balance.
• Implement fall precautions.
• Do not allow a sedated patient to drive, operate machinery, drink alcohol, sign legal documents, or make major decisions for the rest of the day, or for the duration specified in local instructions.

12. Complications

A. Perforation

• Difficult procedure
• Severe diverticular disease
• Adhesions from prior surgery
• Bowel inflammation
• Stricture
• Large polyp removal
• Use of electrocautery
• Advanced age or significant comorbidity

• Severe or increasing abdominal pain
• Rigid abdomen or guarding
• Marked abdominal distension
• Fever
• Tachycardia
• Hypotension
• Shoulder-tip pain
• Dyspnea
• Reduced bowel sounds
• Signs of shock

1. Stop oral intake.
2. Keep the patient NPO.
3. Assess vital signs frequently.
4. Notify the endoscopist or physician urgently.
5. Prepare for imaging, blood tests, IV fluids, antibiotics, or surgery as prescribed.
6. Document symptoms, time of onset, vital signs, notifications, and interventions.

B. Bleeding

• Persistent rectal bleeding
• Passage of clots
• Black or maroon stool
• Dizziness, weakness, syncope
• Tachycardia
• Hypotension
• Pallor
• Falling hemoglobin, if tested

• Assess quantity and appearance of bleeding.
• Monitor hemodynamic status.
• Maintain IV access.
• Inform the endoscopist promptly.
• Prepare for repeat endoscopy, blood tests, fluid resuscitation, transfusion, or admission if ordered.

C. Post-polypectomy electrocoagulation syndrome

• Abdominal pain
• Fever
• Tachycardia
• Localized tenderness
• Leukocytosis

D. Sedation-related cardiopulmonary complications

• Hypoxia
• Apnea
• Aspiration
• Hypotension
• Bradycardia
• Vasovagal reaction
• Arrhythmia
• Myocardial ischemia or infarction

• Stop or withhold sedative medication as appropriate.
• Maintain airway.
• Reposition patient.
• Give oxygen.
• Use suction if necessary.
• Escalate immediately to the endoscopist/anesthesia/emergency team.
• Prepare for reversal medication or resuscitation if ordered.

E. Bowel-preparation complications

• Nausea and vomiting
• Dehydration
• Electrolyte imbalance, including hyponatremia
• Hyperphosphatemia with some preparations
• Renal impairment
• Aspiration
• Rarely, toxic megacolon

F. Rare complications

• Infection or bacteremia
• Splenic injury or splenic rupture
• Diverticulitis
• Volvulus
• Incarceration of a polypectomy snare

13. Discharge Teaching

Teach the patient to:

• Rest for the remainder of the day after sedation.
• Have a responsible adult stay available as advised.
• Avoid driving, alcohol, machinery, and important decisions until sedation has fully worn off.
• Resume diet according to the endoscopy team's instructions.
• Drink fluids unless fluid restricted.
• Expect temporary gas, bloating, or mild cramps.
• Take prescribed medicines as directed.
• Ask specifically when to restart anticoagulants, antiplatelet drugs, diabetic medicines, or iron supplements.
• Keep the follow-up appointment.
• Await biopsy or polyp histology results if specimens were taken.

Seek urgent medical help for:

• Severe, persistent, or worsening abdominal pain
• Fever or chills
• Persistent vomiting
• Increasing abdominal swelling
• Heavy rectal bleeding or passing clots
• Black stool
• Dizziness, fainting, severe weakness, or palpitations
• Shortness of breath or chest pain
• Inability to pass urine or severe dehydration symptoms

14. Nursing Documentation

• Indication for colonoscopy
• Consent verification
• Allergies
• Relevant medical history and medication review
• Anticoagulant/antiplatelet plan, if applicable
• Bowel preparation prescribed, completed, and quality of stool output
• Fasting status and last oral intake
• Baseline vital signs and pain score
• IV site and patency
• Sedation and analgesia medications, dose, route, time, and response
• Oxygen administration and monitoring findings
• Positioning and any changes during procedure
• Specimens obtained, labels, and laboratory dispatch
• Procedure tolerance
• Any complication or adverse symptom
• Recovery observations
• Discharge condition, escort details, and teaching given
• Patient and caregiver understanding of instructions

15. Sample Nursing Care Plan

16. Quick Nursing Checklist

Before colonoscopy

• Verify identity, procedure, consent, allergies.
• Review comorbidities and medications.
• Confirm anticoagulant/antiplatelet and diabetes plan.
• Check bowel-prep completion and stool quality.
• Confirm fasting status.
• Obtain baseline vital signs and relevant results.
• Establish IV access.
• Ensure safe escort/home arrangement if sedated.

During colonoscopy

• Position left lateral.
• Maintain privacy and safety.
• Monitor pulse, BP, respiration, consciousness, and oxygen saturation.
• Assist with equipment, specimens, repositioning, and abdominal pressure as required.
• Observe for sedation-related or vasovagal complications.

After colonoscopy

• Monitor until awake and stable.
• Assess pain, abdominal distension, bleeding, nausea, and vital signs.
• Assist with ambulation.
• Provide written and verbal discharge teaching.
• Escalate urgently for severe pain, fever, hypotension, dyspnea, or significant bleeding.