Performing endoscopy studies

Performing Endoscopy Studies

Endoscopy is a minimally invasive procedure in which a long, flexible tube with a camera (endoscope) is inserted into the body to visualize internal structures. Common endoscopy types include upper GI endoscopy (esophagus, stomach, duodenum), colonoscopy (colon), and bronchoscopy (airways). After completing an endoscopy, findings and any specimens collected must be documented in the system for physician review.

Before you start

• The patient must have an active endoscopy order in the system.
• You must be a trained and credentialed endoscopist or endoscopy assistant (depending on your role and facility policy).
• Verify the type and extent of endoscopy ordered.
• Ensure all endoscopy equipment (scope, biopsy tools, accessories) is sterile, functional, and properly disinfected.
• Confirm patient preparation was completed as ordered (fasting, bowel prep for colonoscopy, etc.).
• Review the patient's medical history, medications, and any allergies or contraindications.
• Have sedation medications and reversal agents available if procedural sedation is planned.

Steps

1. Navigate to the Diagnostics & Laboratory section and locate the pending endoscopy order. Open in Usystems

2. Verify patient identity using two identifiers and confirm informed consent is documented.

3. Review preprocedure requirements:

   • Confirm fasting status (usually NPO for 6+ hours for upper endoscopy).
   • Verify bowel preparation is adequate for colonoscopy (clear liquid stool).
   • Check vital signs and baseline oxygen saturation.

4. Brief the patient:

   • Explain the procedure and what to expect (mild discomfort, camera visualization, possible biopsies).
   • Explain the throat spray or anesthetic if used for upper endoscopy.
   • Reassure the patient that breathing will not be obstructed.
   • If sedation is planned, review sedation risks and benefits; obtain additional consent if required.

5. Administer sedation if ordered (typically conscious sedation for most endoscopy):

   • Establish IV access.
   • Administer sedative and analgesic medications according to protocol.
   • Monitor patient consciousness level and vital signs continuously.
   • Have emergency equipment and reversal agents immediately available.

6. Perform the endoscopy:

   • Position the patient appropriately (left lateral for upper endoscopy, left lateral or prone for colonoscopy).
   • Visualize the anatomy systematically, examining all regions specified in the order.
   • Document findings as you proceed (location, appearance, size of lesions, polyps, inflammation, etc.).
   • Take biopsies, remove polyps, or perform therapeutic interventions as indicated and documented in the order.
   • Take photographs or video recordings of significant findings.
   • If specimens are obtained, label them clearly with patient identity and anatomical location.

7. Monitor patient safety throughout:

   • Continuously assess vital signs and oxygen saturation.
   • Watch for complications (bleeding, perforation, respiratory depression).
   • Be prepared to intervene or call for assistance if complications occur.

8. Once the procedure is complete, document findings in the system:

   • Mark the procedure as Complete or Performed.
   • Record the date, time, and endoscopist name.
   • Document the anatomical regions examined and patency of passages.
   • List all findings (polyps, lesions, inflammation, hemorrhage, abnormalities, etc.) with their location and description.
   • Note any therapeutic interventions (polypectomy, biopsy, injection, hemostasis) performed.
   • Document specimen collection, labeling, and any relevant histology orders.
   • Add notes about procedure tolerance, complications, and recommendations for follow-up.
   • Record sedation medications used and patient recovery details.

9. Save the procedure record. Findings are available for physician review and clinical decision-making.

What happens next

• Photographs or video recordings are archived with the procedure record.
• Any tissue specimens are sent to pathology for analysis.
• A physician reviews the endoscopy findings and writes a report.
• If pathology testing was done, results are linked to the endoscopy record when available.
• The ordering physician is notified that results are ready.
• Follow-up recommendations (e.g., repeat endoscopy, surveillance colonoscopy) are communicated to the patient and ordering physician.

Tips & common mistakes

• Systematic examination: visualize all regions specified in the order; incomplete examination may miss important findings.
• Sedation safety: monitor vital signs and consciousness closely; under-sedation causes patient discomfort, over-sedation risks respiratory depression.
• Specimen handling: clearly label all specimens with patient identity and anatomical location immediately after collection; mislabeled specimens can compromise diagnosis.
• Complication awareness: be alert for bleeding, perforation, or other complications during and immediately after the procedure; early recognition improves patient outcomes.