Antibiotic prophylaxis in gastrointestinal endoscopy



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Integrated Care Pathway for



Endoscopy Unit Procedures

Name: …………………………………………………………………


Hospital Number: …………………………………………………….
Date of Admission: …………………………………………………..
Consultant: …………………………………………………………...
Named Nurse: ………………………………………………………..

OGD Flexi Sig Colon ERCP Bronch Other

Care Pathway for : Pt details
Appointment date and time: Arrival time:
Next of Kin: Name: Address:

Telephone No:

Manual Handling Assessment





Independent: Assistance: Aids:

1 person walking stick

2 people zimmer

Other (please state) hoist

Wheelchair


Weight

Score

<7 stone

44.5kgs
1

7-12 stone

44.5-76.2kgs
2

12-14 stone

76.2-88.7kgs
3

14-16 stone

88.7-101kgs
4

>16 stone

>101.6kgs
5

Medical History

Score

History of falls

within last 48hrs

5

Before 48hrs

3

History of vertigo

Faintness,dizziness



Low haemoglobin
3

Spasm

Epilepsy


7

Other
2 points per

symptom


Resident Gallery


Score

Independent
(A)
0

Low Assistance
(B)
2

Moderate

Assistance



(C)
4

High

Assistance



(D)
7

Bed-ridden

Unconscious/



comatose

(E)

10

Mental State/

Medication


Score

Fully co-

operative


0


Tranquilisers

Hypnotics

Other medication



affecting mobility

manual handling

3

Confused, poor

comprehension

Lack of special

Awareness, poor

co-ordination

5


Agitated

Anxious


Apprehensive

5


Aggressive

Resistive

Depression

Psychotic


2 points per

symptom

Environment

Score

No attachments

0

Attachments eg IV etc

1 point per attachment



Space

constraints

(cannot clear area)

3


Other

3







Unsedated

Sedated

Low Risk 0 – 8

Requires assistance 0 – 1 staff members








Moderate Risk 9 – 15

Requires assistance of 1 – 2 staff members plus may

require handling aids eg handling belt, sliding sheets


Score:




High Risk 16+

Requires assistance of 2 or more staff members plus

Handling aids eg hoist, pat slide, sliding sheets etc


Signature:


Date:




Patient Assessment
Discharge Arrangements:
Name of person collecting: Type of transport:

Telephone Number: Responsible adult at home for

12 hrs? Yes/No



  1. Please list any medications you are presently taking:

……………………………………………………………………………………………………


……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………

  1. Do you have any allergies or sensitivities to any medication, food or latex?

Yes/No (if yes, what?)

……………………………………………………………………………………………………

3. Relevant Past Medical History:
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
Any history of diabetes: Insulin/Tablets/Diet alone

Any history of cardiomyopathy, heart valve disease, valve replacement…………………………….

Any history of internal prosthesis, grafting or stent…………………………………………………..

Any history of unexplained neurological illness……………………………………………………….

Any history of receipt of multiple blood products (e.g. haemophilia)…………………………………
……………………………………………………………………………………………………………..

Any history of being on variant CJD at risk register…………………………………………………..


Indication for Investigation:
…………………………………………………………………………………………………………….




Nursing Admission Plan
Procedure explained Yes/No Explanation understood Yes/No



Time fasted from food ………. Time fasted from fluids ……….

Bowel prep, type ………….. Result of Prep: Good/Fair/Poor

Anti-coagulant therapy Yes/No Result/date last INR/appt: ……….………..

Prophylactic antibiotics Yes/No Chance of pregnancy: Yes/No/NA

Dentures Yes/No Hearing aid: Yes/No

(Caps,crowns,loose teeth) Top/bottom Left/right/both

Glasses/contact lenses Yes/No Internal prosthesis, graft or stent: Yes/No

Type

Identity band/notes/x-rays Checked and correct: Yes/No


Weight

Height

BMI


BP

Temp

Pulse

SpO2

Resps


BM

Moving & Handling Assessment completed























Yes/No


Care Plan:
……………………………………………………………………………………………..
……………………………………………………………………………………………..
……………………………………………………………………………………………..
……………………………………………………………………………………………..
……………………………………………………………………………………………..
……………………………………………………………………………………………..
Nurse’s Signature: ………………………………. Patient’s Signature: ………………………………….

Nursing Record for: ………………………………………………

Endoscopist_________________________ Assistant______________________
Consent obtained Yes/No
Cannula site/type____________________________
Throat spray: Time:

Sedation given: Type/Amount …………………………… Time…………

Opiates given: Type/Amount: ………………………….. Time…………

Antibiotics given: Type/amount:…………………………… Time…………

Other medication: Type/Amount: ………………………….. Time…………

No sedation: ________________________________
Record observations as individually needed:
Peri procedure: Pulse:
Oxygen given: Tolerated well? Yes/No (if no, why)
Sp02: Time into Recovery: …………………am/pm


Post Procedure Recovery

Time


























R


























P


























BP


























SPO2


























Other


























Sedation

Score



























Eyes open: Spontaneously 4

To speech 3

To gentle stimuli 2

To painful stimuli 1
Conscious level: Awake communicates spontaneously 4

Sleeping at times 3

Sleeping for long periods but rousable by command 2

Sleeping but arousable with intense stimuli 1
Airway Awake maintaining airway 4

Sleeping quietly 3

Sleeping but breathing stertorous 2

Labour and irregular breathing 1
Oxygen status No oxygen required 4

Oxygen in progress but to be

discontinued after 30 minutes 3

Oxygen needed for greater than 1 hour 2

Needs medical intervention 1

Adding up these scores will give you one of these categories

Awake 16 - 18

Asleep 14 - 16

Light Sedation 12 – 14

Deep Sedation 5 - 7
Complications/Comments:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
……………………………………………………………………………………………………………Nursing Discharge Record

Absence of pain Yes/No Absence of bleeding Yes/No


Tolerating Fluids/Food



Further investigations:

Dentures/glasses/ Yes/No
OPD Follow up (Date & Time) Yes/No
TTHs Yes/No
Advice Leaflets/Literature Yes/No
Information given (verbal) Yes/No
Accompanied Yes/No
Cannula Removed Yes/No

Any other comments:

…………………………………………………………………………………………………………………..……………………………………………………………………………………………………


Nurse Signature: ……………………………………………..
Time of Discharge: ………………………




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