2.2 Patient Assessment & Pre-Procedure Preparation

The Nurse as the Last Safety Check

Pre-procedure assessment is where the gastroenterology nurse prevents most procedural complications before they happen. On the CGRN, expect scenario questions that ask what you would assess, hold, clarify, or escalate before a patient is sedated and scoped. The recurring exam logic is: identify the risk, then act on the patient-safety priority rather than convenience or schedule.

The Focused GI Assessment

A pre-procedure assessment is targeted, not a full head-to-toe survey. Core elements include:

• Presenting GI history — symptoms, prior endoscopy findings, relevant abdominal surgeries, and the indication for today's procedure.
• Medical and cardiopulmonary history — cardiac disease, obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), diabetes, and renal or hepatic impairment, all of which affect sedation safety and drug clearance.
• Allergies — drugs, latex, contrast, and adhesives; document the specific reaction (rash vs. anaphylaxis), not just the word "allergy."
• Medication reconciliation — with special attention to anticoagulants, antiplatelets, insulin and oral hypoglycemics, and any sedating drugs taken at home.
• Baseline vital signs, weight, and oxygen saturation — the reference point for intra-procedure monitoring and weight-based dosing.
• NPO (nothing by mouth) status and bowel preparation status when applicable.
• Establish IV access and confirm a responsible adult escort is present for discharge after sedation.

Risk Stratification: ASA and Airway

The American Society of Anesthesiologists (ASA) Physical Status Classification estimates baseline physiologic risk and helps decide who can receive nurse-administered moderate sedation versus anesthesia support. Higher ASA class predicts more sedation-related adverse events.

An appended E denotes an emergency procedure, which adds risk at any class.

An airway assessment is mandatory before sedation because moderate sedation can progress unintentionally to deep sedation with loss of protective airway reflexes. Document the Mallampati class (I-IV, based on visible oropharyngeal structures), mouth opening, neck mobility, thyromental distance, dentition (loose teeth, dentures), and any history of difficult intubation, sleep apnea, or stridor. Predictors of a difficult airway should prompt anesthesia consultation before the procedure starts — not after the patient deteriorates.

Anticoagulation and Antiplatelet Management

Managing anticoagulants is a balancing act: holding them lowers procedural bleeding risk but raises thromboembolic risk (for example, in atrial fibrillation, a mechanical heart valve, or a recent coronary stent). Decisions are individualized by the provider based on the bleeding risk of the planned procedure (low risk: diagnostic EGD/colonoscopy with or without biopsy; high risk: polypectomy, ERCP with sphincterotomy, dilation) and the patient's thrombotic risk. Direct oral anticoagulants (DOACs such as apixaban, rivaroxaban) are typically held 1-2 days, warfarin longer with possible bridging, while low-dose aspirin is often continued.

The nurse verifies what was held, the timing of the last dose, whether bridging anticoagulation was used, and escalates any unclear plan before sedation.

Bowel Preparation and Adequacy

For colonoscopy and flexible sigmoidoscopy, bowel preparation cleanses the colon so the mucosa can be fully visualized. Common regimens include polyethylene glycol (PEG) electrolyte solutions and lower-volume preparations (e.g., sodium picosulfate/magnesium citrate, sulfate-based solutions). Split-dose dosing — giving half the preparation the evening before and half 4-6 hours before the procedure — produces superior cleansing and is the recommended standard for most elective colonoscopies; quality scales such as the Boston Bowel Preparation Scale grade the result.

The nurse confirms the patient completed the prep, tolerated it, and is producing clear or light-yellow effluent. Inadequate preparation reduces adenoma detection, can hide flat lesions, and frequently requires the procedure to be rescheduled. Patients with renal impairment, heart failure, cirrhosis, or electrolyte abnormalities need special attention because aggressive prep can cause dehydration and dangerous electrolyte shifts; avoid sodium phosphate preps in renal impairment due to phosphate nephropathy risk.

NPO Guidance

NPO status reduces the risk of pulmonary aspiration under sedation. ASA- and ASGE-aligned fasting guidance for elective sedation is summarized below.

Verify NPO status verbally and against the chart; an unconfirmed or violated NPO status must be reported to the proceduralist before sedation, as it may delay or cancel the case. Recent glucagon-like peptide-1 (GLP-1) agonist use (e.g., semaglutide) delays gastric emptying and is now a recognized aspiration concern that should be flagged.

Informed Consent

Informed consent is the responsibility of the proceduralist, who must explain the procedure, alternatives, benefits, and risks. The nurse's role is to confirm consent was obtained, that the form is signed and dated before sedation, and that the patient — not yet sedated — can describe in their own words what is planned. If the patient cannot, appears confused, or has already received any sedating medication, stop and notify the provider: consent obtained after sedation is not valid.