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:

purpose is to help the scope around the colon

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]

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:

provide external abdominal pressure around the area of the scope
to assist scope movement through the colon and decrease scope
looping within the colon

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:
 where the scope is located in the colon

physician effort to reduce a loop by pulling back / repositioning
scope (to allow technician to provide adequate counter pressure)

best place to start external abdominal pressure is the sigmoid area
(a common place for loop formation)

how to apply external pressure and reposition hand(s) around other
areas of the colon if sigmoid pressure is not effective

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:

awareness of the amount of abdominal pressure exerted to avoid
injury to technician or patient

open hand technique and increased risk of wrist injury to technician

good body mechanics and positioning to ensure optimal comfort for
technician

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

Most pressures, when applied with good body mechanics and
positioning, should be sufficient for 3-5 minutes.

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.

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

The technician needs to be aware of their own height, arm
lengths, and muscle strengths while applying abdominal pressure.

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:
 Be aware of point of pressure (increases with a smaller surface
area where abdominal pressure is applied)

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

External abdominal pressure during colonoscopy does not need to
be exceptionally forceful (with possibly the exception of patients
with obesity or large abdominal girth)

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:

Similar to wound care management, localized and prolonged abdominal
pressure during colonoscopy are discouraged

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

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

Pressure over a broad spectrum is preferred because it allows pressure to
be displaced evenly
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Safe & Effective Abdominal Pressure
References:

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.

Cynthia Edgelow, Ray Hucke, MPH, OT & Jim Prechel, GTS
(2007). The Importance of Positioning During Colonoscopy.
ENDONURSE.
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