UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
Effective Date: February, 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed March 2008 May 2009 November 2011
PURPOSE: To provide guidelines for setting up and assisting with a Flexible Sigmoidoscopy at any UWMF
DEFINITION: The use of the flexible sigmoidoscope to inspect the sigmoid colon.
POLICY: The clinical staff will utilize the following guidelines while assisting with a flexible sigmoidoscopy.
SUPPLIES: Provider’s order, Patient’s record, Permit for Operation, Non sterile gloves, Lubricant, 4X4’s,
Washcloth, Suction machine, 30cc Syringe with adapter filled with sterile water (provider
preference), Emesis basin with sterile water, sterile snares, Flexible sigmoidoscope
Formalin Container, Gown and Drape, yellow gown (provider preference), Suction machine with
canister and tubing (6 feet)
1. Check provider’s order and clarify any inconsistencies.
2. Wash hands and gather equipment.
3. Introduce yourself and identify the patient. Include date of birth. Verify allergies.
4. Provide good light and provide privacy by closing curtains door.
5. Room patient – Refer to Provider Preference List for Rooming Patients.
6. Explain procedure to the patient.
7. Following the provider’s discussion with patient, have patient sign Consent form.
8. Put on gloves and administer two (2) Fleets enemas (if patient has not done so).
9. Remove gloves and wash hands.
10. Set up sigmoidoscope and place the supplies with scope on the cart.
1. Have patient remove clothing from the waist down and wrap waist with non- sterile drape.
2. Following the provider’s discussion with patient ensure that the table is completely flat.
3. Have patient lie on left side with knees slightly drawn up toward the chest.
4. Cover patient non-sterile drape.
5. Elevate table to appropriate height.
6. Put on gloves and assist provider with procedure (as needed).
7. Remove gloves and wash hands.
1. Assist patient to a comfortable position and assist with dressing (if needed)
Direct patient to restroom
Direct patient back to waiting room
Assist patient with follow-up appointment (if needed).
2. Apply gloves and clean all surfaces with Dispatch
Bring instruments to dirty utility room
Discard waste and disposable equipment in proper receptacles
Wash instruments and tray in dirty utility room
Clean scope per standard procedure
Remove gloves and wash hands
3. If sending sample for biopsy:
Place specimen in formalin container
Label specimen, in presence of patient, with the following:
o Patient name and date of birth
o Specimen type
o Date and time of specimen collection
o Provider name
Complete necessary lab forms
Place patient sticker into Pathology log book.
Take labeled specimen container to the lab
4. Documentation (in Progress Notes section of HealthLink) in the patient’s record:
Procedure performed, date & time completed
name and amount of any medications given (using SmartPhrase: .medinclinic)
how the patient tolerate the procedure
follow-up appointment (if any)
WRITTEN BY: Mary Lynn Murray, L.P.N., General Surgery Clinic
REVISED BY: Carol Decker, RN, MSN, Clinical Staff Education
REVIEWED BY: Kelly Meyer R.N., Department of General Surgery
Kowalak, J. P. (Ed.). (2009). Lippincott’s nursing procedures (5th ed.). Ambler, PA: Lippincott Williams &
Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St. Louis, MO: Mosby.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St.
Louis, MO: Mosby Elsevier.
Department of Surgery Date
Medical Director Date