Patient Name: _____________________________________ Date: ______________________

Account Number: _______________ NOTE: Time subject to change

 

COLONOSCOPY PREP - MIRALAX /GLYCOLAX/PEG POWDER

Supplies Needed:

        Pick up Miralax/Glycolax/PEG Powder (238 gram) at your local pharmacy

        64 oz Sports Drink (Gatorade, Propel Fit, Powerade or G2). Use clear, yellow or green only

        Three Dulcolax pills attached

        Clear liquids

 

INSTRUCTIONS FOR THE DAY BEFORE THE EXAMINATION

1.      Place sports drink in the refrigerator in the morning

2.      CLEAR LIQUIDS ONLY THE ENTIRE DAY OF PREPARATION (Day Before Procedure)

a.      Water, soda, apple juice, white grape juice, bouillon, white cranberry juice, black coffee and tea, yellow or green jellos, Italian ice

b.      Avoid milk products (milk, ice cream, yogurt), anything with red, blue, purple or orange dyes and solid foods.

c.       We encourage you to drink lots of clear liquids

3.      At 12:00 pm take the three Dulcolax pills

4.      At 5:00 pm, mix the entire bottle of Miralax (glycolax) with the sports drink in a half-gallon container. Shake or stir until powder is completely dissolved. Drink an 8 oz glass every 15-20 minutes until the solution is gone. It may take a few hours for your bowels to begin to move. Be sure to drink an additional 2-4 8 oz cups of clear liquid after you have finished the prep.

5.      Common side effects bloating and nauseated. If nauseated, walk around and drink a cool glass of water, this will help pass the prep through the stomach and relieve the nausea. Do not lie down.

6.      NOTHING BY MOUTH AFTER MIDNIGHT: No lozenges, hard candy or chewing gum. NO SMOKING AFTER MIDNIGHT.

 

Because you will be sedated for the procedure, you will need a DRIVER. You may NOT walk home, take a taxi, bus or any other form of public transportation. You are advised NOT to make any major decisions until the following day. You are also advised NOT to operate a motor vehicle for 24 hours.

 

Medications:

        Prescribed cardiac and anti-hypertensive (blood pressure) medications should be taken with a sip or water the morning of the procedure

o       ____________________ ____________________ ____________________

        Diabetics hold morning diabetes medicines and only self-administer of the usual morning insulin

o       ____________________ ____________________ ____________________

        If taking Coumadin or Plavix, see special instructions

o       _______________________________________________________________

        Bring all inhalers to your procedure. If you regularly use an inhaler in the am, please use as normal

 

Colonoscopy is considered a very safe procedure. As with any medical procedure, there are potential risks. These risks, although small, include a possibility of reaction to medication (such as an allergy), bleeding (rarely requiring transfusion), and perforation (very rare, but would require surgery). If you have any concerns about these risks, please address them with your physician prior to the procedure.

 

Reviewed by: _______________________ Date: ____________ Patient: ___________________________