Download File - 5AB Orientation

St Paul’s Hospital
Heart Centre
Managing Patients Post SCA/PCI Learning Module
Please take the time to find and review the protocol for Cardiac Cath Lab:
Pre and Post Procedure Care.
Contents
1. Introduction ……………………………………………………………………. 3
a. Learning objectives
b. Learning activities
2. Theory …………………………………………………………………………….. 4
a. Cardiac catheterization
b. Femoral anatomy
3. Patient management post hemostasis ………………………… 7
4. Potential complications and nursing interventions……
a.
b.
c.
d.
e.
f.
g.
h.
8
Bleed or hematoma
Vasovagal reaction
Chest pain
Retroperitoneal hematoma or bleed
Pseudo aneurysm
Arterial occlusion at puncture site
Infection
Radial Specific: forearm hematoma, compartment syndrome
5. Documentation……………………………………………………………… 13
6. Who to call for help……………………………………………………… 14
7. Discharge Teaching…………………………………………..…………… 14
9. Case Studies …………………………………………………………………….15
10. References ……………………………………………………………………….17
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Introduction
All staff must be familiar with caring for pre and post selective coronary
angiogram (SCA) and percutaneous coronary intervention (PCI) patients. This
module will lead you through a study of the procedure, its potential
complications and nursing interventions.
Learning Objectives
Following completion of the learning module, the RN will be able to:
1. Discuss:
 Nursing assessments and interventions associated with care post
interventional procedure
 Assessment and interventions for common complications following
interventional procedure
 Be familiar with the pre and post cardiac cathertization protocols
2. Demonstrate:
 Appropriate assessment of the patient post interventional
procedure
 Management of post-procedural complications
 An ability to effectively teach patients regarding post
interventional procedure activity, dressing care, when to call for
help and risk factor counseling
 Awareness of situations when medical staff must be contacted
 Evaluation of own achieved learning, identify areas of strength
and need for further learning and/or clinical practice
Learning Activities
The RN will perform the following learning activities:
 Review the Cardiac Cath Lab: Pre-Procedure Care and PostProcedure Care Protocols, Going Home after PCI booklet
 Read Managing Patients Post SCA/PCI Learning Module
 Participate in simulation activities associated with the more
common complications post intervention (hematoma, vasovagal
reaction, chest pain)
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Theory
Cardiac Catheterization
SCA and PCI involves the cannulation of a large artery. At St Paul’s
Hospital, these procedures are most commonly done through the right femoral
artery. Other sites include the left femoral and both radial arteries.
Right Heart Catheterization (RHC) involves obtaining pressure readings in
the right (i.e. venous) side of the heart. For this purpose, a major vein is the
approach site. Common vessels used are right and left femoral veins, the
internal jugular and subclavian veins. A #7 French is the usual sheath size for
venous cannulation.
Sheaths are small flexible catheters used as a guide for wires, stents,
balloons etc that are passed through the sheath to perform diagnostic
procedures and percutaneous interventions (PCI). A sheath is introduced into a
large venous or arterial vessel. Common cannulated vessels are the femoral,
radial, internal jugular or subclavian vessels. Sheaths can also be referred to by
brand names such as: “Cordis”, “Medex” or as “Sidearm”. The sheath has 2
components: a one way valve that lies at the surface of the skin and through
which the catheter is threaded, and the side port which can be used as IV
access (only for venous sheaths).
Sheaths come in different sizes: from #5French to #10French. They exist
in full and half sizes; the bigger the number, the bigger the sheath. Angiograms
are commonly performed with a #6 French sheath. PCIs may require sizes #6F,
#7F or #8F . Larger sheaths may require longer clamp times and pose a greater
risk of bleeding.
Sheaths are colour coded. The most common ones are:
 #5F Grey
 #6F Green
 #7F Orange
 #8F Blue
Example of a sheath
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Femoral Anatomy
Moving laterally in towards the medial aspect of the upper thigh you will
find that the vagus nerve, femoral artery and the femoral vein are in close
proximity to each other. The acronym NAVEL (femoral Nerve, femoral Artery,
femoral Vein, EL empty space with lymphatics) can help you to remember and
locate these structures.
Sheath
Skin puncture
Femoral
artery
Artery
puncture
Figure 1: Sheath insertion
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Closure Devices
An intravascular closure device may be used to achieve hemostatis on certain
patients. Generally these are used when you want to
 Avoid interruption of heparin therapy
 Facilitate patient care (agitation or back pain
 Facilitate transfer to another hospital
The device may involve intravascular stitching or the placement of a collagen
plug. The device creates a mechanical seal by sandwiching the arteriotomy
between a bioabsorbable anchor and collagen sponge, which dissolve within 60
to 90 days. Required bed rest is determined from the time the intravascular
closure device was place. If the closure device fails, the patient may require
manual pressure or a compression device to control bleeding.
Angioseal
Glycoprotein IIb/IIIa Inhibitors
The glycoprotein IIb/IIIa inhibitor eptifibatide, more commonly known as
Integrilin, is used on high risk patients during PCI to reduce both short and long
term adverse cardiac events. Antagonizing the GP IIb/IIIa receptor mitigates
the thrombosis cascade and offers clinically significant protection against
ischemic complications of PCI for high risk patients. Some of the characteristics
of the high risk patients were identified as: those greater than 75 years of age,
diabetic, suffered a STEMI within seven days, and those with elevated cardiac
markers.
As this medication is costly and because there are increased bleeding risks
associated with its use, it is used on those patients physicians feel will obtain
the greatest benefit.
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Patient Management Post Hemostasis
Post Hemostasis
The duration of bed rest post hemostasis is:
- 1 hour for radial approach patients
- 2 hours for closure device patients
- 3 hours for SCA patients (femoral)
- 4 hours for PCI patients (femoral)
- 6 hours for interventions requiring a sheath greater than #8
Post Femoral Sheath Removal:
 The head of the bed may be raised 30 degrees
 The patient’s head MUST remain on the pillow at all times.
Lifting the head can produce a “sit-up” effect, pulling on the
groin muscles and causing a disruption in the newly formed
clot
 The affected leg must remain straight for the duration of
bed rest
 The patient may turn from side to side as long as their leg
remains straight
 Patients should be instructed to apply hand pressure to the
groin site PRIOR to coughing
General Care:




The patient should be instructed to apply hand pressure to the insertion
site and call for help immediately if at any point they feel that the
groin/wrist area is wet, warm and/or possibly bleeding
The call bell should ALWAYS be within reach while the patient is on bed
rest
Consult protocol for on-going post procedure care
All patients must have patent IV access
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Potential Complications and Nursing Interventions
Post-Sheath Removal Bleed or Hematoma
1. Possible Causes: Despite the most meticulous technique, some patients
will bleed spontaneously or develop a hematoma following sheath
removal. Hematomas in the soft tissue surrounding the site of the
femoral sheath will feel firm and will have defined boundaries. A
hematoma may cause compression of the femoral nerve that in turn may
cause weakness of the quadriceps muscle for several months. Patients
with aortic insufficiency, wide pulse pressures, hypertensive patients,
obese patients, those on anticoagulants, and female are most
susceptible. Superficial bleeding from soft tissue may appear as slight
ooze. To determine whether it is arterial or superficial briefly occlude
the femoral artery with manual pressure. If it is superficial the ooze will
not stop. Apply absorbent dressing. If it is an arterial bleed, follow
actions as below.
2. Nursing Actions:
a. Immediately re-apply manual pressure to femoral artery site.
Apply pressure until no bleeding is visible from the site. Apply just
enough pressure to achieve hemostasis but not obliterate the
pedal pulses. Expect the pulses to be diminished.
1. Check VS and observe closely. Mark the hematoma’s
contour with a marker if necessary.
2. Maintain 10-15 minutes of continuous manual pressure.
Apply only enough pressure to stop the bleeding (usually
about 80% of the artery should be occluded, not 100%).
Excessive pressure can lead to a vasovagal reaction. As
well, totally occluding the femoral artery for more than
four minutes can lead to lower limb ischemia. When
bleeding stops, instruct patient to remain on bed rest
with affected leg straight for a further 3 hours.
3. If bleeding does not stop despite manual pressure, notify
the MRP. The clamp may need to be reapplied and only a
RN trained in sheath removal may do this. If the clamp
needs to be reapplied, check on 5A to see if there is
someone trained and available to do this. If not, check
with either CSSU or CICU to see if someone is available
who can do it. If no one is available, the MD will have to
reapply the clamp.
4. Discontinue Integrilin or Reopro infusions if ordered by
the cardiologist.
5. If bleeding cannot be controlled with manual or clamp
pressure, page interventional cardiologist or designate.
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Vasovagal Reaction
A vasovagal response is an extreme physiological response. Pressure on a large
artery, and pain, can stimulate the vagus nerve, which will respond by slowing
the heart rate and lowering blood pressure. Anxiety and tissue injury can also
result in a vasovagal reaction.
Early signs include:
 pallor
 nausea
 yawning
 slowing of the heart rate (not applicable to those with a
pacemaker set at a predetermined rate) before a drop in
blood pressure.
 symptomatic hypotension
 cool, clammy and diaphoretic skin
 chest pain
 complaints of feeling unwell
 changes in LOC.
The patient can present with any combination of these symptoms. Vasovagal
reactions may lead to irreversible shock if untreated.
1. Possible Cause:
a. A hematoma, which can put pressure on the vagus nerve.
b. Compression at the access site if intervening (applying manual
pressure) for a hematoma.
c. Blood loss may make the patient more susceptible to a vasovagal
episode. The mere “sight” of blood may precipitate a vasovagal
in some people.
2. Nursing Actions:
a. Give NS 250 cc bolus and Atropine 0.5 mg IV push. The 250 ml NS
bolus may be repeated one more time. The atropine may be
repeated once more at a 5 min interval. Consider monitoring the
patient’s rhythm. Check BP q5min until stabilized.
b. Place the patient’s bed in trendelenberg.
c. If possible, decrease the pressure at the site a little. Decreasing
the pressure and discomfort may help minimize the reaction.
d. Discontinue a nitro patch to limit vasodilation.
e. If the patient fails to respond to treatment, contact the
Interventional Cardiologist or designate.
f. If the patient becomes unstable call a Code Blue
Chest Pain
1. Possible Causes:
a. vessel re-stenosis post PCI
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b. stretch pain from trauma to culprit vessel(s)
2. Nursing Actions:
a. Obtain accurate description of chest pain. Assess intensity,
quality, radiation, relieving or aggravating factors and associated
symptoms. Inquire if the pain is similar to discomfort with balloon
inflation during procedure, previous MIs or previous angina.
b. Record VS and note and changes (increase in BP and heart rate
suggest a cardiac source)
c. Treat suspected cardiac pain as per chest pain protocol and notify
Interventional Cardiologist immediately.
d. If chest pain is chest wall in origin, may treat pain with analgesic
as needed and ordered.
Retroperitoneal Hematoma or Bleed
1. Possible Causes: Although rare, this is a potentially fatal complication.
This can occur when the common femoral artery is punctured above the
inguinal ligament (the puncture site should be below the ligament).
Accumulated blood in the cavity can result in pressure on the femoral
nerve that can result in palsy that affects the leg/foot.
2. Nursing Actions:
a. Know the signs and symptoms which include moderate to severe
pain in the back, flank, leg, lower abdominal quadrant or groin
along with tachycardia and hypotension. Bleeding may not be
visible or palpable at the puncture site. A visible retroperitoneal
hematoma/bluish discolouration in the flank region is a late sign
of hemorrhage.
b. Consider checking hemoglobin and PTT.
c. Notify interventional cardiologist or designate immediately.
Pseudo Aneurysm
1. Possible Causes: Continued anticoagulation after sheath removal, large
sheaths (#10) and hematomas are risk factors for pseudo aneurysm
development. Inadequate hemostasis after a femoral artery puncture
allows blood to enter the wall of the femoral artery and create a false
lumen or “pseudo aneurysm”. The thinner wall of this pseudo aneurysm
may rupture and will require surgical repair or Doppler guided
compression. Most pseudo aneurysms can be detected within 24-72
hours after femoral cannulation.
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Healing puncture
site
Pseudo aneurysm
Solidified blood
in interstitial
space
Arterial lumen
Figure 2: pseudo aneurysm
Tract of nonhealing puncture
Nursing Actions:
a. Assess for a pseudo aneurysm by palpating for a pulsatile mass
and auscultating for bruits routinely until discharge. A femoral
pseudo aneurysm may become prominent more than 24 hours
after sheath removal.
b. Know signs and symptoms which include a pulsatile, usually
painful mass over the artery at the puncture site. Possible nerve
compression may be present and may be indicated by sharp,
stabbing or shooting pain in the groin which may radiate down the
thigh.
c. Notify physician immediately if pseudo aneurysm is suspected.
Arterial Occlusion at Puncture Site
1. Possible Causes: These are rarely seen today with the increased use of
stents, anticoagulants and anti-platelet drugs. However, a thrombus
could develop at the puncture site.
2. Nursing Actions:
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a. Know the signs and symptoms of an arterial occlusion which may
include sudden onset of severe pain or numbness, pallor, cyanosis
or absence of distal pulses in the affected limb.
b. Notify the interventional cardiologist immediately.
Infection
1. Possible Causes: Femoral catheterization can result in phlebitis,
bacteremia and infection. Infection may not be apparent until a few
days following the procedure.
2. Nursing Actions:
a. Know the signs and symptoms of infection that may include
swelling, redness, warm skin and purulent drainage at the
insertion site.
b. Educate the patient on the signs and symptoms of infection, the
precautions to take to prevent infection and the appropriate
action to take if discovered.
Radial Specific Complications
Forearm Hematoma
1. Possible Causes: There are at least three potential causes for the
development of a forearm hematoma,
- Persistent bleeding from the access site: generally occurs only
after removal of the arterial sheath.
- Perforation of the radial artery: can occur during sheath or
catheter insertion and is related to large sheath to artery size
ratios or any other impedance to sheath/catheter entry.
- Perforation of a radial artery side branch: - unlike the femoral
artery, the radial artery has many small side branches. A wire
aggressively advanced into a side branch can result in perforation.
2. Nursing Actions:
a. Signs and symptoms include bleeding at site, development of
hematoma in the forearm, though not necessarily at access site,
numbness/tingling of affected arm as the nerve gets compressed
Apply manual pressure for 15 minutes. If bleeding cannot be
controlled with manual pressure, contact the procedure
cardiologist.
b. Larger or growing hematomas require immediate attention
because there is concern for compartment syndrome.
Compartment Syndrome
Compartment syndrome is the compression of nerves, blood vessels, and
muscle inside a closed space (compartment) within the body. This leads to
tissue death from lack of oxygenation due to the blood vessels being
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compressed by the raised pressure within the compartment. Large or expanding
hematomas require immediate attention because of this concern.
1. Possible causes: Large or expanding hematomas can exert pressure on
the nerves, muscles and blood vessels in the forearm. Symptoms of
compartment syndrome may include pain (out of proportion to what is
expected and not relieved by analgesic), paresthesia (“pins and
needles”), tense and swollen skin of affected area, and pallor.
2. Nursing Actions:
a. Contact the procedure cardiologist immediately if compartment
syndrome is suspected. Left untreated compartment syndrome
can lead to tissue necrosis and possible limb loss.
b. Return patient to bed if ambulating and elevate affected limb.
Documentation


Post sheath removal documentation is to be recorded on the 24 hr
flowsheet.
Post hemostasis VS are Q15 MIN x 4, then Q1H x 3, Q4H x 24 hours and
PRN. Access site must be observed at this time as well.
Who to Call for Help




If you have nursing concerns, call the CSSU RNs and/or the 5A, Cath Lab
or CICU CNLs; the 5AB educator or the Interventional CNS.
If you have medical concerns, call/page the procedure Fellow (1st), or
the procedure cardiologist (2nd) involved in the case.
If the procedure cardiologist is off site:
- call the patient’s admitting cardiologist (if different from
Procedure Cardiologist).
The cardiologist may refer you to the CCU resident.
If the patient is deteriorating and/or very unstable, stay with the patient and call a
CODE BLUE.
Discharge Teaching
 The Discharge Guidelines Angina or Heart Attack Patients is a checklist of
the minimum teaching each patient is to receive prior to discharge. The RN
is to go through each section and ensure that the appropriate
information/handouts are given to the patient. The RN is to complete two
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copies of the discharge guidelines (no photocopies please). Once completed
all patients need to be given their own copy of the completed Discharge
Guidelines Angina or Heart Attack Patients (PHC-HH096).
 All patients who have a PCI should receive the booklet “Your Heart: New
Start” which contains important information on their disease and recovery.
 All patients need to receive the discharge booklet “Going Home after
Angiogram/PCI”. This booklet contains important information that needs to
be reviewed with the patient prior to their discharge. In particular the
areas that need to be emphasized include what to do if chest pain returns;
dressing care; what to do if they start to bleed from the site and the
importance of NOT stopping their Plavix (if prescribed). The importance of
continuing Plavix must be very strongly emphasized with all patients for
whom this medication is prescribed as stent stenosis can happen in as little
as a week if this medication is not taken every day as prescribed.
 All Lower Mainland patients will be referred to Cardiac Rehab/ Healthy
Heart Program. This process is completed by the CNL/CN and involves a
phone call to the Cardiac Rehab Clinic with the name of the patient(s) being
discharged. An appointment is set up at this time and can be customized to
meet patient needs. For example, if the patient only speaks Cantonese they
can be referred to the cardiologist who speaks Cantonese, or if the patient
saw a particular doctor while in hospital, they can have their follow up
appointment set up with that doctor. Each patient is given a brochure for
Cardiac Rehab with the time of their appointment on it. Nurses are still
required to enter a referral to Cardiac Rehab in SCM.
 All Northern Health patients can be referred to a personal education
support system, including access to Healthy Heart, called the Heart Manual
Program. The RN introduces the program to the patient and if the patient
agrees, the RN’s gives the patient the information card and calls the referral
line and leaves patient information. The patient will then receive a call back
with more information. The brochure and phone number are located in the
cubby across from the narcotic cupboard.
 If the patient does not fall within one of these areas, they need to go
through their GP to get a referral to Cardiac Rehab.
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References
Barwon Health Centre for Education & Practice Development. (2008).
Femoral Artery Sheath Management. Geelong, AU.
Dressler, D., & Dressler, K. (2006). Caring for patients with femoral
sheaths. American Journal of Nursing 106 (5), 64A-64H.
Ford, S.A.(2008). Determining best practice: Removal of femoral arterial
sheaths. Thesis (PhD). University of South Carolina.
Galli, A., and Palatnik, A. (2005). Ask the Experts. Critical Care Nurse,
Vol 25, pp. 88-95.
Korjack, E., and Degges, M. ( ). Cardiac Invasive Procedures: Pre- and
Post-Procedure Care. Retrieved April 1, 2011 from http://ce.nurse.com/CE17860/Cardiac-Invasive-Procedures-Pre-and-PostProcedure-Care/
Lins, S., Guffey, D., VanRiper, S., Kline-Rogers, E. (2006), Decreasing
vascular complications after percutaneous coronary interventions, Critical Care
Nurse, Vol 26, No. 6, December, pp. 38-46.
MacRury-Sweet, K. (2011). Learning module for late arterial and venous
sheath removal. Capital Health, Alberta.
O’Grady, E. (2002). Removal of a femoral sheath following PTCA in
cardiac patients. Professional Nurse, 17 (11) Retrieved July 18, 2006 from
http://www.professionalnurse.net/nav?page=pronurse.editorial.cardiaccare&gr
idPage=9
Puma, J., et al (2006). Clinical characteristics predict benefits from
eptifibatide therapy during coronary stenting. Journal of the American College
of Cardiology, Vol. 47, No. 4, pp. 715-718.
Schueler, A. & Shaffer, R (2001). Arterial and venous sheath removal.
In Lynne-McHale, D.J., & Carlson, K.K. (Eds). AACN Procedure Manual for
Critical Care. 4th Ed. (pp.484-488). Philadelphia: W.B. Saunders Company.
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Case Studies
It is 1530 and your patient, a 64 year old man who underwent a PCI around
1420 this afternoon, returns to 5B post sheath removal. His baseline vitals
include BP 109/74, HR 60 (paced), RR 16, and Temp 36.5. Hemostasis was
achieved at 1510, he is on bed rest, and allowed to ambulate at 1910. You go
in to assess him. What specifically will you assess? What are your instructions to
the patient during his bed rest?
It is now 1820 and your patient rings his call bell. You go in to see him and he
says it feels “wet” at the access site on his leg. You check his groin and see
that his access site is bleeding (soaked through the dressing and there is a 9
inch section of his pad covered in blood). What are your interventions at this
point?
As you are applying manual pressure to the site, the patient says he feels
nauseated and light headed. You notice he is pale with a blood pressure of
60/40. His pulse remains paced at 60 bpm. What do you do? What do you think
is happening?
Your interventions help with your patient’s symptoms and his bleeding has
stopped. At what time is it okay to ambulate this patient again?
What teaching will you provide to this patient before he goes home?
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Mr. D is a 70 year old with a history of shortness of breath for the last eight
months and is here for investigation of his symptoms. Other medical history
includes remote kidney stones, hypothyroidism, DMII. VS post angiogram are BP
114/87, HR 102 and irregular, resps 17, SpO2 98% on RA, afebrile. He
underwent an angiogram 3 days ago that showed triple vessel disease (RCA
occluded) and an EF of 10 - 20 %. His echo showed dilated cardiomyopathy.
He is also in uncontrolled atrial fibrillation 92-115 bpm. He is awaiting a MRI to
assess viability.
Current medications include Heparin Standard Protocol (at 28 cc/hr),
furosemide 40 mg IV bid, carvedilol 6.25 mg bid, ramipril 2.5 mg daily,
simvastatin 40 mg daily, ASA 80 mg daily, spironolactone 25 mg daily,
potassium chloride 40 mEq bid, sliding scale insulin, levothyroxine 75 mcg
daily.
This morning Mr. D complains of a sudden onset of left flank pain, waxing and
waning, at about 8 out of 10 on the pain scale. He says it is similar pain to the
pain he had with his kidney stones. His VS are BP 80/69, HR 108 irreg, resps 19,
SpO2 98% on RA. What do you think is going on?
What would your interventions be for Mr. D?
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Mrs. T, 56 years old, is an outpatient who has come to SPH for an angiogram.
She is here for investigation of a two week history of chest discomfort. Her
history is negative for any cardiac disease but she suffers from depression and
is on a SSRI medication. Her VS post procedure are BP 135/75, HR 69, resps 16,
SpO2 98% on RA, afebrile. She is admitted to 5B awaiting discharge at 2100.
Following a PCI with stents to her LAD and circumflex arteries her compression
device was removed at 1600 and it is now 1730. Her VS when she arrives on
the unit are BP 130/77, HR 67, resps 16 and satting well. She is on bed rest
until 2000 and her husband is with her.
It is now 1815 and Mrs. T. rings her bell. You go in and she tells you she is
having chest pain and how can that be after she just had a stent put in. What
are your interventions?
VS are BP 146/79. HR 84, resps 20, afebrile.
It is now 1820 and you ask Mrs. T. how her chest pain is and she says it’s not
any better; in fact it is worse now than before. Her husband says she’ll be okay
and she can take some Tylenol when they get home. What are your next steps?
What do you think is going on?
What are your interventions for Mrs. T.?
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