Page 466 - Cardiac Nursing

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442 P A R T III / Assessment of Heart Disease
3. Nothing by mouth after midnight (or after a light breakfast if cludes an evaluation of the patient’s emotional status and attitude
catheterization is to be in the afternoon). toward catheterization.
4. Premedication with a mild sedative may be given. During the
procedure, a procedural sedation protocol should be 1. Is this the patient’s first cardiac catheterization?
followed. 2. What are the patient’s apprehensions about the procedure?
5. Patients with renal insufficiency should be adequately hy- 3. What has the patient heard about cardiac catheterization? (Pa-
drated before and after the procedure and a minimum tients have sometimes heard “horror stories” from friends or ac-
amount of radiographic low-osmolar contrast medium should quaintances about catheterization experiences and may, there-
be used. The combination of N-acetylcysteine and sodium bi- fore, need reassurance about the safety of the procedure.)
N
N
carbonate infusion before and after contrast infusion has 4. What decisions are being faced? (Patients may be facing good
shown to reduce the risk of contrast induced nephropathy in or bad news about the absence or presence and extent of dis-
patients with renal insufficiency. 15 ease. Thus, the period before catheterization most likely is a
6. Patients with a history of allergy to previous contrast admin- time of anxiety and fear for a variety of reasons. Discussion and
istration, asthma, or drug or food allergies with iodine- reassurance may help to relieve some of these feelings.)
containing substances should receive low-osmolar contrast The catheterization laboratory confronts the patient with
medium and pretreatment with steroids, antihistamine new sights, sounds, and experiences that may be intimidating
(diphenhydramine), and an H 2 blocker (cimetidine or raniti- and frightening. Teaching is aimed at preparing the patient for
dine) are also sometimes used. 16 this experience and should begin in the physician’s office. In
7. Patients who are fasting should take a reduced dose of insulin some institutions, patients are given a video to view before the
or hold dose as directed by physician. Oral diabetic agents are procedure. A printed booklet to which the patient can refer is
usually held the morning of the procedure. Metformin is held also helpful. The following points should be covered in patient
the day of the procedure and 48 hours after the catheteriza- teaching:
tion.
8. Anticoagulation issues are directed by the physician. Acetyl- 1. The patient is given nothing by mouth for 6 to 8 hours before
salicylic acid (ASA) and antiplatelet medications are usually the catheterization and is asked to void before arriving at the
given before catheterization. Warfarin is generally discontin- catheterization laboratory.
ued 3 to 4 days before the procedure until the international 2. Medication is given before or during the procedure, if pre-
normalized ratio is 2.0. Warfarin can be reversed with vita- scribed, but the patient is awake during the procedure.
min K or fresh frozen plasma. If the patient is receiving he- 3. The patient should be instructed in deep breathing, how to
parin therapy, heparin can be continued during the catheteri- stop a breath without bearing down, and in coughing on
zation and discontinued for sheath removal. request. With deep inspiration, the diaphragm descends,
9. Patient to void before going to catheterization laboratory. preventing it from obstructing the view of the coronary
10. There is no evidence-based data to support the prophylactic arteries in some radiographic projections. Bearing down
use of antibiotics. (Valsalva maneuver) increases intra-abdominal pressure and
11. Patients who wear dentures, glasses, or hearing aids should may raise the diaphragm, obstructing the view. After the
be sent to the laboratory wearing them. The patient is bet- injection of contrast medium, coughing is requested to help
ter able to communicate when dentures and hearing aids are clear the material from the coronary arteries. The rapid
in place. Glasses allow the patient to view the angiogram on movement of the diaphragm also acts as a mechanical stim-
the monitor and help keep the patient oriented to the sur- ulant to the heart and helps prevent the bradycardia that
roundings. may accompany the injection of contrast medium. 18,19
4. The appearance of the laboratory should be explained to the
patient, including the general function of the equipment.
Nursing Assessment and 5.The patient wears a gown to the laboratory.
Patient Teaching 6.The patient lies on a table that is hard and narrow.
7. The catheter insertion site is washed with an antibacterial
Nursing assessment and teaching are important parts of patient scrub and hair is removed using a shaver. Usually, both groins
preparation. The nursing assessment includes the patient’s heart are prepped to provide easy access to the other side for pa-
rate and rhythm, blood pressure, evaluation of the peripheral tients with peripheral vascular disease and obstructive disease
pulses of the arms and legs, and assessment of heart and lung preventing catheter advancement or sudden instability during
sounds. The sites for best palpation of the patient’s dorsalis pedis the procedure requiring an intra-aortic balloon pump (IABP).
and posterior tibial pulses are marked on the skin. This informa- The right groin is generally used because the operator stand-
tion will be used for comparison in evaluating peripheral pulses ing on that side of the table has easier access.
after the catheterization procedure. A procedural sedation assess- 8. The expected length of the procedure should be explained to
ment is performed, including assessment of the patient’s cardio- the patient (approximately 1 hour for coronary angiogram
vascular, respiratory, and renal systems. Care is taken to identify and 2 hours with PCI). Complex procedures will be longer.
characteristics or conditions that may cause the patient to be at 9. The patient is given a local anesthetic at the catheter entry
greater risk for complications associated with procedural sedation, site.
such as a history of difficult intubation; history of difficulty with 10. The patient may have warm sensation or experience nausea
sedation; morbid obesity; sleep apnea; extremes of age; severe car- during injection of the coronary arteries with contrast
diac, respiratory, renal, hepatic, or central nervous system disease; medium, most commonly occurring with the injection of the
17
and history of substance abuse. The nursing assessment also in- ventricle during ventriculogram.