Page 478 - Cardiac Nursing

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454 P A R T III / Assessment of Heart Disease
Lower complication rates were noted with experienced opera- tensive care unit depending on the type of procedure done and
tors and the use of a smaller catheter size (6 Fr or less). Higher the patient’s condition. In most facilities, patients undergoing di-
complication rates were noted in patients having right and left agnostic catheterization are cared for in an observational unit,
heart catheterizations, use of catheters greater than 6 Fr, and in- such as an ambulatory care unit or same day surgery unit, for up
creased vascular complications in patients with higher body to 6 hours and then discharged if stable. Patients who have un-
34
weight. Although complications are rare, they do occur and may dergone interventional procedures often stay overnight and are
be life threatening. Early detection and intervention are essential cared for in a telemetry unit or interventional cardiology unit
in prevention. where nurses are specially trained and experienced in postproce-
Local vascular problems at the catheter entry site are the most dure care and have more in-depth knowledge of cardiovascular
commonly seen complications after cardiac catheterization proce- drugs, arrhythmia interpretation, advanced cardiac life support
dures. These problems include minor or major oozing, ecchymo- skills, and management of access sites. If the patient is hemody-
sis, hematoma, or poorly controlled bleeding at the puncture site. namically unstable or has a complication of the procedure, such
Other vascular complications that are less common are vessel as MI, severe respiratory distress, acute or threatened vessel clo-
thrombosis, distal embolization, or dissection, pseudoaneurysm sure post-PCI, tamponade, unstable arrhythmias, or requires
and arteriovenous fistula. A complete list of complications is dis- close observation or intensive nursing care, he or she is trans-
cussed in Chapter 23. ferred to an intensive care unit.
Ventricular arrhythmias occur in response to catheter manipu- After a diagnostic procedure, the femoral arterial or venous in-
lation or contrast medium injection and tend not to recur after troducer sheaths are removed and manual or mechanical pressure
the predisposing stimulus is removed. Atrial and junctional ar- is applied to the access site until hemostasis is achieved. Com-
rhythmias and varying degrees of blocks also occur in response to pression devices or vascular closure devices may be used to achieve
these stimuli. Bradycardia is common in response to injection of hemostasis after a diagnostic or interventional procedure (Chap-
the coronary arteries with contrast or during sheath insertion or ter 23). For interventional procedures in which extensive antico-
removal. agulation was used or IV antiplatelet therapy (i.e., glycoprotein
Allergic reactions to the contrast medium may occur. Sneezing, IIb/IIIa receptor inhibitors) is to be continued for several hours,
itching of the eyes or skin, urticaria, bronchospasm, or other be- the sheath is often left in place until the activated clotting time is
ginning signs of allergy are treated with antihistamines and corti- below a critical level and then removed by either catheterization
costeroids. Anaphylactic reactions are treated with intramuscular laboratory staff or nurses in the postprocedure unit. Nurses caring
or subcutaneous (SQ) epinephrine (1:10,000 concentration), for patients after cardiac catheterization must be prepared to per-
aminophylline, steroids, an antihistamine (diphenhydramine), va- form sheath removal according to institutional policies and guide-
sopressors, and wide-open normal saline IV to support blood lines, and must be able to recognize complications associated with
pressure. For patients with increased risk of an adverse reaction to this procedure. 36–38
contrast medium, low-osmolar, nonionic contrast agent and a pre- After returning from the laboratory, the patient must be thor-
medication strategy including corticosteroids have shown a reduc- oughly assessed. Information about the approach used, the proce-
tion in adverse reactions. Contrast reactions can occur despite pre- dures performed, and any complications experienced during the
medication strategies and the staff must be prepared to treat an catheterization should be obtained from the physician, nurse, or
anaphylactic reaction. Patients with known or suspected allergies technician. Display 20-3 lists typical postcatheterization proto-
to iodine-containing substances, such as seafood or with a prior cols. The elements of the nursing assessment and intervention and
allergic reaction to radiographic contrast, should be pretreated potential findings are listed and explained in the following sec-
with prednisone from 24 to 48 hours before contrast injection. tions.
Premedication consists of an H 1 antihistamine (diphenhy-
dramine) or occasionally an H 2 blocker (cimetidine or raniti-
dine). 16,35 Psychological Assessment and Patient
The catheterization laboratory nurse must be familiar with Teaching
IABP set-up and management, because the IABP is often used Patients are often tired, hungry, and uncomfortable when they
when patients become hemodynamically unstable during a return from the laboratory. They are usually relieved that the
catheterization procedure (Chapter 26). The nurse must also be procedure is over and may already know the preliminary find-
familiar with other equipment used in the laboratory—IVUS, ings of their study. This news may be good or bad, and it is im-
Doppler and pressure wires, balloon catheters and stents, portant to find out what the patient has been told and what this
thrombectomy devices, and atherectomy equipment. Additional means to the patient. The patient may have questions about sur-
skills include access site management, including sheath removal, gery or about what to expect next. Some patients are anxious or
manual pressure for hemostasis, and use of closure devices or depressed. Giving patients the opportunity to express their feel-
FemoStop for hemostasis, and a thorough knowledge of drugs ings about the procedure helps to calm and relax them. Reassure
commonly used during a procedure, such as heparin, bi- the patient by describing the sensations that can be expected,
valirudin, low-molecular-weight heparins, glycoprotein IIb/IIIa such as thirst and the frequent need to urinate although the pa-
receptor inhibitors, antiarrhythmics, vasoactive drugs, and drugs tient has had nothing to eat or drink for several hours. Reem-
used for procedural sedation. phasize the need for bed rest and the need to keep the catheter-
ized limb immobile. Let the patient know that frequent
Postprocedure Care checking of vital signs is routine and not a cause for alarm. Be-
fore hospital discharge, the patient should be instructed regard-
After the procedure, the patient may be transferred to an obser- ing symptoms for which to call the physician and procedures for
vation unit, telemetry unit, interventional cardiology unit, or in- site care (Display 20-4).