Potential Sheath Removal Issues - Assignment Example

Potential Sheath Removal Issues Potential Sheath Removal Issues Introduction Angioplasty relates to a procedure done to improve blood flow in the arteries and veins. This procedure is minimally invasive. The procedure involves insertion of a balloon-tipped catheter into the blood vessel to the narrowed or blocked section where the balloon is then inflated to open the vessel. A bare stent or stent graft may be placed in the blood vessel to keep it open. They are usually placed and expanded inside the artery or vein to prop the walls open. Angioplasty and stenting are used to treat narrowing or blockage of arteries or veins in the body. The blockage may be attributable to conditions including atherosclerosis, coronary artery disease, peripheral artery disease (PAD) and renal vascular hypertension. Carotid artery stenosis, venous narrowing and narrowing in dialysis fistula or grafts can also result in blockage. Patient preparation is essential. Medications, herbal supplements, recent illnesses, medical conditions and allergies should be well documented (Benson et al. 2005). This is because the procedure involves anaesthesia and iodine in the x-ray dye. Medication used especially blood thinners, nonsteroidal anti-inflammatory drugs and aspirin should be reported. The procedure involves imaging using radiation. It is, therefore, essential that women be examined for pregnancy to minimize radiation exposure to the foetus. Before the procedure, patients are restricted to eat or drink except medication. The procedure involves the use of several equipment a balloon catheter, stent, sheath, wire guide and x-ray imaging equipment. The imaging procedure applies the principle of fluoroscopy to develop an angiograph (O’Grady 2002). During the procedure, the guide wire directs placement of the angioplasty balloon catheter and the vascular stent. The sheath is used for catheter exchanges during the procedure. A vascular tube is placed to allow catheter exchanges and is usually removed after the procedure by a nurse. The procedure is executed in an interventional radiology suite by an interventional radiologist. Femoral Artery Angioplasty and Stenting Seldinger technique is the preferred technique for percutaneous catheterization of the femoral artery. It is effective for both arterial and venous access. Although a radial approach is applicable, the femoral approach is the most preferred method. In this procedure, the ideal puncture site is the femoral artery (Berry 2004). The femoral stick is well located to avoid surgical complications. The puncture site is precisely selected to avoid complications associated with the surgical procedure. It is never at or above the inguinal ligament and avoids the point at which the femoral artery divides into its profunda and superficial branches (Ragosta 2010). This ensures ease of catheter advancement and avoids complications that arise after the procedure including hematoma formation, inadequate compression, retroperitoneal bleeding, pseudoaneurysm and thrombotic occlusion. Haemodynamic measurements are performed by advancing the catheter through the femoral vein to the right side of the heart. The procedure commences with the administration of a local anesthetic. The femoral artery sheath, which is usually 1.35-2mm, is then introduced. With the sheath in place, a guide wire is introduced. It guides the angioplasty balloon catheter through the sheath into the femoral artery and up into the aorta. The balloon then gets inflated to open the vessel. Stenting is also guided through the sheath. After completing the procedure, the catheter, there is the removal of the sheath left in place (Chlan, Sabo, & Savik 2005). It is removed four hours after the administration of heparin when the anticoagulants levels drop to an optimal level. The nurse usually carries out this part of the procedure. The catheter in cardiac catheterization is advanced in a retrograde direction up the aorta (Peet et al. 1995). It is advanced around the aortic arch and then goes into the Ostia or across the aortic valve into the left ventricle. Management of Patient with Femoral Artery Sheath Following femoral artery angioplasty and stenting the patient is moved to the Cardiac Cath Lab (CCL) for observation and care. The handover to the RN is a crucial point and communication is vital for the transition to care. The information is exhaustive and should include the surgical procedure performed, and medication administer before, during and after the procedure. Once the patient is in the Cardiac Cath Lab the nurse should monitor them closely. They should periodically check intravenous (IV) infusions and rates and adjust them accordingly (Dressler, & Dressler 2006). The rates should always be as prescribed. The nurse should look out for signs of complications that arise from the procedure including hematoma formation, inadequate compression, retroperitoneal bleeding, pseudoaneurysm and thrombotic occlusion. These should be promptly reported for immediate intervention. Pedal pulses and vital signs should be monitored. The patients comfort should be inquired including pain, chest discomfort and shortness of breath. The femoral artery sheath removal procedure follows the femoral artery angioplasty and stenting. Therefore, while the patient is in the Cardiac Cath Lab it essential to monitor drug levels and time of administration to determine the time of sheath removal (Hamel 2009). One key factor is heparin. It is vital that the dose, as well as the time of administration, is documented (Woods 2005). Before the femoral artery sheath removal procedure, the patient is allowed to sit up to 45°. However, when the patients experience bleeding, they should be directed to lie flat. The bleeding is controlled with manual pressure or by using a FemoStop. In case of chest pain, the 12 Lead ECG should be recorded and reported to the cardiologist. The documentation prior to the femoral artery sheath removal procedure should therefore include vital signs, sensation, color, warmth, movement and pedal pulses of the leg, and tenderness, swelling, bleeding and pain at the insertion site. Urine should also be monitored. The patient should be kept in normal saline, Reopro or Tirofiban, and GTN infusions as ordered. However, the patient must not eat and can only take oral fluids and medication. A RN or a medical officer usually performs the femoral artery sheath removal procedure. Before the procedure, they should confirm from the documentation the time last heparin dose and sheath removal. The equipment should be sterilized and prepared. These include sterile gloves, gauze, a Doppler, the FemoStop pack contains belt, bubble and 3-way tap and FemoStop arch and hand pump. Emergency drugs, atropine, normal saline and lignocaine should be kept nearby. The procedure for femoral artery sheath removal is first attaching the bubble to FemoStop arch, followed by attaching the pressure manometer to 3-way tap and connecting it to the bubble. The FemoStop bubble is inflated 280mmHg, and the 3-way tap turned off. The sheath is cleaned with normal saline. A Doppler assesses the peripheral pulse. This allows the nurse to determine the pressure to apply to obliterate the pulse. The belt is attached first to the left side of the FemoStop arch. The FemoStop dome is centered on the puncture site (Jacobson et al. 2007). FemoStop belt is used to ensure the arch is parallel to the pelvis. The belt is now attached to the right side of the FemoStop arch. The Doppler is again used to assess the pedal pulse, and it is occluded by applying manual pressure on the right side of the FemoStop arch. The sheath is removed in the direction parallel to the leg while occluding the pedal pressure. Occlusion is maintained for three minutes by tensioning the right side of the belt and the pluses then partially reintroduce (Turi 2008). Partial compression of the femoral artery is maintained for twenty minutes, assessed, and monitored using a Doppler (Lehmann, Heath-Lange, & Ferris 1999). The pressure is then gradually reduced, and the bleeding monitored. When no bleeding or hematoma is observed, pressure is released completely. This time is documented as the time of haemostasis. Bleeding or hematoma is monitored and if it arise it is controlled by the FemoStop (Capasso 2006). The patient is directed to keep the leg at rest for six hours. The observations post femoral artery sheath removal procedure should include vital signs, sensation, color, warmth, movement and pedal pulses of the leg, and tenderness, swelling, bruising, bleeding and pain at puncture site. Management of Patient Post Haemostasis It is essential to monitor the patients vital signs carefully. After two hours of lying flat post haemostasis, the patient may be allowed to sit at a 45° angle when they are determined to be haemodynamically stable (Baim & Simon 2006). They are however directed to keep the leg straight. This is so as to prevent hematomas, bleeding and dislodgement of clots. Food is slowly reintroduced starting with light snacks. Mobilization is reintroduced after six hours from the time of haemostasis. The patients are monitored by telemetry overnight. Complications Complications may arise following femoral artery angioplasty, stenting, and sheath removal. It is crucial that they are promptly addressed. The complications include: Vasovagal. The patient’s heart rate may slow down hence causing a drop in blood pressure. This is a result of stimulation the vagus nerve by anxiety, discomfort, pain and pressure in an artery. The patient usually presents with, constant yawning, pallor, and nausea. If it remains untreated, it results in shock (Kussmaul et al. 1995). The patient should be administered atropine infusions and fluids, oxygen, and the bed tilted to lower the head. Bleeding. This is concerned with arterial bleeding as opposed to superficial soft tissue bleeding that can be easily controlled with pressure. Arterial bleeding leads to major loss of hemoglobin and may require a blood transfusion (Kugelmass 2006). A ruptured false aneurysm manifests as hypotension, back pain and bruising since it bleeds into the retroperitoneal area and should be attended to immediately. Hematomas. They are usually firm swellings with defined boundaries caused by bleeding in the soft tissue. Large hematomas may cause edemas. This can result in lost sensation, movement, and obstructed blood flow. They then develop into false aneurysms. Blood leaking from the artery into a cavity causes pseudoaneurysm (King, Philpott, & Leary, 2008). They in turn cause lost sensation and movement by compressing. Thus, causing neuralgia and obstructed blood flow. Pseudoaneurysm may rupture causing bleeding. They are treated using thrombin injection, compressions, and surgical closure. Arterial Occlusion. Arterial Occlusion also relates to Ischaemic Limb. A clot may form in the femoral arterial. This may then affects sensation, causes diminished pulses coolness and pallor. They are controlled using neurovascular observations. Infection. Like in many surgeries, infection is a key concern. It is manifested as redness, heat and puss discharge. The region should be monitored, and any concerns reported. The patients are usually discharged the following day after successful femoral artery angioplasty, stenting and sheath removal. Patient education is essential to avoid complications after discharge (O’Neill 2006). They should be advised on accurate medication use, drug interactions, smoking, and alcohol intake, monitoring potential complication, cleaning, and dressing of the site (Doyle et al. 2008). Follow-up visits with a general practitioner and the cardiologist should also be arranged. The patients should also be advised of the benefits of Cardiac Rehab sessions. Focus on the Case Study The case study exemplifies the proper procedures of femoral artery angioplasty, stenting, and sheath removal. The paramedics administered a loading dose of IV Morphine to Elizabeth on the route, and she continues to have IV Morphine administrated as per chest pain A GTN infusion is commenced at 1ml/hr. once she was at the hospital. Once Elizabeth was in the Emergency Department, she was quickly examined by the Cardiac Registrar, Dr. Burgon and scheduled for an Angiogram. Investigations and medications are carried out including CBE, U&E, INR, APTT, Fasting Lipids and Glucose, Troponin, Blood Gas, Platelets and Fibrinogen tests, 12 lead ECG and Urinalysis. She is also put on GTN infusion and Clopidogrel, and IV Morphine continued. Elizabeth is then transferred to the Cardiovascular Investigation Unit (CVIU) where a femoral angioplasty is performed, and blockage in her left anterior descending artery is successfully stented. In the Angio Suite Recovery area to the Cardiac Care Ward where she is monitored. Monitoring points out a sign that may indicate a complication. Elizabeths left foot had remained pale and cool and that Dorsal and Pedal pulses were present. The Cardiologist performed a Doppler ultrasound on the left foot and determined that there was adequate blood flow emphasizes neurovascular observations (Sulzbach-Hoke et al. 2010). June, an RN removes Elizabeths sheath. After being monitored overnight, she is discharged the next day. The patient and the family are educated, and Elizabeth is advised about a cardiac rehab program. Follow-up visits with a general practitioner and the cardiologist are also be arranged. This case study shows efficient medical care by the nurses and doctors. The patient information is well detailed and comprehensive. Bibliography Baim DS, & Simon D., 2006, Percutaneous approach, including trans-setal and apical puncture in: baim ds, ed. grossman’s cardiac catheterization, angiography, and intervention, Philadelphia, PA: Lippincott Williams & Wilkins. Benson, L., Wunderly, D., Perry, B., Kabboord, J., Wenk, T., Birdsall, B., Vanderbos, L., Roach, V., Goole, R., Crippen, C., Nyirenda, T., Rumsey, L. & Manguba, G.,2005, ‘Determining best practice: comparison of three methods of femoral sheath removal after cardiac inter- ventional procedures’, Heart & Lung, Vol. 34, no. 2, pp. 115-121. 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