Same post, different Specialty

  1. Hi All,
    I'm new to this specialty, but also been awhile since I've had time to get back on Allnurses.com. good to see you all again. I write today because I am seeing more and more post angio cath pts on my medsurg/dialysis unit. My question to you all is this:

    When a pt is brought to my unit for his/her post op 4-6 hr bedrest and assessments how should I be assessing the cath site for hematoma?
    I have heard everything from keeping the sandbag on and vigorously massaging to prevent blood clots, to gently palpating to assure it's simple ecchymosis and not creating hematomas and/or bleeds to visually assessing to assure the pressure dressing remains C/D/I.

    Lastly, is this assessment any different from a post angio cath vs a post stent placement? (stupid question?)

    Sorry for all the mult questions, but my unit can't seem to answer me!!

    Thanks!
    Chloe
  2. Visit Chloe'sinNYNow profile page

    About Chloe'sinNYNow

    Joined: Aug '05; Posts: 560; Likes: 155
    "New Grad" (job hopped the 1st yr); from US
    Specialty: Did the job hop, now in MS. Not Bad!!!!!

    4 Comments

  3. by   dianah
    Chloe, welcome back to AN!

    In our Cath Lab (and that's where I work, not in post-procedure unit, so that's my focus) we do not use sandbags or heavy pressure dressings.
    Rationale: some nurses will not remove the sandbag to visually inspect the site and re: pressure dressings: we want to know immediately if the site is bleeding, not wait till a dressing is saturated.


    Our MDs and Fellows (and Fellowettes ) use either
    * Clo-Sur P.A.D. (topical, when seal is contraindicated) -topped with a 4X4 and
    Tegaderm
    * AngioSeal - topped with a band-aid
    * Mynx (we're starting to use this more, as the Fellows are trained)- topped with a
    band-aid

    Along with VS and distal pulse and extremity assessment, we assess the groin for hematoma by gently palpating 3-4 cm around the puncture site. Site should feel soft (feel of the other side, to compare). Hematoma will feel firm and you'll feel distinct edges where it ends, then the tissue beyond will feel soft.

    If the pt has a dressing, yes you would visually inspect it for C/D/I. I would also peek under the dressing to see if there is any bleeding onto it, and would also palpate as close to the puncture site, again feeling for firmness/hematoma.

    You can do a search for "post cath groin assessment" and see what other places are doing; I found the following w/a search:

    http://nursing.uchc.edu/unit_manuals...e%20Device.pdf


    Peds: http://www.westernchildrensheartnetw...ar.27.2008.pdf

    Slide show: http://www.slideshare.net/California...-complications


    Good questions, keep asking!
    Since you're seeing more and more post-cath pts come to your dept, you might tap into the MDs/Fellows' knowledge by having them give your dept an inservice on post-cath groin care and assessment.
    You may also contact the vendors of whatever closure devices you're seeing used, as they're very happy to come out and inservice on their product.

    Good luck!
  4. by   Spatialized
    Quote from Chloe'sinNYNow
    Hi All,
    I'm new to this specialty, but also been awhile since I've had time to get back on Allnurses.com. good to see you all again. I write today because I am seeing more and more post angio cath pts on my medsurg/dialysis unit. My question to you all is this:

    When a pt is brought to my unit for his/her post op 4-6 hr bedrest and assessments how should I be assessing the cath site for hematoma?
    I have heard everything from keeping the sandbag on and vigorously massaging to prevent blood clots, to gently palpating to assure it's simple ecchymosis and not creating hematomas and/or bleeds to visually assessing to assure the pressure dressing remains C/D/I.

    Lastly, is this assessment any different from a post angio cath vs a post stent placement? (stupid question?)

    Sorry for all the mult questions, but my unit can't seem to answer me!!

    Thanks!
    Chloe
    :yeahthat: Pretty much what Dianah said.
    We don't use sandbags as studies have shown that the weight distribution is too large for adequate control of a bleeder. If you get a bleeder, direct pressure just above the site (remember you anatomy...) for about 5 minutes then reassess. For our stent/intervention patients it is pretty much the same. You may have a higher amount of bleeding issues as the standard is to give antiplatelet meds post-stent as well as meds during the case. Typically our stents were coming back with orders for 300mg of Plavix on arrival to the floor, but I hear that has jumped to 600mg.

    Just keep a close eye on your pulses and any signs of bleeding at the site. A large increase in pain, above and beyond what the patient may have been having previously may be a sign of a further complication, like a pseudoanuerysm or retroperitoneal bleed. Also with your intervention patients, there is still the possibility that they may have additional blockages or in-stent stenosis while fresh out from the lab. On-going chest pain while somewhat expected (see microembolic phenomenom and clot wash-out), pain that doesn't go away or gets worse needs to be attended to.

    Lastly, sometimes, I've found that the Angioseals tend to ooze, not sure if anyone else has had this issue. Also, closure devices can fail and you need to know what to do in that case.

    Cheers,
    Toms
  5. by   Nurse_Miami
    Hi All,

    We previously had some of the same issues you guys have mentioned and recently switched over to the Clo-Sur plus PAD. I believe it is the same product Dianah mentioned, but has an antimicrobial barrier. We were specifically having issues with oozing from the Angioseal especially with pt's on high ACT's. The pad worked with ACT's up to 250 ( we try no to pull if they r that high -200 prefered) and in diagnostic case 300+. There was hemostasis on average in 7-10 minutes ( We held 15 to be safe with high ACT's) and were ambulating in 2 hrs. These pads have helped us out with keeping the patient comfortable and I didnt have to sit holding manual compression.
    Hope this helps
    -Miami
  6. by   al7139
    Hi, I work on a Tele/med unit, and we get post cath patients with or without percutaneous interventions (i.e. stenting).
    First, there are lots of different closure devices for the insertion site, which is usually the groin, but sometimes they use the brachial in the arm. For each device the bedrest time is different.
    We use 3 most commonly at our hospital.
    Boomerang- has a coagulant on the tip, which decreases bedrest (usually 2-3 hours) and decreases hold time (the time pressure is held manually after pulling the sheath). The coagulant also assists in healing.
    Syvek- same bedrest and hold time as the boomerang.
    Angioseal- bedrest is 5-6 hours. It is a collagen plug that is absorbed in the body within 90 days. This hold time is 20 minutes.
    We RARELY use sandbagging at the hospital, and sheaths are not pulled on our unit. They are pulled in the cath lab or ICU by nurses with special training to do this.
    As for what we assess:
    We look at the site: is it swollen? is there bruising? is the dressing C/D/I, or is there drainage? Is the drainage old (dried, brown) or is it fresh (bright red)? If there is drainage, how much? Is the dressing saturated, or just spotted?
    We also palpate the site. It should be soft,andnon or mildly tender.
    Also palp distal pulses. They should be equal and the same as pre cath.
    Palpation of the cath site will tell you if there is a problem. Here are a few:
    A firm raised area with or without bruising that is very painful with definite edges you can feel means there is a hematoma, and it may still be bleeding. We mark the edges and hold pressure 2-3 cm ABOVE the insertion site until the bleeding stops or the hematoma is not getting bigger. Watch VS, and keep B/P <150/80. Check B/P every 5 minutes. Insert a foley to keep the bladder empty because a full bladder can keep pressure at the site in the wrong place and cause more bleeding. Call your MD. Give pain meds if needed.
    *Some pain at the site is expected, but should be mild, not severe.*
    A patient can have a rebleed (the insertion site opens and starts bleeding), evidenced by pulsatile bleeding, not a steady stream. It looks really scary, and the patient CAN bleed to death if not caught, but is easily managed. Hold pressure above the site (2-3cm), and manage B/P as above until bleeding stops. Call for assistance, do not leave patient. Notify your MD. I usually get an order for extended bedrest no matter what closure device was used, because of the patients increased risk.
    A vasovagal response to pressure on the femoral artery is evidenced by nausea, bradycardia, and hypotension. This can happen with a hematoma. Treat with Atropine 0.6mg IVP, IV fluids, and trendelenburg. Obviously call your Doc for further orders.
    The worst post cath complication is the hardest to diagnose unless you know about it: that is a retroperitoneal bleed. This is BAD! The patient is bleeding into their abdomen and you may not see bruising, etc. It is caused by the catheter piercing the artery at any point in the body, not just at the insertion site.
    The patient will have vague complaints of abdominal or lower back pain.
    There will be sudden signs of shock (hypotension, tachycardia, diaphoresis, pale skin, possibly nausea, anxiety).
    Hold pressure 2-3 cm above the site as always.
    Check B/P every 5 minutes.
    Start fluids wide open.
    Notify your Doc STAT! This is a MAJOR emergency! If your hospital has a medical response team for emergencies activate it for further assistance in treatment.
    Also it is not normal for the limb to be cold without palpable pulses. Both limbs should be equal in pulse strength, and temp (unless there is another disease process, in which case they should feel the same as they did pre cath). Is is also not uncommon for a patient who has had a stent placed to feel some chest pain after the cath. This is caused by cardiac tissue reperfusion (similar to when your foot falls asleep, then starts to wake up again). Post cath chest pain should, however never be assumed to be normal, because it can also be a sign that the stent has clotted, which is an emergent situation. Other side effects of this are diaphoresis, and hemodynamic instability (high B/P), and chest pain that increases. If it is normal reperfusion the chest pain will stay the same and resolve itself over the next 12 or so hours. Either way tell your MD.
    Lastly to answer your last question:
    Stenting is when a device is used to open up a blocked coronary artery. This is known as percutaneous intervention. An angioseal is a closure device used to close the insertion site where the cardiac catheter is inserted. Most of the time it is a femoral artery, but sometimes they use the brachial artery in the arm. So, you can have a post angiocath without a stent, and you can have a stent with a different closure than an angioseal.
    I hope this helps.
    Amy

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