fem-pop bypass

[nunursetoo]

Hi , just got a call at home from nurse who assumed care of my group of patients on day shift (i work nights). I had a pt who had a fem pop bypass and is two days post op. when I assessed her last night she had palpable pulses bilaterally dp & pt to both feet. I did notice that the operative leg had stronger palpable pulses but the other non operative leg was definitely palpable. Auscultated with doppler also and were audible slightly monophasic in the non operative left pt. Anyway the day nurse called me at home and said that the pulses in the non operative foot are non palpable now and foot is cold. said she just wanted to make sure that i did actually have positive pulses last night. I'm sure that she had positive bi lateral pulses last night but now i'm worried sick for the pt and I felt like the nurse was sort of putting blame on me. she said she found that the pulses were negative in non op foot @ 3pm it seemed to me she should have assessed the pulses @ start of her shift. I'm also a new nurse and pretty paranoid about making mistakes or missing things! Just needed to vent - Does anyone have any info on why the non operative leg would have absent dp and pt pulses when the operative leg has great pulses? And do you think im out of a job!!

[meownsmile, BSN, RN]

I dont think you are out of a job. The nurse that called you should have been in there long before 3pm and checked those pulses, capillary refill and warmth of extremity. We do circ checks on fem-pop bypasses at least every 4 hours because normally we are doing vitals q4 on a patient that close postop.

She could be trying to push off her lack of prioritizing on you but as long as you charted your findings, charted that you also doppled and noted capillary refill and whether the extremity was cool or warm to touch you have done your job. But anyway,, hadnt the physician been in there to see the patient or was HE really the one who found the circulation was inadequate. Maybe she had been in and "done" her assessment and was trying to corroborate hers with your assessment. She's probly the one in the hot seat.

[begalli]

Does anyone have any info on why the non operative leg would have absent dp and pt pulses when the operative leg has great pulses?

First, your assessment documents your findings. If anyone is culpable for not noting a pulseless extremity or a change in doppler/palpable findings, it would be the oncoming nurse who did not assess her patient.

As far as what could cause the other extremity to lose pulse? I wonder if the femoral artery was first opened via PTA (percutaneous transluminal angioplasty)? This is sometimes the case with the many vascular patients we receive in the ICU following vascular bypasses. Since they enter through the oppsite side for the PTA, there is a risk of occlusion of the opposite artery. Both limbs have to be watched carefully.

Also, did the patient at any time have a line in the right groin? Frequently PVD patients have such terrible access, lines (cvc's or art lines) have to be placed in the giant vessels. Of course there's always the complication of occlusion, spasm, or stenosis in this case.

Those are just a couple of ideas. So many things can happen to folks with PVD when they're lying in a hospital bed. Infection, clots, stenosis, vascular or arterial spasm, etc, being a big problem with these patients. I'll bet if you asked the docs, they would not be surprised that the "good" leg is now compromised.

Here's a really good description of fem-pop bypass and PTA:

http://www.stanfordhospital.com/healthLib/greystone/heartCenter/heartProcedures/femoralPoplitealBypassSurgery.html

I will add that usually after a bypass like this the "bad" leg becomes the "good" leg as the problem has been taken care of and bloodflow restored. It's not unusual for the pulses of the unaffected leg to seem highly diminished in comparison to the surgically repaired leg.

As long as you do your assessments, have confindence!

[barefootlady, ADN, RN]

Great post Galli. Your explanations were wonderful. I would hope a day shift nurse had made 2 assessments by 3 PM on a post fem/pop less than 72 hours old. If someone is in the hot seat it would be that nurse if you have charted all findings and included a doppler assessment. We always did q 4 hours x 72 hours unless ordered otherwise. If there was continued edema, drains present, bleeding, or bruising we continued it for at least another 24 hours or until doctor gave other order. I hate to say this, but if she was behind in her assessments then she should have informed the CN, so CN could make an assessment of the patient. Being new it's difficult to always get the routine down pat, but that does not mean it is not done, it means you ask for help. I am sure you will not be in trouble if you did all you say you did and charted it.