Patient began bleeding from groin site....

[raindrop]

I work on a tele/med floor and had just received a patient who has 2 stents placed. The patient was began bleeding from the site around an hour after I got her. I applied pressure just above the site for 20 minutes and the bleeding subsided, no hematoma felt. Our unit does not use sandbags, so I just applied pressure manually.

Anyway, I wanted to page the MD to let him know what had happened. It was 0200 a.m., and I thought this is something the MD would want to know. Plus, she was due for a hefty dose of Plavix per protocol and I didn't know whether or not I should give it. I felt like this was a damned if I do, damned if I don't situation. If I give the Plavix, I will get introuble since she did bled (because she wasn't compliant with keeping her leg straight), or, if I don't give it, I will get in trouble.

The charge nurse told me she never calls the MD if a patient experienced bleeding that subsided. And she would just hold the Plavix and call him in the morning at around shift change because "he will be awake by then". I didn't understand her rationale, because she really didn't have one. I called him anyway, 2 x's actually, and he never called me back. I held the Plavix for 4 hours ....

what should I have done in this scenerio. When the patient bleeds, should I call the MD? ANything else that I should do aside from pressure and monitoring VS? And as far as the plavix??

New to tele and haven't had much training.

[MunoRN, RN]

We don't usually call the Doc for a re-bleed since their isn't much to be done about it from their end, although our tele floor gets a lot of post caths so re-bleeds aren't that unusual and we're pretty comfortable with dealing with them, if you weren't comfortable with the situation then calling might be in order, but not just for a 2AM FYI.

We would not hold the plavix for a re-bleed even if it is still currently oozing. Stents are at high risk for re-occlusion just after placement which is why plavix (and effient, integrilin, angiomax, etc) is so important. Even if it means holding pressure for longer, that's a small price to pay to avoid fully thrombosed stent.

[CCL RN, RN]

Never hold the plavix! Eegads...

You can hold pressure longer on the bleeding, place an immobilized on the pts leg to prevent bending, place a fem stop... Etc. These are the things to do to treat the side effects of plavix.

To treat the side effects of holding plavix, requires a trip back to the cath lab in the future to reopen those stents, or a heart attack.

Which is easier to treat, and best for your patient?

This is why we give plavix on the table. So these type of situations don't happen.

Plavix is the *only* thing keeping those stents open, and it takes a while for the dose to start working.

A clot may already be in the works. That pt may come back in the very near future. I don't mean to be an alarmist, but holding the plavix is the worst thing you can do.

Sounds like your charge nurse needs some re-education...

[nyrn5125]

Never hold the plavix after a stent. Restenosis of the stent can happen quickly. We have had to call in nurses from other units if we needed the help to hold manual pressure for way more than 20 minutes. You should have sandbags on your floor and if not send an aide to the cath lab to get you one. I would not have called unless they were losing excessive amounts of blood and i thought the groin needed closure. Oozing from the puncture site the MD is not going to want to be woken up for.

[surferbettycrocker]

i would check your policy if there is one honestly. where i used to work we would call docs for expanding hematomas. i have seen people vagal when having pressure held-be ready to hold that groin and get your nursing friends to deal with a hr in 30s' and bp in the 60's if need be. :redbeathe but this is just my if oozing stops then no harm no foul ig uess the doc enjoys his much needed nap