S/P Cardiac Cath question

[megananne7]

I had a pt the other night (med surg unit, specializing in ischemic CVAs). I had this pt the night before, she was admitted with "chest pain & syncope", but she denied any syncopal episodes to me. No c/o chest pain the entire time I had her. She was a direct admit from the MD office for work up.

Had a cardiac cath and came back shortly before my shift began. When I went to assess she was still sleepy from the procedure, c/o pain at the cath site 10/10. Took VS, stable... Checked the cath site, which was dry. Called the MD, who just ordered Toradol IVP.

Later that night, I transferred her to the cardiac floor (why wasn't she admitted there when she first came in anyway? We are a medical tele floor, not cardiac tele) b/c we needed a tele bed. In report, the nurse told me she shouldn't be having that much pain at the site. I mentioned this to my preceptor and she said it was OK b/c cardiac caths ARE very painful and in my assessment, there was nothing out of the ordinary.

I trust my preceptor because she's worshipped on our floor as she's been there the longest and knows everything about anything (so I've heard anyway!).

But did I miss something? Was there something else I should've done?

[shellsgogreen]

it depends on each case - i've had some pt's c/o pain at the site, and no complications noted, and others who don't complain of pain at all.

close monitoring of the patient, and f/u if the pain was relieved by the med, incl v/s plus i ensure that all peripheral pulses are palpable, especially the site distally.

[nurturing_angel]

I have experiened several cardiac caths as a patient and with the exception of the last one, had only a mild aching at the cath site. The last one I had complications with and had severe pain with for several weeks post op.

[BRK97]

There could have been an underlying complication starting that you may not have been able to see.

The only thing you could do was see if the medication worked or not and advocate for better pain control for your patient. If you are transferring care, it becomes the responsibility of the new nurse caring for the patient.

[glasgow3]

A report of pain 10/10 at the site post cath is in no way normal. I am surprised that neither the physician nor your preceptor believes otherwise.

Realistically, other than following your post cath orders to the letter including related documentation, and fully documenting your conversation with the physician, there is little more that a staff nurse could do. Obviously you would also document the patient's response to the physicians's order (Toradol).

That said, pseudoaneuryisms are not THAT uncommon post cath; Unless I knew something relevent about this particular patient's pain/drug history, if I were the physician I might start thinking about ruling out that potential complication via doppler or at the least ordering an H&H in 3-4 hours.

Under the circumstances you would want to carefully document what the site looked like just prior to transfer as to any visable swelling, lack of pulsation or bruit appreciated etc in order to CYA.

[BrokenRNheart]

This patient shouldn't have come back to you.

Pain of 10/10 is not common for cath site especially with her being sleepy.

Some people rate any pain as 10/10. I noticed that overweight people tend to rate the pain high. I worked PCU and never had a post cath with pain 10/10 at the site, even with a hematoma or bleed.

Did she have back pain? How were her vitals? Was there a lump or bruise?

During the time that you had her, with a rating of 10/10, I would think something would have gone bad and you would have learned real quick. Toradol is a great pain reliever but strange for post cath. Did the ordering doctor know this patient? Maybe know she had a poor tolerance for pain or other issues?

Check with the floor you transferred her to and see what you can find out. It doesn't sound right at all. I think this person was rating high because you would have had a real quick lesson in cardiovascular complications/emergencies if not.

I'm surprised that your preceptor didn't advise you to contact the staff from the floor she should have gone to.

[suzanne4, RN]

Patients post cardiac cath need to go at least to a tele unit, they should not be placed on a med-surg unit unless you have full monitoring capabilities.

And the other posters here are correct: Having 10/10 pain at the site and there are some issues going on to begin with. Toradol is not used routinely for pain at the site either, so unless the physician did something during the procedure that you are not aware of, would wonder about this. It also can cause more bleeding if that is what was going on underneath in the groin area. Routinely, you will see orders for tylenol or morphine.

You did as you were supposed to do, always go with your sixth sense, it is usually the correct one, and make sure to document, document, document.

[diveRN]

As mentioned, 10/10 isn't normal, assuming the patient understands the pain scale. If the pt is not grimacing, gaurding, or otherwise displaying other s/s of pain (inc VS), I'll treat very conservatively. I usually do NOT use "0 is no pain, 10 is the worst you've ever felt" because some people don't want any pain whatsoever and will tell you 10/10 even with mild pain. I use "0 is no pain, 10 is like being dipped head first into a vat of boiling acid." That usually helps put the pain into perspective. An ER doc taught me that.

Anyway, keep in mind, if a hematoma is forming, the dressing can remain dry and intact. If mild pressure on the cath site causes very acute pain, then you likely have a hematoma. Direct pressure and/or a sandbag or femstop is appropriate.

A baseline H&H when you discovered the problem would've been appropriate as well.

[Virgo_RN, BSN, RN]

That would be sending up red flags for me.

[megananne7]

Now you all have me worried that I didn't catch something I should have.

Of course, when she rated the pain 10/10, red flags went up. I checked the site and took VS, which were WNL. She is an overweight woman, and I did have to "lift up" her stomach to check the site.

As for the person saying she should've been transferred to a tele floor... We do have tele, but its medical tele. We don't usually get cardiac pts. Most of our pts are CVA, TIA, change in LOC, pneumonia, peritoneal dialysis pts, and a few chronic and acute renal failures. Do you mean she should've been transferred to a cardiac tele floor or did you not read we have tele? A little confused there.

It is possible she may have misunderstood my pain scale. I usually ask pts "0 is no pain and 10 is the worst pain ever".

But now I am all nervous I did something wrong and now she's suffered a consequence which I am unaware of now that she is out of my care.

[rn undisclosed name]

Now you all have me worried that I didn't catch something I should have.

Of course, when she rated the pain 10/10, red flags went up. I checked the site and took VS, which were WNL. She is an overweight woman, and I did have to "lift up" her stomach to check the site.

As for the person saying she should've been transferred to a tele floor... We do have tele, but its medical tele. We don't usually get cardiac pts. Most of our pts are CVA, TIA, change in LOC, pneumonia, peritoneal dialysis pts, and a few chronic and acute renal failures. Do you mean she should've been transferred to a cardiac tele floor or did you not read we have tele? A little confused there.

It is possible she may have misunderstood my pain scale. I usually ask pts "0 is no pain and 10 is the worst pain ever".

But now I am all nervous I did something wrong and now she's suffered a consequence which I am unaware of now that she is out of my care.

In my experience I've never had anyone rate their pain as 10/10 for a post cath insertion site. The only time someone has had moderate to severe pain is with a hematoma. I also don't think Toradol was appropriate for pain if bleeding was an issue or a possibilty. I've never had anything more than T#3 ordered. It is also possible she misinterpreted your pain scale. If she is someone with a really high tolerance for pain maybe she's never experienced very severe pain and this was the worst pain she has experienced if said to her the way you said.

I also worked on a medical tele floor and it was not uncommon at all to take post cath patients. Of course we usually took the ones who did not have an intervention performed and no sheath in place. If they did have an intervention performed they went to a different monitoring area and once they were completely recovered and ambulating we would get them back. Every hospital just does it different.

[RobLPN]

I had a pt the other night (med surg unit, specializing in ischemic CVAs). I had this pt the night before, she was admitted with "chest pain & syncope", but she denied any syncopal episodes to me. No c/o chest pain the entire time I had her. She was a direct admit from the MD office for work up.

Had a cardiac cath and came back shortly before my shift began. When I went to assess she was still sleepy from the procedure, c/o pain at the cath site 10/10. Took VS, stable... Checked the cath site, which was dry. Called the MD, who just ordered Toradol IVP.

Later that night, I transferred her to the cardiac floor (why wasn't she admitted there when she first came in anyway? We are a medical tele floor, not cardiac tele) b/c we needed a tele bed. In report, the nurse told me she shouldn't be having that much pain at the site. I mentioned this to my preceptor and she said it was OK b/c cardiac caths ARE very painful and in my assessment, there was nothing out of the ordinary.

I trust my preceptor because she's worshipped on our floor as she's been there the longest and knows everything about anything (so I've heard anyway!).

But did I miss something? Was there something else I should've done?

I do s/p CC all the time, doesn't sound like you missed anything. V/s good, site good? yes, then medicate and keep on truckin. of course, monitor closely. We also have some great CC nurses that would gladly come up and assess the patient with me if I had any concerns.

We all know 10/10 doesn't always mean 10/10.