Patients undergoing vascular intervention

Patientsundergoingvascularintervention

Best practice guidance fornursing staff

Chair:Edna Piper, Plymouth Hospitals HC (NHS) Trust,Derriford Hospital, Devon

Lead contributors:Jill Bishop, South Devon HC (NHS) Trust,Torbay Hospital, Devon

Elaine Wright, Princess Alexandra Hospital (NHS) Trust,Harlow, Essex

Other contributors:Lizete Pearson, Southampton University Hospital (NHS) Trust,Hampshire

Caroline Rushton, Royal Devon and Exeter HC (NHS) Trust,Wonford Hospital, Devon

Angela Shash, Northampton General Hospital (NHS) Trust,Northamptonshire

Sarah Wilson, Leeds Teaching Hospital (NHS) Trust,West Yorkshire

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AcknowledgementsWith thanks to contributors from the RCN ImagingNurses Forum

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ContentsIntroduction 1

1. Pre-procedure 2

2. Peri-procedure 3

3. Post-procedure 4

4. References and further reading 5

5. Glossary 5

IntroductionThis guidance was developed by the Royal College ofNursing (RCN) Imaging Nurses Forum. It aims tosupport radiology nurses1 in providing a clinicallyeffective and safe environment when assisting withprocedures that provide diagnostic images of patients'blood vessels and treatment of vascular problems.

Patients undergoing these procedures will either beadmitted to a ward or a planned investigation unit, ortransferred to the radiology department. Alternatively,they might be admitted directly to the radiologydepartment as day cases. The preparation for theprocedure will be the same in all cases.

This document is divided into three parts and followsthrough a sequence of actions:

✦ pre-procedure (preparation)

✦ peri-procedure (during)

✦ post-procedure (after).

This sequence is for guidance only, and local policy andpractice, which may vary between hospitals, should befollowed.

The guidance aims to facilitate consistency throughoutradiology departments and to give radiology nurses abasis on which to organise and develop their ownservice and department.

Patients undergoing vascularinterventionBest practice for nursing staff

1 Where ‘radiology nurse’ is used in this document, it denotes:‘A registered nurse on the Nursing and Midwifery CouncilRegister,’ in accordance with NMC guidance (2004).

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Pre-procedureApproximately two weeks before the procedure, aregistered radiology nurse should pre-assess the patient.Although it is best practice to see the patient before

their procedure, in some instances this assessment maybe in the form of a telephone call. All informationobtained should be documented in the patient’s notes.

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ActionPre-assessmentExplain the procedure to the patient, includingbenefits, risks and potential complications.During this assessment a social and medical history,including allergies, current medication and pregnancystatus (for females aged 12-55) should be taken.

Undertake a physical assessment and obtain aWaterlow score.Give Warfarin and Metformin information to thepatient as per Royal College of Radiologists (RCR) andlocal guidelines.Obtain an up to date urea and electrolyte level forpatients who have diabetes and renal disease.

Obtain an HbA1c blood test from diabetic patients.On the day of the procedurePatients who are taking anticoagulants may need anINR/APTT level. Refer to local guidance or consult thepatient's anti-coagulation specialist if appropriate.Consent from the patient will be obtained by theclinician performing the procedure, or a designatedprofessional with sound knowledge of the procedure.In some instances the patient’s full assessment will betaken at this stage. Baseline observations and footpulses will be recorded.Insert an intravenous cannula, ensuring local guidanceis followed.

Shave one or both groin areas as necessary.

Complete the pre-procedure checklist.Offer the patient use of the toilet.

Escort the patient to the interventional/angiographyroom, and hand over patient information to theradiology scrub/circulating nurse.

Reason for action

Ensures the patient can make an informed decisionabout going ahead and knows what to expect.Ensures the patient is medically stable for theprocedure and avoids the risk of radiation to pregnantwomen. This assessment will produce an individualcare plan/pathway and identify the expected dischargeof the patient.Assesses individual patient needs, and identifies tissueviability risk.Minimises the risk of bleeding and renal impairmentdue to Metformin induced lactic acidosis.

Ensures adequate fluid balance and minimumadministration of contrast medium, preventing renalimpairment.Establishes blood sugar levels.

Minimises risk of haemorrhage.

Establishes that the patient has full understanding ofwhat is involved and the benefits and risks, and wishesto proceed.Allows rapid assessment of the patient and limb status,enabling immediate action if there is any deteriorationduring and after the procedure.Allows immediate administration of emergency drugsand intravenous fluids, in case the patient develops avaso-vagal or anaphylactic reaction or become haemo-dynamically compromised.Maintains a clinically clean environment and preventsinfection. Also helps patient comfort afterwards ifadhesive drapes and dressings are used.Ensures all details are correct and it is safe to proceed.Promotes patient comfort, prevents a full bladderobscuring the field of view, and minimises the risk ofurine retention after the procedure.Ensures safe delivery of the patient, allays their anxietyand promotes patient security.

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Peri-procedureThe nursing team should include registered, qualifiednurses who are competent in performing the role ofscrub nurse and circulating nurse and who possess

advanced resuscitation skills. This ensures appropriatemonitoring, support and safe delivery of patient carethrough observation.

✦2

ActionAssist with positioning the patient and maintaincontinuous communication. Provide limb support withthe use of tissue viability aids as required.Explain the equipment to the patient.Connect the patient to an ECG, blood pressure andoxygen saturation monitor, and record at 15 minuteintervals, or more frequently if required.The scrub nurse prepares all equipment (e.g. cathetersand wires) using aseptic technique.The circulating nurse assists the scrub nurse inpreparing and checking drugs and solutions, andobtains equipment when required. NMC regulation is followed.The scrub nurse assists the radiologist during theprocedure with the handling of instruments,guidewires and catheters.Following assessment, the radiology scrub nurse, willbe able to flush arterial catheters, as per local guidance.At the end of the procedure the scrub nurse disposes ofall sharps and clinical waste in accordance with localpolicy.The circulating nurse makes sure the patient's carepathway/plan is completed and signed. The radiologistshould document special post-procedure orders.The scrub nurse gives a comprehensive handover to theescorting recovery nurse, covering the success of theprocedure, the patient's provisional diagnosis, post-procedure care and potential complications.Both nurses check the puncture site and foot pulses.Explain to the patient the need for post-procedure carebefore they leave your department.

Reason for actionEnsures patient’s dignity, comfort, warmth andreassurance. Prevents pressure sores.

Reassures the patient and reduces any anxiety.Allows early identification of complications, ensuringprompt reaction.

Maintains sterility throughout procedure, andminimises infection risk.Ensures correct drug/solution is administeredaccording to local policy, and that equipment is readilyavailable.

Maintains smooth running of the procedure and keepsrisks to a minimum.

Prevents the formation of micro-emboli.

Reduces the risks to patients and staff by followinglocal policies on infection control, clinical risk andhealth and safety.Ensures complete documentation for easy access andfuture reference, and makes sure appropriatetreatments are carried out in the follow-up period.Ensures proper follow-up by informing the recoverynurse of future care and possible complications.

Reassures and informs the patient about what toexpect, and gains their compliance in future care.

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Post-procedureThe patient may be transferred back to the wardfollowing their procedure or be cared for in theradiology department. Post-procedure instructions

should be identified, documented and followed toprevent complications occurring.

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ActionTransfer the patient onto a bed/trolley and ask them tolie flat for several hours (depending on local policy).Monitor the patient at 15 minute intervals for pulse,blood pressure, oxygen saturation levels, respirationrate, puncture site and limb status.The length of time during which frequent observationsare taken will depend on local policy and the patient'scondition and puncture site status.Refer to local/company policy if a puncture device isused.If the patient's condition deteriorates, contact theradiology/vascular team immediately.If haemorrhage or haematoma occur at the puncturesite, put on sterile gloves and press firmly over the site.Summon assistance.Observe and mark the size of any haematoma, andreport any increase.Fluid intake can commence as per local policy,assistance will be required by the patient.Encourage the patient not to bend the affected leg(s).Assist the patient with elimination by applyingpressure to the puncture site when they are using abedpan or urinal.Help the patient to gently mobilise once bed rest iscomplete.If the patient complains of numbness around theirthigh muscle or down the leg, return them to bed restuntil the numbness ceases.Inform the radiologist who performed the procedure.

Once the patient is mobilised ready for discharge, givepost-procedure instructions on emergency assistance,wound care and mobilisation.A follow-up appointment (per local policy) should bemade.

Reason for actionMinimises the risk of haemorrhage or haematomaformation.Detects early signs of complications.Signs of hypovolaemic shock and abdominal or backpain will accompany a retroperitoneal bleed which isnot visible.

All devices have specific instructions for use.

Ensures immediate intervention.

Achieves haemostasis.

Identifies further growth/spread.

Prevents dehydration. Assistance is required by thepatient as they will still be on bed rest.Minimises risk of haemorrhage or haematoma.Minimal movement of the groin will reduce risk ofhaemorrhage or haematoma.

Ensures safe mobility, and prevents falls.

The femoral nerve can become blocked by the localanaesthetic. Waiting for this to decrease prevents thepatient falling.The radiologist will prescribe further treatment ifnecessary.Keeps the patient reassured and informed. Gives accessto support once they are discharged, reducingcomplications.Enables the patient to obtain a diagnosis andinformation about further treatment.

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References andfurther readingBraun M, Nemeck A and Vogelzang R (1997)Interventional radiology procedure manual, New York:Churchill Livingstone.

Howatson-Jones I L (2001) Relieving the pressure inthe radiology department, British Journal of Nursing,10 (4), pp.219-228.

Mallett J and Dougherty L (2000) Manual of clinicalnursing procedures (5th edition), Oxford: BlackwellScience.

National Association of Theatre Nurses (1998)Principles of safe practice in the perioperativeenvironment, Harrogate: NATN.

National Confidential Enquiry into PerioperativeDeaths (2000) Interventional vascular radiology andinterventional neurovascular radiology report, London:NCEPOD. Available from: www.ncepod.org.uk

Nursing and Midwifery Council (2004) The NMC codeof professional conduct, London: NMC.Available from: www.nmc-uk.org

Nursing and Midwifery Council (2005) Guidelines forrecords and record keeping, London: NMC.

Royal College of Nursing (2000) Pressure ulcer riskassessment and prevention. Technical report,London: RCN.

Royal College of Radiologists (1999) Guidelines withregard to Metformin-induced lactic acidosis and x-raycontrast medium agents, London: RCR. Available from:www.rcr.ac.uk

Royal College of Radiologists and Royal College ofNursing (2001) Guidelines for nursing care ininterventional radiology, London: RCR/RCN.Available from www.rcr.ac.uk

GlossaryAPTT – activated partial thromboplastin timeA definition is available from:http://medicine.ucsf.edu/htc/clinicians

INR – International Normalised RatioA definition is available from:http://medicine.ucsf.edu/htc/clinicians

HbAlc – glycosylated haemoglobin.A definition is available from:www.healthopedia.com/glycosylated-hemoglobin

NMC – Nursing and Midwifery Council

RCR – Royal College of Radiologists

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March 2006

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