What are the nursing interventions after an angiogram?

Nursing Management during Angiography and Interventional Procedures

The objective of this chapter is to offer guidelines for developing clinical standards of practice related to nursing care and management of patients during all phases of interventional radiology (IR) procedures. Although the emphasis here is on nursing, all members of the IR patient care team should be knowledgeable and familiar with each patient’s individual circumstances. The Joint Commission provides National Patient Safety Goals which are directed toward improvement in patient safety, organizational performance, documentation, and quality of care. It is the IR nurse’s professional responsibility to demonstrate competency, collegiality, and patient advocacy. Good practice requires a culture of commitment to patient safety, effective communication, efficiency, and teamwork. The IR nurse must maintain patient privacy and ensure confidentiality, safe transportation of patients, adherence to departmental policies regarding safe attire, infection control, and other safety practices in the procedural area and throughout the patient’s care.

Preprocedure Nursing Considerations

In preparation for an IR procedure, the nurse must thoroughly review the patient’s case, clinical history, presentation, and indication for the procedure—working to ensure safe conditions for the patient’s care. Although the workflow and patient movement through the continuum of care differs for inpatients and outpatients (OPs), those who undergo OP or same-day admit procedures require the same workup as inpatients. For all patients, the preparation begins with a review of the chart for preprocedural nursing assessment and development of a plan of care.

For OPs in particular, the nurse should be familiar with the case prior to conducting preprocedure phone screen, which is best accomplished 72 to 48 hours in advance in order to address all needs. The OP phone screen familiarizes the nurse with the patient and provides an opportunity to educate the patient about the procedure and what to expect upon arrival to the department and to address the patient’s concerns. The nurse should

1. Follow established criteria at time of scheduling the procedure to determine whether the patient is a candidate for phone screen, or if an appointment for face-to-face evaluation is needed, and whether an anesthesia consult may be necessary.

2. Hospital policy regarding allowing a family member to provide/receive information about the patient within the context of the preprocedure phone call must be followed.

Procedure-Specific Considerations

1. Review chart, history, indication for procedure.

2. Review of systems: conducted by the nurse to learn of any clinical conditions that may require additional attention. This can be done during a phone screen prior to the day of the procedure.

a. Cardiovascular: coronary artery disease (CAD), congestive heart failure (CHF), valvular disease, arrhythmia

b. Respiratory: cystic fibrosis, asthma obstructive sleep apnea, use of continuous positive airway pressure (CPAP), noninvasive positive-pressure ventilation (NPPV), or bilevel positive airway pressure (BIPAP), O2 requirements, artificial airway

c. Gastrointestinal (GI): dietary restrictions/requirements, nutrition/metabolic screening

(1) Diarrhea, dental problems, difficulty swallowing, persistent nausea/vomiting (N/V), appetite, weight loss/gain, bone marrow transplant (BMT), tube feeds, total parenteral nutrition (TPN), end-stage diseases, esophageal disease/surgery, major burn/trauma, major GI or oral surgery, myocardial infarction (MI)/stroke, diabetes, surgical patient more than 70 years old, pressure ulcer

d. Genitourinary: problems with urination, anuria, ostomy, suprapubic Foley catheter

e. Reproductive/sexual health: female; last menstrual period (LMP), pregnancy, breastfeeding

f. Tubes/lines/drains: such as percutaneous nephrostomy tubes, biliary tubes, abscess drains, blood suction/drains, chest tubes, peritoneal abscess drains

g. Skin assessment: rashes, open wounds/sore, discoloration, redness, itchiness

h. Musculoskeletal: difficulty walking, moving extremities, assistive devices for walking, Morse Falls Scale, deteriorating/debilitating conditions affecting mobility

i. Internal/external devices: pacemaker/defibrillator, joint/valve, piercings/tattoos, medication patches, subcutaneous ports, external catheters

j. Pain: current, chronic, new onset; location, character duration, frequency scores per hospital policy

k. Assistive/prosthetic devices: dentures, glasses/contacts, hearing aids, crutches/cane, walker

l. Past anesthesia/sedation history: IR procedures are routinely performed under moderate sedation or some form of anesthesia (monitored anesthesia care [MAC] or general anesthesia). It is important for the nurse to be familiar with patient’s existing documented history and physical (H&P), including surgical history in which anesthesia was utilized:

(1) Head/neck surgery/cancer

(2) Prior complications with anesthesia

(3) Blood relatives who have anesthesia complications (malignant hyperthermia [MH])

(4) Postoperative nausea/vomiting

(5) Difficult intubation/extubation

(6) Ability to lie flat for duration of pre-, intra-, and postprocedure as appropriate

(8) Previous history/problems tolerating procedural sedation—agents/amounts from previous experiences

3. Preprocedure laboratory testing: Blood work is necessary with numerous IR procedures. Patients need to be instructed if any preprocedure blood work is needed to be drawn and the rationale for the needed blood work. Oftentimes, evaluation of renal function is mandatory for procedures where contrast is necessary. Additionally, other factors, such as coagulation status, need to be known for determining
risk of bleeding. Patients requiring blood work should be told to have it done few days prior to the procedure when possible to avoid delays the day of the procedure. When of childbearing age, may require testing at least 7 days prior to the procedure

4. Allergies: known allergies with description of types of reactions; past reactions involving contrast, severity, and interventions. Patients with known contrast reactions may be premedicated with steroids, antihistamines, and H2 antagonists. It is important for the IR nurse conducting the intake screen to inquire if the patient has had a “breakthrough” reaction after receiving premedication; this information must be communicated to the IR provider.

5. Medications: It is important to review the patient’s current prescription medications because some of them may be contraindications for the procedure, if not stopped or managed appropriately. Patients should bring a list of their medications with them. Hospital policy regarding patients bringing medications from home for use in hospital should be known by the nurse.

a. Anticoagulants—increased risk of bleeding during IR procedure. Patients should be informed well in advance to “hold” medications in preparation to undergo a procedure.

b. Nonsteroidal anti-inflammatories (NSAIDs)—in general, do not cause significant bleeding problems except in patients with existing coagulopathies, hemophilia, von Willebrand disease, or severe thrombocytopenia. Paradoxically, NSAIDs tend to diminish the antiplatelet effect of aspirin when given concomitantly and therefore should not be given to patients receiving aspirin therapy for cardiovascular disease.

c. Diabetic agents—insulin regimen or oral agent administration for control of glucose needs to be known, to provide instructions on when to self-administer these prior to the procedure. Additionally, metformin instructions “to hold for 48 hours postadministration of contrast” should be explained to the patient.

d. Cardiac and antihypertensives

6. Discharge planning: Planning for the discharge should begin prior to the procedure.

a. Transportation: Special consideration for transportation, indicated hospital admission, or home health care should be discussed with the patient at the time of the phone screening. For OPs who will be going home after meeting postprocedure discharge criteria, it is important to plan for traveling home with a responsible companion especially if moderate sedation or MAC/general anesthesia was utilized for the procedure.

b. Psychosocial support: Undergoing an IR procedure can be a very stressful time for the patient. It is important to inquire about the patient’s sources of emotional support. Family and caregivers should be involved in the patient’s care if agreeable. The nurse should screen for depression, anxiety, self-harm, suicide, and domestic abuse. Special needs should be taken into consideration (e.g., language, cultural/psychosocial, physical, spiritual). Address and facilitate practices related to religion, culture, or alternative/complementary therapies that will need to be integrated as part of the care as appropriate.

c. Behavioral screening: Risks for tobacco use, alcohol use (Clinical Institute Withdrawal Assessment [CIWA] score), and drug use should be inquired about additional support needed to assist the patient.

d. Patient education: The nurse conducting the preprocedure screen has an opportunity to educate the patient on what to expect upon arrival on the day of the procedure including parking, registration process, preprocedure nursing process, consenting, and meeting with the members of the IR team.

e. Advance care directives (ACD): Indicate whether copy is in medical record or status, otherwise. Offer information regarding ACD and whether patient accepted or refused the information.

7. Instructions for date of service: Patient instructions in preparation for an upcoming procedure are important to ensure optimization and decrease possibility of having to be rescheduled. Instructions should include:

a. Home medications on hold

b. Home medications which can be taken with a sip of water (i.e., antihypertensives such a β-blocker)

c. Explanation of nil per os (NPO) 6 hours prior to the procedure when moderate sedation, MAC, or general anesthesia is to be utilized

d. Transportation back home needs to be via companion or caregiver

e. Preprocedures for specific imaging/interventions and personal belongings.

Please see checklist below, which can be tailored for OP or inpatient (IP) use:

Preprocedure Nursing Evaluation Checklist

Outpatient Phone Screen □ Patient Chart Review □

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