Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab

“I am currently developing practice standards for nurses in the cath lab at my facility and am having difficulty finding standards related to frequency of monitoring, assessments, and documentation during procedures.” — Patricia Gilman APRN, MSN, ACNS-BC

Finding documentation of standards (such as what you are looking for) can be difficult. Unfortunately, the cath lab is somewhat unique, because it includes critical care needs as well as procedural needs often performed on an outpatient basis.

The “major” books of cardiac catheterization guidelines (by Kern, Braunwald, and Grossman) do not specifically answer your questions, nor provide direct standards to reference. Most mention “continuously” or “closely” when it comes to assessment and vital signs monitoring.

While we could discuss each of these items in detail, let’s try to briefly address these generically.

Assessments

In most states, patient assessment is a legal responsibility of the licensed nursing staff. “Assessment” can range from the initial contact assessment to the assessment of discharge capability, and everything in between. Depending upon your state, the assessment of a patient may or may not be a task that the nurse can delegate. You would need to check with your state board of nursing to find that out.

Monitoring

I will briefly state the obvious: get a baseline set of vital signs before the procedure and monitor them constantly during the procedure for unexpected changes compared to baseline. Of course, continuous arterial monitoring and pulse oximetry will occur throughout the procedure, in most instances. Staff should recognize that there are “expected” changes in vital signs related to the patient (anxious before medications and calm afterwards), therapies (nitroglycerine and changes in blood pressure), and equipment (transducer falling off of holder, etc.). Diligence is required to observe vital sign changes that occur as a precursor to something unexpected (complications). Staff monitoring the patient should react to such changes early on.

Whether you take a manual blood pressure every 3 minutes or every 10 minutes, or somewhere in between, is a facility choice. There are no specific standards that I can find, nor that I am aware of, that dictate an absolute answer.

Of course, The Joint Commission (TJC) requirements for conscious sedation require that the patient receive continuous monitoring by a nurse during the period of time that the patient is sedated. Most hospitals that follow TJC guidelines already have policies/protocols in place for staff to follow.

During the diagnostic procedure, monitor the heart rate and oxygen saturation continuously via pulse oximetry. Monitor airway patency, respiratory rate, blood pressure and appropriate level of consciousness and responsiveness, every 5 to 15 minutes. After the procedure, use the Aldrete score and monitor airway patency, oxygen saturation and pain score every 5 minutes for at least 30 minutes, then every 15 minutes for 1 hour, and then every 30 minutes until the patient meets the discharge criteria on the institution’s designated scoring system.¹ [Note: these are guidelines from a textbook1, and are open to changes for your departmental needs.]

For inpatients, my experience has been that most labs use something similar to an every “15 minutes x 4,” “30 minutes x 2,” and then “1 hour x 4” approach to post-procedural vital sign monitoring for inpatients.

Arterial puncture sites require a little more observation in the early periods post-procedure. Assess peripheral pulses and insertion site q15min × 4, then q1h for 4 hours, then as ordered.² Discussion about post-procedure care of the puncture site is worthy of a future article.

Documentation

Documentation systems for cath labs are specific to the cath lab. Whether you use Witt (Philips Medical, Bothell, Wash.) or MacLab (GE Medical Systems, Waukesha, Wisc.) or another vendor, only your facility can decide what should be documented and to what detail. Many factors can help decide this, such as dictation requirements of physicians, automated vital signs, durable medical supplies database, and so on.

Certainly, vital signs, progress of the procedure, equipment used, medications administered and patient status should be recorded. Again, the detail of your documentation is based upon the requirements of your department and facility.

It can be frustrating sometimes when looking for guidance for cath lab procedures. Never be afraid to look for guidance from your colleagues at other facilities. Take all the recommendations and change them to meet your situation. Resources such as Cath Lab Digest’s “What Do You Think?” column for readers, the message board (Heart2Heart) at www.cathlab.com, and the Society for Invasive Cardiovascular Professionals (SICP, www.sicp.org) can be a big help to at least get you started.

Ask your question at tginapp@rcisreview.com.

References

1. Perry AG, Potter PA. Clinical Nursing Skills and Techniques. 7th ed. St. Louis, Missouri: Mosby; 2010.
2. Tucker SM, Canobbio MM, Paquette EV, Wells MF. Patient Care Standards: Collaborative Planning & Nursing Interventions. 7th ed. St. Louis, Missouri: Mosby; 2000.