Hypotension in Cardiac Catheterization Laboratory: Patient Management
Si m u l a t e d C l i n i c al E x p e r ie n c e (S CE ™) Over view Lear ning O b je c tiv e s

Location: Cardiac Catheterization Laboratory History/Information: The patient is a 57-year-old woman transferred to the cardiac catheterization laboratory for a procedure after presenting to the Emergency Department (ED) this morning with a purple and extremely tender right lower extremity. She is alert and oriented to person, place and time. Her pain rating scale is a 10/10. She told the Emergency Department staff her foot began hurting about a week ago and had been becoming more and more tender and slightly more discolored as each day passed. She thought it would “go away with time.” When she awoke this morning, her toes were purple in color, and she was unable to touch them secondary to the immense pain. Her husband drove her to the hospital immediately. Her weight is 65.0 kg. Other findings include normal heart tones, clear lung sounds, positive bowel sounds and clear yellow urine from a urinary catheter inserted in the emergency department. Her medical history consists of hypertension, partial lumpectomy of the right breast seven years ago, alcohol abuse and hyperlipidemia. She is allergic to angiotensin converting enzymes inhibitors and angiotensin receptor blockers. She takes metoprolol 25mg twice per day at home for hypertension management. She has been married for 25 years and has two adult children. She reports that she smokes one pack of cigarettes per day and generally drinks two distilled alcoholic drinks per day. Blood work was drawn, but the results are not yet available. The emergency department team has transferred the client to the cardiac catheterization laboratory after inserting left jugular venous access and a urinary catheter. Healthcare Provider’s Orders: Cath Lab orders: Consent for diagnostic catheterization right femoral artery with possible tissue-plasminogen activator administration, possible thrombectomy Insert IV catheter in the left arm IV D5%/0.45%NS at 75mL/hour Consent for conscious sedation Oxygen at 2L per minute via nasal cannula Midazolam 2mg IV push at start of procedure CBC, Chemistry; BUN; creatinine; coagulation panel, lipid panel prior to procedure Insert urinary catheter prior to procedure Prepare right groin per cardiac catheterization laboratory protocol Vital Signs every 5 minutes

1. Implements a rapid, accurate physical assessment including cardiac rhythm interpretation and focused vascular assessment for the patient experiencing vascular flow obstruction (APPLICATION). 2. Acts promptly on physician’s orders in preparing patient for the procedure (APPLICATION). 3. Discusses goals, procedures and agents used for conscious sedation (COMPREHENSION). 4. Discusses pathophysiology of risk factors, co-morbidities and treatments for presented clinical condition (COMPREHENSION). 5. Correlates available data to identify the cause of hemodynamic instability (ANALYSIS). 6. Collaborates effectively with a physician in developing and implementing a plan for treatment of symptomatic hypotension (SYNTHESIS).

ECS® Program for Nursing Curriculum Integration (PNCI®)

Learner 1

Q ues t i o n s t o P r e pa r e f o r th e S im u la t e d Clinical Experience
1. What places a patient at risk for a lower extremity vascular flow obstruction? 2. What questions should the nurse ask the patient at risk for a lower extremity vascular flow obstruction? 3. What should the nurse focus on during the assessment of a patient with a lower extremity vascular flow obstruction? 4. What medical management could the nurse anticipate for a patient with a lower extremity vascular flow obstruction? Symptomatic hypotension? 5. What preparation should be done before sending a patient to the catheterization laboratory for a procedure? 6. What might cause symptomatic hypotension during an interventional procedure to resolve vascular flow obstruction? 7. What assessments should be performed when hypotension or hemodynamic instability is suspected? 8. What are possible negative results that might occur with treatment of symptomatic hypotension? What if symptomatic hypotension goes untreated? 9. What are possible nursing interventions and their rationales for symptomatic hypotension?

R eferences

Best practices: Evidence-based nursing procedures (2nd ed.). (2006). Philadelphia: Lippincott. Freeman, R. (2008). Current pharmacologic treatment of orthostatic hypotension. Clinical Autonomic Research 18, 14-19. Garcia, L. (2006). Epidemiology and pathophysiology of lower extremity peripheral arterial disease. Journal of Endovascular Disease 13, 113-120. Joanna Briggs Institute for Evidence Based Nursing and Midwifery. (2007). Best practice: Vital signs. Retrieved May 30, 2008 from http://www.joannabriggs.edu.au/ best_practice/bp8.php?win=NN. Lewis, S. L. et al. (2007). Medical-surgical nursing: Assessment and management of clinical problems (7th ed). Philadelphia: Mosby. McGee, S. (2007). Evidence-based physical diagnosis (2nd ed.). Philadelphia: Saunders. National Guidelines Clearinghouse. (2008). Preoperative tests: The use of routine pre-operative tests for elective surgery: Evidence, methods and guidance. Retrieved May 30, 2008 from http://www.guideline.gov/summary/summary.aspx?view_ id=1&doc_id=5068&nbr=003552&string=Pre-Operative+AND+Diagnostic. Registered Nurse Association of Ontario. (2007). Nursing best practice guideline: Assessment and management of pain. Retrieved May 30, 2008 from http://www. rnao.org/storage/29/2351_BPG_Pain_and_Supp.pdf. Skidmore-Roth, L. (2008). Mosby drug guide for nurses (8th ed.). Philadelphia: Mosby. Wissgott, C., Richter, A., Kamusella, P. and Steinkamp, H. (2007). Treatment of critical limb ischemia using ultrasound enhanced thrombolysis (PARES) trial: Final results. Journal of Endovascular Therapy 14(4), 438-444. Wunder, A. and Klohs, J. (2008). Optical imaging of vascular pathophysiology. Basic Research in Cardiology 103(2), 182-191.

HPS® Program for Nursing Curriculum Integration (PNCI®) Hypotension in Cardiac Catheterization Laboratory: Patient Management

Learner 2

© 2008 METI, Sarasota, FL; Original Author: Mary Pieper-Warren, Edward Avrutin and Andrea Giachetti., Marin Community College. Reviewer: Kimberly S. Martin, Daytona Beach College. v.4 August 2008