Standards of Nursing Care for Neuro Angiographic Procedures (including NIR Stroke)
System / Within Normal Limits (WNL)Neurological / Alert, awake, and oriented to time, place, and person. Memory and speech
normal. Pupils equal and reactive to light. Eyes track objects together. Face
Symmetrical. Gag and cough reflexes present. Movement of all four limbs
Symmetrical and purposeful. Extremity sensation intact without numbness or
paresthesia.
Cardiovascular/Peripheral Vascular / Apical pulse regular, NSR, S1S2 present. Skin warm, and dry with supple
turgor. Capillary refill < 3 sec. Radial, dorsalis pedis, and posterior tibial
pulses > +2 palpable. No edema.
Respiratory / Respirations regular, quiet, and non-labored. Lungs symmetrical and equally
aerated throughout all lobes. Breath sounds clear. Sputum thin, white, or
clear; small to moderate amount. ETT/trach site clear.
Gastrointestinal / Abdomen soft and flat or rounded. Bowel sounds present. Tolerates
prescribed diet.
Genitourinary / Voids independently. Urine is clear and yellow in color.
Musculoskeletal / Full ROM in all joints. Limb strength ≥ 4+ (movement against gravity and
some resistance). Supple muscle tone in all limbs. Pain free muscles and
joints. Balance maintained when sitting up in bed, chair, or standing.
Positions self independently while in bed. Ambulatory.
Integumentary / Skin warm, dry, and intact. Mucous membranes pink, moist, and intact.
Pressure points without erythema or breakdown. Braden score ≥ 16. Central
and peripheral line sites clear.
Wound/Incision / Edges well approximated and pink. Normal temperature and non tenderness in
surrounding tissue. Granulation tissue present.
Psychosocial / Patient/family able to communicate needs. Patient’s/family’s anxiety level
commensurate with patient’s medical condition.
Education / No barriers to teaching/learning. Patient/family ready to learn.
Patient/Procedure Assessment / Nursing Interventions / Desired Patient Outcomes / Documentation
ENVIRONMENT/SAFETY
*Prior to patient admission: Evaluate
Procedure room for functioning suction withYankauer tip, airway supplies (nasal, oral andface mask), oxygen (nasal cannula & non-rebreather set-up) & Ambu bag
Ensure monitoring equipment is working properly. / *Replace missing items as needed.
*Ensure availability of various sizes of oral/nasal airways/face masks, Ambu bag
All patient care items are disposable after use.
*Location of emergency numbers/code button
*Location and integrity of emergency cart/emergencymedications / Have emergency drug box available and supplies ready for emergency use. / Crash cart checklist
The exam table is clean and prepared for a procedure. / Radiology staff is responsible to clean and disinfect all x-ray and exam table surfaces with Sani-wipe clothes. All patient care items are disposable after use.
PRE-PROCEDURE NURSING ASSESSMENT OF PATIENT
*Upon admission: Evaluate patient and patient documentation for the following:
*Patient ID/allergy bracelet/falls precautionbracelet
*Preoperative history and medications
*Planned procedure(s)
*Patient lines, tubes, and drains (if any)
*Intake and output (if any)
*Blood product administration (if any)
*Neuro Assessment at baseline
*Coagulation studies are reviewed / *Identify yourself and identify and greet the patient
*Use 2 patient identifiers-source document with ID band
*Verify procedure and site, physician, and procedure date
*Establish a reassuring environment on admission to reduce anxiety
*Verify the following: NPOrequirements, transportation with responsible adult (for out-patients), support person’s contact information, valuables
*Ask patient to void prior to procedure
*Obtain/validate medical history to include allergies, previous anesthetic/sedation problems
*Abuse screening
*Suicide risk assessment
*Assess presence of Advanced Directive
*Identify level of understanding of procedure and obstacles to learning
*Contact interpreter or interpreter services whennecessary
*Identify and document nursing problems andinterventions
*Get baseline neuro assessment
*Get baseline vascular assessment including peripheral pedal pulses
*Coagulation studies are reviewed prior to the procedure. Inform MD if patient is on Coumadin, Plavix and/or Aspirin.
Check Surgical consent; blood consent (if indicated);H & P within 30 days of procedure with a 24hour update if needed; / *Satisfactory transfer of care from inpatient nursing care provider to Radiology RN (if applicable)
Patient has understanding of the plan for the procedure and is prepared. / Apex
Pre-Procedure:
The team suspends all other activities and participates in the Universal Protocol checklist. /
- Verify patient identity
- Verify procedure and site
- History and physical completed within last 30 days
- Interval update of H&P if more than 24 hours old
- Consent signed, dated, witnessed
- Results of lab pathology and radiology studies are present and matched to patient
- Required blood products, implants, devices and equipment are present and functioning.
- Required specimens for blood bank obtained
Radiation protection: / Patients of childbearing age will be screened for pregnancy. Gonadal shielding will be placed under the table pad per policy. ALARA will be used. All staff will wear lead protection. / Apex
Contrast precautions: / Patients will be screened for the risk of allergies and risk of contrast induced nephropathy. Pre-medication is given for patients with known allergies. Follow contrast administration guidelines for checking creatinine and eGFR levels. Sodium bicarbonate protocol may be ordered for patients at risk for contrast induced nephropathy. / Prevent contrast induced nephropathy / Apex
Patient Education / Review patient education information with patient and family to answer any questions they may have. Prepare post procedure written instructions to be given after the procedure is completed. / Apex
PROCEDURE NURSING ASSESSMENT
Patient positioning: Patient is to lie supine on the table. / Support bony prominences with cushioning. Use head foam under the patient’s head, foam heel protection, and foam coccyx protection if necessary. Stabilization straps or Velcro straps will be used to position patient securely on the table. / Proper and safe positioning, prevent pressure ulcers, prevent falls.
Monitoring:
Monitor EKG, BP, O2 sat, respirations, level of consciousness, and response to sedation. / EKG lead placement should be placed away from area of interest. Non-invasive BP cuff should be placed opposite the arm with the IV, if possible. Monitor vital signs and patient response to procedure continuously. / Document vital signs at least every 15 minutes in Apex
Patient/Procedure Assessment / Nursing Interventions / Desired Patient Outcomes / Documentation
Preparation of sterile tray and supplies / See “NIR tray set up” for tray contents and set up. The technologist will open neuro angiogram pack onto procedure table using recommended practices to maintain a sterile field.
0.9 Normal Saline is added to the 2500 ml guidewire blue bowl, and container is labeled with contents. Any additional solutions, medications, contrast material that is poured into containers by the staff is to be shown and verified with the physician. The container will be labeled with the contents, concentration. Pre-printed sterile labels are included in the tray. A blank label for written labeling is available.
No Solutions other than contrast are to be used on the back table.
No Antiseptics (H202) are to be used during the case at any time.
All containers are to be labeled and checked by the Physician at the time of pouring. Any solution intended for patient use is to be checked and rechecked prior to administration by the person administering.
Management of Flush bags and lines / All intra-arterial infusion lines are to be double checked for air bubbles. The final check will be performed by the Neuro Interventional radiologist.
Table contrast is verified as:
Heparin 1000 units in 100 mL Omnipaque 300 (pressure bag)
Heparin 1000 units to 100 mL Omnipaque 240 (injector contrast)
Heparin 500 units to 50 mL Omnipaque 240 (injector contrast)
Flush solution is verified as:
Heparin 5000 units in 1000 mL 0.9 Normal Saline (table flush)
Heparin 1000 units in 1000 mL 0.9 Normal Saline (to introducer sheath)
Patient Skin prep / Expose the skin site after proper verification of procedure and site.
The surgical site and surrounding areas should be clean. Cleansing can be accomplished before the surgical prep by washing the surgical site with any of the following methods:
Soap and water scrub or shower
Betadine scrub – Pour Betadine onto sterile 4x4 sponge gauge and apply to skin in a circular fashion, scrub to cleanse the skin for 60 seconds.
Chlorhexadine scrub - Pour Hibiclens (chlorhexadine) onto sterile 4x4 sponge gauge and apply to skin in a circular fashion, scrub to cleanse the skin for 60 seconds.
The surgical site should be assessed before skin preparation by nursing. Note if there are areas of pre-existing rashes or skin abrasions. If hair is to be removed, use a safety razor or safety electric razor to shave the affected area. The recommended razor is the sterile skin saver razor, item number 233133.
When indicated, the surgical site and surrounding area should be prepared with an antimicrobial agent. Selection of antimicrobial agents is based on patient history of hypersensitivity reactions, location of the surgical site, and patient skin condition.
The recommended prep is ChloraPrep, item number 1159. This prep is FDA approved and meets the recommendations for skin antisepsis by the CDC for catheter insertion.
The technologist will use the ChloraPrep stick to prep an area large enough in consideration.
Using sterile technique, apply the ChloraPrep to the skin in a circular motion for 30 seconds from center outwards. Allow the area to dry completely before draping. / Prevent site infection
Patient Draping: The patient is prepped and draped for the procedure. Sterile practices are in place in the sterile field. / Sterile techniques and practices are observed in the sterile area. All staff wears appropriate attire in the established sterile field area: Mask, head cover, close fitting garments. Using sterile technique, the patient is prepped and draped for the procedure by the technologist or nurse. Using aseptic technique, establish a sterile barrier over the patient’s groin site.
Drape the patient with sterile femoral angio drapes.
Cover upright lead barrier with a sterile half sheet.
Cover ceiling mounted lead barrier with a band bag. / Maintain sterile field to prevent contamination.
Airway management: Observe constantly for open and clear airway. / Suction is to be ready for suctioning of oral secretions at all times. Prompt assessment and intervention by a well-trained team and appropriate use of available equipment for monitoring and airway support are essential in preventing iatrogenic complications. Be prepared to use airway adjuncts whichinclude oropharyngeal airways (oral airway) and nasopharyngeal airways (nasal trumpet) in a variety of sizes. / Patient has open and clear airway.
Pain Management: Assess the patient for pain and tolerance of procedure. / In collaboration with the proceduralist, provide pain relief with opiates of choice. Common medications used for pain relief are Fentanyl and Versed. / Patient is able to tolerate the procedure. / Apex
Management of femoral artery puncture. / Femoral puncture closure is typically done using the StarClose or AngioSeal device. Provide betadine, gauze dressing, steristrips and antibiotic ointment for groin dressing. Give patient instructions to care givers and patient.
Monitor for bleeding, hematoma, and pain at puncture site. Monitor for clinical features of retroperitoneal hemorrhage including: hypotension, tachycardia, flank pain, abdominal pain, groin pain, diaphoresis, declining Hct/Hb, decrease in urine output, altered LOC, restlessness, increase urge to urinate/defecate. / Promote healing of puncture site / Apex
Foley catheter / Foley catheters are generally placed as ordered for lengthy Neuro interventional cases. / Apex document flowsheet
APEX documentation / For nurse sedation cases, the procedure is documented in Sedation Narrator. For anesthesia case, the RN will document the ‘Time Out’ in Apex and anesthesia will document patient monitoring and medications administered during the procedure. / Apex Sedation Narrator
Documentation of ACT (Activated Clotting Times) / Baseline and repeat ACTs are documented in Apex by entering the result in “Edit and enter results”. Write the ACT and time of Heparin dose on the dry erase board in the room. Repeat ACT is done 5 minutes after Heparin is given. After Heparin is given, set the TIMER for every hour as a reminder to check ACT level every hour. / Monitor coagulation status
Common medications during Neuro Angio or Stroke case / The following medications are removed from the Pyxis machine as ordered:
1% Lidocaine with Sodium Bicarbonate (Buffered Lidocaine)
Heparin 1,000 units/mL
Protamine Sulfate 50 mg
TPA 50 mg vial with 50 mL sterile water
Phone Numbers / Neuro ICU x 31873
PACU x 31292
Respiratory Therapy 443-1350
Anesthesia E-1 x 31234
NeuroVascular service
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