Nurse, Patient and Family Relationship in the Cath Lab
Editor’s Note: Building healing relationships with patients and families and efficient teamwork are integral to Nursing at BWH. In this narrative, Deirdre Hamilton, RN, from the Cardiac Catheterization Laboratory captures how a nurse connects with her patient and family, acknowledges the importance of comfort measures to maintaining humanness and demonstrates highly developed knowledge and skill in a high-tech environment.
As my day starts out, I’m tired and not very eager to communicate before my morning cup of tea, but I have a patient in slot 10 waiting for me in the recovery area. Three nurses, three anxious family members and a cardiac diagnostic fellow surround a patient on a stretcher when I walk in. One nurse stands at the patient’s feet, checking pedal pulses and documenting on the patient’s pre-procedure record. The next nurse takes vital signs: puts the thermometer in the patient’s mouth, a “sat probe” on his finger and puts the BP cuff on one arm and then the next. The third nurse holds on to the patient’s left arm as she skillfully starts an IV and starts administering IV fluid. Meanwhile, the fellow is discussing the risks and benefits of the procedure, reassuringly stating that these procedures usually go very comfortably and smoothly, but that there is a risk of bleeding, stroke and death.
With his extremities extended and occupied by busy nurses doing skillful and efficient jobs, the patient and family stare wide-eyed at the physician who is explaining the details of this scary cardiac procedure. The consent is signed, brief questions are addressed and the physician leaves the bedside.
The pre-procedure record, vital signs and prep are completed, and quickly the bustle around the stretcher quiets down. I am alone with the patient, his wife and his two sons. I receive a call from the procedure room telling me they are ready to roll, the start time is getting late. The patient is technically ready, but I take a few minutes to prepare for my part in the case. My part in this production is about to start.
I begin with an introduction and an explanation of my role. I continue with a discussion about what the patient should expect in the procedure: the hard flat table, the cold room and even colder soapy prep, the sting of the lidocaine and the instructions for holding his breath, coughing or turning his head while the x-rays are taken. I tell him that he has to hold still. I tell him that I am going to be the one giving him the IV medications for conscious sedation throughout the procedure, and I will do my best to keep him relaxed and comfortable. Most importantly, I tell him that if he needs anything, his nose scratched, a blanket moved, more medicine for pain or anxiety, or a question answered, I am just two feet away, and I am there with the team just for him.
I answer what seem like simple, meaningless questions: How long will it take? Do I have to stay overnight? What do I do if I have to go to the bathroom? Where will my clothes be? What about my glasses? These questions seem important to him and his wife, I am glad I took the time to answer them. I make a plan with the family about where I’ll find them when we are done, and when they’ll get to speak with the doctor.
I take another minute to review his chart. I make sure he has had his aspirin, that his labs are OK, and his IV is functioning. I know his history, his presenting problem and the plan for the procedure. My patient has been having chest discomfort for two months every time he tries to exercise. A positive stress test, a strong family history and a lot of convincing brought him into the Cath Lab.
He confirms he is “just a little nervous,” although his high BP and the nodding heads of his family relay more anxiety than he is ready to admit. I remind him I would worry if he was not at all nervous and together we make a plan to keep him relaxed and comfortable during the procedure.
When I feel like my patient and I have established a rapport that ensures that I know him well enough to take care of him safely, and that he feels his questions are answered and his anxiety somewhat dulled, I direct his family to the waiting room and roll my patient into the procedure.
As a team, the x-ray tech, the CV tech and I get him ready on the table. The hard table and cold soap were just as I had prepared him for. Once all the monitors are on and with a confirmation of the physician I start IVCS. My patient and I talk a bit, about his family and where he lives. His conversation is more relaxed now, the drugs are kicking in and the fear of the unknown is diminishing.
The procedure starts, sheaths are inserted, pictures are taken and my patient asks if we have started the procedure. He calls me by name from a groggy sleep and asks me again where I live. I know he’s comfortable.
We find a coronary occlusion and plan to fix it. The physician explains this to the patient who says, “Great, that sounds great!” The diagnostic fellow who worked up the patient pre-procedure leaves the case and an interventional fellow enters for the intervention. The physician asks me if the patient has been on aspirin, and gives me verbal orders for heparin and a 2b3a inhibitor. I clarify the integrillin order considering the patient’s platelets are 90, and his anticoagulation orders are changed. I quickly anticoagulate my patient and the intervention begins.
During ballooning the patient wakes up and reports he feels pressure in his chest. He rates the pain, the physician is aware, I give more fentanyl and reassure him this is normal and it will go away when they take out the balloon. It does, and he reports quickly that he feels much better.
A couple more pictures during the intervention and the occasional ectopy turns into V-tach on the monitor. My patient is awake, complaining of heaviness again in his chest. The physician yells to cardiovert, but my patient is talking to me. I quickly give more sedation, place the gel pads on his chest, and try to calmly explain his heart is in a fast rhythm as he looks at me in wonder. I pick up the paddles as he loses consciousness, and within 15 seconds of the rhythm change, I cardiovert his VT to sinus rhythm. At this point he has a normal rhythm and a stable blood pressure, but he is so sleepy he is barely breathing. An anesthesiologist arrives as I open the patient’s airway, and I am grateful for the team member who thought to call Anesthesia to secure the airway. The anesthesiologist orders romazicon to reverse the versed. Within ten seconds he is awake and asking what happened.
The physician and I explain the change in his heart rhythm and the need for the electric shock. He says, “I wondered why someone hit me in the chest.” At this point the procedure is over and my patient is comfortable, and happy the procedure is over, as am I.
I get him situated in the recovery area, and review the plan for admission, bed rest and the next 24 hours. I get his family, and then call the physician to the bedside to talk to his wife and sons. I hand over my patient to the nurse in the recovery area feeling like I have left no loose ends. My patient has made it through his scary, slightly complicated cardiac procedure safely and comfortably. He says: “Thank You!” and I move on to my next patient and family.