Femoral Sheath Removal: Early Ambulation Essay

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Introduction

Artery disease is recognized as one of the major causes of death in the Western world. The strategies implemented for diagnosing and treating this condition deserve serious consideration to define the possible drawbacks in current practices and identify the ways for enhancing the effectiveness of methods and improving the level of patients’ comfort. The treatment strategies used for patients with symptoms of artery disease include pharmacologic management, percutaneous coronary intervention (PCI), and coronary angiography (CA). The latter is the interventional techniques that can be used either for diagnosing the patients or treating stenosis in coronary vessels afterward.

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Traditionally, the CA and PCI techniques were followed with a prolonged period of bed rest within which the immobilized patients had to lie flat which resulted in their discomfort because of leg and back pain and the lack of social support. Pollard et al (2003) and Ormiston (2002) noted that the period of bed occupancy, in particular, a setting is longer than it is necessary. Evaluating the rates of vascular complications, this paper will address the feasibility and safety of reducing the period of bed occupancy after CA and PCI procedures for reducing the patient’s back pain, increasing their comfort, and enhancing the efficiency of using the hospital resources.

Body

The study conducted by Lunden, Bengton, and Lundgren (2006) provides a valuable insight into the main underlying causes of the patients’ discomfort caused by the demand of lying flat after the CA and PCI, shedding light upon the aspects of physiological pain and moral dissatisfaction because of their unmet needs, uncertainty about their condition and the lack of social support. The qualitative approach chosen by the scholars for investigating the research problem was effective for achieving the research goals. The researchers concluded that regardless of the technical developments, patients’ experience with CA and PCI has not undergone any significant changes since 1997 and requires reconsideration.

The rationale for selecting this study is the valuable empirical research of not only the patients’ emotions and bodily sensations, but also the role of the practitioners in reducing their suffering. Thus, describing the measures which need to be taken by the nurses in the clinical settings to prevent the patients’ anxiety and discomfort, the scholars indicate the opportunities for the practical implications of their findings. The study conducted by Lunden, Bengton, and Lundgren (2006) is valuable for viewing the problem in its complexity.

Along with creating a comfortable psychological climate and providing social support, the practical solution for the problem of the patients’ back pain and discomfort caused by the prolonged immobilization after the CA and CPI is shortening the period of bed occupancy. However, the implementation of this solution requires additional evaluation of the possible hazards of vascular complications.

The study undertaken by Schiks et al (2008) was aimed at comparing the rates of punctuation site complications in patients from early and late ambulation groups. The results of this research have shown that the complication rates did not increase in the early ambulation group as compared to the late ambulation group, while there were no statistically significant differences between the levels of comfort in patients of both groups. In this non-randomized comparative study, the experimental group was ambulated after four hours of staying in bed, while the control group stayed in bed till the next morning.

The measurement of complication rates through the examination of hematomas and bleeding only is the limitation of this research which understates the rest of significant aspects, such as patients’ back pain, for example. Another limitation of this study is consideration of the four hours only, while other scholars offered even shorter periods. Ishiyama et al (2002), Kato et al (2009), and Dowling et al (2009) offered ambulation three hours after the intervention, while Farmanbar et al (2008) concluded that ambulation two hours after the CA is safe and feasible.

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Even earlier ambulation 90 minutes after the sheath removal was offered by Gall et al (2006) and ambulation only 1 hour after the catheter removal was suggested by Doyle et al (2006) who concluded that this strategy does not affect the overall complication rates. However, the rationale for selecting the study by Schiks et al (2008) is its relevance to clinical practice and focus on punctuation site bleeding as one of the possible complications.

The study by Walker et al (2008) extends the existing empirical data by evaluating the complication rates in patients who are ambulated 3, 4, and 6 hours after the removal of the catheter. The examination of hemorrhage, pseudoaneurysm, and hematoma formation was used as the measurements for indicating the complication levels. Stating that the requirement to stay in bed for 6 hours after the sheath removal lacks adequate justification and is based rather on tradition than on the real needs of patients and demands of nursing practice, the scholars evaluated the possible consequences of shortening the pre-ambulation period of immobilization.

The quasi-experimental approach utilized by the researchers allowed them to prove the inappropriateness of the traditional 6 hours period of bed occupancy. Tagney and Lackie (2005), Benson (2004), and Boztosun et al (2008) concluded that early ambulation of patients after the CA and CPI procedures results in acceptable bleeding complication rates and can be regarded as safe. Thus, the study by Walker et al (2008) is valuable for its insight into the necessity of implementing changes in the current nursing practices for overcoming the existing stereotypes.

The study conducted by Hoglund (2010) sheds light upon the positive and negative effects of early mobilization of patients after the CA and CPI, considering the possible benefits and complications of reducing the pre-ambulation period. The rationale for selecting this study is the complex approach implemented by researchers for evaluating the effects of early ambulation upon not only the patients’ physiological condition but also their perceived comfort. Pointing at the importance of defining the optimal length of bed occupancy and immobilization after the intervention procedures, the scholars conducted a single-center trial for comparing the outcomes of 5 and 1.5 hours of post-procedural bed rest.

Significantly, this study takes into account the aspect of the patients’ back pain as one of the measurement parameters which was undertreated by the previous researches. One more advantage of this research is the consideration of the long-term consequences of the procedures and exploration of the patients’ comfort not only during but also after the period of bed rest. Chair et al (2003) noted that the reduction of the back pain and associated discomfort in patients can allow changing the patients’ attitudes towards CA procedures in general.

A different approach to the solution of the problem of the patients’ discomfort during the prolonged periods of immobilization after the CPI and CA procedures was adopted by Augustin, de Quadros, S, and Sarmento-Leite (2010) who along with earlier ambulation offered to change the patients’ position during the bed occupancy. To overcome the stereotype concerning the negative effects of changing the patients’ position in the form of bleeding and other complications, the scholars conducted a randomized trial and concluded that the changes in the patient position did not produce any significant increase in bleeding and hematoma complications.

Yilmaz, Gurgun, and Dramali (2007) pointed out the benefits of raising the bed head at about 30 or 45 degrees along with changing the patients’ position to increase their comfort without any complications. It is significant that investigating the underlying causes of the fatigue and discomfort, the researchers paid attention to the not only duration of immobilization but also the patient’s position during bed rest.

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The study by Rezaei-Adaryani, Ahmadi, Asghari-Jafarabadi (2009) focused on the effects of changing the patients’ position and early ambulation upon the intervention outcomes in general. After conducting a single-blind controlled trial, the scholars concluded that changing the position accompanied with the early ambulation can be effective for reducing the patients’ fatigue and increasing their satisfaction without any significant hazards of complication occurrence.

The rationale for selecting this article is the complex approach implemented to assessing the level of increased comfort, not underestimating the amounts of hematomas and bleeding complications at the same time. Additionally, Gillane and Pollard (2009) and Dessidery (2005) pointed out the positive effects of early ambulation for not only increasing patient’s comfort and satisfaction but also maximizing the efficiency of using the hospital resources.

Conclusion

In general, it can be concluded that the rationale for selecting the articles under consideration for this research is their valuable insight into the positive implications and complication rates for assessing the feasibility and safety of earlier ambulation of patients after CPI and CA procedures.

Reference List

Augustin, AC, de Quadros, AS, and Sarmento-Leite, ES 2010, ‘Early sheath removal and ambulation in patients submitted to percutaneous coronary intervention: A randomized clinical trial’, International Journal of Nursing Studies, vol. 47, pp. 939-945.

Benson, G 2004, ‘Changing patients’ position in bed after non-emergency coronary angiography reduced back pain’, Evidence-Based Nursing, vol. 7, no. 1, pp. 19- 24.

Boztosun, B, Gunes, Y, Yildiz, A, Bulut, M, Saglam, M and Kargin, R 2008, ‘Early ambulation after diagnostic heart catheterization’, Angiology, vol. 58, no. 6, pp. 743-746.

Chair SY, Taylor-Piliae RE, Lam G 2003. ‘Effect of positioning on back pain after coronary angiography’ Journal of Advanced Nursing, vol. 42, pp.470–8.

Dessidery, A, Tonello, D, Coscarelli, S, Alitto, F, Daniotti, A and Chioin, R 2005 ‘Early mobilization after percutaneous catheterization and vascular closure with a novel device (star-close)’ American Journal of Cardiology, vol 96, no. 96, pp. 1408-1409.

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Dowling, K, Todd, D, Siskin, B, Dolen, E, and Sansivero, G 2002, ‘Early ambulation after diagnostic angiography using 4-F catheters and sheaths: A feasibility study’, Journal of Endovascular Therapy, Vol. 9, No. 5, pp. 618-621.

Doyle, B, Konz, B, Lennon, R, Bresnahan, J, Rihal, CS 2006, ‘Ambulation 1 hour after diagnostic cardiac catheterization: A prospective study of 1009 procedures’, Mayo Clinic Proceedings, vol. 8, no. 12, pp. 1537-1540.

Farmanbar, R, Chinikar, M, Gozalian, M, Baghaie, M, and Roshan, ZA 2008, ‘The effect of post coronary angiography bed-rest time on vascular complications’, The Journal of Tehran University Heart Center, vol. 3, no. 4, pp. 225-228.

Gall, S, Tarique, A, Natarajan, A, and Zaman, A 2006, ‘Rapid ambulation after coronary angiography via femoral artery access: A prospective study of 1,000 patients’ Journal of Invasive Cardiology, vol. 18, no, 3, pp. 109-110.

Gillane, O, and Pollard, M 2009, ‘Early ambulation of patients post-angiography with femoral puncture’, The British Journal of Cardiology, vol. 16, no. 3, pp. 137-140.

Hoglund, J, Stenestrand, U, Todt, T and Johanson, I 2010, ‘The effect of early mobilization for patient undergoing coronary angiography: A pilot study with focus on vascular complications and back pain’ European Journal of Cardiovascular Nursing, pp. 1-7.

Ishiyama, K, Hashimoto, M, Tate, E, Sakuma, I, and Hirano, Y 2002, ‘Feasibility of early ambulation three hours after transfemoral angiography using a 4 French sheath’ Nippon Igaku Hoshasen Gakkai Zasshi vol. 62, no. 7, pp. 362-365.

Kato, F, Sato, Y, Yuasa, N, Abo, D, Sakuhara, Y and Oyama, N 2009, ‘reduction of bed rest time after transfemoral noncardiac angiongraphy from 4 hours to 2 hours: A randomized trial and a one-arm study’, Journal of Vascular and Interventional Radiology, vol. 20, no. 5, pp. 587-592.

Lunden, M, Bengtson, A, and Lundgren, S 2006, ‘Hours during and after coronary intervention and angiography’ Clinical Nursing Research, vol. 15, no. 4, pp. 274-289.

Ormiston, JA, Shaw, BL, Panther, MJ, and Ruygrok, PN 2002, ‘Percutaneous coronary intervention with bivalirudin anticoagulation, immediate sheath removal, and early ambulation: A feasibility study with implications for day-stay procedures’, Catheterization and Cardiovascular Interventions, vol. 55 no. 3, pp. 289-293.

Pollard, SD, Munks, K, Wales, C, and Cumberland, DC 2003, ‘position and mobilization post-angiography study (PAMPAS): A comparison of 4.5 hours and 2.5 hours bed rest’ Heart, vol. 89, pp. 447-448.

Rezaei-Adaryani, M, Ahmadi, F, Asghari-Jafarabadi, M 2009, ‘The effect of changing position and early ambulation after cardiac catheterization on patients’ outcomes: A single-blind randomized controlled trial’, International Journal of Nursing Studies, vol. 46, pp. 1047-1053.

Schiks, I, Schoonhoven, L, Aengevaeren, W, Nogarede-Hoekstra, C, and Verheught, F 2008, ‘Ambulation after femoral sheath removal in percutaneous coronary intervention: A prospective comparison of early vs. late ambulation’, Journal of Clinical Nursing, vol. 18, pp. 1862-1870.

Tagney, J and Lackie, D 2005, ‘Bed-rest post-femoral arterial sheath removal – What is safe practice? A clinical audit’ Nursing in Critical Care, vol. 10, no. 4, pp. 167-173.

Two hours of bed rest is feasible for patients undergoing transfemoral noncardiac angiography by using a 4–5-F sheath and/or a 4-F catheter, especially those with a normal platelet count.

Walker, S, Jen, C, McCosker, F and Cleary, S 2008, ‘Comparison of complications in percutaneous coronary intervention patients mobilized at 3, 4 and 6 hours after femoral arterial sheath removal’, Journal of Cardiovascular Nursing, vol. 23, no. 5, pp. 407-413.

Yilmaz, E, Gurgun, C, Dramali, A 2007, ‘Minimizing short-term complications in patients who have undergone cardiac invasive procedure: A randomized controlled trial involving position change and sandbag’ Anadolu KArdiyol Derg, vol. 7, pp. 390-6.

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