Nursing care for women undergoing Uterine Fibroid Embolisation

Nursing care for women undergoing Uterine Fibroid EmbolisationJan Jackson BSc (Hons), DMS, CMS, RN, SEN (UK)Head Nurse, Imaging Directorate, Hammersmith Hospitals NHS Trust, London, UK

Hammersmith HospitalsNHS Trust

UFE - BackgroundFirst used in late 1970s to control post-partum bleedRavina et al (1995) published results on treatment for UF disease - effective in controlling symptoms 80-94% - fewer complications - over 7,000 women treated

UFE - ReputationReputation of being quick and safe

UF - What are they?Common growths in female population (20 -50%)Smooth muscle in originPredominantly benignMay be associated with reproductive disordersAsymptomatic fibroid do not require treatment

UF - Type of FibroidIntramural - common and develops in the wall of uterusSubserosal - develops under outside covering of uterusSubmucosal - develops under the inner lining of the uterus and is lease common and problematic

UF - Population affectedIncreased incidence between the ages of 35 - 49Afro-Caribbean women higher riskGeneric and hormonal factors

UF - SymptomsAbnormal vaginal bleeding (menorrhagia)Pelvic painPelvic pressure (large fibroid) on bladder, bowel, kidneys causing increases urination, constipationInfertility, recurrent spontaneous abortion, pre-term labour

UF - DiagnosisPhysical exam (bimanual-abdomen)UltrasoundMRIHysterosalpingogramCTHysteroscopy

UltrasoundUF Diagnosis (Cont)

UF Diagnosis (Cont)Magnetic Resonance Imaging

UF Diagnosis (Cont)Hystersalpingogram

UF - Treatment optionsSymptoms management Surgery - NSAID- Hormone Therapy- Hysterectomy- Myomectomy

HysterectomyUF - Treatment options (cont)

UF - Treatment options (cont)Endometrial ablationThermal ablation of uterus fibroid - percutaneous insertion of laser fibres - focussed USUterine Fibroid Embolisation (UFE)

Uterine Fibroid Embolisation (UFE)Less invasiveNon-surgicalPerformed by Interventional RadiologistsBlood flow in the right and left uterine arteries is occluded and the fibroids are deprived of their blood supplyOcclusion leads to necrosis and death of the fibroids

UFE - IndicationsReferred by gynaecologistSymptomatic patients who have failed other therapy or do not wish to have surgery

UFE ContraindicationsCoagulation disorder or other contraindication to angiographyInfectionOther uterine pathology e.g. endometriosis, adenomyosis, cancerPatients who desire fertility and have exhausted other alternatives

UFE Before ProcedurePelvic US TA/TV or MRIExcluding malignancyGynaecological examination - reviewedDiscuss with interventional radiologistProcedure explained Patient information leafletConsent

UFE

THE ROLE OF THE IMAGING NURSE

UFE - Patient preparationl

UFE - Patient preparationImaging nurse visits patient prior to procedureAssessmentPatient preparation instructionAnalgesiaAntibiotic

Nursing documentation

UFE - Hammersmith HospitalPre -procedurePatient admits to wardSeen by radiologist - consent Prepare for procedure e.g. NBM, shavedCollected by IA to ImagingImaging nurse received patient and hand over from ward nurseCheck patientMedication - Diclofenac suppository 100 mg

UFE - Hammersmith HospitalProcedure TechniqueConscious sedationLocal anaesthesiaFemoral puncturePelvic arteriogram performed Use of microcatheters and guidewires to select uterine arteriesPVAFinal uterine arteriogram

UFE - Arteriogram

UFE - conscious sedation Adult Sedation policy To allow gastric emptying: - Solid food up to 4 hours prior to procedure. - Clear fluids up to 2 hours prior to procedure. - Nil by mouth.American Society of Anaesthesiologists Task Force on Sedation and Analgesia by non-anaesthesiologists (1996) Practice guidelines for sedation and analgesia by non-anaesthesiologists

UFE - Peri-procedureConscious sedationPain management - pain assessmentMonitor vital signsComfort and reassuring patientDocumentation

UFE - Nursing documentation.

PERI-OPERATIVE PROCEDURAL OBSERVATIONS

ECG, Blood Pressure, Pulse, Respiration, O2 Saturation, O2, Temperature and Medication Recordings

Date

Time

B

220

L

210

O

200

O

190

D

180

170

P

160

R

150

E

140

S

130

S

120

U

110

R

100

E

90

80

70

P

60

U

50

L

40

S

30

E

20

10

0

Respiration

O2 Sat %

O2 L / Min

ECG Rhythm

DRUGS

Lidocaine

% ml

Buscopan mg

Glucagon mg

Fentanyl mcg

Hypnovel mg

Heparin units

Contrast

Batch no

NURSING INTERVENTIONS

Intra Procedure

Post Procedure Evaluation

Respiratory

Self Ventilating (

O2 __________ L / min

Via Mask ( Nasal cannula (

GA ( Intubated (

Ventilated (

Self ventilating (

O2 __________ L / min for ______ hr

Chest X-Ray (

Checked (

Cardiovascular

Refer to observation chart

Infusion: _______________________

---------------------------------------------------

Neurological

Conscious level

Awake ( Drowsy (

Rousable ( Specify __________

Conscious level

Fully awake ( Drowsy (

Orientated (

Other ________________________

Pain

Analgesia

(

Sedation

(

Local Anaesthesia

(

Refer to observation chart (

Pain free (

Comfortable (

Pain scale 0 5: _________

(1 = no pain, 2= mild, 3 = moderate, 4 = severe, 5 = unbearable)

Hygiene/ Dressing

Puncture site:

Femoral artery: Right ( Left (

Jugular vein:Right (Left (

Puncture site ____________________

Pedal pulses Right (Left (

Drainage _______________________

Specimens taken_________________

Ultrasound guidance ( Fluoroscopy (

Nursing Documentation

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Notes and property returned with patient Yes / No

Signature _________________________________Print Name ____________________________

Date _____________________________________Time _________________________________

Ward Nurse Signature _______________________ Print Name ____________________________

POST PROCEDURE CARE FOLLOWING:

Femoral/visceral angiography/angioplasty/stenting:

1. The patient must lie flat with one pillow for six hours.

2. Nursing staff must check the patient puncture site for bleeding or haematoma, monitor and record pedal pulses, blood pressure, pulse and respiration as follows:

hourly for two hours

hourly for two hours

1 hourly for two hours

2 hourly for four hours

4 hourly for eight hours

3. The patient should be encouraged to drink plenty of fluids (unless otherwise advised) in order to excrete contrast medium given.

4. The patient should be discouraged from bending the leg with puncture site in order to minimise bleeding or haematoma.

5. Firm pressure must be applied at all times over puncture site when coughing, moving or using bedpan.

6. The patient may sit up in bed if observations are stable and satisfactory after six hours.

7. If bleeding or haematoma occur, consult medical officer immediately.

NB. HH patients may require bed rest for up to 18 hours depending on procedure, which will be advised accordingly by radiologist.

Percutaneous transhepatic cholangiogram/biliary stent:

1. The patient may sit up in bed and remains bed rest for six hours.

2. Nursing staff must check the patient drainage site for oozing or haematoma, monitor and record blood pressure, pulse, respiration and measure drainage as follows:

hourly for two hours

1 hourly for two hours

2 hourly for four hours

4 hourly for eight hours

3. The patient may eat and drink as advised by medical officer.

Liver/renal biopsy:

1. The patient must lie on the biopsy side for six hours and remains on bed rest for 24 hours.

2. Nursing staff must check the patient puncture site for bleeding or haematoma, monitor and record blood pressure, pulse and respiration for:

hourly for two hours

hour for two hours

1 hourly for two hours

2 hourly for four hours

4 hourly for eight hours

3. Administer analgesia as prescribed.

4. The patient may eat and drink as advised by medical officer.

NB: Following transjugular liver biopsy, the patient may sit up in bed and remains on bed rest for four hours.

Nephrostomy/ureteric stent:

1. The patient may sit up in bed and remains on bed rest for