QLexNursing

Evidence of patient education done before the consent form is signed

📌 Patient education must precede informed consent so the patient understands the indication, risks, benefits, and alternatives of a cardiac catheterization.

📌 The record should reflect an individualized teaching session that considered the patient’s health literacy, language needs, learning preferences, and readiness to learn.

📌 Best practice includes using teach-back to verify comprehension and documenting the patient’s questions and responses.

📌 Proper documentation protects patient autonomy and fulfills the nurse’s legal and ethical duty to educate.

📌 Thorough education also reduces pre-procedure anxiety, improves adherence to NPO/medication instructions, and supports safer outcomes.

Administration of ordered preoperative medications

📌 The chart should show which pre-procedure medications were given, exact times, and doses (e.g., sedatives/analgesics per order, medications to continue such as beta-blockers, and those specifically ordered to hold).

📌 Accurate documentation confirms provider instructions were followed and allows anesthesia/cath-lab teams to assess onset/peak effects and hemodynamic stability.

📌 The nurse should verify allergies, vital signs, and relevant lab values (e.g., coagulation or renal function when applicable) prior to giving medications and record these checks.

📌 Recording patient response (e.g., level of sedation, pain relief, adverse effects) supports ongoing evaluation and safety.

📌 Clear MAR entries and narrative notes ensure continuity of care from the unit to the cath lab and reduce medication errors.

A signed consent form

📌 A valid, signed informed consent verifies that the patient voluntarily agrees to the procedure after the provider’s explanation of purpose, risks, benefits, and alternatives.

📌 The nurse’s role is to witness the signature, verify identity and decisional capacity, and ensure all questions were addressed prior to signing.

📌 The form should include the specific procedure name, date/time, and, when appropriate, the site; it must be in the patient’s preferred language (with an interpreter if needed).

📌 Consent must be obtained before any sedating pre-medications that could impair capacity; this safeguard should be visible in the timeline of documentation.

📌 Proper consent documentation offers legal protection and upholds the ethical principle of respect for autonomy.

A complete history and physical examination

📌 A current H&P establishes baseline status (cardiac, pulmonary, neurological) and identifies risk factors relevant to catheterization (e.g., bleeding risk, vascular disease).

📌 It should capture allergies (including prior contrast reactions), medication reconciliation (especially anticoagulants/antiplatelets), and pertinent comorbidities.

📌 Objective findings—vital signs, cardiopulmonary exam, distal pulses—are crucial for pre- and post-procedure comparisons (e.g., monitoring limb perfusion after femoral/radial access).

📌 Recent labs (e.g., renal function if iodinated contrast is planned, coagulation profile when indicated) guide procedure planning and safety.

📌 A thorough H&P supports risk stratification, anticipates complications, and informs the interdisciplinary team’s intra- and post-procedure decisions.