MS procedures

Thrombolytic Therapy in Nursing

Types of Thrombolytic Therapy

1. Systemic Thrombolysis

• Thrombolytic agents administered intravenously (IV) target clots systemically.

• Commonly used for:

  • Acute myocardial infarction (MI)

  • Ischemic stroke

  • Massive pulmonary embolism

2. Catheter-Directed Thrombolysis (CDT)

• Agents delivered directly to the clot site via a catheter under imaging guidance.

• Used for localized clots:

  • Deep vein thrombosis (DVT)

  • Peripheral arterial thrombus

  • Localized emboli

I. Pre-Procedure Nursing Interventions

1. Verify Physician’s Order and Patient Eligibility

• Confirm indications for therapy:

  • Systemic: Acute MI (within 12 hours), ischemic stroke (within 4.5 hours).

  • CDT: Documented localized thrombus through imaging (e.g., angiography, ultrasound).

• Assess contraindications:

  • Active bleeding

  • Recent major surgery or trauma

  • History of hemorrhagic stroke

  • Uncontrolled hypertension (>180/110 mmHg).

• Rationale: Ensures safety and efficacy of therapy.

2. Perform Baseline Assessments

• Vital Signs: BP, HR, RR, temperature.

• Neurological Assessment: Glasgow Coma Scale (GCS) for stroke cases.

• Cardiac Monitoring: Obtain baseline ECG for MI.

• Laboratory Tests: CBC, PT, aPTT, INR, fibrinogen levels, kidney function tests (creatinine, BUN).

• Imaging Studies: CT scan (for stroke), angiography/ultrasound (for CDT).

• Rationale: Baseline data aids in monitoring responses and identifying complications.

3. Secure Intravenous Access

• For Systemic: Insert at least two large-bore IV lines.

• For CDT: Prepare for catheter insertion under sterile conditions.

• Rationale: Ensures safe drug administration and blood sampling, minimizing repeated punctures.

4. Prepare Emergency Equipment

• Ensure availability of:

  • Oxygen and suction equipment.

  • Crash cart with reversal agents (e.g., aminocaproic acid, cryoprecipitate).

• Rationale: Readiness for adverse events like bleeding or allergic reactions.

5. Educate the Patient and Obtain Consent

• Explain the purpose, benefits, risks, and expected outcomes of therapy.

• Rationale: Informed consent ensures patient understanding and cooperation.

6. Maintain NPO Status (if required)

• Necessary for stroke patients or those undergoing CDT.

• Rationale: Prevents aspiration risk during the procedure or post-therapy.

II. Procedure: Administration of Thrombolytic Therapy

1. Systemic Thrombolysis

a. Administer the Thrombolytic Agent

• Common agents: Alteplase (tPA), Reteplase, Tenecteplase.

• Example for Alteplase:

  • Stroke: 0.9 mg/kg over 60 minutes.

  • MI: 15 mg IV bolus, followed by weight-based infusion.

• Rationale: Restores blood flow by dissolving clots.

b. Monitor the Patient Continuously During Infusion

• Vital Signs: Every 15 mins for the first hour, then every 30 mins.

• ECG Monitoring: Detect arrhythmias (common in MI).

• Neurological Checks: Every 15 mins for ischemic stroke cases.

• Rationale: Early detection of complications like hypotension, arrhythmias, or neurological decline.

c. Assess for Signs of Bleeding

• Check IV sites, gums, skin for bruising, hematuria, or black tarry stools.

• Rationale: Increased bleeding risk due to systemic therapy.

d. Document Therapy Administration and Response

• Record infusion details, vital signs, and adverse reactions.

• Rationale: Ensures continuity of care and safety monitoring.

2. Catheter-Directed Thrombolysis (CDT)

a. Assist with Catheter Insertion

• Maintain sterile technique during catheter insertion under imaging guidance.

• Rationale: Prevents infection and ensures accurate placement.

b. Administer Thrombolytic Agent Locally

• Gradual infusion via catheter: Alteplase 0.5-1 mg/hr for up to 24-48 hours.

• Rationale: Minimizes systemic risks while dissolving the clot.

c. Monitor the Patient Continuously

• Vital Signs: Monitor hourly.

• Distal Perfusion: Assess pulses, limb color, temperature, and capillary refill.

• Catheter Site: Monitor for bleeding, hematoma, or signs of infection.

• Rationale: Ensures clot resolution and detects localized complications.

d. Immobilize the Affected Limb

• Maintain strict bed rest to prevent catheter displacement.

• Rationale: Facilitates clot dissolution and preserves catheter integrity.

e. Document the Procedure and Assessments

• Record infusion rate, catheter site condition, and patient response.

• Rationale: Provides accurate records for ongoing care.

III. Post-Procedure Nursing Interventions

1. Monitor Vital Signs and Bleeding

• Systemic: Every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and hourly for 24 hours.

• CDT: Hourly during infusion and post-catheter removal.

• Check all invasive sites, gums, mucous membranes, stool, and urine.

• Rationale: Early detection of bleeding ensures prompt intervention.

2. Neurological and Cardiac Monitoring

• Neurological: Perform GCS and pupillary checks for stroke patients.

• Cardiac: Monitor ECG for arrhythmias post-MI.

• Rationale: Detects complications like reocclusion or hemorrhage.

3. Maintain Bed Rest and Activity Restrictions

• Avoid IM injections, invasive procedures, and trauma.

• For CDT: Immobilize the catheterized limb until removal.

• Rationale: Reduces bleeding risk and ensures therapy effectiveness.

4. Monitor Laboratory Values

• PT, aPTT, INR, fibrinogen, and CBC levels.

• Rationale: Evaluates clotting function and therapy response.

5. Assess for Complications

• Bleeding: Watch for intracranial hemorrhage symptoms (headache, altered mental status).

• Allergic Reactions: Rash, hypotension, bronchospasm.

• Reocclusion: Sudden return of symptoms.

• Rationale: Early recognition ensures timely management.

6. Remove Catheter (for CDT)

• Apply pressure dressing to the puncture site after removal.

• Rationale: Prevents post-procedure bleeding.

7. Patient Education

• Teach the patient to report:

  • Bleeding signs (black stools, hematuria, unusual bruising).

  • Symptoms of reocclusion (chest pain, weakness, limb swelling).

  • Emphasize follow-up and medication adherence.

• Rationale: Promotes early detection of complications and recovery compliance.

8. Document All Findings and Interventions

• Record vital signs, neurological status, lab results, and post-procedure assessments.

• Rationale: Ensures comprehensive care and supports clinical decisions.

Key Differences Between Systemic and CDT

• Administration Route:

  • Systemic: Intravenous.

  • CDT: Direct catheter-based delivery.

• Duration:

  • Systemic: Short-term (minutes to 1 hour).

  • CDT: Gradual (hours to 48 hours).

• Target:

  • Systemic: Systemic clot dissolution.

  • CDT: Localized clot treatment.

• Bleeding Risk:

  • Systemic: Higher (systemic effects).

  • CDT: Lower (localized effects).

• Monitoring Focus:

  • Systemic: Vital signs, systemic bleeding.

  • CDT: Catheter site, perfusion, localized bleeding.