الفهرس 
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Abstract
Percutaneous Coronary Intervention (PCI) becomes an appropriate treatment of Cardio Vascular Disease (CAD) due to the significant developments in the diagnosis and treatment of CAD (Kushner, et al., 2009). According to the American Heart Association (2012), in 2010 an estimated 954,000 inpatient PCI procedures were performed for inpatients in the United States.
After performing coronary procedure correct technique and early sheath removal is essential to stop bleeding and minimize vascular complications and other potential complications (shoulders. 2008 & Lins. et al., 2006).
Few protocols exist which outline the appropriate techniques and methods to remove sheaths that are utilized during PCI, the American Association of critical care nurses has published guidelines for sheath removal at 2017 which has published in the 7th edition of the AACN procedure manual for high acuity, progressive and critical care (Wiegand. 2017).
The aim of this study was to determine outcomes of implementing guidelines of sheath removal on patients post trans-femoral coronary procedures. To achieve this aim; a quasi-experimental research design was used to conduct this study which was carried out in the CCU at the Smouha University Hospital. A convenience sample of 70 newly adult patients admitted post trans-femoral coronary procedure was included in this study, patient with history of neurovascular disorders in the lower limb distal to the site of sheath removal and patients who have vascular complications during trans-femoral coronary procedure excluded from this study.
Two tools were used in this study; Tool one: “Sheath removal observational checklist”, this tool was developed by the researcher based on the AACN guidelines (Levine, G. N., & Bittl, J. A. 2016).to observe the procedure of sheath removal. It includes:-
• Pre-procedure interventions
• Procedure performance
• Post procedure assessment
Tool two: “Patient outcome assessment tool”, this tool was developed by the researcher after reviewing the relevant literature (Burns, S. M. 2014) (Levine, G. N., & Bittl, J. A. 2016) (Fuster, V. 2005). It was used to assess the patient outcomes; it consists of three parts.
• Part I: Neurovascular assessment.
• Part II: Puncture site assessment.
• Part III: Cardiovascular and hemodynamic stability assessment.
Approval of ethics committee of the faculty of nursing was obtained. Permission to conduct the study was obtained from hospital responsible authority after explanation of aim of the study and delivery of an official letter from the Faculty of Nursing. The study tools were tested for content validity by 7 experts in the field of the study. The necessary modifications were done accordingly. . Reliability of the tools was measured using Cronbach Alpha reliability, the reliability coefficients of tool one was (r = 0.950) and tool two was (r = 0.742) which is acceptable. A pilot study was carried out on 10% of the study sample in order to test the clarity and applicability of the research tools. Data were fed to the computer and analyzed using Statistical Package for Social Sciences (SPSS/ version 20.0) software.
For Control Group; Patients were subjected to sheath removal routine hospital care used in the study settings.
For Study Group; Sheath removal guidelines were implemented through four phases: - assessment phase, preparation phase, implementation phase and evaluation phase.
For both groups; after sheath removal the patient’s outcomes have been assessed and recorded using tool two at 5 times; immediately, after 30 minutes, after an hour, after 2 hours, after 4 hours except puncture site where tool two part two was assessed twice; immediately and after 4 hours.
The main results of the current study revealed that most of the studied groups of patients were ranged between 50 to 55 years old; the study group of patients was (42.9%), while (51.4%) was at the control group of patients. (65.7%, 51.4%) of the study and the control group of patientswere females respectively. (65.7%, 60%) of the study and the control group of patients were subjected to coronary angiography respectively. (42.9%, 54.5%) of the study and the control group of patients were not working respectively. (65.7%, 60%) of the study and the control of patients were 6 hours length of stay respectively.
Regarding the presence of comorbidities, it can be detected that there was no significant difference (P= 0.597) between the two groups of patients. However, (40%) of both studied groups had a history of cardiovascular disorders.
Regarding BMI, it can be noted that there was no significant difference (P= 0.029) between the two groups of patients. However, (60%, 77.1%) of study and control of patients were over weighted.
According to practice before sheath removal
It can be noted that in the control group of patients the following steps did not done including:- the temperature for the extremity distal to the site of sheath removal did not assessed for (74.3 %) of patients, the strength of pulse and the sensation did not assessed for (71.4 %) and the cardiac monitor did not prepared for (45.6 %) of patients.
According to practice during sheath removal
It can be noted that in the control group of patients the following steps did not done including: - performing hand hygiene before applying sterile gloves did not do for (85.7 %) of patients, the middle finger of the left hand did not placed to feel the femoral pulse, the pedal pulse did not located with right hand, pressure in the groin did not applied to occlude the pedal pulse, released the pressure slightly until the pedal pulse just return did not done and taken care of not to occlude pulse totally did not done for (91.4 %) of patients.
According to practice after sheath removal
It can be noted that in the control group of patients the following steps did not done including: - the extremity distal to the site of sheath removal not assessed for mobility for (91.4 %) while capillary refill and temperature did not reassessed for (88.6 %) and pain did not reassessed for (85.7 %) of patients. However documented of the method of sheath removal, time hemostasis obtained and duration of compression did not done for (88.6 %) of patients.
According to performance of sheath removal
It can be noted that there is a significant difference between the studied groups before the procedure in patient`s assessment and preparation of equipment (p= 0.000), also there is a significant difference between the studied groups during the procedure, after procedure and total performance level (p=0.000).
Sheath removal outcomes
According to neurovascular outcomes
It can be noted that there is a significant difference between the studied groups at zero time at sensation (p = 0.003) and capillary refill (p = 0.039), while there is no significance between the studied groups at 4 hours’ time interval.
According to puncture site outcomes
It can be noted that there is no significant difference between the studied group at zero time and 4 hours’ time interval at bleeding, ecchymosis, hematoma, localized tenderness, pulsating mass and new bruits.
According to cardiovascular and hemodynamic stability outcomes
It can be noted that there is no significant difference between the studied group at zero time and 4 hours’ time interval at heart rate, blood pressure, respiratory rate, body temperature, chest pain and shortness of breath.
According to mean score of experienced complications
It can be noted that there is no significant difference between the studied groups at zero and 4 hours’ time interval (p= 0.070, p=0.469).
According to total complications mean scores and patients characteristics at zero time of sheath removal between the studied groups.
It can be noted that there is a significant difference between the studied groups in age (p=0.000), presence of co-morbidities (p=0.000), length of stay, type of the procedure (p=0.000), occupation (p=0.007) and BMI (p=0.002) while there in no significant difference in sex (p=0.195).
According to total complications mean scores and patients characteristics after 4 hours of sheath removal between the studied groups.
It can be noted that there is a significant different between the studied groups in age (p=0.000) length of stay and type of procedure (p=0.051). While there is no significant difference between the studied group in sex, occupation, BMI and presence of co-morbidities (p= 0.685, 0.355, 0.129, 0.266 and 0.157).
It can conclude thatthe results of the current study demonstrate a decrease in the rate of post-PCI complications following implementation of the sheath removal protocol. However, since the rates were already quite small from a statistical standpoint, we were not able to conclude that the decrease in rates of complications was statistically significant.
The most important recommendations of this study are as follow: sheath removal guidelines should be incorporated into post coronary procedures practice; this will be assist health care professionals in the removing sheath as correct technique of sheath removal is essential to stop bleeding and minimize vascular complications and other potential complications. Clinical and theoretical training on sheath removal guidelines should be included in nursing and medical core curriculum. Moreover additional researches are needed to address the barriers of applying sheath removal guidelines to provide alternative strategies to apply these guidelines.