R E S E A R C H I N B R I E FThe effect of ambulation afte.docx

R E S E A R C H I N B R I E F
The effect of ambulation after cardiac catheterization on patient
outcomes
Sek Ying Chair MBA, PhD, RN
Assistant Professor, The Nethersole School of Nursing, The
Chinese University of Hong Kong, Hong Kong, China
David R Thompson PhD, MBA, RN, FRCN, FESC
Director and Professor of Clinical Nursing, The Nethersole
School of Nursing, The Chinese University of Hong Kong, Hong
Kong, China
Shu Kin Li MBBS, FRCP
Chief of Service, Department of Medicine, Pamela Youde
Nethersole Eastern Hospital, Hong Kong, China
Submitted for publication: 24 August 2005
Accepted for publication: 26 January 2006
Introduction
Cardiac catheterization remains the most definitive procedure
for diagnosis and evaluation of coronary artery disease

(Woods et al. 2005). Currently, cardiac catheterization has
become a routine diagnostic procedure performed in many
hospitals in Hong Kong. Although it can be performed
through brachial, radial, or femoral arteries (Woods et al.
2005), the transfemoral puncture is the most common
approach (Noto et al. 1991, Chair et al. 2003). However,
because vascular complications occur in 0Æ43–5Æ8% of
transfemoral cardiac catheterization patients (Noto et al.
1991, Lehmann et al. 1997, Chair et al. 2003), strict bed rest
and immobilization of the catheterized leg have been consid-
ered essential to reduce the risk of their development
(Grossman 1980, Woods et al. 2005). The recommended
bed rest duration after transfemoral cardiac catheterization
varies from two to 24 hours (Baum & Gantt 1996, Chair
et al. 2003). Many patients find it difficult to use the bedpan
or urinal in the recumbent position during bed rest, more-
over, studies reported that back pain severity increased with
longer duration of bed rest after cardiac catheterization

(Barkman & Lunse 1994, Baum & Gantt 1996, Chair et al.
2003). Therefore, to obtain optimal patient outcomes, the
length of bed rest duration after cardiac catheterization
should be minimized.
Aims
The aims of this study were to compare patient outcomes of
vascular complications, back pain, and urinary discomfort
between patients ambulated at four and 12–24 hours (usual
care) post-transfemoral cardiac catheterization.
Methods
Patients admitted for elective cardiac catheterization at a
general hospital in Hong Kong Island were recruited to the
study. Inclusion criteria were that patients should be ethnic
Chinese, aged over 18 years, had no bleeding disorders, were
not receiving anti-coagulant therapy within the previous
24 hours before the procedure, had no back pain, blood
pressure <180/110 mmHg before the procedure and no
complications developed during cardiac catheterization.

Patients were randomly assigned to either a control or
experimental group according to a computer-generated
random table of number. Patients in the experimental group
were ambulated after four hours bed rest postcardiac
catheterization, whereas patients in the control group were
ambulated the morning after the procedure, 12–24 hours
Correspondence: Sek Ying Chair, The Nethersole School of
Nursing,
The Chinese University of Hong Kong, Shatin, New Territories,
Hong Kong, China. Tel: (852) 2609 6225, E-mail:
[email protected]
edu.hk
� 2007 Blackwell Publishing Ltd
212 doi:10.1111/j.1365-2702.2006.01599.x
after bed rest depending on the time the patient had the
procedure completed during the day (usual care).
The puncture site was assessed for vascular complications
hourly for the first six hours then the next morning at
08:00 hours using the guidelines (Christenson et al. 1976).

Significant bleeding was defined as blood loss estimated at
>100 ml, haematoma >5 cm in width or bleeding that led to
further attempts to reestablish haemostasis by manual pres-
sure, sandbag, or reinforcement of pressure dressing. For all
patients, back pain was assessed at four hours, eight hours and
the next morning at 08:00 hours after cardiac catheterization
by using a visual analogue scale consisting of a 100-mm long
line with the left anchor representing ‘no pain’, and the right
anchor representing ‘the worst possible pain’. Urinary discom-
fort was assessed at six hours after the procedure by use of a
five-point Likert scale self-developed measurement consisting
of four questions, a higher value referring to more urinary
discomfort. The test–retest reliability of the urinary discomfort
measurement on 18 subjects was significantly correlated
(r ¼ 0Æ95, P < 0Æ001), and the Cronbach’s alpha was 0Æ876.
Findings
A total of 86 (male, n ¼ 41; female, n ¼ 45) subjects
completed the study, 43 in each group with a mean age of

63 years (SD ¼ 9Æ6, range 34–75). Fifty-six (65%) subjects
had either received no formal education or were educated at
elementary level, and eight (9Æ3%) had received a college
education. Most (65Æ1%) subjects had a monthly family
income <HK$8000 (approximately US$1000). Seventy-one
patients (82Æ6%) were either retired or housewives. Table 1
shows that the two groups were not significantly different in
age, gender, education level, and monthly household income.
Occupation status was significantly different between the two
groups (chi-square, P ¼ 0Æ009) with more retired subjects in
the control groups but more housewives in the experimental
group.
There was no difference between the two groups on vascular
complications. One subject in the control and none in the
experimental group developed bleeding at the puncture site
that required manual pressure to re-establish haemostasis
(Fisher’s exact test, P ¼ 1). Repeated measures analysis of
variance was used to evaluate the back pain experienced across
time and between groups. There was a significant difference
between the two groups at the three time intervals on back

pain intensity (F2,83 ¼ 9Æ80, P < 0Æ001) with the control
group reporting more pain at each time interval. Moreover,
the two groups also differed significantly on urinary discom-
fort (t65Æ6 ¼ 3Æ24, P ¼ 0Æ006) with the control group
experi-
encing higher levels of urinary discomfort (Table 1).
Table 1 Demographic and outcomes comparisons between
groups
Control (n ¼ 43) Experimental (n ¼ 43) P-value Statistical test
used
Age [years: mean (SD)] 63Æ2 (±9Æ7) 62Æ7 (±9Æ7) 0Æ816 t-
Test
Gender, n (%)
Male 19 (44Æ2) 22 (51Æ2) 0Æ517 Chi-square
Female 24 (55Æ8) 21 (48Æ8)
Educational level, n (%)
No formal education 11 (25Æ6) 12 (17Æ9) 0Æ729 Mann–
Whitney U-test
Primary school 16 (37Æ2) 17 (39Æ6)
Secondary school 13 (30Æ2) 9 (20Æ9)
University 3 (7) 5 (11Æ6)
Monthly household income, n (%)
£HK$8000 22 (51Æ2) 34 (79) 0Æ052 Mann–Whitney U-test
HK$8001–$18 000 14 (32Æ6) 6 (14)
>HK$18 001 7 (16Æ2) 3 (7)

Occupation, n (%)
Retired 30 (69Æ8) 21 (48Æ8) 0Æ009 Chi-square
Housewife 4 (9Æ3) 16 (37Æ2)
Presently working 9 (20Æ9) 6 (14)
Vascular complications, n (%) 1 (2Æ3) 0 (0) 1Æ00 Fisher’s
exact test
Back pain
Four hours 1Æ55 0Æ97 <0Æ001 Repeated measure of
ANOVAANOVA
Eight hours 4Æ41 1Æ34
The next morning 4Æ01 1Æ77
Urinary discomfort 2Æ57 1Æ09 0Æ006 t-Test
Research in brief
� 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing,
16, 212–214 213
Discussion
Prolonged bed rest in the supine position is difficult for many
patients who have undergone cardiac catheterization. Some
patients complain of back pain and have the desire to move
from side to side. Others complain of difficulty to urinate in a
supine position. In this study, patients allowed to ambulate at

four hours postcardiac catheterization experienced signifi-
cantly less back pain and less urinary discomfort, but did
not experience any increase in vascular complications at
puncture site.
The average age, high unemployment rate, low education
standard and low-income level of patients in this study was
reflective of the study site which is less affluent than the
general Hong Kong population
Implications for practice
The results suggests that early ambulation may play a
substantial role in reducing back pain and urinary discomfort
in post-transfemoral cardiac catheterization. Allowing pa-
tients to get out of bed after four hours of bed rest following
cardiac catheterization could be introduced into routine
practice in Hong Kong, as it was found to be safe and might
aid in promoting patient comfort without increasing the
incidence of vascular complications. In addition, the shorter
bed rest duration may reduce the nursing time needed for

administering analgesics or back rubs to relieve back pain.
Early ambulation after cardiac catheterization may also
reduce the nursing time needed for assisting patients to use
urinal and bedpan during bed rest period after the procedure.
References
Barkman A & Lunse C (1994) The effect of early ambulation on
patient comfort and delayed bleeding after cardiac angiogram: a
pilot study. Heart & Lung 23, 112–117.
Baum RA & Gantt DS (1996) Safety of decreasing bedrest after
coronary angiography. Catheterization and Cardiovascular Diag-
nosis 39, 230–233.
Chair SY, Taylor-Piliae RE, Lam G & Chan S (2003) Effect of
po-
sitioning on back pain after coronary angiography. Journal of
Advanced Nursing 42, 470–478.
Christenson R, Staab E, Burko H & Foster J (1976) Pressure
dres-
sings and postarteriographic care of the femoral puncture site.
Radiology 119, 97–99.

Grossman W (1980) Cardiac Catheterization and Angiography.
Lea
& Febiger, Philadelphia, PA.
Lehmann KG, Feris ST & Heath-Lange SJ (1997) Maintenance
of
hemostasis after invasive cardiac procedures: implications for
outpatient catheterization. Journal of American College of
Cardi-
ology 30, 444–451.
Noto T, Johnson LW, Krone R, Weaver WF, Clark DA, Kramer
JR
& Vetrovec GW (1991) Cardiac catheterization 1990: a report
of
the registry of the society for cardiac angiography and interven-
tions (SCA&I). Catheterization and Cardiovascular Diagnosis
24,
75–83.
Woods SL, Froelicher ESS, Motzer SU & Bridges EJ (2005)
Cardiac
Nursing, 5th edn. Lippincott, Philadelphia, PA.
Research in brief

214 � 2007 Blackwell Publishing Ltd, Journal of Clinical
Nursing, 16, 212–214
060 Reading and Writing Climate Change
“Are Electric Vehicles Really So Climate Friendly?”
Hans-Werner Sinn
The Guardian
November 25, 2019
Germany’s automobile industry is its most important industrial
sector. But it is in crisis, and not only because it is experiencing
the effects of a recession brought on by Volkswagen’s cheating
on emissions standards, which sent consumers elsewhere. The
sector is also facing the existential threat of exceedingly
strict European Union emissions requirements, which are only
seemingly grounded in environmental policy.
The EU clearly overstepped the mark with the carbon dioxide
regulation that went into effect on 17 April 2019. From 2030
onwards, European carmakers must have achieved average
vehicle emissions of just 59 grams of CO2 per km, which
corresponds to fuel consumption of 2.2 litres of diesel
equivalent per 100 km (107 miles per gallon). This simply will
not be possible.
As late as 2006, average emissions for new passenger vehicles
registered in the EU were around 161 g/km. As cars became
smaller and lighter, that figure fell to 118 g/km in 2016. But
this average crept back up, owing to an increase in the market
share of gasoline engines, which emit more CO2 than diesel
engines do. By 2018, the average emissions of newly registered
cars had once again climbed to slightly above 120 g/km, which
is twice what will be permitted in the long term.
Even the most gifted engineers will not be able to build internal
combustion engines (ICEs) that meet the EU’s prescribed
standards (unless they force their customers into soapbox cars).
But, apparently, that is precisely the point. The EU wants to
reduce fleet emissions by forcing a shift to electric vehicles.

After all, in its legally binding formula for calculating fleet
emissions, it simply assumes EVs do not emit any
CO2 whatsoever.
The implication is that if an auto company’s production is split
evenly between electric vehicles and ICE vehicles that conform
to the present average, the 59 g/km target will be just within
reach. If a company cannot produce electric vehicles and
remains at the current average emissions level, it will have to
pay a fine of about €6,000 (£5,150) per car, or otherwise merge
with a competitor that can build electric vehicles.
But the EU’s formula is nothing but a huge scam. Electric
vehicles also emit substantial amounts of CO2, the only
difference being that the exhaust is released at a remove – that
is, at the power plant. As long as coal- or gas-fired power plants
are needed to ensure energy supply during the “dark doldrums”
when the wind is not blowing and the sun is not shining, EVs,
like ICE vehicles, run partly on hydrocarbons. And even when
they are charged with solar- or wind-generated energy,
enormous amounts of fossil fuels are used to produce EV
batteries in China and elsewhere, offsetting the supposed
emissions reduction. As such, the EU’s intervention is not much
better than a cutoff device for an emissions control system.
Earlier this year, the physicist Christoph Buchal and I published
a research paper showing that, in the context of Germany’s
energy mix, an EV emits a bit more CO2 than a modern diesel
car, even though its battery offers drivers barely more than half
the range of a tank of diesel. And shortly thereafter,
data published by VW confirmed that its e-Rabbit vehicle
emits slightly more CO2 than its Rabbit Diesel within the
German energy mix. (When based on the overall European
energy mix, which includes a huge share of nuclear energy from
France, the e-Rabbit fares slightly better than the Rabbit
Diesel.)
Adding further evidence, the Austrian thinktank Joanneum
Research has just published a large-scale study commissioned
by the Austrian automobile association, ÖAMTC, and its

German counterpart, ADAC, that also confirms those findings.
According to this study, a mid-sized electric passenger car in
Germany must drive 219,000 km before it starts outperforming
the corresponding diesel car in terms of CO2 emissions. The
problem, of course, is that passenger cars in Europe last for
only 180,000km, on average. Worse, according to Joanneum,
EV batteries don’t last long enough to achieve that distance in
the first place. Unfortunately, drivers’ anxiety about the cars’
range prompts them to recharge their batteries too often, at
every opportunity, and at a high speed, which is bad for
durability.
As for EU lawmakers, there are now only two explanations for
what is going on: either they didn’t know what they were doing,
or they deliberately took Europeans for a ride. Both scenarios
suggest that the EU should reverse its interventionist industrial
policy, and instead rely on market-based instruments such as a
comprehensive emissions trading system.
With Germany’s energy mix, the EU’s regulation on fleet fuel
consumption will not do anything to protect the climate. It will,
however, destroy jobs, sap growth, and increase the public’s
distrust in the EU’s increasingly opaque bureaucracy.
https://www.theguardian.com/environment/2019/nov/25/are-
electric-vehicles-really-so-climate-friendly
In introduction, the author points the automobile that is most
important industry in Europe to make readers initially think that
the context is about the relationship between the Europe and the
cars, and then he gives an example that about cheating on
emission standards to deeply clarify what he would discuss
about in the following paragraph. Therefore, for the following
paragraph, to persuade the readers, the author instantly show the
numbers of emission in carbon dioxide in 2019, and the goal
they want to achieve after 2030. Also, he gives the gasoline
engine and diesel engine to compare which emit more CO2, and
shows the trend of CO2 emission between 2006 to 2018. It

indicates that the average emissions for new registered vehicles
were around 161g/km in 2006, and then because the cars
become smaller and lighter, the emission falls to 118g/km.
However, the emission climbs back to 120g/km by 2018. After
the author discuss the gasoline engine, he tries to guide readers
to the electric vehicles. And then he instantly points out the
flaws which EU consider that EVs do not emit any CO2. He
states that the formula is a scam because of EV’s battery. It uses
a lot of fossil fuel to produce EV batteries, and it just offsets
the emission reduction. Moreover, he gives another evidence to
convince readers. He published a research paper with the
physicist. The paper is about EV emits slightly more CO2 than
diesel car, although the battery offers drivers more than half
range of a tank of diesel. And the data is from VW.
Furthermore, the author gives the study that shows only if the
EV must drive over 219,000 km, it equals to the CO2 emission
of the diesel cars, but the batteries cannot last for this distance.
After that, he gives his solution that the EU need to modify its
policy in its emissions trading system. Also, he believes that the
EU would not do anything on this issue because it will influence
many stratus. Consequently, after analyzing the whole passage,
I found that author use a lot of ethos concept, like facts,
research, and numbers, to get readers’ credibility. By using
these evidences, he can easily convince his readers. Also, he
uses the proper ideas to give his solution, and conclusion, and
then he lets readers more believe the author’s passage.
PAGE 106 JOURNAL OF VASCULAR NURSING
SEPTEMBER 2016
www.jvascnurs.net
Evaluation of feasibility and safety of
changing body position after transfemoral
angiography: A randomized clinical trial

Sina Valiee, PhD, Mohammad Fathi, PhD, Nooshin Hadizade,
MD, Daem Roshani, PhD, and Parvin Mahmoodi, MS
From t
Kurdista
Nursing
Kurdista
Departm
Departm
Sanand
Univers
Corresp
Commit
Street, S
Funding
Kurdista
31229/1
1062-03
Copyrig
http://dx
Background: Considering the growing number of patients who
suffer from cardiovascular and coronary artery disease
and the significant importance of angiography in the diagnosis
of coronary artery disease, this study investigated the ef-
fects of position change on the acute complications of coronary
angiography.
Methods: This study was a randomized clinical trial. Sixty

patients undergoing coronary angiography, which was per-
formed by a single operator were selected by convenience
sampling method and were assigned to intervention or control
groups by randomized block design (30 cases in each group).
Intervention group patients’ position was changed according
to schedule, whereas patients in the control group remained in
the supine position in complete bed rest. At the entrance
hours, 3, 6, 8, and 24 hours after the angiography, patients in
both groups were evaluated in terms of vascular complica-
tions, urinary retention, low back pain, groin pain, and comfort.
Data were analyzed by repeated measures, Friedman,
Mann–Whitney, chi-square, independent t-test, and
Kolmogorov–Smirnov tests with SPSS-22.
Results: The two groups did not show any significant difference
in terms of demographic, clinical, and preinterventional
catheterization characteristics (P > 0.05). There was no
significant difference with regard to vascular complications
including hematoma (P = 0.149), bleeding (P > 0.01), bruise (P
= 0.081), and thrombosis in the two groups of patients
during 5 consecutive reviews. However, there was a significant
statistical difference regarding low back pain
(P < 0.001), groin pain (P < 0.001), urinary retention (P = 0.02),
and comfort (P < 0.001).
Conclusions: The results of this study showed that changing the

positions of patients after angiography based on the
provided program created no change in the incidence of
vascular complications (hematoma, bleeding, thrombosis, and
bruise) but resulted in reduced severity of back pain, groin pain,
urinary retention, and increased patients’ comfort. (J
Vasc Nurs 2016;34:106-115)
Cardiovascular disease is one of the leading causes of death
for women and men of all ethnicities and races,1 and it is ex-
pected to remain the most common cause of death in the world
until 2020.2 Among heart disease, coronary artery diseases is
the most common and life-threatening one.3
he Social Determinants of Health Research Center,
n University of Medical Sciences, Sanandaj, Iran;
Department, School of Nursing & Midwifery,
n University of Medical Sciences, Sanandaj, Iran;
ent of Epidemiology and Biostatistics, Medicine
ent, Kurdistan University of Medical Sciences,
aj, Iran; Student Research Committee, Kurdistan
ity of Medical Sciences, Sanandaj, Iran.
onding author: Parvin Mahmoodi, MS, Student Research
tee, Kurdistan University of Medical Sciences, Pasdaran
anandaj, Iran (E-mail: [email protected]).
: This work was supported by the Research Council of
n University of Medical Sciences (grant number 1035/
4).
03/$36.00
ht � 2016 by the Society for Vascular Nursing, Inc.

.doi.org/10.1016/j.jvn.2016.05.001
There are different diagnostic methods for assessing coronary
artery disease.4 Coronary angiography is the golden standard
test
to identify the presence and extent of atherosclerotic disease of
coronary artery.5 Annually, nearly three million cardiac
catheter-
izations are done in the United States of America.6
Angiography
involves injecting a radiopaque dye into the coronary arteries
un-
der fluoroscopy which determines the condition of the coronary
arteries and the degree of atherosclerosis.
7
Although the risks and complications associated with angiog-
raphy depends on the patient’s condition, operator’s skill, and
judgment, any invasive procedure has some complications asso-
ciated with the procedure.5 Coronary angiography can be ac-
cessed via the potential arteries included brachial, radial and
femoral arteries.7–11 About 95% of angiography is performed
via femoral artery.12,13
Access to the heart via femoral artery can be accompanied with
complications such as arrhythmia, vascular complications
(bleeding, hematoma, and thrombosis), injury and myocardial
ischemia, coronaryartery perforation, hemodynamic collapse,
cer-
ebrovertebral accident including transient ischemic attack,
allergy
to contrast media and acute renal failure.14–18 Demonstration
of
these complications can be divided in two main form of acute
and chronic. The former includes hematoma, bleeding,

thrombosis, urinary retention, low back pain, and groin pain.5
Studies have shown that to avoid possible complications due
to arterial injuries, the current method of treatment after
Delta:1_given name
Delta:1_surname
Delta:1_given name
Delta:1_surname
Delta:1_given name
mailto:[email protected]
http://dx.doi.org/10.1016/j.jvn.2016.05.001
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jvn.2016.05
.001&domain=pdf
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Vol. XXXIV No. 3 JOURNAL OF VASCULAR NURSING
PAGE 107
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angiography in many health care facilities in Iran is to have the
patient rest in the supine position with the head angle of zero
de-
grees for 8–24 hours and keeping 4 kg (8.82 lbs) sandbag on the
catheter insertion site for 6 hours,19–21 which has often been
conducted based on tradition and experience.19 This insistence
on bed rest for patients after coronary catheterization can lead
to restlessness, discomfort, and frequent complaint of back and
groin pain.
11
About 42% of patients who get out of bed after
4 hours of rest experience back pain.24 In addition, 11.4% of

pa-
tients undergoing this procedure may develop urinary reten-
tion.14,25 Back pain, groin pain, and urinary retention leads to
the use of analgesic medications and urinary catheterization
which are associated with their own specific complications. To
avoid complications resulting from the use of analgesic
medications and urinary catheterization, nonmedical measures
and nursing care are appropriate.10
Development of technology along with procedures requires
appropriate medical and nursing care.
22,23
Although there is
much evidence for medical approach to care, little evidence
exists to support the suggestions relating to management areas
such as patient’s position, the time of getting out of bed, and
the time of removing sandbag which are generally related to
the nursing activities territory.9,24-26 A recent literature
review
showed that caring of patients undergoing cardiac
catheterization requires a revision in key areas of nursing
care.19,22,25 Abdollahi et al14 (2013) reported that in addition
to
changes in body position and leaving the bed early, no vascular
complications in patients undergoing coronary angiography
was seen, whereas urinary retention in the control group was
observed. Rezaei-Adaryani et al
19
(2009) reported that patients
whose positions were switched during the period of bed rest
had experiences less fatigue but more comfort and satisfaction
in the 3, 6, 8, and 24 hours after arrival to the postangiography

ward. In addition, changes in body position had no significant
impact on increased bleeding and hematoma compared with
the control group.19 Heravi et al27 (2013) comparing the
patients
in supine positions with the head angle of 0, 15, 30, 45, and 60
in
separate groups reported that patients with head angle of 45�
had
experienced the lowest pain, so it was declared as the best
position.
One of the nursing measures is changing the position of the
patient who has undergone transfemoral angiography during
bed rest, but it is avoided due to the fear of the vascular
complications.
The effects of position change in patients after transfemoral
angiography during bed rest will be evaluated as it relates to
vascular complications. This study aimed to determine the ef-
fect of changing position on urinary retention, back pain, pain
in the groin, and comfort of patients undergoing coronary
angiography.
METHOD
The study is a single-blind randomized clinical trial in two
groups which was approved by the Kurdistan University of
Medical Sciences research Council. The study’s proposal is
registered at (www.irct.com) by the registration number
IRCT2015091424018N1.
Sample size and sampling
The samples were chosen by convenience sampling method,
and they were randomly allocated into control and intervention
groups. The sample size with 95% confidence interval and
80% statistical power was estimated 60 patients (30 patients in
the intervention group and 30 patients in the control group)

(Figure 1).
Participants
Participants were patients undergoing coronary angiography.
Inclusion criteria included nonemergency catheterization, age
18–65 years old, less than 180/100 mm Hg blood pressure,
absence of active bleeding disorders, prothrombin time (PT),
and partial thromboplastin time (PTT) of less than 16 and 90
sec-
onds, respectively, consent to participate in the study, angiog-
raphy via the femoral artery, no history of deep vein
thrombosis (DVT) before the procedure, not being treated with
thrombolytic (not taking streptokinase) and anticoagulant drugs
(not taking warfarin), no history of diabetes with sensory prob-
lems, not taking any analgesic medications before the
procedure,
not suffering from peripheral arterial disease, no history of uri-
nary problems, no history of allergy to contrast media, no
depen-
dency to drugs, lack of chronic low back pain, absence of blood
and liver diseases. Exclusion criteria included needle entrance
more than once to access the artery, cardiopulmonary resuscita-
tion during angiography, movement disability, and disorder in
the level of consciousness in a way that the patient can not
coop-
erate to change position and incomplete termination of clinical
intervention period.
Ethical considerations
This study was approved by the Research Council of Kurdi-
stan University of Medical Sciences with the contract number
1035/31229/14 and was confirmed for ethical considerations by
receiving the moral code muk.rec.1394.194 from the ethics
com-

mittee of Kurdistan University. While explaining the purpose
and
method of study for the patients, informed consent was obtained
from them.
Measuring tool
The instrument used to collect and record information in this
was a three-part questionnaire which was designed according to
the study.
The first part was demographic and clinical information form
which contained information about age, height, weight, gender,
marital status, education, occupation, history of smoking, dia-
betes, history of previous coronary angiography, systolic and
dia-
stolic blood pressure, body mass index, PT, PTT, international
normalized ratio, and platelet count which was recorded based
on the information contained in patients’ medical records.
Patients’ blood pressure was measured and recorded by one
person using a mercury sphygmomanometer (ALP K2 model:
no 300-VS; Tanaka Sangyo Co, Ltd, Tokyo, Japan) which was
calibrated before the start of the study. Their height and weight
were measured and recorded by one person using digital scales
(Bermend BD7750) and centimeters. The second section con-
tained procedural information form which contained the length
http://www.irct.com
Assessed for eligibility (n = 81)

Excluded (n= 15):
• Chronic Low Back Pain(n = 6)
• unwillingness to participate in
the study(n = 4)
• history of taking
anticoagulant(n = 2)
• Dependence on opium (n = 3)
Randomized (n = 66)
Allocated to intervention group(n = 33):
• Received routine care (n = 33)
• Did not received routine care (n = 0)
A
llo
ca
ti
on
E
nr
ol
lm
en
t
Allocated to control group (n = 33)
• Received changing of body

position(n = 33)
• Did not receive allocated
intervention(n = 0)
F
ol
lo
w
u
p
Lost to follow up (n =3):
• Had anaphylactic reactions to the
contrast agent(n =2)
• Failure to did angiography because
of obstruction in abdominal aortic
(n =1)
Lost to follow up (n =3):
• Had chest pain and take analgesic
medications (n=2)
• 3 times needle inserted to access
artery (n =1)
A
na
ly

si
s
Analyzed (n =30) Analyzed (n =30)
Figure 1. Consolidated Standards of Reporting Trials
(CONSORT) flow diagram.
SEPTEMBER 2016
www.jvascnurs.net
of angiography, homeostasis time, size of the catheter used,
injury of the femoral artery, and the type and volume of contrast
agent, diagnosis of coronary artery stenosis which were
prepared
using a chronometer and the information contained in patient
records.
Part three of the evaluation form included angiographic com-
plications such as hematoma, bleeding, urinary retention, back
pain, groin pain, and comfort. Back pain, groin pain, and
comfort
were measured and recorded with standard numeric rating
scale.28 Patients’ comfort level was measured by a general
ques-
tion about the overall level of comfort at the time of measure-
ment. The patients were asked to rate their comfort from 0 to
10 grades. The validity of this scale was set by Johnson and
Carol.22 The reliability was estimated by Farrar et al and Good
et al to be 0.78 and 0.83.29,30 Hematoma shape and bruise was
placed on transparent paper and then on graph paper, and the
side of intended shape was measured and recorded (based on
the biggest length and width) per square centimeter. The
amount of bleeding was measured by weighing Gauze soaked
in blood by 0.1 gm sensitive Japanese scale (standard future).

Urinary retention was also analyzed based on patient interview.
All the measurements were carried out by the principal
researcher.
Intervention procedures
After the selection of eligible patients for inclusion into the
study and providing the necessary explanations, obtaining
informed consent, necessary data were obtained from medical
re-
cords, and blood pressure was measured and recorded. The pa-
tients were randomly entered into to the intervention group.
After controlling patients’ vital signs and marking dorsal pedis
and posterior tibialis pulses on their feet, the patients were
entered in the angiography catheterization room. On completion
of angiography and exiting the catheterization laboratory, the
sheath was removed by cardiology nurses, mechanical or manual
homeostasis was applied on the insertion site until the blood
coagulated. The time hemostasis was measured by stopwatch,
and it procedural information was recorded based on the case.
After hemostasis, 2 folded 4 � 4 (4 cm length and width)
gauzes was put on the catheter site (the reason of making the
gauzes 2 folded was to expose the catheter insertion site to the
maximum extent possible for ease of evaluating complications).
Transparent bandage covered the dressing to check for the ease
in
monitoring for hematoma and bleeding. Then, two 4 kg (8.82
lbs)
sandbags were placed on the site, and the second sandbag was
removed after stabilization of the patient. The patient came to
the postangiography ward with only one sandbag. After entering

TABLE 1
PROTOCOLS OF BODY POSITION AND METHODS OF
ANALYSIS IN THE GROUPS
Group 1st & 2nd hour 3rd & 4th hour 5th hour 6th hour 7th &
8th hour 9th hour 24th hour
Intervention
Group
Supine Supine, HOB Right side, HOB Left side, HOB Sitting
position OOB OOB
45� El 15� El 15� El
Control group Supine Supine Supine Supine Supine OOB OOB
HOB = head of bed; EL = elevation.
PAGE 109
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the control group patients to the postangiography ward routine,
cares were performed. The patient was immobile in the supine
position, with head angle of zero degree, 8 hours complete bed
rest, and 4 kg (8.2 lbs) sandbags was put on the site where the
catheter was inserted for 6 hours.
After entering the intervention group patients to the post
angiography ward, the patient had 8 hours complete bed rest,
4 kg sandbag was put on the site where the catheter was inserted
for 6 hours, but changing position was applied while taking rest
in the bed for 8 hours (Table 1). During the first and second
hours,
the patient was kept in the supine position and the head angle of

zero degree. During the third and fourth hours, the patient was
kept in the supine position with the head angle of 45�. During
the fifth and sixth hours, the patient was lying on the left or
right
side with the head angle of 15� and in the seventh and eighth
hour
the patients were cared in the sitting position (Table 2). The
third
part of the questionnaire was measured and recorded immedi-
ately after entering the ward, third, sixth, eighth, and 24th hours
later (before discharge from the ward; Table 2).
Statistics
After collecting data to assess the normal distribution of data,
Kolmogorov–Smirnov test was used. To compare the two inter-
vention and control groups in terms of demographic, clinical,
and procedural quality, chi-square and Fisher’s exact tests were
used. Moreover, to compare quantitative variables independent
t-test and Mann–Whitney tests were used.
RESULTS
Eighty-one patients were assessed for inclusion criteria.
Some patients were excluded from the study for the following
reasons including; three patients because of a history of chronic
low back pain, four patients because of an unwillingness to
participate in the study, two patients because of the history of
anticoagulant, and three patients due to taking opium. Thirty-
three patients were assigned to each group. During the study,
in the intervention group, two patients were excluded from the
study due to chest pain and taking analgesic and one patient
due to needle entrance to the arteries more than once. In the
con-
trol group, two patients were excluded due to anaphylactic reac-
tions and one patient due to stenosis in the abdominal aorta.

Finally, two groups (n = 30, each group) were analyzed. There
was no significant difference between the two groups of
participants in terms of demographic and clinical data include
of mean age, height, weight, systolic blood pressure, diastolic
blood pressure, body mass index, PT, PTT, platelet count, inter-
national normalized ratio, homeostasis time length, contrast me-
dia volume, amount of smoking, marital status, education level,
smoking history, history of diabetes, history of previous
coronary
angiography, rupture of the femoral artery, final diagnosis,
recommend treatment, and the amount of stenosis in the right
coronary, left main coronary, left circumflex arteries, and the
two groups were homogenous (Tables 3 and 4). But in terms of
gender, occupation, catheter size, type of contrast, the stenosis
of left anterior descending artery, and duration of angiography
were significantly different (Tables 3 and 4). The mean age of
the patients was 10.445 � 57.71, and 34 patients (56.66%)
were male and 58 (96.65%) were married.
The results showed that the incidence of hematoma between
the two groups was not significant. Moreover, hematoma in the
intervention group (P = 0.006) was significantly different at
different times, but in the control group (P = 0.149), the differ-
ence was not significant (Table 4).
Considering the P values in Table 5, to compare between
intervention and control groups at different times, there were
no significant differences between the intervention and control
groups in terms of hematoma (Table 5).
The results showed that the incidence of urinary retention in
the control group (P = 0.023) and intervention group (P = 0.020)
were significantly different at different times (Table 4). With
re-
gard to the P values in Table 5, pairwise comparison between
intervention and control group at different times, there were no

significant differences between the intervention and control
groups in terms of complications of urinary retention (Table 4).
Furthermore, the incidence of thrombosis remained un-
changed at different times and was not observed in none of the
participants.
In addition, the incidence of bleeding was significantly
different in terms of time (P $ 0.001). The test results of
Bonfer-
roni procedure showed that in the control group at third, eighth,
and 24th hours were not significantly different in terms of the
mean of this variable and in the intervention group there was a
significant difference only between the time of entrance and
the other times.
The results showed that the incidence of bruise between the
two groups in different measurements did not differ
significantly
in terms of time (P = 0.081).
TABLE 2
DISTRIBUTION OF UNITS IN TERMS OF VARIABLES
Variable Group Mean � SD P value
Age* Control 56.56 � 9.15 0.401
Intervention 58.86 � 11.74
Heighty Control 164.16 � 11.31 0.151

Weight* Control 74.88 � 21.67 0.52
The number of cigarettes smoked per
dayy
Control 8.1 � 4.1 0.076
No. of previous angiographyy Control 0.66 � 0.33 0.076
Systolic blood pressurey Control 122.26 � 19.11 0.653
Diastolic blood pressure
y
Control 74.03 � 11.58 0.583
Volume of contrast dyey Control 51.33 � 23 0.564
BMI
y
Control 55.99 � 36.64 0.6
PTy Control 11.73 � 0.86 0.364
PTT

y
Control 31.7 � 3.00 0.298
Plt count* Control 245230 � 9.15 0.298
Intervention 250610 � 80.01
INRy Control 17 � 1.15 0.292
Duration of hemostasis periody Control 7.95 � 3.69 0.603
Duration of angiography periody Control 23.78 � 10.51 0.031
Intervention 245230 � 9.15
BMI = body mass index; INR = international normalize rate; PT
= protrombin time; Plt count = platelet count; PTT = partial
thromboplastin time.
*T independent.
yMann–Whitney.
SEPTEMBER 2016
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The results showed that the incidence of groin pain was
significantly different in terms of time (P > 0.001). The results
of Bonferroni for comparing sampling time between the inter-
vention and control groups showed that during the study period
except at zero and 24th hour the difference was significant in
terms of intended complication.
The results showed that the incidence of comfort (based on
numeric rating scale) had a significant difference in terms of

time in this complication (P = 0.001). Bonferroni procedure
for pairwise comparisons of the sampling time between the
intervention and control groups during the study period showed
a significant difference except for the time of admission and
24th hour. Moreover, there was a significant difference for the
incidence of back pain in terms of time. Bonferroni for pairwise
comparisons of the sampling time between the intervention and
control groups during the study period showed a significant dif-
ference in terms of comfort except for the time of entrance and
24th hour.
TABLE 3
DISTRIBUTION OF SUBJECTS BASED ON QUALITATIVE
VARIABLES BETWEEN THE TWO GROUPS OF
CONTROL AND INTERVENTION
Variable Subgroup Intervention Control P value
Gender** Male 22 12 0.009
Female 8 18
Marital status** Married 30 28 0.492
Single 0 1
Widow 0 1
Divorced 0 0

Education** Illiterate 22 18 0.445
Under diploma 7 9
Diploma 1 3
Academic 0 0
Job status** Clerk 2 1 0.002
Self-employed 19 6
Retired 3 4
Housewife 6 18
Unemployed 0 1
Smoking history* Has 17 8 0.018
Has not 13 22
Diabetes record* Has 7 9 0.559
Has not 23 21
Angiography
history**
Has 1 6 0.103
Has not 29 24
Catheter size** F400 1 0 0.006
F500 1 0
F600 20 29

F700 8 1
Rupture of the
femoral artery**
Has 0 0 1.00
Has not 30 30
Type of contrast
media**
Meglumine 14 20 0.019
Visipaque 16 7
Meglumine and
Visipaque
0 3
Disease diagnosis* NECA 10 16 0.425
1VD 2 2
2VD 12 7
3VD 6 5
Significance stenosis
of coronary
arteries
*RCA 9 7 0.559
**LMCA 1 0 1.00

*LAD 14 6 0.028
**LCX 4 8 0.333
(Continued)
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TABLE 3
CONTINUED
Variable Subgroup Intervention Control P value
Urinary
retention***
Has 9 10
Has not 21 20
F00 = French; NECA = normal epicardial coronary arteries;
1VD = one vessel disease; 2VD = two vessel disease; 3VD =
three vessel disease; RCA = right
coronary artery; LMCA = left main coronary artery; LCX = left
circumflex artery; LAD = left anterior descending.
Chi-square test**, Fisher exact test*, and Friedman test*.

JOURNAL OF VASCULAR NURSING
SEPTEMBER 2016
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DISCUSSION
The findings of this study showed that changes in body posi-
tion after angiography did not create a change in the incidence
of
vascular complications including hematoma, bleeding, throm-
bosis, and bruising compared to the control group, whereas uri-
nary retention was reduced. In addition, changing body
position reduced back pain, groin pain, and finally improved
the comfort of the patient.
Other studies finding agree with the results of this study and a
significant difference in the incidence of complications after
cor-
onary angiography at the catheter insertion site between the
inter-
vention and control groups was not reported. For example,
TABLE 4
RESULTS OF ACUTE COMPLICATIONS
Variable Group Hour 0 Hour 3rd
Hematoma* Control 1.07 � 3.23 1.07 � 3.23
Intervention 0.43 � 2.19 0.43 � 2.19
Urinary retention* Control 2 1.93 � 0.25
Intervention 1.93 � 0.25 2.56 � 3.68
Bruise
y

Control 1.08 � 3.37 1.1 � 3.37
Intervention 0.35 � 1.82 0.36 � 1.82
Bleeding
y
Control 0 0.01 � 0.07
Intervention 0 0.01 � 0.05
Back painy Control 2.74 � 2 3.1 � 4.46
Intervention 2.66 � 1.6 3.3 � 2.83
Groin painy Control 0.26 � 0.63 3.1 � 2.57
Comforty Control 9.66 � 1.82 7.6 � 2.48
Thrombosisy Control 0 0
Intervention 0 0
*Friedman test.
yRepeated measures test.
Abdollahi et al (2015) studied the simultaneous effects of early
ambulation (4 hours of bed rest) and changes in body position
with a different protocol from this study. The time points for
analyzing the patient in terms of complications were different.
In their study, no hemorrhage and hematoma was reported. It
was found that changes in body position in and early ambulation
after coronary interventions did not increase the vascular
complications.14
Furthermore, the results indicated that changes in body posi-
tion had no impact on the incidence of acute vascular complica-
tions, including hematoma and bleeding. Moreover, Yeganeh
Khah et al (2012) compared the effect of different ways of

chang-
ing patients’ position on the vascular complications of after
Hour 6th Hour 8th Hour 24th Sig
0.61 � 1.78 0.31 � 0.97 0.08 � 0.43 0.006
0.33 � 1.64 0.1 � 0.40 0 0.149
1.83 � 0.37 1.76 � 0.43 1.8 � 0.4 0.023
1.8 � 0.4 1.7 � 0.46 1.9 � 0.25 0.02
1.03 � 3.18 0.8 � 2.54 0.12 � 0.45 0.081
0.16 � 0.73 0.026 � 0.14 0.026 � 0.14
2.3 � 12.77 0.16 � 0.54 4.38 � 7.56 0.001>
0.01 � 0.03 0.11 � 0.19 5.34 � 4.59
3.14 � 5.8 3.26 � 4.03 1.85 � 0.43 0.001>
3.14 � 2.3 2.75 � 1.56 0
4.86 � 3.08 3.7 � 2.74 2.36 � 2.20 0.001>
1.96 � 2.37 1.86 � 2.16 1.66 � 2.45
6.03 � 2.2 6.6 � 2.4 8.63 � 1.67 0.001>
8.5 � 2.2 7.9 � 2.39 8.9 � 2.15
0 0 0 0
0 0 0 0
TABLE 5
MANN–WHITNEY TEST TO COMPARE THE
GROUPS TWO BY TWO IN TERMS OF STUDY
TIME

Variable Measurement time P value
Hematoma Entrance time 0.317
Third hour 0.579
Sixth hour 0.394
Eighth hour 0.222
24th hour 0.222
Urinary retention Entrance time 0.312
Third hour 0.563
Sixth hour 0.741
Eighth hour 0.977
24th hour 0.154
PAGE 113
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coronary angiography and reported that none of the patients
developed bleeding and arterial occlusive and no significant dif-
ference between intervention and control groups were observed
in changing body position.
Rezaei-Adaryani et al (2009) compared the effect of three
different body positions including the supine position, changing
the head angle and changing side by side in three separate
groups
and found that changing body positions did not have an impact
on the amount of bleeding and hematoma of the two groups at

different times after angiography.19 This study was different
from Adaryani study because it was a comparative study con-
ducted on two groups, and different body positions were used,
but the findings were consistent with the Adaryani study. Acute
vascular complications after coronary angiography are hema-
toma, bleeding, and thrombosis.14–18
Farmanbar et al (2012) studied changes in body position and
duration of bed rest in two separate groups. Fisher’s exact test
showed no significant difference between the two groups. In
this study, patients had sandbags just for 2 hours and after 4
hours
changing position they got out of bed. Three patients in the con-
trol group and one patient in the experimental group had hema-
toma. One case of bleeding in the control group and one in the
intervention group were reported as well.
31
However, in this
study, the effect of changing position was studied not only on
the complications but also on back pain, groin pain, urinary
retention, and comfort, and the rate of incidence of
complications
was lower. Nyshabouri and Ashke-e-torab (2007) studied the ef-
fect of changing the bed angles on the incidence of vascular
com-
plications and reported no case of hematoma, bleeding, and
thrombosis among the groups.32 In this study after two hours
of rest in the supine position, the patient’s head angle was in
45� because in previous studies the lowest amount of complica-
tions was in this position. Therefore, changing body positions in
the bed based on the presented method had no effect on the
incidence of vascular complications such as hematoma,
bleeding,
and thrombosis and did not make any complications in the pa-

tients. Based on several studies, movement limitations and com-
plete bed rest resulted in frequent complaint of low back
pain.14
As a result patients request for analgesic and changing position
frequently to resolve the pain in the bed.19 Therefore, relieving
pain and providing patient comfort without increasing vascular
complications after coronary angiography is one of the nursing
goals.13
Yilmaz et al (2007) in Turkey studied the effect of sandbags
and changing the patient’s position on the incidence of vascular
complications, and they claimed that there was no difference
be-
tween the groups of patients who had or had not sandbag on the
site of catheter insertion. However, the pain severity in the
group
who had changing positions was by far less than the other group
which is consistent with the findings of our research. Moreover,
there was no significant difference between the two groups in
the
second hour which was not in accordance with our findings
21
because in Yilmaz et al study the sandbag was on the site of
cath-
eter insertion for two hours and a half, whereas in our study it
was
6 hours.
To compare changes in bleeding, bruise, back pain, groin
pain, comfort, and thrombosis over time within groups repeated
measures test was used and if the difference was significant
Bon-
ferroni test was used. To compare changes regarding hematoma

and urinary retention over time within groups Friedman test was
used, and for pairwise comparison of intervention and control
groups Mann–Whitney test was used based on distinct time of
study.
Back pain and urinary retention were observed as common
complication in looking after patients undergoing angiography.
Relying on noninvasive methods to empty the bladder is prefer-
able because bladder catheterization increases the risk of
urinary
tract infection.22 Abdolahi et al (2015) in a study regarding
changing positions compared the control and experimental
groups with a different protocol from this study and found that
no significant differences exist between the two groups in terms
of complications of urinary retention14 which is consistent with
our study. Pairwise comparisons of sampling time showed that
there was significant difference in terms of the intended compli-
cation between intervention and control groups during the study
period except at zero and 24th hour which was probably due to
the reason that at the zero hour patients in both groups were in
supine position with head angle of zero degree and at 24th
hour both groups were out of bed and as a result due to the
equality of body position, it is expected that the difference did
not become significant.
Changing body position in the bed improves the patient’s
comfort.13 Many teams emphasizes on immobilitzation to avoid
bleeding, which can cause patient comfort Rezaei-Adaryani
et al
19
(2015) in a study regarding changing positions compared
the control and experimental groups with a different protocol
from this study and found that the intervention group had
signif-

icantly more comfort at third, sixth, eighth hours, and the morn-
ing after angiography compared with the control group which
was consistent with our study.19 Change in body position based
on the proposed manner resulted in decrease in lower back
pain, groin pain, urinary retention, and increase in comfort.
SEPTEMBER 2016
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Limitations and suggestions for future research
It is recommended that in future studies analyze the impact of
early ambulation, the duration of keeping sandbag on the
catheter
insertion and sandbags with different weights on the incidence
of
acute and chronic complications at different time points from
this
study, to improve care after coronary angiography.
CONCLUSIONS
The results of this study showed that changing position after
angiography based on the method provided, without change in
the incidence of vascular complications (hematoma, bleeding,
thrombosis, and bruise) reduced the severity of back pain, groin
pain, urinary retention, and improved patients’ comfort. By
changing position in bed after coronary angiography, nurses can
increase patients’ comfort. New nurses tend to be cautious and
the more seasoned nurses adhere to routine. Therefore, it is
recom-
mended that cardiology and postangiography ward nurses, use

the
position change based on the present study. Interventionalist
and
nurse comfort play a role in patient comfort and reposition.
Inter-
ventionalists will need to address any postprocedural complica-
tion for patients which may affect the level of their comfort. We
can reduce the complications including urinary retention,
discom-
fortback and groin pains by positionchange. So by decreasing
the-
ses complications, the interventionalists comfort will increase
due
to lower discuses about postprocedural complications and their
high level of comfort affect patients comfort.
ACKNOWLEDGMENTS
Hereby, the authors want to appreciate the Deputy of
Research at Nursing and Midwifery faculty of Kurdistan Uni-
versity of Medical Sciences, angiography and cardiac ward’s
staff at Tohid Hospitals affiliated with Kurdistan University of
Medical Sciences and all those patients who have helped us in
this study. This study entitled the Comparative Study of the
Effects of Sand Bag Keeping Time and Changing Body Posi-
tion on Acute Complications of Coronary Angiography in
Referring Patients to the Sanandaj Tohid Hospital, 2015 is a
part of MS thesis of Parvin Mahmoodi which is approved in
Kurdistan University of Medical Sciences.
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http://www.jvascnurs.netEvaluation of feasibility and safety of
changing body position after transfemoral angiography: A
randomized clinical trialMethodSample size and
samplingParticipantsEthical considerationsMeasuring
toolIntervention
proceduresStatisticsResultsDiscussionLimitations and
suggestions for future
researchConclusionsAcknowledgmentsReferences

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