NIghtingale Healthcare
Addressograph
Pre-Cardiac Catheterization / Intervention Checklist
Date: ___/____/____
Height: _______
Time: _______
T ____o F
Weight: _____ lb. = _______ kg.
P ____
R ____
BP ____/____ mm Hg
Allergies: ___________________________________________
Pre-Procedure Meds & IV's:
Normal Saline @
ml/hr
Time Given / Started
Nurse's Signature
Medications Taken Today:
ASA 325 mg po
Time Given / Started
Nurse's Signature
Pre-Procedure Checklist
1.
2.
3.
4.
5.
6.
I.D. bracelet present.
Authorization for treatment form signed.
History and physical on chart.
Patient/Family Information Form completed.
Consent for appropriate procedure signed.
Allergies recorded on front of chart.
7. Height and weight recorded on front of chart.
8. Procedure scheduled with Cath Lab.
9. Pre-op teaching initiated:
 Heart Cath film viewed.
 Printed material reviewed.
10. Lab results (within last 72 hours) recorded to the
right and any abnormal value called to the
cardiologist.
11. Pre-procedure ECG done.
12. Right groin clipped to midline.
13. NPO after 2400 except for meds.
 If procedure scheduled for after 1200, patient
may have clear liquids until 0800.
 Have patient take meds (except diuretics) with
a sip of water the morning of the procedure.
14. IV started at 0700 day of procedure in the left
arm that is truly patent.
15. Valuables (jewelry, money, prosthesis) removed.
Glasses and dentures may be worn.
16. Voided on call to Cath Lab.
17. Right pedal pulses checked.
18. Family escorted to waiting room.
YES
NO
COMMENTS
Be sure to ask about allergies to iodine
and/or shellfish!
Hgb / Hct: _____ Plt Ct.: ___________
Potassium: _____
BUN: _________ Creatinine: _______
PT: __________
PTT: ___________
Within last 72 hours or if patient reports chest
pain.

Hold AM insulin the morning of the
procedure unless otherwise ordered, but
administer sliding scale insulin.
 Notify MD if patient is on Glucophage.
 Contact cardiologist for further orders if
patient is on heparin.
 If patient going for an intervention, a second
18-20 gauge line with a prn adapter must be
started.
Disposition of valuables:

If going for an intervention, insert a Foley in
women. May insert prn for men.
Right DP:_______ Right PT: ______
Nurse's Signature: ________________________________
Form # PCS
1/01