#467: Groin Management After Femoral Access

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Groin management is nurse-lingo for the care involved after a patient has had the femoral artery or vein accessed, such as with a cardiac catheterization or interventional radiology procedure. This lesson focuses on nursing care after the sheath has been removed and hemostasis has been achieved since sheath removal typically occurs in the procedural area (though not always!). 

Looking at this from the perspective of the post-op nurse, your job is to maintain activity and bedrest restrictions, prevent bleeding, and monitor for complications. In other words, you are managing that groin! 

Before we dive into the details, let’s do a quick review and answer some questions you may have. 

• What is a sheath? A sheath is a hollow plastic tube that is placed into the vessel to provide a stable, continuous access port for inserting and exchanging catheters and other instruments for various procedures such as cardiac catheterization or interventional radiology procedures.
• Are sheaths arterial or venous? Sheaths can be either arterial or venous.
• Do sheaths come in different sizes? Yes they do! Sizes range from 4 Fr up to 24 Fr, but common sizes range around 6 to 12 Fr.
• What are the potential complications? Potential complications include bleeding (which can be life threatening), hematoma, distal limb ischemia, pseudoaneurysm, and arterial dissection.
• What are risk factors for bleeding? Risk of bleeding increases with anticoagulant or antiplatelet therapy, sheath sizes larger than 6 Fr, female, age 75 and older, obesity or low body weight, peripheral vascular disease, renal disease, and thrombocytopenia.

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L: How does the patient LOOK? 

What you will see after the procedure depends on how hemostasis was achieved. Four common ways to do this are:

• Manual hold – In some cases, the nurse or tech simply applies firm, consistent pressure to the site until hemostasis is achieved. With arterial access, this can take up to 20 – 30 minutes. With venous access, it’s typically around 10 to 15 minutes.
• Mechanical device – The FemOStop device can replace the need for a manual hold by providing directed and adjustable hands-free pressure to the access site. The device features an inflatable dome which is placed against the site and secured into place. The dome is inflated so that it is 10 to 20 mmHg higher than systolic blood pressure for a brief period of time (no more than three minutes). It is then deflated to a level that allows perfusion to the limb and then deflated slowly every few minutes until it is completely deflated and hemostasis is achieved. 
• Vascular closure device – Vascular closure devices (VCDs) include products such as Vascade, StarClose, Angio-Seal, and Perclose. These devices shorten the duration to hemostasis and bedrest requirements dramatically. Some benefits of VCDs are that they provide an alternative to manual compression, they are more effective for large vessel hemostasis, they tend to be more comfortable for the patient, they have shorter bedrest requirements, and they allow for earlier ambulation (in most cases).
• Sutures – In some cases, the internal puncture is sutured closed. This could involve the application of a 3-way stopcock externally through which the suture ends are threaded to allow for tightening and loosening of the internal sutures. This is called a “woggle” and is not very commonly used. 

If hemostasis was achieved using a manual hold or mechanical device, the patient will most likely have a compression device at the groin post-op. A common brand is SafeGuard, which is an adhesive dressing with a small inflatable dome filled with 30 to 40 ml of air. This dome exerts gentle continuous pressure for an hour or two after hemostasis is achieved and then slowly deflated.

Otherwise, the patient will simply have a small piece of gauze with or without a transparent dressing at the site of the puncture. In all cases they will be supine and the head of the bed will be flat or at a gentle incline. Note that HOB angle is extremely important and will be dictated by the physician’s orders.

The patient generally will not have pain related to the procedure though many times, patients complain of back pain due to positioning and the need for extended bedrest.

A: What ASSESSMENTS will you perform after sheath removal?

Priority assessments after sheath removal involve monitoring for any signs of complications. The frequency of assessments will vary based on facility policy but a common cadence is q 15 minutes x 1 hour, then q 30 min x 1 hour, then q 60 mins x 4 hours.

• Visualize the site. Look for bleeding, oozing, swelling (which indicates hematoma development), and bruising. Be sure to check between the patient’s legs and underneath them as well as bleeding can be slow and sneaky. Note that a small dot of blood may be present on the dressing upon arrival. Make sure you confirm with the RN that is transferring care to ensure it is not a new bleed. Document the size of the drainage and keep a close eye on it!
• Palpate the site. Press all around the puncture site looking for any areas of firmness and tenderness (hematoma) or a pulsatile mass (pseudoaneurysm). The site should be soft and non-tender.
• Assess neurovascular status. Monitor the peripheral extremity for any signs of ischemia or altered blood flow. Things to assess include pulses, capillary refill, color, temperature, sensation, movement, and edema.
• Monitor the dressing. It’s also important to monitor the status of the dressing, whether it’s a SafeGuard or a simple gauze dressing. If a SafeGuard or similar device is being used, this is where you would also track how much air is in the inflatable dome, which measures how much pressure is being applied to the site.
• Other key assessments. It’s also important to assess vital signs and the patient’s pain level. Hypotension and tachycardia are later signs of bleeding that hopefully get noticed earlier!

T: What TESTS are conducted for a patient after sheath removal?

Routine testing isn’t utilized after sheath removal, though tests you are interested in generally relate to the patient’s coagulation status, though some tests may be conducted to evaluate complications.

• CBC – Determine the patient’s platelet level since thrombocytopenia will put the patient at high risk for bleeding. It’s also a good idea to know the patient’s baseline hgb level so you can compare it if bleeding does occur.
• Coags – If available, check coagulation labs such as PTT, aPTT, PT and INR.
• Ultrasound – An ultrasound may be utilized to evaluate a pseudoaneurysm or large hematoma.
• CT scan – Imaging may be needed if a retroperitoneal bleed is suspected.

T: What TREATMENTS are provided for a patient with a groin puncture?

Most of your interventions during this period are aimed at preventing bleeding, increasing patient comfort, and managing the SafeGuard (if using). 

• Maintain bedrest – The physician will order a specific duration for bedrest, which can range from two to six hours, depending on methods used and the patient’s condition.
• Keep extremity flat and maintain HOB restrictions – The affected extremity must be kept still and flat for the duration of bedrest. However, note that your orders may state the HOB can increase up to 30-degrees after a specified period of time. The extremity should continue to be kept still even when HOB is raised. When raising the HOB, do so slowly and in increments, watching for signs of bleeding at each stage.
• Pain/discomfort management – If your patient is having pain, most of the time it will be related to their position. Back pain is a very common complaint while on supine bedrest. Medication may need to be utilized, especially when the patient’s discomfort is jeopardizing their ability to lie still. If the physician has written orders specifying the patient can be log-rolled, this can be helpful to relieve pressure off the back.
• Prevent increases in intrathoracic pressure – Since increased intrathoracic pressure can cause the site to bleed, it’s important the patient avoid certain movements or actions. Things that increase intrathoracic pressure include coughing, sneezing, yelling or laughing, lifting the head off the pillow, and bearing down. Unfortunately, many patients cough after surgery, especially if the throat was irritated such as during a TEE. Whenever the patient is coughing, or doing anything else that could increase intrathoracic pressure, it’s vital you press firmly on the site to prevent the groin from “popping.”

• Toileting – Helping a patient void while on strict supine bedrest can be challenging. It’s very difficult to urinate while completely supine, and bearing down to have a bowel movement could cause the vessel to “pop.” To help facilitate urination, you can place the bed in reverse Trendelenburg which shifts urine to the base of the bladder to help activate the micturition reflex. For male patients, placing a urinal is easy and doesn’t compromise the groin site. However, using a bedpan with female patients could compromise the site and should be avoided if other options, such as the PureWick external catheter, are available.
• SafeGuard management – While practice varies depending on facility policy, general guidelines for managing the SafeGuard include:
  • Begin deflation 1 to 2 hours after hemostasis was achieved.
  • If no signs of bleeding are present, deflate the bulb by 5 to 10 ml every 15 minutes using a 60 ml syringe. Perform a full assessment of the site after each deflation and stay close to the patient throughout the process so any bleeding can be noticed quickly.
  • Be careful not to deflate beyond the capacity of the device as this produces negative pressure, which can cause tissue damage. 
  • If bleeding occurs during the deflation process, re-inflate to the previous level of pressure.
  • The fully deflated SafeGuard can remain in place as a sterile dressing. This is helpful in case bleeding does occur as it can simply be re-inflated.
• Resume activity – Once the patient’s bedrest has been completed, it’s important to resume activity carefully and slowly. Be mindful that getting the patient up and out of bed to ambulate for that first time is a high-stakes moment where you will need to be very watchful for a bleed.
• Manage bleeding – If the site does bleed, apply pressure until hemostasis is achieved. If the femoral vein was accessed, apply pressure slightly below the access site. If the artery was accessed, apply pressure slightly above the access site. This helps decrease blood flow to the puncture itself and reduce how much blood leaks out of the vascular space. If bleeding cannot be managed with a manual hold, a FemOStop may be utilized. Always let the physician know if any bleeding or other complications occur.
• Return to the procedure area – If the patient bleeds and the bleeding cannot be controlled in the post-op setting, they may need to return to the cath lab or interventional radiology for advanced intervention by the physician.

E: How do you EDUCATE the patient and family?

The main theme of your patient education for groin management revolves around bleeding prevention and risk management. 

• Lie flat with the affected leg(s) still and straight for two to six hours. In some cases, the patient may be able to elevate up to 30-degrees and/or be log-rolled. 
• Avoid actions that increase intrathoracic pressure such as coughing, laughing, yelling, straining, or lifting their head off the pillow. 
• If the patient feels the urge to cough or sneeze, they should let the nurse know so pressure can be placed against the groin site. Alert and oriented patients can be shown how to splint when coughing or sneezing.
• Let the nurse know if they feel a “popping” or warm sensation at the groin, or if they begin to experience pain at the site. Wetness at the site is likely bleeding, so they should speak up if that occurs, too.
• Notify the nurse if they experience back, flank or abdominal pain. While back pain is often due to positioning, it could also indicate a retroperitoneal bleed.
• Alert the nurse if their toes or feet begin to tingle or feel numb, as this can indicate reduced blood flow due to a clot or bleeding.
• Assessments will be frequent and gradually decrease throughout the duration of bedrest.
• If bleeding occurs, the bedrest duration starts over.
• After discharge, they will need to adhere to any activity restrictions such as lifting heavy objects for a duration specified by their physician.
• Avoid submerging the puncture site in water for at least a week (no baths, hot tubs, or swimming).
• If their procedure involved contrast dye, fluids will help flush the dye from their system.

Groin management is one of those things that can seem straightforward…right up until it isn’t. When you know how to prevent complications while keeping a close eye on potential red flags, you can catch problems early and intervene quickly. Want to dive deeper into vascular assessment? I’ve got you covered in episode 274 right here!

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Last Updated on July 19, 2026 by Maureen Osuna, MSN, RN