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FOUNDATIONS OF TR BAND CARE
Anton's Story — A Case-Based Module for Med/Surg Telemetry RNs
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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WHAT YOU'LL LEAVE WITH
- Identify normal and abnormal findings in distal perfusion with a TR Band
- Describe patent hemostasis and why it matters
- Apply the NA 10-199 monitoring schedule
- Recognize complications and respond per policy
- Sequence safe TR Band removal — including the response to bleeding
CONTINUE →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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WHERE ARE YOU STARTING FROM?
Choose your path. Both routes cover the same content — the order and depth differ.
I'VE CARED FOR A TR BAND PATIENT
Expedited route — same education, faster path. Each correct answer confirms your knowledge with a brief refresher on the take-home points. Wrong answers route you to the full content slide.
Experienced Path
THIS IS NEW TO ME
Start with the assessment skills you already use, build up through Anton's story, and learn the protocol in context.
Foundations Path
Same education for every learner. Your choice is about how fast you get through it.
KECK MEDICINE OF USC · NPD CRITICAL CARE
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FOUNDATIONS
YOU ALREADY KNOW HOW TO SPOT POOR PERFUSION
You assess distal perfusion every shift. Before we introduce the TR Band, let's confirm what you're already using.
KEY POINT
These same five senses are how you'll assess every TR Band patient.
CONTINUE TO KC →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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FOUNDATIONS
BLEEDING RISK DOESN'T END WHEN THE DRIP STOPS
Anton received heparin during his procedure. Even after the infusion ends and a puncture site appears clotted, bleeding can recur.
- Anticoagulation effects persist beyond the infusion itself — the body needs time to clear the medication and restore normal clotting.
- Puncture sites can rebleed from movement, pressure changes, or simply because the initial clot was fragile.
- Hematomas can develop slowly — what looks fine at hour 1 may not look fine at hour 3.
That's why we monitor on a schedule — we'll get to the specifics in a few slides.
KEY POINT
Why we keep watching: anticoagulation effects persist beyond the drip.
CONTINUE TO KC →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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FOUNDATIONS
TWO PIECES OF INFORMATION
A pulse oximeter gives you two things: a number (oxygen saturation) and a waveform (pulsatile flow). On a TR Band patient, the waveform on the thumb is your real-time signal that blood is reaching the hand.
THE WAVEFORM
Visual proof of pulsatile blood flow at the sensor site. No waveform = no reliable signal, no matter what the number says.
THE NUMBER
What percentage of hemoglobin is carrying oxygen. Useful — but only meaningful if the signal is reliable.
Watch the line, not just the percent — you'll see why when Anton's findings shift later in this module.
KEY POINT
Number without waveform = unreliable. Watch the line, not just the percent.
CONTINUE TO KC →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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FOUNDATIONS
MEET ANTON MARSHALL
Anton is 58 years old. Two weeks ago, on an evening walk with his wife Josephine, he became short of breath. Over the next few days he noticed swelling in his ankles and worsening shortness of breath with everyday activities.Josephine got him in to see his cardiologist, Dr. Singh. Given Anton's history of hypertension, hyperlipidemia, and type 2 diabetes, Dr. Singh was worried about acute coronary syndrome. Labs confirmed an NSTEMI. Anton was admitted to Keck and scheduled for a coronary angiogram via right radial access — which is where his TR Band journey begins.
CONTINUE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
PATENT HEMOSTASIS — THE GOAL OF THE TR BAND
After radial access, a clear plastic band wraps the wrist. Two small air-filled balloons apply pressure to the radial artery. The goal is patent hemostasis:
- "Patent" = open
- Puncture closed
- Artery still flowing
Your assessments confirm both are happening — bleeding stopped AND blood reaching the hand.
KEY POINT
Bleeding stopped. Blood flowing. Both confirmed by your assessment.
CONTINUE →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
PATENT HEMOSTASIS — THE GOAL OF THE TR BAND
After radial access, a clear plastic band wraps the wrist. Two small air-filled balloons apply pressure to the radial artery. The goal is patent hemostasis:
- "Patent" = open
- Puncture closed
- Artery still flowing
Your assessments confirm both are happening — bleeding stopped AND blood reaching the hand.
KEY POINT
Bleeding stopped. Blood flowing. Both confirmed by your assessment.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
PATENT HEMOSTASIS — THE GOAL OF THE TR BAND
After radial access, a clear plastic band wraps the wrist. Two small air-filled balloons apply pressure to the radial artery. The goal is patent hemostasis:
- "Patent" = open
- Puncture closed
- Artery still flowing
Your assessments confirm both are happening — bleeding stopped AND blood reaching the hand.
KEY POINT
Bleeding stopped. Blood flowing. Both confirmed by your assessment.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
ANTON RETURNS TO 5N
CASE · 1015
You are Domingo, the receiving nurse. Angela hands off: TR Band placed at 0955 with 12 cc of air. Heparin during procedure. Anti-platelet meds started. Here's the inflation syringe.
SpO2
98%
RR
16
HR
78
BP
132/78
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
WHY IS ANGELA HANDING YOU A SYRINGE?
CASE · 1015, CONTINUED
As Angela completes the handoff, she hands you a small green-tipped syringe and says: "Keep this with him."
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
- Circulation (color, temperature, capillary refill, pulse)
- Sensation (normal vs. tingling/numb)
- Movement (gentle finger movement)
- Access site (dry vs. bleeding/hematoma)
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
CONTINUE TO KC →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
- Circulation (color, temperature, capillary refill, pulse)
- Sensation (normal vs. tingling/numb)
- Movement (gentle finger movement)
- Access site (dry vs. bleeding/hematoma)
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
- Circulation (color, temperature, capillary refill, pulse)
- Sensation (normal vs. tingling/numb)
- Movement (gentle finger movement)
- Access site (dry vs. bleeding/hematoma)
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
- Circulation (color, temperature, capillary refill, pulse)
- Sensation (normal vs. tingling/numb)
- Movement (gentle finger movement)
- Access site (dry vs. bleeding/hematoma)
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
YOUR FIRST ROUND OF CHECKS
CASE · 1030
Initial assessment complete. Anton looks comfortable, right hand pink and warm, pulse ox shows 98% with a strong waveform, access site dry. You document and step out to grab supplies. Before you do — how often will you be back?
SpO2
98%
RR
16
HR
76
BP
130/76
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
WHAT DOES A GOOD CHECK LOOK LIKE?
Your assessment can land in one of three patterns. Recognizing which is happening is what makes you effective.
PATENT HEMOSTASIS
Bleeding stopped. Blood flowing.
· Hand pink, warm · Cap refill <3 sec, palpable pulse · SpO₂ 98% with strong waveform · Site dry, no hematoma
ANCHORED IN POLICY
VENOUS CONGESTION
Outflow restricted. Inflow preserved.
· Hand swollen, dusky-purple · Cap refill borderline · SpO₂ acceptable with waveform · Pulse palpable
WORTH A SECOND LOOK
ARTERIAL COMPROMISE
Blood not reaching the hand.
· Hand pale, cool · Cap refill >3 sec · SpO₂ low / absent waveform · Pulse diminished/absent
POLICY HARD STOP
Same hand, three different stories. Your assessment is the difference between them.
CONTINUE TO KC →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
ANTON CALLS YOU
CASE · 1200
Anton calls. His right hand feels "tingly and cold."
Site
Dry
Thumb SpO2
Cap Refill
92%
4 seconds
Hand Temp
Cool
Ulnar Pulse
Weak
WHAT IS YOUR PRIORITY ACTION?
REPOSITION SENSOR, REASSESS IN 15 MIN
NOTIFY PROCEDURAL CARDIOLOGIST
DEFLATE BAND BY 3 mL
DOCUMENT & CONTINUE SCHEDULED CHECKS
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
THE FINDINGS HAVEN'T RESOLVED
CASE · 1205 — 5 MINUTES LATER
You repositioned Anton's arm gently, as the cardiologist suggested. You rechecked. The findings are essentially unchanged — and the cardiologist is now delayed in another procedure.
Patient Report
Still tingly
Thumb SpO2
Cap Refill
91%
4 seconds
Hand Temp
Cool
Ulnar Pulse
Weak
WHAT'S YOUR NEXT MOVE?
DOCUMENT THE RECHECK AND RETURN TO ROUTINE CHARTING
CONTINUE CURRENT MONITORING; WAIT FOR THE CARDIOLOGIST
PAGE THE CARDIOLOGIST AGAIN; REQUEST ORDER FOR PARTIAL DEFLATION
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
REMOVAL IS A PROTOCOL, NOT A PROCEDURE
The TR Band comes off in stepped, timed increments — never all at once. The rhythm is what makes it safe.
- Verify provider order for date/time and protocol
- Remove 3 mL of air, observe for bleeding
- Wait 5 minutes
- Repeat steps 2–3 until band is empty
- After empty: Monitor 5 more minutes
- If dry: Remove band, apply 2×2 + Tegaderm
- Begin post-removal monitoring (q15 ×4, q30 ×2, q1h ×2)
KEY POINT
Reapplication of a TR Band is not permitted. If bleeding prevents completion within the ordered window, notify the provider.
CONTINUE TO KC →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
REMOVAL IS A PROTOCOL, NOT A PROCEDURE
The TR Band comes off in stepped, timed increments — never all at once. The rhythm is what makes it safe.
- Verify provider order for date/time and protocol
- Remove 3 mL of air, observe for bleeding
- Wait 5 minutes
- Repeat steps 2–3 until band is empty
- After empty: Monitor 5 more minutes
- If dry: Remove band, apply 2×2 + Tegaderm
- Begin post-removal monitoring (q15 ×4, q30 ×2, q1h ×2)
KEY POINT
Reapplication of a TR Band is not permitted. If bleeding prevents completion within the ordered window, notify the provider.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
REMOVAL IS A PROTOCOL, NOT A PROCEDURE
The TR Band comes off in stepped, timed increments — never all at once. The rhythm is what makes it safe.
- Verify provider order for date/time and protocol
- Remove 3 mL of air, observe for bleeding
- Wait 5 minutes
- Repeat steps 2–3 until band is empty
- After empty: Monitor 5 more minutes
- If dry: Remove band, apply 2×2 + Tegaderm
- Begin post-removal monitoring (q15 ×4, q30 ×2, q1h ×2)
KEY POINT
Reapplication of a TR Band is not permitted. If bleeding prevents completion within the ordered window, notify the provider.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
REMOVAL TIME
CASE · 1355
Anton's TR Band has been in place for four hours. The provider order specifies removal at 1355 per the conservative protocol. You've verified the order, retrieved the inflation syringe from the bedside, and are ready to begin.
If site dry after monitoring, remove band itself
Drag the steps to the left into the correct order for safe TR Band removal.
Apply 2×2 + Tegaderm dressing to site
Begin post-removal monitoring schedule
Monitor site for 5 minutes after empty
Remove 3 mL of air, observe for bleeding
Continue removing 3 mL q5 minutes until empty
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
YOU SEE BLOOD AT THE SITE
CASE · 1405 — REMOVAL IN PROGRESS
You've completed two deflations per protocol — band started at 12 mL, now holds 6 mL. As you remove the next 3 mL, bright red blood appears at the access site.
Site
Bleeding
Band Volume
Thumb SpO2
6 mL
98%
Hand Color
Pink
Hand Temp
Warm
WHAT IS YOUR NEXT ACTION?
APPLY PRESSURE, RAPIDLY REMOVE REMAINING AIR
REINFLATE 3 mL, WAIT 15 MIN, RESTART PROTOCOL
REMOVE THE BAND ENTIRELY, HOLD MANUAL PRESSURE
REAPPLY A FRESH TR BAND WITH 12 mL
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
JOSEPHINE WALKS IN
CASE · 1430 — BAND IS OFF
Anton's TR Band came off cleanly after the restart. Site is dry, dressing in place. As you finish charting, Josephine walks into the room and asks: "Is he okay to use his arm now? He's been wanting to text our daughter."
Band Volume
Thumb SpO2
6 mL
98%
Cap Refill
< 3 sec
Hand
Pink, Warm
Site
Dry, Dressed
WHAT DO YOU TELL JOSEPHINE — AND WHAT DO YOU DO NEXT?
TELL HER HE CAN USE THE ARM NORMALLY NOW
TELL HER HE'S ON STRICT BEDREST UNTIL DISCHARGE
TEACH THE RESTRICTIONS, START POST-REMOVAL MONITORING
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
THE BAND IS OFF — NOW WHAT?
CASE · 1435
Anton's TR Band has been removed. Site is dry, 2×2 + Tegaderm dressing in place. He's resting comfortably. You've taught the activity restrictions. Now — when do you come back to check on him?
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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EXPERIENCED
FOUNDATIONS
ANTON ASKS ABOUT GOING HOME
CASE · 1500
Anton is feeling much better. His post-removal checks have been reassuring — site dry, hand pink and warm, cap refill brisk. He's already thinking ahead and asks: "Once I'm home, how careful do I have to be with this arm?" Josephine is at his bedside, listening.
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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ANTON GOES HOME
Anton's TR Band came off cleanly. The post-removal monitoring rhythm finished without incident. Site stayed dry. Hand stayed pink and warm. The next morning, the cardiology team rounded. They cleared Anton for discharge with dual anti-platelet therapy and a new heart failure medication regimen. Cardiac rehab referral, dietary counseling, follow-up in two weeks. Josephine drove him home that afternoon. Anton walked out using his left arm for the bag, his right arm relaxed at his side — exactly the way the teaching landed. He texted his daughter from the car. The reason this went well isn't luck. It's that his nurses — including you — knew what to assess, when to escalate, how to follow the protocol, and how to teach. That's the work.
CONTINUE TO RECAP →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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FIVE THINGS TO CARRY FORWARD
1 | PATENT HEMOSTASIS: Pressure that stops bleeding AND preserves flow. Your assessment confirms both. 2 | THE MONITORING RHYTHM: q15 ×4 → q30 ×2 → q1h while the band is on. Same rhythm post-removal. 3 | THE AFFECTED ARM IS OFF-LIMITS: No BP, blood draws, or new IVs in that arm while the band is on. 4 | BLEEDING DURING REMOVAL: Reinflate, wait 15, restart. Never reapply a new band. 5 | WHEN TO NOTIFY: Cap refill >3 sec, absent ulnar pulse, cyanosis, numbness, pain, bleeding, or hematoma.
KEY POINT
Questions? Reach out to your unit educator or NPD.
RESOURCES →
KECK MEDICINE OF USC · NPD CRITICAL CARE
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WHERE TO GO FROM HERE
POLICY
NA 10-199 | Radial Compression Device
Available on Keck SharePoint under Nursing Operating Policies.
ANCHORED IN POLICY
MANUFACTURER REFERENCE
Terumo TR Band | Instructions for Use
Available through Materials Management or the Terumo product page.
WORTH A LOOK
CONTACTS
Unit NPD Educator
Unit Educator: [insert name and contact]
REACH OUT
Lani Thong | 2 EW | NPD
email
email
Policy
IFU
Thank you! you can close module now.
KECK MEDICINE OF USC · NPD CRITICAL CARE
⚠ SPEED MAKES THIS WORSE
RUSHING REMOVAL ESCALATES THE BLEEDING.
You remove the remaining 6 mL rapidly. Bleeding intensifies. A hematoma begins to form around the site. You now need extended manual pressure and the cardiologist is paged urgently. The compression balloon is the only thing currently controlling the puncture. Rushing removal once bleeding has started removes that control. The policy answer is to reinflate, wait 15 minutes, and restart.
← BACK TO DECISION
✓ ANCHORED IN POLICY — & PATIENT-CENTERED
THE TRANSITION GOES SMOOTHLY.
You apply the dressing. You begin the post-removal schedule: q15min ×4, q30min ×2, q1h ×2. You teach Anton and Josephine: minimize use of the right arm for 6 hours, keep the wrist straight and avoid lifting/pushing/gripping with that hand for 48 hours, call the nurse for any swelling, bleeding, or color/sensation changes. A radial arm board is available if he needs help remembering. Anton uses his left hand to text his daughter. Removal is a transition, not an endpoint. Post-removal monitoring and teaching matter as much as the removal itself.
CONTINUE →
CONTINUOUS PULSE OX
A pulse oximeter on the affected thumb gives you real-time confirmation that blood is reaching the hand past the band. Watch the waveform AND the number — both matter.
✓ ANCHORED IN POLICY — AND IN ADVOCACY
THE SYSTEM WORKED BECAUSE YOU ADVOCATED WITHIN IT.
You re-page. The cardiologist gives a verbal order to release 3 mL of air immediately and recheck in 5 minutes. You document the order, perform the deflation per policy, and reassess. 5 minutes later: pulse stronger, cap refill 2 sec, SpO₂ 97% with strong waveform. Anton says, "It feels better." Escalation isn't one-and-done. When the clinical picture isn't improving and the provider is delayed, pushing the escalation forward is part of the work.
CONTINUE →
The only way to safely inflate or deflate the band. The inflation syringe is the only tool designed to fit it — which is why that syringe needs to stay at the bedside for the duration of TR Band care.
THE AIR PORT
Anton's right hand is swollen and dusky-purple. Thumb SpO₂ reads 97% with a clear waveform, and the radial pulse is palpable. Which card describes what you're seeing?
Scenerio
arterial compromise
venous congestion
Patent Hemostasis
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The removal protocol:
- Verify provider order, retrieve inflation syringe
- Remove 3 mL → wait 5 minutes → repeat until empty
- Monitor 5 more minutes after empty
- If dry: remove band, apply 2x2 + Tegaderm
- If bleeding mid-removal: reinflate, wait 15 min, restart
- Reapplication of a new band is not permitted
NEXT QUESTION →
The only way to safely inflate or deflate the band. The inflation syringe is the only tool designed to fit it — which is why that syringe needs to stay at the bedside for the duration of TR Band care.
THE AIR PORT
✓ ANCHORED IN POLICY
YOU STAYED IN SCOPE AND PROTECTED THE PATIENT.
The cardiologist is paged. While you wait, you continue monitoring, reposition the arm to rule out positional artifact, and keep the inflation syringe accessible. The cardiologist calls back: "I'm coming to assess. In the meantime, reposition the arm and recheck in 5 minutes." 5 minutes later, the findings haven't resolved and the cardiologist is delayed. What's your next move?
CONTINUE →
⚠ THE FINDINGS HAVEN'T RESOLVED
DOCUMENTING ISN'T ADDRESSING.
Repositioning didn't change the picture. Cap refill is still 4 seconds, the pulse is still weak, the patient is still symptomatic. Charting that you rechecked doesn't change any of that. The right move is to re-escalate the active concern — not to walk away from it. The cardiologist is delayed; your follow-up is what keeps the patient on their radar.
← BACK TO DECISION
15 MINUTES LATER…
YOU'VE LOST TIME.
You reassess. Thumb SpO₂ now reads 86% with an intermittent waveform. Anton reports his hand is now "really cold and starting to ache." Cap refill is now 5 seconds. Confirming a sensor reading is reasonable when the picture is ambiguous. But when objective findings (cap refill, weak pulse, cool hand) line up with subjective findings (tingling, cold), waiting 15 minutes is borrowed time. The findings are worse and you need to escalate now.
← BACK TO DECISION
CONTINUOUS PULSE OX
A pulse oximeter on the affected thumb gives you real-time confirmation that blood is reaching the hand past the band. Watch the waveform AND the number — both matter.
✓ ANCHORED IN POLICY
THE BLEEDING STOPS. YOU RESTART CLEANLY.
You reinflate 3 mL. The bleeding stops. You wait 15 minutes, then restart the deflation protocol from 6 mL. Five minutes later, you remove the next 3 mL — site stays dry. Five minutes after that, you remove the final 3 mL — still dry. The band is empty. Now you wait the required 5 minutes before removing the band itself. The band is empty and the site is dry. The wife walks in and asks if Anton can use his arm yet. What do you tell her, and what do you do next?
CONTINUE →
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Treating removal as the endpoint underestimates rebleeding risk. Per Policy NA 10-199, the same front-loaded monitoring rhythm continues after the band comes off — q15 minutes ×4, q30 minutes ×2, q1 hour ×2 — because anticoagulation effects and clot stability don't reset the moment the band is removed.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The monitoring rhythm:
- First Hour | q15 minutes x 4
- Second Hour | q30 minutes x 2
- Remaining Duration (while band on) | q1 hour
- Same rhythm post-removal
- Risk doesn't end at removal
NEXT QUESTION →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
Discharge teaching points:
- Minimize use of affected arm for at least 6 hours
- Keep wrist straight, no lifting/pushing/gripping for 48 hours
- Watch for swelling, bleeding, color or sensation changes
- Radial arm board available if compliance is a concern
NEXT QUESTION →
OVERSHOT THE RESTRICTION
BEDREST ISN'T REQUIRED — AND ISN'T PRACTICAL.
Total immobilization isn't supported by the policy and creates compliance problems of its own (deconditioning risk, patient frustration, family confusion). The restriction is specific to the affected arm: wrist straight, no lifting/pushing/gripping for 48 hours. Anton can walk, eat, and use his left hand normally. A radial arm board helps if you're worried about compliance.
← BACK TO DECISION
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Choosing 'once per hour from the start' or 'only when the patient reports symptoms' underestimates how front-loaded the risk actually is. Per Policy NA 10-199, the schedule is q15 minutes ×4, q30 minutes ×2, then q1 hour while the band is in place — because the first two hours carry the highest risk of both rebleeding and perfusion compromise.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
TIME IS PERFUSION
YOU WAITED. THE PICTURE GOT WORSE.
The cardiologist arrives 25 minutes later. By that time, Anton's pulse is absent and the hand is cold. The band is removed urgently; the patient is sent for vascular evaluation. Waiting isn't a neutral action. When the picture isn't improving and the provider is delayed, the right next step is to push the escalation forward — not to assume the original call covered it.
← BACK TO DECISION
⚠ DOCUMENTATION ISN'T ESCALATION
FINDINGS PROGRESSED DURING THE DELAY.
30 minutes later, Anton reports severe pain. His hand is now visibly pale, the radial pulse is absent, and there's still no bleeding. Documenting is essential. It isn't enough on its own when objective and subjective findings line up. This situation met the notification threshold the moment you saw cap refill of 4 seconds and a weakened pulse with patient-reported symptoms.
← BACK TO DECISION
CONTINUE TO KC →
Two small air-filled balloons line the inside of the band. When inflated, they apply targeted pressure to the radial artery — enough to stop bleeding at the puncture, but not enough to cut off blood flow to the hand. This is the mechanism of patent hemostasis.
TWO COMPRESSION BALLOONS
Two small air-filled balloons line the inside of the band. When inflated, they apply targeted pressure to the radial artery — enough to stop bleeding at the puncture, but not enough to cut off blood flow to the hand. This is the mechanism of patent hemostasis.
TWO COMPRESSION BALLOONS
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
The inflation syringe isn't a generic supply or a one-time tool. It's the only syringe that can safely deflate the band - and it needs to stay with the patient until removal.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
BYPASSES THE PROTOCOL
MANUAL PRESSURE ISN'T THE FIRST MOVE HERE.
Manual pressure can stop bleeding, but it bypasses the controlled deflation process the policy is built around. The TR Band is designed to allow incremental pressure reduction — pulling it off mid-removal and switching to manual compression isn't the first action. There are emergent situations where direct pressure becomes necessary (uncontrolled hemorrhage). For a single bleed mid-removal, the policy answer is: reinflate 3 mL, wait 15 minutes, restart.
← BACK TO DECISION
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The inflation syringe - three things to remember:
- Only this syringe can safely deflate the band
- Stays at the bedside in a safe, marked location for the duration
- Losing it delays removal and creates a safety risk
NEXT QUESTION →
⚠ POLICY HARD STOP
REAPPLICATION OF A TR BAND IS NOT PERMITTED.
Once a band has been removed or significantly deflated, a new one is not a substitute. This is one of the few absolute prohibitions in Policy NA 10-199. The correct response: reinflate the 3 mL you just removed, wait 15 minutes, restart removal. If repeated bleeding prevents you from completing removal within the ordered timeframe, notify the provider.
← BACK TO DECISION
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Including the BP cuff on the affected arm isn't aligned with Policy NA 10-199. Per the policy, no BP, blood draws, or new IVs are permitted on the affected arm while the band is in place.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Removing all the air at once, skipping the 5-minute observation between deflations, or reapplying a new band aren't options the policy supports. Per NA 10-199, removal is 3 mL of air at a time with 5 minutes of observation between each step — and reapplication of a TR Band is not permitted. If bleeding prevents completion, reinflate the volume just removed, wait 15 minutes, and restart
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The six-point arrival check:
- Color, temperature, capillary refill — affected hand
- Radial AND ulnar pulses — palpate both
- Sensation and gentle finger movement
- Access site for bleeding or hematoma
- Continuous pulse ox on affected thumb (waveform AND number)
- Off-limits: No BP, blood draws, or new IVs on the affected arm
NEXT QUESTION →
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Telling Anton 'no restrictions' or 'complete bedrest' both miss the policy guidance. Per NA 10-199, the patient should minimize use of the affected arm for at least 6 hours and avoid lifting, pushing, or gripping with that hand for 48 hours. A radial arm board is available if compliance is a concern — but full immobilization isn't required and isn't practical.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The monitoring rhythm:
- First Hour | q15 minutes x 4
- Second Hour | q30 minutes x 2
- Remaining Duration (while band on) | q1 hour
- Same rhythm post-removal
- Front-loaded because risk is front-loaded
NEXT QUESTION →
⚠ OUTSIDE YOUR SCOPE
THE BAND MANIPULATION BACKFIRED.
You remove 3 mL. Bleeding now appears at the access site, and the cardiologist arrives concerned that the perfusion issue may have been a sensor problem, not a band issue. Per Policy NA 10-199, the nurse does not independently adjust the air volume except during the formal ordered removal process. Some perfusion changes need provider assessment — not just less compression.
← BACK TO DECISION
CONTINUOUS PULSE OX
A pulse oximeter on the affected thumb gives you real-time confirmation that blood is reaching the hand past the band. Watch the waveform AND the number — both matter.
⚠ THE SITE REBLEEDS
NO RESTRICTIONS WAS THE WRONG MESSAGE.
Anton picks up his phone with his right hand and rotates the wrist to angle the screen. The puncture site rebleeds. Per policy, post-removal teaching is specific: minimize use of the affected arm for at least 6 hours, avoid lifting or pushing with that arm for 48 hours. The puncture needs time to fully heal.
← BACK TO DECISION
Two small air-filled balloons line the inside of the band. When inflated, they apply targeted pressure to the radial artery — enough to stop bleeding at the puncture, but not enough to cut off blood flow to the hand. This is the mechanism of patent hemostasis.
TWO COMPRESSION BALLOONS
The only way to safely inflate or deflate the band. The inflation syringe is the only tool designed to fit it — which is why that syringe needs to stay at the bedside for the duration of TR Band care.
THE AIR PORT
TR Band Module — Anton's Story (Build v1)
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Transcript
01
module 1 of 1
FOUNDATIONS OF TR BAND CARE
Anton's Story — A Case-Based Module for Med/Surg Telemetry RNs
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
02
slide 2 of 24
WHAT YOU'LL LEAVE WITH
CONTINUE →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
03
slide 3 of 24
WHERE ARE YOU STARTING FROM?
Choose your path. Both routes cover the same content — the order and depth differ.
I'VE CARED FOR A TR BAND PATIENT
Expedited route — same education, faster path. Each correct answer confirms your knowledge with a brief refresher on the take-home points. Wrong answers route you to the full content slide.
Experienced Path
THIS IS NEW TO ME
Start with the assessment skills you already use, build up through Anton's story, and learn the protocol in context.
Foundations Path
Same education for every learner. Your choice is about how fast you get through it.
KECK MEDICINE OF USC · NPD CRITICAL CARE
04
slide 4 of 24
FOUNDATIONS
YOU ALREADY KNOW HOW TO SPOT POOR PERFUSION
You assess distal perfusion every shift. Before we introduce the TR Band, let's confirm what you're already using.
KEY POINT
These same five senses are how you'll assess every TR Band patient.
CONTINUE TO KC →
KECK MEDICINE OF USC · NPD CRITICAL CARE
05
slide 5 of 24
FOUNDATIONS
BLEEDING RISK DOESN'T END WHEN THE DRIP STOPS
Anton received heparin during his procedure. Even after the infusion ends and a puncture site appears clotted, bleeding can recur.
- Anticoagulation effects persist beyond the infusion itself — the body needs time to clear the medication and restore normal clotting.
- Puncture sites can rebleed from movement, pressure changes, or simply because the initial clot was fragile.
- Hematomas can develop slowly — what looks fine at hour 1 may not look fine at hour 3.
That's why we monitor on a schedule — we'll get to the specifics in a few slides.KEY POINT
Why we keep watching: anticoagulation effects persist beyond the drip.
CONTINUE TO KC →
KECK MEDICINE OF USC · NPD CRITICAL CARE
06
slide 6 of 24
FOUNDATIONS
TWO PIECES OF INFORMATION
A pulse oximeter gives you two things: a number (oxygen saturation) and a waveform (pulsatile flow). On a TR Band patient, the waveform on the thumb is your real-time signal that blood is reaching the hand.
THE WAVEFORM
Visual proof of pulsatile blood flow at the sensor site. No waveform = no reliable signal, no matter what the number says.
THE NUMBER
What percentage of hemoglobin is carrying oxygen. Useful — but only meaningful if the signal is reliable.
Watch the line, not just the percent — you'll see why when Anton's findings shift later in this module.
KEY POINT
Number without waveform = unreliable. Watch the line, not just the percent.
CONTINUE TO KC →
KECK MEDICINE OF USC · NPD CRITICAL CARE
07
slide 7 of 24
FOUNDATIONS
MEET ANTON MARSHALL
Anton is 58 years old. Two weeks ago, on an evening walk with his wife Josephine, he became short of breath. Over the next few days he noticed swelling in his ankles and worsening shortness of breath with everyday activities.Josephine got him in to see his cardiologist, Dr. Singh. Given Anton's history of hypertension, hyperlipidemia, and type 2 diabetes, Dr. Singh was worried about acute coronary syndrome. Labs confirmed an NSTEMI. Anton was admitted to Keck and scheduled for a coronary angiogram via right radial access — which is where his TR Band journey begins.
CONTINUE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
08
slide 8 of 24
EXPERIENCED
FOUNDATIONS
PATENT HEMOSTASIS — THE GOAL OF THE TR BAND
After radial access, a clear plastic band wraps the wrist. Two small air-filled balloons apply pressure to the radial artery. The goal is patent hemostasis:
- "Patent" = open
- Puncture closed
- Artery still flowing
Your assessments confirm both are happening — bleeding stopped AND blood reaching the hand.KEY POINT
Bleeding stopped. Blood flowing. Both confirmed by your assessment.
CONTINUE →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
08
slide 8 of 24
EXPERIENCED
FOUNDATIONS
PATENT HEMOSTASIS — THE GOAL OF THE TR BAND
After radial access, a clear plastic band wraps the wrist. Two small air-filled balloons apply pressure to the radial artery. The goal is patent hemostasis:
- "Patent" = open
- Puncture closed
- Artery still flowing
Your assessments confirm both are happening — bleeding stopped AND blood reaching the hand.KEY POINT
Bleeding stopped. Blood flowing. Both confirmed by your assessment.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
08
slide 8 of 24
EXPERIENCED
FOUNDATIONS
PATENT HEMOSTASIS — THE GOAL OF THE TR BAND
After radial access, a clear plastic band wraps the wrist. Two small air-filled balloons apply pressure to the radial artery. The goal is patent hemostasis:
- "Patent" = open
- Puncture closed
- Artery still flowing
Your assessments confirm both are happening — bleeding stopped AND blood reaching the hand.KEY POINT
Bleeding stopped. Blood flowing. Both confirmed by your assessment.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
09
slide 9 of 24
EXPERIENCED
FOUNDATIONS
ANTON RETURNS TO 5N
CASE · 1015
You are Domingo, the receiving nurse. Angela hands off: TR Band placed at 0955 with 12 cc of air. Heparin during procedure. Anti-platelet meds started. Here's the inflation syringe.
SpO2
98%
RR
16
HR
78
BP
132/78
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
10
slide 10 of 24
EXPERIENCED
FOUNDATIONS
WHY IS ANGELA HANDING YOU A SYRINGE?
CASE · 1015, CONTINUED
As Angela completes the handoff, she hands you a small green-tipped syringe and says: "Keep this with him."
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
11
slide 11 of 24
EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
CONTINUE TO KC →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
11
slide 11 of 24
EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
11
slide 11 of 24
EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
11
slide 11 of 24
EXPERIENCED
FOUNDATIONS
WHY THIS SCHEDULE MIRRORS THE RISK CURVE
The first two hours after band placement are the highest-risk window for both rebleeding and perfusion compromise. The monitoring schedule front-loads attention where the risk lives.
AT EACH CHECK, YOU ASSESS:
KEY POINT
Front-loaded checks = front-loaded risk. Same rhythm post-removal.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
12
slide 12 of 24
EXPERIENCED
FOUNDATIONS
YOUR FIRST ROUND OF CHECKS
CASE · 1030
Initial assessment complete. Anton looks comfortable, right hand pink and warm, pulse ox shows 98% with a strong waveform, access site dry. You document and step out to grab supplies. Before you do — how often will you be back?
SpO2
98%
RR
16
HR
76
BP
130/76
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
13
slide 13 of 24
EXPERIENCED
FOUNDATIONS
WHAT DOES A GOOD CHECK LOOK LIKE?
Your assessment can land in one of three patterns. Recognizing which is happening is what makes you effective.
PATENT HEMOSTASIS
Bleeding stopped. Blood flowing.
· Hand pink, warm · Cap refill <3 sec, palpable pulse · SpO₂ 98% with strong waveform · Site dry, no hematoma
ANCHORED IN POLICY
VENOUS CONGESTION
Outflow restricted. Inflow preserved.
· Hand swollen, dusky-purple · Cap refill borderline · SpO₂ acceptable with waveform · Pulse palpable
WORTH A SECOND LOOK
ARTERIAL COMPROMISE
Blood not reaching the hand.
· Hand pale, cool · Cap refill >3 sec · SpO₂ low / absent waveform · Pulse diminished/absent
POLICY HARD STOP
Same hand, three different stories. Your assessment is the difference between them.
CONTINUE TO KC →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
14
slide 14 of 24
EXPERIENCED
FOUNDATIONS
ANTON CALLS YOU
CASE · 1200
Anton calls. His right hand feels "tingly and cold."
Site
Dry
Thumb SpO2
Cap Refill
92%
4 seconds
Hand Temp
Cool
Ulnar Pulse
Weak
WHAT IS YOUR PRIORITY ACTION?
REPOSITION SENSOR, REASSESS IN 15 MIN
NOTIFY PROCEDURAL CARDIOLOGIST
DEFLATE BAND BY 3 mL
DOCUMENT & CONTINUE SCHEDULED CHECKS
KECK MEDICINE OF USC · NPD CRITICAL CARE
15
slide 15 of 24
EXPERIENCED
FOUNDATIONS
THE FINDINGS HAVEN'T RESOLVED
CASE · 1205 — 5 MINUTES LATER
You repositioned Anton's arm gently, as the cardiologist suggested. You rechecked. The findings are essentially unchanged — and the cardiologist is now delayed in another procedure.
Patient Report
Still tingly
Thumb SpO2
Cap Refill
91%
4 seconds
Hand Temp
Cool
Ulnar Pulse
Weak
WHAT'S YOUR NEXT MOVE?
DOCUMENT THE RECHECK AND RETURN TO ROUTINE CHARTING
CONTINUE CURRENT MONITORING; WAIT FOR THE CARDIOLOGIST
PAGE THE CARDIOLOGIST AGAIN; REQUEST ORDER FOR PARTIAL DEFLATION
KECK MEDICINE OF USC · NPD CRITICAL CARE
16
slide 16 of 24
EXPERIENCED
FOUNDATIONS
REMOVAL IS A PROTOCOL, NOT A PROCEDURE
The TR Band comes off in stepped, timed increments — never all at once. The rhythm is what makes it safe.
KEY POINT
Reapplication of a TR Band is not permitted. If bleeding prevents completion within the ordered window, notify the provider.
CONTINUE TO KC →
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
16
slide 16 of 24
EXPERIENCED
FOUNDATIONS
REMOVAL IS A PROTOCOL, NOT A PROCEDURE
The TR Band comes off in stepped, timed increments — never all at once. The rhythm is what makes it safe.
KEY POINT
Reapplication of a TR Band is not permitted. If bleeding prevents completion within the ordered window, notify the provider.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
16
slide 16 of 24
EXPERIENCED
FOUNDATIONS
REMOVAL IS A PROTOCOL, NOT A PROCEDURE
The TR Band comes off in stepped, timed increments — never all at once. The rhythm is what makes it safe.
KEY POINT
Reapplication of a TR Band is not permitted. If bleeding prevents completion within the ordered window, notify the provider.
← BACK TO QUESTION
📎 NA 10-199
KECK MEDICINE OF USC · NPD CRITICAL CARE
17
slide 17 of 24
EXPERIENCED
FOUNDATIONS
REMOVAL TIME
CASE · 1355
Anton's TR Band has been in place for four hours. The provider order specifies removal at 1355 per the conservative protocol. You've verified the order, retrieved the inflation syringe from the bedside, and are ready to begin.
If site dry after monitoring, remove band itself
Drag the steps to the left into the correct order for safe TR Band removal.
Apply 2×2 + Tegaderm dressing to site
Begin post-removal monitoring schedule
Monitor site for 5 minutes after empty
Remove 3 mL of air, observe for bleeding
Continue removing 3 mL q5 minutes until empty
KECK MEDICINE OF USC · NPD CRITICAL CARE
18
slide 18 of 24
EXPERIENCED
FOUNDATIONS
YOU SEE BLOOD AT THE SITE
CASE · 1405 — REMOVAL IN PROGRESS
You've completed two deflations per protocol — band started at 12 mL, now holds 6 mL. As you remove the next 3 mL, bright red blood appears at the access site.
Site
Bleeding
Band Volume
Thumb SpO2
6 mL
98%
Hand Color
Pink
Hand Temp
Warm
WHAT IS YOUR NEXT ACTION?
APPLY PRESSURE, RAPIDLY REMOVE REMAINING AIR
REINFLATE 3 mL, WAIT 15 MIN, RESTART PROTOCOL
REMOVE THE BAND ENTIRELY, HOLD MANUAL PRESSURE
REAPPLY A FRESH TR BAND WITH 12 mL
KECK MEDICINE OF USC · NPD CRITICAL CARE
19
slide 19 of 24
EXPERIENCED
FOUNDATIONS
JOSEPHINE WALKS IN
CASE · 1430 — BAND IS OFF
Anton's TR Band came off cleanly after the restart. Site is dry, dressing in place. As you finish charting, Josephine walks into the room and asks: "Is he okay to use his arm now? He's been wanting to text our daughter."
Band Volume
Thumb SpO2
6 mL
98%
Cap Refill
< 3 sec
Hand
Pink, Warm
Site
Dry, Dressed
WHAT DO YOU TELL JOSEPHINE — AND WHAT DO YOU DO NEXT?
TELL HER HE CAN USE THE ARM NORMALLY NOW
TELL HER HE'S ON STRICT BEDREST UNTIL DISCHARGE
TEACH THE RESTRICTIONS, START POST-REMOVAL MONITORING
KECK MEDICINE OF USC · NPD CRITICAL CARE
20
slide 20 of 24
EXPERIENCED
FOUNDATIONS
THE BAND IS OFF — NOW WHAT?
CASE · 1435
Anton's TR Band has been removed. Site is dry, 2×2 + Tegaderm dressing in place. He's resting comfortably. You've taught the activity restrictions. Now — when do you come back to check on him?
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
21
slide 21 of 24
EXPERIENCED
FOUNDATIONS
ANTON ASKS ABOUT GOING HOME
CASE · 1500
Anton is feeling much better. His post-removal checks have been reassuring — site dry, hand pink and warm, cap refill brisk. He's already thinking ahead and asks: "Once I'm home, how careful do I have to be with this arm?" Josephine is at his bedside, listening.
BEGIN MODULE →
BEGIN MODULE →
KECK MEDICINE OF USC · NPD CRITICAL CARE
22
slide 22 of 24
ANTON GOES HOME
Anton's TR Band came off cleanly. The post-removal monitoring rhythm finished without incident. Site stayed dry. Hand stayed pink and warm. The next morning, the cardiology team rounded. They cleared Anton for discharge with dual anti-platelet therapy and a new heart failure medication regimen. Cardiac rehab referral, dietary counseling, follow-up in two weeks. Josephine drove him home that afternoon. Anton walked out using his left arm for the bag, his right arm relaxed at his side — exactly the way the teaching landed. He texted his daughter from the car. The reason this went well isn't luck. It's that his nurses — including you — knew what to assess, when to escalate, how to follow the protocol, and how to teach. That's the work.
CONTINUE TO RECAP →
KECK MEDICINE OF USC · NPD CRITICAL CARE
23
slide 23 of 24
FIVE THINGS TO CARRY FORWARD
1 | PATENT HEMOSTASIS: Pressure that stops bleeding AND preserves flow. Your assessment confirms both. 2 | THE MONITORING RHYTHM: q15 ×4 → q30 ×2 → q1h while the band is on. Same rhythm post-removal. 3 | THE AFFECTED ARM IS OFF-LIMITS: No BP, blood draws, or new IVs in that arm while the band is on. 4 | BLEEDING DURING REMOVAL: Reinflate, wait 15, restart. Never reapply a new band. 5 | WHEN TO NOTIFY: Cap refill >3 sec, absent ulnar pulse, cyanosis, numbness, pain, bleeding, or hematoma.
KEY POINT
Questions? Reach out to your unit educator or NPD.
RESOURCES →
KECK MEDICINE OF USC · NPD CRITICAL CARE
24
slide 24 of 24
WHERE TO GO FROM HERE
POLICY
NA 10-199 | Radial Compression Device
Available on Keck SharePoint under Nursing Operating Policies.
ANCHORED IN POLICY
MANUFACTURER REFERENCE
Terumo TR Band | Instructions for Use
Available through Materials Management or the Terumo product page.
WORTH A LOOK
CONTACTS
Unit NPD Educator
Unit Educator: [insert name and contact]
REACH OUT
Lani Thong | 2 EW | NPD
email
email
Policy
IFU
Thank you! you can close module now.
KECK MEDICINE OF USC · NPD CRITICAL CARE
⚠ SPEED MAKES THIS WORSE
RUSHING REMOVAL ESCALATES THE BLEEDING.
You remove the remaining 6 mL rapidly. Bleeding intensifies. A hematoma begins to form around the site. You now need extended manual pressure and the cardiologist is paged urgently. The compression balloon is the only thing currently controlling the puncture. Rushing removal once bleeding has started removes that control. The policy answer is to reinflate, wait 15 minutes, and restart.
← BACK TO DECISION
✓ ANCHORED IN POLICY — & PATIENT-CENTERED
THE TRANSITION GOES SMOOTHLY.
You apply the dressing. You begin the post-removal schedule: q15min ×4, q30min ×2, q1h ×2. You teach Anton and Josephine: minimize use of the right arm for 6 hours, keep the wrist straight and avoid lifting/pushing/gripping with that hand for 48 hours, call the nurse for any swelling, bleeding, or color/sensation changes. A radial arm board is available if he needs help remembering. Anton uses his left hand to text his daughter. Removal is a transition, not an endpoint. Post-removal monitoring and teaching matter as much as the removal itself.
CONTINUE →
CONTINUOUS PULSE OX
A pulse oximeter on the affected thumb gives you real-time confirmation that blood is reaching the hand past the band. Watch the waveform AND the number — both matter.
✓ ANCHORED IN POLICY — AND IN ADVOCACY
THE SYSTEM WORKED BECAUSE YOU ADVOCATED WITHIN IT.
You re-page. The cardiologist gives a verbal order to release 3 mL of air immediately and recheck in 5 minutes. You document the order, perform the deflation per policy, and reassess. 5 minutes later: pulse stronger, cap refill 2 sec, SpO₂ 97% with strong waveform. Anton says, "It feels better." Escalation isn't one-and-done. When the clinical picture isn't improving and the provider is delayed, pushing the escalation forward is part of the work.
CONTINUE →
The only way to safely inflate or deflate the band. The inflation syringe is the only tool designed to fit it — which is why that syringe needs to stay at the bedside for the duration of TR Band care.
THE AIR PORT
Anton's right hand is swollen and dusky-purple. Thumb SpO₂ reads 97% with a clear waveform, and the radial pulse is palpable. Which card describes what you're seeing?
Scenerio
arterial compromise
venous congestion
Patent Hemostasis
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The removal protocol:
NEXT QUESTION →
The only way to safely inflate or deflate the band. The inflation syringe is the only tool designed to fit it — which is why that syringe needs to stay at the bedside for the duration of TR Band care.
THE AIR PORT
✓ ANCHORED IN POLICY
YOU STAYED IN SCOPE AND PROTECTED THE PATIENT.
The cardiologist is paged. While you wait, you continue monitoring, reposition the arm to rule out positional artifact, and keep the inflation syringe accessible. The cardiologist calls back: "I'm coming to assess. In the meantime, reposition the arm and recheck in 5 minutes." 5 minutes later, the findings haven't resolved and the cardiologist is delayed. What's your next move?
CONTINUE →
⚠ THE FINDINGS HAVEN'T RESOLVED
DOCUMENTING ISN'T ADDRESSING.
Repositioning didn't change the picture. Cap refill is still 4 seconds, the pulse is still weak, the patient is still symptomatic. Charting that you rechecked doesn't change any of that. The right move is to re-escalate the active concern — not to walk away from it. The cardiologist is delayed; your follow-up is what keeps the patient on their radar.
← BACK TO DECISION
15 MINUTES LATER…
YOU'VE LOST TIME.
You reassess. Thumb SpO₂ now reads 86% with an intermittent waveform. Anton reports his hand is now "really cold and starting to ache." Cap refill is now 5 seconds. Confirming a sensor reading is reasonable when the picture is ambiguous. But when objective findings (cap refill, weak pulse, cool hand) line up with subjective findings (tingling, cold), waiting 15 minutes is borrowed time. The findings are worse and you need to escalate now.
← BACK TO DECISION
CONTINUOUS PULSE OX
A pulse oximeter on the affected thumb gives you real-time confirmation that blood is reaching the hand past the band. Watch the waveform AND the number — both matter.
✓ ANCHORED IN POLICY
THE BLEEDING STOPS. YOU RESTART CLEANLY.
You reinflate 3 mL. The bleeding stops. You wait 15 minutes, then restart the deflation protocol from 6 mL. Five minutes later, you remove the next 3 mL — site stays dry. Five minutes after that, you remove the final 3 mL — still dry. The band is empty. Now you wait the required 5 minutes before removing the band itself. The band is empty and the site is dry. The wife walks in and asks if Anton can use his arm yet. What do you tell her, and what do you do next?
CONTINUE →
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Treating removal as the endpoint underestimates rebleeding risk. Per Policy NA 10-199, the same front-loaded monitoring rhythm continues after the band comes off — q15 minutes ×4, q30 minutes ×2, q1 hour ×2 — because anticoagulation effects and clot stability don't reset the moment the band is removed.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The monitoring rhythm:
NEXT QUESTION →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
Discharge teaching points:
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OVERSHOT THE RESTRICTION
BEDREST ISN'T REQUIRED — AND ISN'T PRACTICAL.
Total immobilization isn't supported by the policy and creates compliance problems of its own (deconditioning risk, patient frustration, family confusion). The restriction is specific to the affected arm: wrist straight, no lifting/pushing/gripping for 48 hours. Anton can walk, eat, and use his left hand normally. A radial arm board helps if you're worried about compliance.
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⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Choosing 'once per hour from the start' or 'only when the patient reports symptoms' underestimates how front-loaded the risk actually is. Per Policy NA 10-199, the schedule is q15 minutes ×4, q30 minutes ×2, then q1 hour while the band is in place — because the first two hours carry the highest risk of both rebleeding and perfusion compromise.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
TIME IS PERFUSION
YOU WAITED. THE PICTURE GOT WORSE.
The cardiologist arrives 25 minutes later. By that time, Anton's pulse is absent and the hand is cold. The band is removed urgently; the patient is sent for vascular evaluation. Waiting isn't a neutral action. When the picture isn't improving and the provider is delayed, the right next step is to push the escalation forward — not to assume the original call covered it.
← BACK TO DECISION
⚠ DOCUMENTATION ISN'T ESCALATION
FINDINGS PROGRESSED DURING THE DELAY.
30 minutes later, Anton reports severe pain. His hand is now visibly pale, the radial pulse is absent, and there's still no bleeding. Documenting is essential. It isn't enough on its own when objective and subjective findings line up. This situation met the notification threshold the moment you saw cap refill of 4 seconds and a weakened pulse with patient-reported symptoms.
← BACK TO DECISION
CONTINUE TO KC →
Two small air-filled balloons line the inside of the band. When inflated, they apply targeted pressure to the radial artery — enough to stop bleeding at the puncture, but not enough to cut off blood flow to the hand. This is the mechanism of patent hemostasis.
TWO COMPRESSION BALLOONS
Two small air-filled balloons line the inside of the band. When inflated, they apply targeted pressure to the radial artery — enough to stop bleeding at the puncture, but not enough to cut off blood flow to the hand. This is the mechanism of patent hemostasis.
TWO COMPRESSION BALLOONS
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
The inflation syringe isn't a generic supply or a one-time tool. It's the only syringe that can safely deflate the band - and it needs to stay with the patient until removal.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
BYPASSES THE PROTOCOL
MANUAL PRESSURE ISN'T THE FIRST MOVE HERE.
Manual pressure can stop bleeding, but it bypasses the controlled deflation process the policy is built around. The TR Band is designed to allow incremental pressure reduction — pulling it off mid-removal and switching to manual compression isn't the first action. There are emergent situations where direct pressure becomes necessary (uncontrolled hemorrhage). For a single bleed mid-removal, the policy answer is: reinflate 3 mL, wait 15 minutes, restart.
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✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The inflation syringe - three things to remember:
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⚠ POLICY HARD STOP
REAPPLICATION OF A TR BAND IS NOT PERMITTED.
Once a band has been removed or significantly deflated, a new one is not a substitute. This is one of the few absolute prohibitions in Policy NA 10-199. The correct response: reinflate the 3 mL you just removed, wait 15 minutes, restart removal. If repeated bleeding prevents you from completing removal within the ordered timeframe, notify the provider.
← BACK TO DECISION
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Including the BP cuff on the affected arm isn't aligned with Policy NA 10-199. Per the policy, no BP, blood draws, or new IVs are permitted on the affected arm while the band is in place.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Removing all the air at once, skipping the 5-minute observation between deflations, or reapplying a new band aren't options the policy supports. Per NA 10-199, removal is 3 mL of air at a time with 5 minutes of observation between each step — and reapplication of a TR Band is not permitted. If bleeding prevents completion, reinflate the volume just removed, wait 15 minutes, and restart
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The six-point arrival check:
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⚠ NOT YET — ROUTING TO REFRESHER
Let's revisit the fundamentals.
Telling Anton 'no restrictions' or 'complete bedrest' both miss the policy guidance. Per NA 10-199, the patient should minimize use of the affected arm for at least 6 hours and avoid lifting, pushing, or gripping with that hand for 48 hours. A radial arm board is available if compliance is a concern — but full immobilization isn't required and isn't practical.
Click below to be routed to the Content Reveal slide — same one the Foundations path sees as primary content. After the refresher, you'll return here to re-attempt.
GO TO REFRESHER →
✓ ANCHORED IN POLICY
You've Got It
Right answer. Quick refresher to keep us on the same page - these are the take-home points...
refresher - take-home points
The monitoring rhythm:
NEXT QUESTION →
⚠ OUTSIDE YOUR SCOPE
THE BAND MANIPULATION BACKFIRED.
You remove 3 mL. Bleeding now appears at the access site, and the cardiologist arrives concerned that the perfusion issue may have been a sensor problem, not a band issue. Per Policy NA 10-199, the nurse does not independently adjust the air volume except during the formal ordered removal process. Some perfusion changes need provider assessment — not just less compression.
← BACK TO DECISION
CONTINUOUS PULSE OX
A pulse oximeter on the affected thumb gives you real-time confirmation that blood is reaching the hand past the band. Watch the waveform AND the number — both matter.
⚠ THE SITE REBLEEDS
NO RESTRICTIONS WAS THE WRONG MESSAGE.
Anton picks up his phone with his right hand and rotates the wrist to angle the screen. The puncture site rebleeds. Per policy, post-removal teaching is specific: minimize use of the affected arm for at least 6 hours, avoid lifting or pushing with that arm for 48 hours. The puncture needs time to fully heal.
← BACK TO DECISION
Two small air-filled balloons line the inside of the band. When inflated, they apply targeted pressure to the radial artery — enough to stop bleeding at the puncture, but not enough to cut off blood flow to the hand. This is the mechanism of patent hemostasis.
TWO COMPRESSION BALLOONS
The only way to safely inflate or deflate the band. The inflation syringe is the only tool designed to fit it — which is why that syringe needs to stay at the bedside for the duration of TR Band care.
THE AIR PORT