A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE REGARDING CARE

OF PATIENTS UNDERGOING CARDIAC CATHETERIZATION AMONG

STAFF NURSES IN A SELECTED HOSPITAL, BANGALORE.
M.Sc. Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

By,
Ms. SAJILA.S
I YEAR M.Sc. NURSING
2012-2013

Under the Guidance of

HOD, Department of Medical and Surgical Nursing
Anuradha College of Nursing.
Hegganahalli Cross
Vishwaneedam Post
Magadi Road
Bangalore 91

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

CURRICULAM DEVELOPMENT CELL
CONFIRMATION FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Registration number

Name of the candidate

Ms. Sajila.S.

Address

Hegganahalli Cross,Vishwaneedam Post,

Magadi Road, Bangalore-91 .

Name of the institution

Anuradha College of Nursing

Course of study and subject

M.Sc. Nursing in Medical and Surgical Nursing.

.Date of admission to course

15-5-2012

Title of the topic

A descriptive study to assess the knowledge

regarding care of patients undergoing cardiac
catheterization among staff nurses in a selected
hospital, Bangalore.

Brief resume of the intended work

Signature of the student

Guides Name

Remarks of the guide

Signature of the guide

Co-guides name

Signature of co-guide

HODs name

Signature of HOD

Principals Name

Principals Mobile No

Principals E-mail ID

Remarks of the Principal

Principals signature

Attached

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Ms. SAJILA. S
NAME
OF
THE
CANDIDATE
1
I YEAR M.Sc. NURSING,
AND
ADDRESS
ANURADHAWORK
COLLEGE OF
6.
BRIEF
RESUME OF THE INTENDED
NURSING,
HEGGANAHALLI CROSS,
VISHWANEEDAM POST,
MAGADI ROAD,
BANGALORE-91.
INTRODUCTION
2

Coronary
heart disease (CHD),
also known
as coronary
NAME OF THE
INSTITUTION
ANURADHA
COLLEGE
OF artery disease is
NURSING,
a narrowing of the blood vessels (coronary
arteries) that supply
oxygen and blood to
HEGGANAHALLI
CROSS,
VISHWANEEDAM POST,
the heart. Coronary heart disease is generally
caused
by atherosclerosis- when plaque
MAGADI
ROAD,
BANGALORE-91.
(cholesterol substances) accumulates on the artery walls, causing them to narrow,

resulting OF
in less
bloodAND
flow to the heart.
Sometimes
a clot
form which
can
COURSE
STUDY
M.Sc
NURSING
INmay
MEDICAL
AND
SUBJECT
SURGICAL NURSING
obstruct the flow of blood to heart muscle. Coronary heart disease commonly causes

angina pectoris (chest pain), shortness of breath, heart attack (myocardial infarction)
DATE OF ADMISSION TO THE
and other symptoms1.
COURSE
15-5-2012
According to the National Institutes of Health (NIH), USA, coronary
TITLE OF THE TOPIC:
heart disease is the leading cause of death for males and females in the USA. 17.6

million Americans were thought to have had the condition in 2006. It caused the
A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE
death of over 425,000 people in the USA in 2006. According to the National Health
REGARDING CARE OF PATIENTS UNDERGOING CARDIAC
Service (NHS), UK, coronary heart disease causes the death of 1 in every 4 men and
CATHETERIZATION AMONG STAFF NURSES IN A
1 in every 6 women in the United Kingdom - it is the UK's biggest killer. The risk of
SELECTED HOSPITAL, BANGALORE.
developing the disease increases with age. More males are affected than females2.
Due to an increase in incidence and prevalence of coronary artery
disease (CAD), there has been a rapid progress in the treatment of CAD with
proliferation of specialized cardiac care units, intensive care units, cardiac
catheterization laboratories and facilities for bypass surgery. Cardiac catheterization

has been and currently remains the gold standard for the diagnosis of coronary artery
disease. It is estimated that there are over 400 catheterization laboratories currently in
India and nearly half of them are located in six major cities3.

Cardiac catheterization is performed to evaluate coronary artery disease,

valvular heart disease, congestive heart failure, and/or certain congenital (present at
birth) heart conditions, such as atrial, septal defect or ventricular septal defect, when
other less invasive types of diagnostic tests indicate the presence of one of these
conditions. It is a common medical procedure that rarely causes serious problems.
But complications can include bleeding, infection, pain where the catheter was
inserted, and damage to blood vessels. .Other less common complications of the
procedure include an arrhythmia ,damage to the kidneys, blood clots, heart attacks
and low B.P3.
Although coronary heart disease cannot be cured completely, it can be
managed much more effective today than in the past. Treatment consists mainly of
lifestyle changes, and perhaps some medical procedures and medications. Recently
the cardiologists all over the world are engaged in discovering new diagnostic and
therapeutic methods for cardiovascular diseases. Even though a lot of complications
detected after cardiac catheterization, the cardiac catheterization positions as the key
procedure with diagnostic as well as therapeutic properties2.

6.1
NEED FOR THE STUDY
A cardiac catheterization is an invasive, non-surgical procedure done to

study the arteries that bring blood to the heart muscle and to check the function of the
main pumping chamber of your heart. During the procedure, a small hollow tube
(catheter) is inserted into an artery (blood vessels) of the wrist or groin. The catheter
is then passed through the blood vessel into a heart chamber or to an artery supplying
blood to the heart .Special X-ray dye or contrast is injected through the catheter into
the arteries. This will outline the coronary arteries to show any existing blockages or

narrowing. This procedure is done under local anesthesia. Most patients have
minimal discomfort during cardiac catheterization4.
Cardiac catheterization is a common outpatient procedure nowadays.
According to American Heart Association Statistics 2004, every year over 50, 00,000
cardiac catheterizations were performed in the United States to diagnose and treat
heart disease. By 2008, this has increased to more than 1.5 million which are done
primarily to diagnose or monitor heart disease. The most common site for access to
the coronary circulation is the femoral artery. In Britain, 2658 cardiac catheterizations
per million populations are performing every year2.
The incidence and prevalence of coronary artery disease (CAD) has
increased tremendously in India too during the last two decades. There has also been
a rapid progress in the treatment of CAD with proliferation of specialized cardiac
care units, intensive care units, cardiac catheterization laboratories and facilities for
bypass surgery. It is estimated that there are over 400 catheterization laboratories
currently in India and nearly half of them are located in six major cities5.
A study had done to assess the prevalence and associated risk factors in
patients undergoing routine cardiac catheterization. Convenience samples of 1,302
of 1,651 consecutive patients undergoing diagnostic cardiac catheterization were
selected. Of the 1,302 abdominal aortograms performed, 1,235 (95%) were deemed

of adequate quality for the evaluation of renal artery anatomy. Renal artery disease
was identified in 30% patients. Insignificant renal artery stenosis was found in 187
(15%), significant stenosis was found in 188 (15%). Significant unilateral disease
was present in 11%, and bilateral disease was present in 4 samples6.

A study conducted to find out current complications of diagnostic and

therapeutic cardiac catheterization. Procedures include 1,609 diagnostic
catheterizations, 933 percutaneous trans luminal coronary angioplasties and 199
percutaneous balloon valvuloplasties. The mortality rate was 0.28% but ranged from
0.12% for diagnostic catheterizations to 0.3% for coronary angioplasty, 1.5% for
balloon valvuloplasty. Emergency cardiac surgery need in 12 angioplasty patients
(1.2%). Cardiac perforation in 7 patients (0.2%), of whom 6 were undergoing
valvuloplasty, and 5 emergency surgery .Complications requiring operative repair in
1.9% of patients , ranging from 1.6% for diagnostic catheterization to 1.5% for
angioplasty and 7.5% for valvuloplasty7

Cardiac catheterization is usually performed in a specially designed

cardiac catheterization suite in a hospital. A cardiac catheterization team consists of
physician, a nurse, a circulating nurse, and a radiologic technologist. Nurses role in
removing femoral sheaths after the procedure, achieving haemostasis, assessing for
potential complications, maintaining bed rest, immobilizing the patient's affected
limb, providing emotional support, educating patients, and promoting patient
comfort. The nurses must have an advanced knowledge and understanding of cardiac
catheterization so that any procedural complications may be handled rapidly and
effectively5.

6.2
REVIEW OF LITERATURE
INTRODUCTION

Review of literature is a key step in research process. It refers to an

extensive, exhaustive and systematic examination of publication relevant to the
research project. Before starting any new study or project reviews of previous studies
and experiences related to the proposed investigation should be done8.
The review of literature is defined as a broad, comprehensive, indepth, systematic and critical review of scholarly publication, unpublished scholarly
print materials, AV materials and personal communication8.

In this study the review of literature is divided into 3 main subdivisions. They are:
1. Review of literature regarding cardiac catheterization.
2. Review of literature related to knowledge of staff nurses regarding cardiac
catheterization.
3. Review of literature regarding care of patients undergoing cardiac catheterization.
1.Review of literature regarding cardiac catheterization :

A study was conducted to examine the patient education on anxiety

among Chinese patients with heart disease undergoing cardiac catheterisation. A

randomised experimental design was used. Data collected from a regional major
hospital in Hong Kong. Anxiety of all subjects reached the highest at the time just
before cardiac catheterisation and recorded the lowest at the time following the
procedure. A lower level of anxiety was experienced by the experimental subjects
who received the education intervention when compared with the control subjects
who did not receive the education intervention before cardiac catheterisation9.

A study was conducted to examine the association between use of right

heart catheterisation during the 1st 24 hours of care in ICU and subsequent survival
and length of stay. 5735 critically ill patients were selected for this study. Patients
with right heart catheterisation had an increased mortality(odds ratio,1.24;95%
confidence interval,1.03-1.49).The mean length of stay in the ICU was 14.8 (5,9,17)
days with right heart catheterisation and 13.0 (4,7,14)days without right heart
catheterisation . Patients with higher baseline probability of surviving 2 months had
the highest relative risk of death following right heart catheterisation10.

A study had done to determine the effect of nursing intervention

utilizing music therapy or sensory information on Chinese patients anxiety prior to
cardiac catheterisation. An experimental design was used. 45 hospitalized adult
undergoing cardiac catheterisation were randomly assigned. Anxiety, uncertainty and
mood state were measured using self-reported questionnaires. After controlling for
age, the use of music therapy or sensory information did not reduce anxiety;
improved mood state; reduce uncertainty; decrease heart or respiratory rate among
subjects undergoing cardiac catheterisation11.

A study was conducted to find out a comparison of structured versus

guided pre heart catheterisation information on mood states and coping strategies.
Using a two-group pre-test/post-test design, 89 subjects were randomly assigned to
two different preparatory nursing interventions. Data were collected on out patients

coping resources and mood states which served as measures of stress. No significant
differences in stress were found between the guided and the structured preparatory
information groups. The results indicated that a variety of approaches can be used to
prepare patients for outpatient heart catheterisation procedures12.
A study had done to estimate the frequency and nature of complication
in patients undergoing diagnostic cardiac catheterisation time, trends in complication
since introduction of a voluntary co-operative audit.41 cardiac centres joined this
study. 211645 diagnostic procedures in adults and 7582 paediatric procedures were
registered. The overall complication rate for adult procedures was 7.4/1000, with
mortality 0.7/1000; for paediatric procedures the complication rate was similar but
mortality rather higher. Time trends across the decade showed both complication and
mortality decreasing from 9.5-5.8/1000 and from 1.4-0.4/1000, respectively13.

A study was conducted to evaluate the incidence and significance of

complications resulting from the use of flow- directed, balloon-tipped catheters to
monitor critically ill patients. A prospective study of 116 pulmonary artery
catheterizations.

Arrhythmias,

including

premature

atrial

or

ventricular

depolarizations, ventricular tachycardia, and transient right--bundle branch block

occurred during 90 of the 116 insertion procedures. In 2 cases (1.7%) staphylococcal
bacteremia probably originated from the catheter. In addition, the pulmonary artery
catheter led to 2 cases (1.7%) of subclavian vein thrombosis14.

A study was conducted to assess the complication of cardiac

catheterisation of neonates, infants and children. Fatal complication were rare in all
age groups (0.26%). Arrhythmias and arterial complication accounted for 78% of all
complication. Although the incidence of arrhythmias was high (8.3% of all cases),
almost all responded to simple therapeutic measures.5 arrhythmias resulted in clinical

deterioration and 2 contributed to death. Complication was particularly common after

brachial arteriotomy in patients with co-arctation of the aorta (16%) 15.

A study had done to follow certain strategies to minimise vascular

complications after cardiac catheterisation. More than 230 of the complication were

associated with the access site, including bleeding, haematoma formation, retro
peritoneal bleed, pseudo aneurysm and arterio venous fistula formation. Of the 230
vascular complication reported, the most often stated causes of the problem were
medication errors, inconsistency in patient assessments, unrecognised changes in
patient condition ,sheath removal and lack of appropriate interventions when
complication occurred16.
2.Review of literature related to knowledge of staff nurses regarding cardiac
catheterization:
A study was conducted among critical care nurses to assess the
knowledge

and

understanding

of

nursing

personnel

regarding

cardiac

catheterization. The mean knowledge score was 48.5% for nurses who had years of
experience in critical care settings. The study concludes that a wide variation in the
understanding of the use of the cardiac catheterization exists among nurses. The
result indicates that current teaching practices regarding the cardiac catheter need to
be re-evaluated and specific credentialing policies need to be considered17.
A study was conducted to compare knowledge of a Nurse Practitioner to
Medical Staff in the Preparation of Patients for Diagnostic Cardiac Catheterizations.
345 patients were eligible for the study. Major adverse clinical events occurred in
0/175 (0%) patients in the NP group and 2/161 (1.2%) patients in the JMS group.
(Risk difference = -1.2%, upper boundary of the 95% confidence interval = 2.0%)
The cardiologist's evaluation that the patient's preparation was acceptable was high in
both groups: NP group 98.3% vs. JMS group 98.8%. Patient satisfaction, assessed by
questionnaire, was greater in the NP group18.

3.Review of literature regarding care of patients undergoing cardiac

catheterization:
A study conducted to determine whether there was a significant

difference in the incidence of bleeding from catheter insertion site between those
patients who remained in bed for 12 hours and those who remained in bed for 6 hours
post procedure.There was no significant difference between the 2 groups .Post
procedure bed rest was reduced from 12-6 hours in tertiary care medical centres.
Decreasing time in bed reduced cost and patient discomfort19.
A study had done for identifying the nursing diagnoses related to the

psychological and social aspects of elderly patients

undergoing cardiac

catheterization, according to the Adaptation Theory of Calista Roy. A semi

structured interview used. The analysis identified the nursing diagnoses: alteration in
maintenance of the health, anxiety, and alteration in the family process. The nursing
actions were: to create a trust climate for the aged to listen and to respect feelings,
faiths and referring values to the situation; to guide the patient with relationships to
the procedure20.

STATEMENT OF THE PROBLEM

A descriptive study to assess the knowledge regarding care of patients
undergoing cardiac catheterization among staff nurses in a selected hospital
Bangalore.

OBJECTIVES OF THE STUDY

The objectives of the study are:

 to assess the knowledge regarding care of patients undergoing cardiac

catheterization among staff nurses.
to find the association between the knowledge levels of staff nurses regarding
the care of patients undergoing cardiac catheterization with selected
demographic variables.

HYPOTHESIS
6.3

All hypothesis will be tested at 0.05 level of significance.

H1: There will be increased knowledge regarding care of patients undergoing
cardiac catheterization among staff nurses.
H2: There will be significant association between the knowledge level of staff
nurses regarding care of patients undergoing cardiac catheterization with

6.4

selected demographic variables.

OPERATIONAL DEFINITIONS
1. ASSESS:
It refers to evaluate the knowledge level of staff nurses regarding care of patients
undergoing cardiac catheterization.

6.5
2. KNOWLEDGE:

Knowledge refers to a persons awareness or information gained through experience

or education about care of patients undergoing cardiac catheterization.
3. CARDIAC CATHETERIZATION:
Cardiac catheterization is a procedure whereby a radio-opaque catheter is passed
from an arm vein to the heart. Its passage through the heart can be watched on a

6.6

screen. Also blood pressure readings and specimens can be taken, thus aiding
diagnosis of the heart abnormalities.
4. STAFF NURSE:
A person trained to care for the sick or infirm.

ASSUMPTIONS

Staff nurses will have some knowledge regarding the care of patients

undergoing cardiac catheterization.

Staff nurses will improve their knowledge regarding the care of patients

undergoing cardiac catheterization.

DELIMITATIONS
The study is delimited to:
staff nurses in a selected hospital, Bangalore.
sample size is 30.
those who are willing to participate in the study.

PROJECTED OUTCOME
The present study will help the staff nurses to develop adequate knowledge regarding

6.7

the care of patients undergoing cardiac catheterization.

MATERIALS AND METHODS

7.1.SOURCE OF DATA
The data will be collected from staff nurses who are working in a selected

6.8

Hospital, Bangalore.
7.1.1. RESEARCH DESIGN
The research design selected for this study is descriptive design.
RESEARCH APPROACH

 A survey approach is considered suitable for this study.

7.1.2.SETTING

6.9

The study will be conducted in a selected hospital, Bangalore.

7.1.3. POPULATION
The population selected is staff nurses who are working in a selected
hospital, Bangalore.

7.0

7.2.METHODS OF DATA COLLECTION

7.2.1.SAMPLING PROCEDURE
The Sampling Technique adopted for this study is purposive sampling.
7.2.2.SAMPLE SIZE
The sample size is 30 staff nurses.
7.2.3.INCLUSION CRITERIA
The criteria for the sampling selection of staff nurses are:
staff nurses who are willing to participate in the study.
knowing English.

7.2.4.EXCLUSION CRITERIA
Auxiliary nurses and midwives
Nurses who are not willing to participate.
7.2.5 INSTRUMENT INTENDED TO BE USED
SELECTION OF TOOL

A structured questionnaire technique was adopted. The questionnaires

consist of total number of 30 questions. The questions were divided into two sections.

Section A: DEMOGRAPHIC DATA

It deals with demographic data including age, sex, religion, income and
work experience.
Section B: KNOWLEDGE QUESTIONS
It consists of 25 multiple choice questions to assess the knowledge
regarding care of patients undergoing cardiac catheterization among staff nurses.
SCORING PROCEDURE
In knowledge aspect each multiple choice questions consist of 3
alternatives with correct response and two distracters. Each correct response carries
the same score of one and two distracters carry the score of zero. The maximum
possible score was 25.

SCORING INTERPRETATION
Level of knowledge

Range

Adequate knowledge

Above 20

Moderately adequate knowledge

Between 15&20

Inadequate knowledge

Below 15

7.2.6. DATA COLLECTION METHOD

A validated structured questionnaire scheduled was used to collect data

about the knowledge regarding care of patients undergoing cardiac catheterization

among staff nurses. The total samples for major study consists of 30 staff nurses.
They were taken by purposive sampling. Permission will be obtained from the
Nursing superintendent and Ward In- charge before conducting the study.
Interview will be conducted between 10 am to1 pm. The duration will be 4 weeks.
The duration of 30 minutes will be spend per each sample.

7.2.7 PILOT STUDY

Pilot study is a small scale version or a trial run done in preparation for a
major study.
6 samples will be selected and study will be conducted to find out the
feasibility.

7.2.8 DATA ANALYSIS PLAN

The data obtained was planned to analyze on the basis of objectives of the study
using descriptive and inferential statistics.

The plan for data analysis is as follows:

Frequencies and percentage of distribution will be used to

analyze the demographic data.

Mean, Median , Mode and Standard deviation is used for

assessing the knowledge scores.

Chi-square test is used to find out the association
between the knowledge with selected demographic variables.
The significant findings will be experienced in tables,
figures and graphs.

DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE

CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
- No-

HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?
YES, Ethical clearance will be obtained from the research committee of Anuradha

college of nursing. Permission will be taken from the hospital and consent will be
taken from the study subjects before the collection of data.

LIST OF REFERENCES

7.3

1. Brenda .G.Bare, Suzanne.C.Smeltzer. Text Book of Medical-Surgical

Nursing. 10th edition. U.S: Lippincott William &Wilkins publication;2004;
Pg no: 885-888.

7.4
2. Johns Hopkins Medicine Health Library Cardiac Catheterization procedure
Overview2001; Volume: 3.Pg no: 56-8. http://www.hopkinsmedicine.org/
3. Basavanthappa. B.T. Text book of Medical- Surgical Nursing. 5th edition.
New Delhi: Jaypee Publisher; 2003; Pg no: 555-553.
4. Lewis.S.M, Heitkemper.M.M&Dirksen. S.R. Medical-Surgical Nursing. 4th
edition. Philadelphia: Mosby publications; 2004; Pg no: 785-786.
5. Joyce. M. Black, Jane Hokanson. Medical -Surgical Nursing. 7th edition.

New Delhi: Elsevier publications; 2005; Pg no: 1222-1223.

6. Connors, Alfred F, Speroff, Theodore, Dawson, Neal V, Thomas, Charles.
The effectiveness of right heart catheterization in the initial care of critical
care unit.September 18, 1996; 276, 11; Research Library; Pg no: 889.
7. Polonen.P, Ruokonen.E, Hippelainem.M, Poyhonen.M, Takala.J. A
randomized, controlled trial of the use of pulmonary artery catheters in high
risk surgical patients.2003;Pg no:514.OpenUrlCrossRefMedlineWeb of
Science
8. Beck, Hungler, Polit. Essentials of Nursing Research, Methods, Appraisal &

8.0

Utilization. 5th edition. U.S: Lippincott Williams & Wilkins;2001;

Pg no: 68-70.
9. Dominic Shung Kit Chan, Heung Wan Cheung. The effects of education on
anxiety among Chinese patients with heart disease undergoing cardiac
catheterization in Hong Kong. Contemporary Nurse: Vol. 15; 2003;
Pg no: 310-320.

10. Alfred .F.Connors, Theodore Speroff, Neul .V.Dawson, Charles Thomas.

Examine the association between use of right heart catheterisation during the
first 24 hours of care in ICU and subsequent survival, length of stay,
intensity of care and cost of care. 2000; Pg no: 103-8.
11. Ruth.E.Taylor Piliae. European Journal of Cardio vascular nursing. October
2002; Volume: 1; Pg no: 203-211.
12. Susan Houstan, Ph.D.; Mary Eagen, R.N; Donna Doughtery R.N. A
comparison of structured versus guided pre heart catheterisation information
on mood states and coping strategies. U.S.A; April 2006; Pg no: 68-72.
13. West.R, Ellis.G, Brooks.N. Estimate the frequency and nature of
complication in patients undergoing diagnostic cardiac catheterisation time,
trends in complication since introduction of a voluntary co-operative
audit. England; 2006; Pg no: 810-814.http://www.americanheart.org.
14. Elliott.C.G, Zimmerman.G.A . Chest Journal. Complications of
pulmonary artery catheterization in the care of critically ill patients. U.S.A;

1999; Volume: 76; Pg no: 647-652.http://www.nhlbi.nih.gov.

15. Paul Stranger, M.D; Micheal .A. Heymann, M.D and Harold Tarnoff, M.D.
Complication of cardiac catheterisation of neonates, infants and children.
2003; Pg no: 23-28.
16. Pennsylvania Patient Safety Advisory. Strategies to minimise vascular
complications after cardiac catheterisation. Pennsylvania;2007; June;4(2);
Pg no: 58-63.

17. Manuel.L.Fontes, Wayne Bellows. Journal of Cardio-Thoracic and

Vascular Anaesthesia. U.S: Elsevier Publication. Volume: 13; 1999;
Pg no: 521-527.
18. R. Michael Wyman, MD, Robert D. Safian, MD, Valerie Portway, BSc,
John J. Skillman, MD. Chest Journal .2000; Volume 3; Pg no: 68-72.
19. Arlene W. Keeling, Elaine Knight,Vicki Taylor . Post cardiac

catheterization time-in-bed study: Enhancing patient comfort

through nursing research.U.S.A; February 1994; Volume 7, Issue 1;
Pages 1417. http://dx.doi.org
20. De Oliveira MF. Nursing care to elderly patients undergoing heart

catheterization: a proposal according to the Adaptation Model of Calista

Roy; 2006 Sep-Oct; 59(5):642-6.

9.

SIGNATURE OF THE CANDIDATE

10.

REMARKS OF THE GUIDE

11.

NAME AND DESIGNATION OF

11.1 GUIDE

11.2. SIGNATURE

11.3.CO-GUIDE

11.4.SIGNATURE

11.5.HEAD OF THE DEPARTMENT

11.6. SIGNATURE

12

12.1. REMARKS OF THE PRINCIPAL

12.2 .SIGNATURE