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NURSING DIAGNOSES AND RISK OF HEMATOMA AND BLEEDING FOR
VASCULAR PROCEDURES PERFORMED IN A LARGE HOSPITAL IN
NORTHERN MINAS GERAIS
Janaína Oliveira Farias1
Daniel Silva Moraes2
Mirela Lopes de Figueiredo3
Marlete Scremin4
Júnia Tamires Souza Vieira5
Maria Esméria Neta6
Daniella Fagundes Souto7
Márcia Beatriz Lima Pimenta8
Marcell Gonçalves Grillo9
Dinariam Gonçalves Silva10
Émile Lilian Pereira de Oliveira11
Emmilly Lucciane Alves Maria12
Bianca Oliveira Leite13
1 Prominas College
2 Prominas College
3 Montes Claros State University
4 University of the Joinville Region
5 University Center of Northern Minas Gerais
6 Montes Claros State University
7 Montes Claros State University
8 University Center of the Federal District
9 Faculty of Health and Humanities Ibituruna
10 University Center of Northern Minas Gerais
11 Faculty of Health and Humanities Ibituruna
12 University Center of Northern Minas Gerais
13 Faculty of Health and Humanities Ibituruna
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Brunna Ariely Lopes de Souza14
Ângela Neves Costa15
Anderson Neco Rocha16
Fernanda Fagundes Fonseca17
Abstract: The World Health Organization (WHO) estimates that in the year 2030, approximately 23.6
million people will die as a result of cardiovascular diseases. Thus, nursing care becomes essential
for comprehensive care, as well as for the recovery of clients with cardiovascular and cerebrovascular
diseases through the systematization of nursing care. This study aimed to identify the main nursing
diagnoses of patients undergoing endovascular therapy in a large hospital located in the north of
Minas Gerais and to associate conditions sensitive to the risk of hematoma and bleeding. It refers to a
descriptive, documentary study with a quantitative approach that was carried out in the endovascular
therapy sector of Santa Casa de Montes Claros - MG. Data analysis was performed using descriptive
statistics and bivariate analysis. The study universe consists of 1,266 medical records of clients, who
were treated at the endovascular diagnosis and therapy service and underwent therapeutic procedures
in the period from 2017 to 2019. 59.0% were female, mean age 65.3 (± 13.6), the main comorbidity was
arterial hypertension (68.4%) and the most common procedure was coronary angioplasty (67.6%). The
most prevalent diagnosis was the risk of hematoma and bleeding (44.4%), which was associated with
sex, medications, arterial hypertension, health insurance and other diagnoses. Thus, it is important
that nurses know how to classify and identify risks and complications in relation to endovascular
procedures so that a care plan is applied according to the patient’s need.
Keywords: Nursing process. Cardiovascular diseases. Hemodynamics.
14 Faculty of Health and Humanities Ibituruna
15 Montes Claros State University
16 UNIFG University Center
17 University Center of Northern Minas Gerais
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INTRODUCTION
Brazil has been experiencing a peculiar and rapid change in the eating habits and lifestyle of
its population, where it previously had high rates of malnutrition in the 1970s, and by 2008, half of its
adult population was overweight.The World Health Organization (WHO) estimates that by the year
2030 approximately 23.6 million people will die as a result of cardiovascular diseases (TESTON).et
al.., 2016; FREIREet al.., 2017).
In this context, it is possible to observe that cardiovascular diseases stand out among the main
health problems. These affect the circulatory system as well as other organs, leading to irreversible
damage, causing limitations, changes in quality of life, and even death. They are considered chronic
non-communicable diseases and are experiencing a growing increase in Brazil due to the aging
population and a high incidence of risk factors such as: smoking, alcoholism, dyslipidemia, systemic
arterial hypertension (SAH),diabetes mellitus(DM), obesity, sedentary lifestyle, diet lacking in
vegetables and fruits, and stress. Changing these habits and adopting a healthy lifestyle is fundamental
to preventing these diseases (TESTON).et al.., 2016; BRANT et al.., 2017; FREIREet al.., 2017).
However, preventive policies have not been effective in recent years in Brazil, as the country
has undergone a signicant transition in its demographic and epidemiological prole, notably
regarding stroke and coronary artery disease, two important chronic non-communicable diseases
(NCDs). Global stroke epidemiology reveals that it is the second leading cause of death worldwide,
with an increasingly early onset in adults aged 35 to 64. It is estimated that by 2030, approximately
7.8 million people will die due to a stroke (BRAZIL).et al.., 2014; SOUZA et al.., 2017). Hemodynamic
procedures are widely used in the diagnosis and treatment of these events.
The period following endovascular procedures demands actions from the healthcare team,
ensuring quality care for the client. Therefore, it is the nurse’s responsibility to plan and organize
individualized care, based on needs not only in the postoperative period but throughout the entire
intraoperative period. Nursing care must be qualied, individualized, and carried out through the
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nursing diagnosis (ND), and for this, the nurse must have knowledge of the pathology, the setting, and
clinical reasoning about the client’s situation. (BARRETTA)et al., 2017)
Nursing care becomes fundamental for comprehensive care, as well as in the recovery
of clients with cardiovascular and cerebrovascular diseases. Therefore, nursing has increasingly
sought to improve its eld of practice, based on scientic methodology, such as the Nursing Care
Systematization (SAE), which is a fundamental method to ensure the quality of care and organization
of nursing work (RIBEIRO).et al.., 2017).
Reinforcing that the systematization of nursing care (SAE) is essential to contribute to the
identication of problems, establishing care plans for successful treatment, SAE is an activity exclusive
to nurses, enabling the professional to identify and group the problems encountered. This allows them
to be interpreted and possible care plans to be developed through pre-planned interventions, providing
the client with quality care (SANTOS).et al.., 2014).
It is therefore observed that it is important to systematize nursing care, as this instrument
will guide the nurse’s conduct in team management situations, which may result in individualized
and humanized care, positively reecting on the quality of care as well as reducing mortality
(AMARANTE et al., 2009).
The nursing process (NP) is a work method that seeks to be an instrument of care in
professional practice. In the second phase of the NP, nursing diagnoses (ND) are highlighted, which
are clinical assessments of individuals’ responses to health problems, capable of guiding nursing
interventions, directing care, and encouraging the patient to participate in their treatment, contributing
to the achievement of results. Then, special nursing languages, such as the taxonomy of nursing
diagnoses developed by NANDA-I, bring standardization to the practice of the profession, pointing
out the areas that contribute to nursing in this care scenario (RIBEIRO).one at., 2017; OLIVERA et
al., 2016).
The Hemodynamics sector is a specic sector for imaging exams, such as coronary
angiography, cerebral and limb arteriography, coronary angioplasty, and aneurysm embolization.
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It is demonstrated that the hemodynamics service uses differentiated materials, such as catheters,
introducers, and guide wires. These materials have a high cost, and some are reusable (LEMOS).et
al.., 2017).
Thus, the present study aimed to identify the main nursing diagnoses of patients undergoing
endovascular therapy in a large hospital located in Northern Minas Gerais and to associate conditions
sensitive to the risk of hematoma and bleeding.
METHODOLOGY
This refers to a descriptive, documentary study with a quantitative approach that was carried
out in the endovascular therapy sector of Santa Casa de Montes Claros – MG. Being a documentary
research, the study universe consists of 1,266 patient records of those who were treated in the
endovascular diagnosis and therapy service and underwent therapeutic procedures between 2017 and
2019.
For data collection, notes from the medical records of patients undergoing vascular procedures
at CEDITEN were used, according to the data collection questionnaire. Assessments were made of
variables related to socio-demographic and clinical data, seeking to identify the main risks to which
they are exposed in order to formulate nursing diagnoses.
Data collection took place between August 2019 and February 2020 in the Human
Development Center (CDH) and the Medical and Statistical Archiving Service (SAME). During this
period, the researchers experienced some difculties, such as a lack of available appointment times
and power outages during data collection, which delayed the process, among others.
The study was authorized by the Human Development Center (CDH) of the Irmandade
Nossa Senhora das Mercês hospital (Santa Casa de Montes Claros – Minas Gerais) and approved
by the Ethics and Research Committee of the State University of Montes Claros and the Santa Casa
de Caridade de Montes Claros, through opinion CEP/UNIMONTES nº379.298/2019, respecting the
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bioethical precepts established according to Resolution nº 466/12, which deals with research involving
human beings.
In order to organize and synthesize the collected data to achieve the proposed results, the
statistical analysis and organization of this data was performed using SPSS version 20. The database
was transcribed from Microsoft Excel. Descriptive statistics were performed with presentation in
tables and graphs; the values were described as mean, standard deviation, percentage, minimum,
maximum, and absolute values. For bivariate comparison, the diagnostic variable “Risk of hematoma
and bleeding” was chosen and cross-referenced with all other categorical variables using the Chi-
square test. The signicance level adopted was 5%, with a p-value < 0.05 considered statistically
valid.
RESULTS
A total of 1266 patients underwent some type of endovascular procedure between 2017 and
2019 at the aforementioned hospital. There was a predominance of females (745 – 59.0%), the average
age was 65.3 (± 13.6), with the youngest being 6 years old and the oldest 102 years old. Regarding the
type of care provided, 66.1% were elective. Concerning chronic diseases, hypertension was the most
prevalent (68.4%), and 259 (20.5%) of the patients had diabetes (Table 1).
Regarding medication use, 950 (75.0%) use home medications, and 721 (56.9%) used
continuous aspirin + clopidogrel during hospitalization. A large number of procedures were covered
by the Unied Health System (SUS) (78.43%), and the remainder were covered by other health
insurance plans.
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Table 1:Absolute values and percentage distribution of the variables year of the procedure,
sociodemographic and health data of patients undergoing endovascular procedures in a hospital in
Northern Minas Gerais.
Variable N (%)
Again 2017 435 34,4
2018 417 32,9
2019 414 32,7
Sex Masculine 517 41,0
Feminine 745 59,0
Service rating Elective 830 66,1
Urgency 426 33,9
Agreement THEIR 993 19,7
Agreement 246 79,5
Particular 10 0,8
Hemodynamic Procedures Peripheral Angioplasty 140 11,1
Carotid Angioplasty 112 8,9
Coronary Angioplasty 850 67,6
Embolization 156 12,4
Chronic diseases* Hypertension 863 68,4
Diabetes 259 20,5
Smoking 29 2,3
Hypercholesterolemia 12 0,9
Medications* Home Medical 950 76,1
AAS + Clopidogrel 721 59,1
Level of consciousness Conscious 1182 95,9
Unconscious 50 4,1
Drug allergy Try 22 1,8
No 1210 98,2
Bladder Elimination Try 1137 94,8
No 1199 5,2
* In these variables, the categories are not complementary, so an individual can belong to two or more
categories, and the sum of the percentages does not equal 100%.
Four types of endovascular procedures were recorded, with coronary angioplasty being the
most prevalent (67.6%), followed by embolization (12.4%), peripheral angioplasty (11.1%), and carotid
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angioplasty (8.9%) (Table 1). The number of times each diagnosis was made for the entire sample
was counted; the most frequently cited diagnoses were: Risk of hematoma and bleeding (44.4%);
Risk of falls (29.3%); Risk of skin injury (8.2%); Risk of infection (6.6%); Self-care decit (6.3%); and
Impaired skin integrity (5.2%). The average number of diagnoses received per patient was 1.0 (± 1.4),
with the highest number of diagnoses per patient being 8 and the lowest being 0 (Graph 1).
Chart 1: Absolute values of the number of diagnoses received by patients undergoing endovascular
procedures at a hospital in Northern Minas Gerais.
Clinical signs assessed during hospitalization are also described here: mean systolic blood
pressure 136.3 (± 30.7), diastolic blood pressure 75.3 (± 17.6), heart rate 73.8 (± 15.5), and mean
oxygen saturation 97.6 (± 2.2).
Bivariate analyses demonstrate a statistical association when comparing the presence
or absence of the diagnosis of Risk of hematoma and bleeding with the other variables. A larger
proportion of women (58.4%) were not diagnosed with the risk, and 100% of patients with private
health insurance were also not. The chronic condition hypertension is positively associated with the
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Risk of hematoma and bleeding, given that a larger proportion of people without the disease (63.2%)
do not have the diagnosis. Home medication and the use of aspirin + clobidogrel also showed an
association with p < 0.05. Regarding the other nursing diagnoses, all were positively associated, such
that the presence of Risk of hematoma and bleeding predisposes to the presence of other diagnoses
as well (Table 2).
Table 2: Bivariate comparison of the presence of a risk diagnosis for hematoma and bleeding with
other sociodemographic variables, health variables, and other nursing diagnoses, absolute values and
percentages, of patients undergoing endovascular procedures in a hospital in Northern Minas Gerais.
Variables Risk of hematoma and bleeding. P value
No Try
Sex Masculine 266 (51,6%) 250 (48,4%) 0,017*
Feminine 433 (58,4%) 309 (41,6%)
Service rating Elective 463 (55,9%) 365 (44,1%) 0,772
Urgency 234 (55,1%) 191 (44,9%)
Agreement THEIR 128 (52,2%) 117 (47,8%) 0,010*
Agreement 554 (56,0%) 436 (440%)
Particular 10 (100%) 0 (0%)
Hemodynamic procedures Peripheral Angioplasty 71 (51,1%) 68 (48,9%) 0,543
Carotid Angioplasty 66 (58,9%) 46 (41,1%)
Coronary Angioplasty 469 (55,4%) 378 (44,6%)
Embolization 91 (58,3%) 65 (41,7%)
High blood pressure No 252 (63,2%) 147 (36,8%) 0,000*
Try 449 (52,3%) 410 (47,7%)
Diabetes No 571 (56,8%) 434 (43,2%) 0,092
Try 131 (51,0%) 126 (49,0%)
Smoking No 689 (55,9%) 544 (44,1%) 0,236
Try 13 (44,8%) 16 (55,2%)
Hypercholesterolemia No 693 (55,4%) 557 (44,6%) 0,175
Try 9 (75,0%) 3 (25,0%)
Home medication No 200 (67,1%) 98 (32,9%) 0,000*
Try 492 (51,9%) 456 (48,1%)
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Aas + clopidogrel No 324 (65,1%) 174 (34,9%) 0,000*
Try 352 (48,9%) 368 (51,1%)
Level of consciousness Conscious 666 (56,4%) 515 (43,6%) 0,062
Unconscious 21 (42,9%) 28 (57,1%)
Drug allergy No 672 (55,7%) 535 (44,3%) 0,916
Try 12 (54,5%) 10 (45,5%)
Bladder eliminations No 28 (45,2%) 34 (54,8%) 0,081
Try 641 (56,5%) 494 (43,5%)
Impaired skin integrity No 687 (57,5%) 508 (42,5%) 0,000*
Try 13 (20,0%) 52 (80,0%)
Decit of self-care No 681 (57,6%) 501 (42,4%) 0,000*
Try 20 (25,3%) 59 (74,7%)
Risk of falling No 662 (74,4%) 228 (25,6%) 0,000*
Try 37 (10,0%) 332 (90,0%)
Allergy risk No 693 (57,2%) 518 (42,8%) 0,000*
Try 7 (14,6%) 41 (85,4%)
Risk of skin injury No 662 (57,4%) 491 (42,6%) 0,000*
Try 34 (33,0%) 69 (67,0%)
Risk of infection No 673 (57,2%) 504 (42,8%) 0,000*
Try 27 (32,5%) 56 (67,5%)
* P-value < 0.05, statistically signicant.
DISCUSSION
This study achieved its proposed objective by identifying the main nursing diagnoses used
for patients undergoing endovascular procedures in hemodynamics, based on the absolute and relative
frequency of the main nursing diagnoses: Risk of hematoma and bleeding, Risk of falls, Risk of skin
injury, Risk of infection, Self-care decit, and Impaired skin integrity. Furthermore, the research was
able to associate the nursing diagnosis of Risk of hematoma and bleeding with the study variables:
sex, health insurance, hypertension, home medication, aspirin + clopidogrel, impaired skin integrity,
self-care decit, risk of falls, risk of allergies, risk of skin injury, and risk of infection.
Studies indicate that the prevalence of patients with cardiovascular diseases and endovascular
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procedures is more common among men. For example, a study of patients undergoing coronary
angioplasty shows that “65.89% of men are predominant, while women represent 34.11% of the total
number of samples”. However, in this study, the prevalence of endovascular procedures was prominent
among women, representing 58.84%, while men represented 40.83% (LIMA).et al.,2018).
Regarding chronic diseases and comorbidities, Systemic Arterial Hypertension (68.4%) and
Diabetes Mellitus (20.5%) stand out. These comorbidities were also found in a study that identied that
78.9% of subjects had Systemic Arterial Hypertension and 57.9% had Diabetes Mellitus. In another
study, the frequent comorbidities were Systemic Arterial Hypertension (50%), Diabetes Mellitus
(25%), and Systemic Arterial Hypertension + Diabetes Mellitus (10%). These numbers reinforce the
need for health professionals to implement health education and necessary actions at different levels
of care, both for early diagnosis and access to treatment of these pathologies so that they do not
affect the health of individuals requiring endovascular treatment in the future (CRUZ).et al.., 2010;
ROCHAet al.., 2006).
These numbers reinforce how important knowledge of risks and comorbidities is at different
levels of healthcare. Aiming to prevent potential complications, nursing professionals should invest
efforts in the Nursing Process, focusing on building a good diagnosis, thus enabling them to provide
holistic, individualized, and humanized care, highlighting the importance of the Nursing Process in
the care of patients undergoing endovascular procedures, with the perspective of providing satisfactory
care (CRUZ).et al.,2010; ROCHAet al.., 2006).
Cardiovascular diseases have been the leading cause of death and are responsible for a
high frequency of hospitalizations. Much progress has been made in the treatment of coronary heart
disease, and percutaneous intervention is becoming increasingly prevalent. In this context, patient
care is provided by a multidisciplinary team, and the nurse plays an important role in care, as they
are the professional who assists the patient throughout their hospital stay (COLÓSIMO).et al.., 2015).
The nurse responsible for the Hemodynamics sector prioritizes comprehensive care from
a holistic perspective of the individual, addressing human responses to health conditions and life
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processes, or vulnerabilities to such responses, thus identifying health problems and risk states.
Based on the characteristics found in the anamnesis and physical examination, nursing diagnostic
indicators are identied, including dening characteristics and factors related to the problem, as well
as vulnerabilities, which indicate risk diagnoses for that patient. It is emphasized, therefore, that the
diagnostic phase guides the achievement of results sensitive to nursing interventions (NANDA).et al.,
2015).
Nursing diagnoses are based on the following principle: “a clinical judgment of the individual’s,
family’s, or community’s responses to vital processes or current or potential health problems, which
provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is
responsible.” Therefore, clinical judgment of the individual’s and family’s responses, vital signs, and
current or potential health problems is applied, strengthening the selection of nursing interventions to
achieve outcomes for which the nurse is responsible. The effective application of the nursing process
leads to improved quality of care (ARAÚJO).et al., 2005).
In this study, the diagnosis of Risk of Bleeding and Hematoma was the most predominant,
with invasive procedures being a risk factor. Risk of bleeding is dened as “vulnerability to a reduction
in blood volume that can compromise health.” According to a study conducted in a hemodynamics
laboratory of a university hospital in the Metropolitan Region of Rio Grande do Sul, Brazil, with
patients undergoing cardiac catheterization, “bleeding at the puncture site was observed as the second
most common vascular complication.” Another study, conducted in 47 hospital centers across all
Brazilian federative regions, analyzed the occurrence of adverse cardiovascular events in patients
undergoing angioplasty according to the arterial access route, and found severe bleeding in 1.1%
of the sample, with no statistically signicant difference between the radial and femoral routes.
(VASCONCELOS)et al., 2015)
Similarly to the present study, another study conducted in the Hemodynamics unit of two
different hospitals located in the Itajaí Valley region of Santa Catarina, which aimed to characterize the
nursing care prioritized by the hemodynamics nurse for patients undergoing cardiac catheterization
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and coronary angioplasty procedures, presented the risk of bleeding and hematoma as one of the main
nursing diagnoses (RÉGIS A.P., ROSA G.C.D., LUNELLI T, 2017).
However (NEVESet al.,(2018) contradicts in its study conducted in a Coronary Intensive Care
Unit (CICU) of a Public Hospital in the Federal District between December 2016 and March 2017 that
the main nursing diagnoses in patients undergoing vascular procedures are impaired cardiovascular
function and risk of ineffective renal perfusion.
Angioplasty it is a This procedure can be performed on patients during cardiac catheterization
and involves, in the immediate post-procedure period, restricting movement of the lower limbs and
trunk, mainly in the rst eight hours after a heart attack, to prevent complications such as hematoma
formation or hemorrhage, and there may also be a risk of falls (VAUGHANS).et al.., 2012). This
justies the high frequency of diagnoses related to self-care, bed mobility, and bleeding risk in this
study.
The risk of bleeding and hematoma in angioplasty is related to the surgical treatment or the
presence of an aneurysm. The risk of infection was one of the prevalent diagnoses in the study and
may be related to invasive procedures such as bladder catheterization, central access, chest drains,
as well as tissue destruction and inadequate primary defenses (broken skin) due to cardiac surgery
(OLIVEIRA).et al.,2012; REISet al.,(2010). Invasive procedures and prolonged hospital stays increase
susceptibility to pathogens. Therefore, the greater the number of invasive procedures, the greater the
risk of infection (OLIVEIRA).et al.,2012; REISet al., 2010).
Some studies have shown that vascular complications occur mainly in the rst six hours
after invasive endovascular procedures. This shows how much action the nursing team can take in
preventing and reducing major complications. Care provided only to recovered patients requires
attention and needs to be properly managed. The nursing prescription after the operation should
mainly include rest time, checking the pulse and puncture site, vital signs, and paying special attention
to the treatment of bleeding and hematoma (ROCHA).et al., 2009; PAGANet al., 2012).
The nursing diagnosis for risk of falls is the most common after brain procedures such
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as aneurysm embolization, followed by other diagnoses such as: impaired physical mobility, risk
of aspiration, impaired ambulation, impaired verbal communication, and urinary incontinence
(HERDMAN et al., 2018).
A study on the mechanisms involved in the increased risk of bleeding in patients with a
history of stroke or transient ischemic attack using antiplatelet agents showed that patients using
the anticoagulant Clopidogrel have a higher incidence of major bleeding, according to studies
that included patients with...unstable ischemic myocardial syndromeIt varies from 2% to 17.6%.
This variation depends on the bleeding classication used, the characteristics of the population,
the techniques employed in the hemodynamics laboratory (puncture site, size of introducers, use
of occlusion devices, among others) and the antithrombotic regimen employed (DOKTOROVA).et
al.,(2013). In this study, 56.95% of patients use anticoagulants, ASA + Clopidogrel, which presented
a higher risk of bleeding. Therefore, greater attention from nursing professionals regarding the use of
this medication is highlighted.
Stroke and coronary artery disease are considered major public health problems, not only in
terms of hospital care at the time of the stroke, but also in the rehabilitation and quality of life of these
patients, who often require expensive and lengthy treatments that do not yield the expected results,
leading to individuals who are unproductive for society (RODRIGUES).et al.,2008; ANDRADEet
al.., 2009).
Therefore, it is becoming increasingly necessary for nursing professionals to be trained to care
for these patients from the moment they enter the hospital. This requires that the nursing team provide
these different types of care and that their practices be grounded in the science of nursing care, based
on theories and research, such as the nursing process, patient assessment, nursing diagnosis, planning,
outcome setting, intervention, and continuous patient reassessment (HERDMAN).et al.,2018; FIVEet
al., 2016).
The present study presented limitations such as its cross-sectional nature and the sample of
users from a single service, which, although representative, makes it difcult to extrapolate the results
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to other scenarios. During the data collection period, several difculties were identied, including
scheduling conicts between the researchers and the research locations, due to the use of the rooms
for training, since they were the same rooms used both for the research and by the institution for
internal activities. Other difculties relate to the lack of electricity at the institution, and nally,
access to some information present in the data collection instrument.
CONCLUSION
The application of the nursing process is directly associated with the control of each risk
factor, which in most cases are modiable. The results highlight the need for measures to promote,
prevent, and rehabilitate clients already affected by cardiovascular diseases, seeking to improve the
quality of life of the individual. The association of hematoma and bleeding risk with the variables
identied points to a constant need for attention and observation by nursing professionals regarding
the prole of the patients served, their comorbidities, medications used, and clinical condition.
It is assumed that the data from this research can contribute to the creation of plans for
carrying out actions with an emphasis on the promotion, protection, and rehabilitation of the
population. Therefore, the importance of continuing to analyze the nursing diagnoses of clients
undergoing vascular procedures is noted. This is done with a view to a line of care aimed at reducing
harm and complications through the training of healthcare teams, thus contributing to the quality of
care provided.
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