NUTC 3113 CB, Fall 2024: Blueprint for Exam 2
Exam 2 has 50 items: 42 multiple choice, 3 multiple response (select all that apply, drag and drop format,
plus/minus scoring, partial credit possible), 2 cloze (drop down, partial credit possible) and 3 short answer
(which may include calculations). For the calculation items, you must include the unit of measurement
(milliliters, tablets, kilograms, pounds, milliliters per hour, units per hour, etc.) to earn credit. Rules
learned in Therapeutics related to preceding and trailing zeros will be applied to this exam. If the answer
to a calculation item includes a decimal, round to the nearest tenth. For the cloze items, you may need to
use the touch screen or touch pad to allow you to see all the options for each part of the question. All
items are valued at 2 points each.
In client teaching, you must be able to determine statements by the client that indicate understanding of
the information taught and, conversely, statements that indicate the client does not have an understanding
of the information.
Labs and lab values covered in Patho and earlier this semester in Adult I are considered foundational
material. From the content covered since Exam 1, you may be asked questions related to glucose values
(fasting, post-prandial, and HgA1c), liver function tests (included in the discussion of TB meds), and/or
treatment of potential side effects of chemotherapy.
Topics covered on the exam may include:
Calculation for medication administration and intake & output recording (may include insulin drips)
Infection control strategies
Prioritization of care – either several clients or several orders for a single client
Strategies to treat signs and symptoms
Cardiovascular Disease
Assessment and monitoring techniques:
Expected findings in healthy individuals and in those with cardiovascular disease:
Diagnostic tests
Diet recommendations for clients with cardiac disease
Goal : reduce sodium and water retention to decrease the workload of the heart
Include:
- Omit table salt (no added salt)
- reduce sodium intake 3g daily
- if salt intake must be reduced further the pt may need to eliminate high sodium food and all salt in
cooking; sodium 2g daily
- collab with dietitian
- few pt might be placed in severe fluid restriction
o EXCEPT for pt with excessive aldosterone secretion since they may experience thirst and
drink 2L daily.
 Have AP record I and O ; weight pt daily b4 breakfast for most accurate weight .
Monitor:
- Expected DECREASE in weight bc excess fluid is excreted from the body
Behavioral interventions
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- Anxiety and frustration is comm.
Advance HF
- pt are high risk for depression
Interventions:
- asses pt and their families for anxiety and depression
o ask : methods of coping , hx of depression
o if present notify Primary health care provider for further assessment
Medications and related nursing activities (may include medication teaching and monitoring lab values)
ACEI’s and ARBS
- started slowly
- first dose associated with RAPID drop in BP
- Pt are at risk for HYPOTENSION
 Are those with initial SBP less than 100; 75+ yr old ; serum sodium less than 135;
or are volume depleted
- MONITOR: bp every HR for several hrs after intimal dose and each time the dose is increase.
o REPORT TO HCP ANY SYSTOLIC BP LESS THAN 90
 If this problem occurs place pt flat and elevate the legs to increase cerebral
perfusion and promote venous return
Diuretics and Dehydration
- Diuretics are 1st line drug of choice for older adults with HF and fluid overload
o Older pt can become dehydrated. Signs are
 Acute confusion
 Dec. urine output
 Dizziness
 NURSE: provided evidence-based interventions to reduce the risk for falls
Nitrates
- Venous vasodilators
- For a HF with persistent dyspnea
- Administered IV, PO, topical
- With IV Nitrate monitor:
 BP (even when increasing dosage)
 Pt may report headache initially
 ASSURE them they will develop a tolerance to this effect and the
headache with cease or diminish
 ACETAMINOPHEN can be given to help relieve discomfort
Digoxin
- For CHRONIC HF , afib, sinus rhythm
- Interfere with ANTACIDS
Monitor:
 For drug toxicity since this drug can increase mortality especially in older adults
 S&S
o anorexia, fatigue, blurred vision, and changes in mental status, especially in older
adults
Aldosterone antagonist
- monitor for HYPERkaleai and renal failure
o if hyperkalemia occurs pt can try every other day dosing
- if creatin level rise stop medication
HCN channel blocker
- Ivabradine
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- Advise pt to take med with meals
- Teach pt to check radial pulse and report low HR or irregularity of HCP
Heart failure: left-sided and right-sided; signs and symptoms of each
Hypertension (HTN): Essential (primary) and secondary hypertension; demographic groups at greatest
risk for HTN; diet
Peripheral arterial disease
Hypoxia: early signs and symptoms vs. late signs and symptoms (consider both cardiac and respiratory
aspects)
Varicose veins: treatment strategies
Pulmonary Disease
Assessment and monitoring techniques; expected findings in healthy individuals and in those with
respiratory disease
Ventilation, perfusion, diffusion, gas exchange
Diagnostic tests
Medications and related nursing activities (may include medication teaching and monitoring lab values)
Asthma: medications (including related nursing activities): See Iggy pp. 545-546, Table 24.1,
Common Examples of Drug Therapy: Asthma Prevention and Treatment
Chronic obstructive pulmonary disease (COPD; includes chronic bronchitis and emphysema):
medications; diaphragmatic breathing (review the video); recommended diet; expected health
assessment findings for the disorder
Pneumonia (PNU): including risk factors for pneumonia, diagnostic procedures; priority groups for
pneumococcal polysaccharide vaccination
Tuberculosis (TB): medication regimen (including client teaching and monitoring lab values); see Iggy
p. 588, Table 25.4, Common Examples of Drug Therapy: First-Line Treatment for
Tuberculosis and Slides 58 and 59 in presentation
Atelectasis, prevention strategies
Diabetes
Hyperglycemia and hypoglycemia, signs and symptoms of each (Iggy p. 1370, Table 56.8)
Diabetes Mellitus, Type 1 and Type 2 (Iggy, p. 1348, Table 56.2)
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Glycemic control (See Iggy, Laboratory Profile: Diabetes Mellitus, p. 1351, Table 56.3)
Target minimum blood glucose level
Signs and symptoms
Treatment strategies
Inheritance
Groups at risk for developing the disorder, (Iggy, p. 1350 and Box 56.3)
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The rate of DM is 14.5% among American Indians and Alaska Natives, 12.1% among nonHispanic Blacks, 11.8% among those with Hispanic origin, 9.5% among non-Hispanic Asians,
and 7.4% among non-Hispanic Whites
BOX 56.3 Indications for Screening Asymptomatic Adults
BMI, Body mass index; GDM, gestational diabetes mellitus.
• Testing for diabetes is considered at any age in adults with a BMI greater than 25 kg/m2 (or
greater than 23 kg/m2 in Asian Americans) with one or more of these additional risk factors:
• First-degree relative with diabetes
• Physically inactive
• Member of a high-risk ethnic population (e.g., African American, Latino, Native American,
Asian American, or Pacific Islander)
• Hypertensive (>140/90 mm Hg or on therapy for hypertension)
• High-density lipoprotein (HDL) cholesterol level less than 35 mg/dL (0.90 mmol/L) and/or a
triglyceride level greater than 250 mg/dL (2.82 mmol/L)
• Polycystic ovary syndrome
• History of cardiovascular disease
• Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], impaired glucose tolerance, or impaired
fasting glucose) should be tested yearly.
• Females diagnosed with GDM should have lifelong testing every 3 years.
• For all other patients, testing should begin at age 35. If results are normal, testing should be
repeated at a minimum of 3-year intervals
Complications, including how/what to monitor
Microvascular and macrovascular
Are changes in large blood vessels and small blood vessels in tissue and organs frm chronic
HYPERgycemia
Macrovascular complications
 MI
o Reduce thru aggressive management of hypertension, hyperglycemia, and
hyperlipidemia
o Nursing Priority : interventions to reduce modifiable risk factors associated with CVD
 Smoking cessation, stress management, balanced diet , physical activity BP
management and maintained prescribed lipid-lowering drug therapy and
aspirin in use
 PVD (Ischemia Gangrene)
o Nurses should teacjt
 CVA risk
o Increase risk for atherosclerosis
 Reduced immunity
o Risk for developing infection on exposure to bacteria and other organism
Microvascular complication
 Diabetic retinopathy
o Annual eye exams at diagnosis
o Keeping blood glucose, blood pressure, and lipid levels within target ranges are important
in the prevention of DR. Therefore, people with DM should have routine ophthalmic
evaluations to detect vision problems early before vision loss occurs.
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 Diabetic peripheral neuropathy (nerve dysfunction)
o Give thermometer for these patients
o Cognitive dysfunction and erectile
o Late signs are foot ulcers and deformities
o Chronic hyperglycemia leads to DPN through blood vessel changes and reduced
tissue perfusion that cause nerve hypoxia, which leads to poor nerve impulse
transmission.
o To much glucose can affect nerves and impair motor nerve conduction
 Diabetic nephropathy (kidney dysfunction)
o Decrease HTN to prevent
Strategies to delay onset of complications
Strategies to decrease potential injury
Sick day management: see Iggy p. 1372, Box 56.12, Patient and Family Education: Sick-Day Rules
BOX 56.12
Patient and Family Education
Sick-Day Rules
• Notify your primary health care provider or diabetes health care provider that you are ill.
• Monitor your blood glucose at least every 2 to 4 hours.
• Test your urine for ketones even if your blood glucose is in range, particularly if you are vomiting.
• Continue to take insulin or other antidiabetic agents unless instructed otherwise by your diabetes health
care provider.
• To prevent dehydration, drink 8 to 12 ounces (240–360 mL) of sugar-free liquids every hour that you are
awake. If your blood glucose level is below your target range, drink fluids that contain sugar.
• Continue to eat meals at regular times.
• If unable to tolerate solid food because of nausea, consume more easily tolerated foods or liquids equal
to the carbohydrate content of your usual meal.
• Call your diabetes health care provider for any of these problems:
• Persistent nausea and vomiting
• Persistent hypoglycemia
• Moderate or high ketones
• Blood glucose elevation after two supplemental doses of insulin
• High (101.5°F [38.6°C]) temperature or increasing fever; fever for more than 24 hours
• Treat diarrhea, nausea, vomiting, and fever as directed by your diabetes health care provider.
• Get plenty of rest.
Diabetic ketoacidosis [DKA] (See Iggy, Figure 56.12 and Table 56.9)
Signs and symptoms
 polyuria, polydipsia, polyphagia, a fruity odor to the breath, vomiting, abdominal pain, and
weakness. If confusion or Kussmaul respirations are present, DKA can quickly lead to shock
and coma. Mental status can vary from total alertness to profound coma.
Treatment
 First assess the airway, level of consciousness, hydration status, electrolytes, and blood
glucose level. Check the patient’s blood pressure, pulse, and respirations every 15 minutes
until stable.
 Closely assess the patient’s fluid and electrolyte balance.
o Restore blood volume an maintain perfusion of vital organs
 The second outcome of replacing total body fluid losses is achieved more slowly.
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Hyperglycemic-hyperosmolar state (syndrome) [HHS] (See Iggy Figure 56.13 and Table 56.9)
Signs and symptoms
 Blood glucose levels may exceed 600 mg/dL (33.3 mmol/L), and blood osmolarity may
exceed 320 mOsm/L.
 CNS problems and cellular dehydration
Treatment
 Rehydrate the pt and restore blood glucose level within 36-72 hrs.
 the first priority for fluid replacement in HHS is to increase blood volume
 Assess the patient hourly for signs of cerebral edema (i.e., abrupt changes in mental status,
abnormal neurologic signs, and coma)
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 A slow but steady improvement in CNS function is the best evidence that fluid management is
satisfactory.
Cancer and Immunosuppression
Radiation therapy
Teaching re: protection of radiated area
Radiation therapy and fatigue; long-term nature of fatigue
IV chemotherapy and administration through peripheral IV lines
Nursing intervention to prevent complications, including extravasation
Administering chemotherapeutic medications
What personal protective equipment (PPE) is required? Protection
from side effects in clients receiving chemotherapy:
epoetin alfa (Epogen); filgrastim (neupogen); mesna (Mesnex); oprelvekin (Neumega)
Prevention of infection in clients with cancer: see Iggy p. 395, Box 18.8, Patient and Family Education:
Prevention of Infection
Chemotherapy-induced peripheral neuropathy (CIPN)
Common finding on health assessment
Consider risks to the client with CIPN – what risks are increased specific to this problem?
Chemotherapy-induced nausea and vomiting
Oral care, strategies for clients with mucositis: see Iggy p. 397, Box 18.11, Patient and Family
Education: Mouth Care for Patients with Mucositis
Priority assessment in client with cancer
Chemotherapy-related cognitive impairment (CRCI): assessment
Nurse’s role in providing information/resources to clients with cancer and their families
Clients with cancer and co-occurring acute or chronic health problems
Importance of assessing symptoms of the additional diagnoses, and consideration of their
relationship to the specific cancer
Consider the treatment regimens for the other health problems
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Adult 1 Exam 2 Outline:
Cancer and care of the immunocompromised patient:
Cell growth:
• Hypertrophy- tissue increases in size due to each cell enlarging
• Hyperplasia- tissues increases in size due to an increase in the number of cells • Both
hyperplasia and hypertrophy increase tissue size
•
Benign vs. Malignant cell growth- both types of altered cell growth o Benign- usually not
considered harmful, usually does not require intervention (Exception is benign brain tumors)
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•
 Typically made up of normal cells growing in the wrong place or at the wrong
time, because of a problem with cellular regulation
Ex. Moles, uterine fibroids, skin tags, endometriosis, nasal polyps
 Look like the tissue they come from, and specific differentiated functions
continue to be performed
 Tight adherence of benign cells to one another
 Orderly growth
 Normal chromosomes are usually found (euploidy) o Malignant- indicates
cancer, can lead to death without (and sometimes even with) intervention
 Anaplasia- loss of specific appearance of the parent cell
 Increasing nuclear-cytoplasmic ratio- the cancer cell nucleus is bigger than that of
a healthy cell, and the actual cancer cell is smaller than that of a healthy cell
 Loose adherence (allows for migration/metastasis)
 Specific functions are lost
 Contact inhibition does not occur (persist cell division continues)
 Abnormal chromosomes
 Harmful to normal body tissue
Primary vs. Secondary tumors:
• Primary tumor- the point of origin, where the original tumor formed o It is possible, but unusual,
for an individual to have two primary tumors at the same time (tumors are unrelated to one
another)
• Secondary (metastatic) tumor- developed from cancer cells that have moved from the primary
location o Identified by the tissue from which it arose (parent tissue) o 2 efficient ways of cancer
spread: bloodstream and lymphatic system
Cancer risk factors:
• Lung cancer- smoking (which increases your risk for any solid tumor)
• Breast cancer- female gender, increasing age, genetic mutation (BRACA-1 or BRACA-2), early
menarche, late menopause, dense breasts
• Colorectal cancer- low fiber or high fat diet
• Skin cancer- UV light exposure, genetics
• Prostate cancer- genetics (North-Western Europe, Caribbean Islands, Australia, and North
America are at a higher risk)
• Cervical cancer- early sexual initiation, multiple partners, HIV
• Testicular cancer- HIV, family history
Dietary habits to reduce cancer risk:
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•
•
•
•
•
•
•
Avoid excessive intake of animal fat
Avoid nitrates (found in lunch meats, sausage, bacon)
Minimize intake of red meat
Limit alcohol consumption per day o 1 drink for women o 2 drinks for men
Increase bran consumption
Increase intake of cruciferous vegetables (broccoli, cauliflower, brussels sprouts, and cabbage)
Eat foods high in vitamin A (apricots, carrots, spinach, sweet potatoes, beef liver) and vitamin C
(citrus fruits, tomatoes, peppers, strawberries, broccoli, kale)
Cancer prevention:
• Primary prevention- strategies implemented to prevent the occurrence of cancer o avoidance of
known or potential carcinogens o Modifying associated risk factors
o Removal of “at risk” tissue o Chemoprevention o Vaccination
• Secondary prevention- slowing the process of disease/preventing complications of its inception at
any point, typically through frequent screenings o Regular screenings/genetic screening
Diagnosis of cancer:
• H and P- history and physical exam
• Differential diagnosis- the process of determining what the patient is experiencing (typically using
lab tests) to rule out or rule in a certain diagnosis
o Diagnostic tests include: serum chemistry, CBC, X-rays, USG, MRI, nuclear imaging,
angiography, microscopic histology, tumor markers (biomarkers), and lymph node biopsy
• Direct visualization- when the tumor is directly visualized with the eye, or with surgical loupes, a
microscope, or an endoscope
Clinical staging of cancer:
• Lower staging means the patient is more likely to achieve a cure or have a longer lifespan
• Staging scale:
o Stage 1- tumor is limited to the tissue of organ
o Stage 2- limited local spread of the tumor
o Stage 3- extensive local and regional spread of the tumor
O Stage 4- metastasis
•
Used with SOLID tumors
TNM classification- another way to grade tumor growth
 T (primary tumor)- the size of the tumor, how far it has
spread within the organ of origin or the nearby tissues
 N (Lymph nodes)- has the cancer spread to surrounding
lymph nodes ; regional
 M (metastasis)- has cancer spread to distant organs?
•
Double time and mitotic index (% of actively dividing cells)
Warning signs of cancer:
• C- changes in bowel or bladder habits
• A- a sore that does not heal
• U- unusual bleeding or discharge
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•
•
•
•
T- thickening or lump in the breast or elsewhere
I- indigestion or difficulty swallowing
O- obvious change in a wart or mole
N- nagging cough or hoarseness
Use ABCDEF for moles that may be cancer
General Disease-related consequences of cancer (and/or its treatment):
• Reduced immune and blood-producing function
• Altered GI structure and function
• Altered peripheral nerve function
• Motor and sensory deficits
• Pain
• Decreased respiratory function
• Increased risk for pathological fractures
• Can affect bone
Cancer treatments:
• Surgery- the oldest form of cancer treatment, surgery alone can result in a cure rate of about 30%,
so patients typically need additional treatment
o o Prophylaxis- removes potentially cancerous tissue as a means of preventing cancer
development
 Performed when a patient has an existing premalignant condition or a strong
predisposition for development of a specific cancer
o Diagnosis- portion of the tissue is removed and observed under a microscope for
cancer cells
o Cure- removes all cancer tissue
o Control (debulking)- removing some of the cancer, allowing other treatment
methods to be more effective
o Palliation- surgery done to reduce pain or improve quality of life (not curative) o
Assessing therapy effectiveness- “second look surgery” used to restage patients with
cancer to define reoccurrence, plan therapy, and perform tumor debulking
o Reconstruction- increases function or enhances appearance
• Radiation therapy- goal is to destroy cancer cells with minimal damaging effects to the
surrounding normal cells,
• a local treatment
•
Ionizing radiation- damages the DNA directly or DNA-damaging free radicals are formed, which
leads to a change in cellular regulation
• Radiation dose- the amount of radiation absorbed by the body
 3 factors determine radiation dose:
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•
 The distance of the radiation source to the cell
 The length of treatment
 The amount of exposure (the amount of radiation delivered)
Exposure- amount of radiation delivered
Radiation Delivery Methods and Devices
Distance of radiation source to targeted cells
o Indications:
 Adjuvant therapy (used with another form of therapy for better outcomes)
 Curative
 Palliative
o Teletherapy- when the radiation source is located at a spatial distance from the tumor
 Typically occurs when tumors inside the body are radiate through the skin from
sources outside the body
o Bradytherapy- closed therapy, the radiation source is placed within the patient’s body so
that comes into direct or continuous contact with the cancer for a certain period
 A high dose of radiation is applied to the tumor, which a relatively low dose is
applied to the surrounding tissue
 Since the radiation source is within the patient, they can be a potential hazard to
others
 Sealed vs. Unsealed brachytherapy:
• Unsealed- radiation enters the body and is eliminated through waste
o the patient’s waste is radioactive, so it must be handled and
disposed of properly
• Sealed- radiation that is implanted on or near the tumor, emitting low
continuous energy to the tumor
o The patient emits radiation (can be a hazard), but their waste
is not radioactive
Iggy Box 18.3
Best Practice for Patient Safety and Quality CareCare of the Patient With Sealed Implants of
Radioactive Sources
• Assign the patient to a private room with a private bath.
• Place a “Caution: Radioactive Material” sign on the door of the patient’s room.
• If portable lead shields are used, place them between the patient and the door.
• Keep the door to the patient’s room closed as much as possible.
• Wear a dosimeter film badge at all times while caring for patients with radioactive implants. The
badge offers no protection but measures a person’s exposure to radiation. Each person caring for the
patient should have a separate dosimeter to individually calculate specific radiation exposure.
• Wear a lead apron while providing care. Always keep the front of the apron facing the source of
radiation (do not turn your back toward the patient).
• If you are attempting to conceive, do not perform direct patient care, regardless of whether you are
male or female.
• Nurses who are pregnant should not care for these patients; do not allow women who are pregnant or
children younger than 16 years to visit.
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• Never touch the radioactive source with bare hands. In the rare instance that it is dislodged, use longhandled forceps to retrieve it. Deposit the radioactive source in the lead container kept in the patient’s
room.
• After the source is removed, dispose of dressings and linens in the usual manner. Other equipment
can be removed from the room at any time without special precautions and does not pose a hazard to
other people.
o
o
Side effects of radiation therapy
 Acute and late effects
 Changes vary according to site
• Ex. Lung cancer radiation patients will present with
esophagitis/pharyngitis and pulmonary fibrosis
 Local skin changes and hair loss
 Altered taste sensations
 Fatigue (may worsen as treatment progresses and continue even after the
treatment ends)
 Bone marrow suppression
• Risk for anemia, infection, and bleeding
Patient centered care regarding radiation:
 Provide accurate information to help patients cope
 Skin care needs during radiation
 Do not remove temporary ink markings (determine where radiation will occur)
 Avoid skin irritation
 Avoid exposure to sunlight
 Follow radiation-oncology department’s policy for skin care product use
 Nutritional support
 Care for xerostomia (dry mouth)
 Teach about risk factors for fractures (specifically for bones exposed to radiation)
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 Exercise and sleep interventions for fatigue
Box 18.5 Patient and Family EducationSkin Protection During Radiation Therapy
 • Wash the irradiated area gently each day with either water or a mild soap and water as
prescribed by your radiation therapy team. Rinse soap thoroughly from your skin.
 • Avoid friction to the area being treated. Use your hand rather than a washcloth.
 • If ink or dye markings are present to identify exactly where the beam of radiation is to be
focused, take care not to remove them.
 • Dry the treatment area with patting rather than rubbing motions; use a clean, soft towel or
cloth.
 • Use only powders, ointments, lotions, or creams that are prescribed by the radiation
oncology department on your skin at the radiation site.
 • Wear soft clothing over the skin at the radiation site.
 • Avoid wearing belts, buckles, straps, or any type of clothing that binds or rubs the skin at
the radiation site.
 • Avoid exposure of the irradiated area to the sun; protect this area by wearing clothing over
it.
 • When outdoors, stay under awnings, umbrellas, and other forms of shade during the times
when the sun’s rays are most intense (10 a.m. to 4 p.m.).
 • Avoid heat exposure.
•
Chemotherapy- treatment of cancer with chemical agents to promote
tumor cell destruction, can be administered IV or PO o Used to cure
cancer or increase survival time
o Adjuvant- chemotherapy used with another type of therapy
(surgery and/or radiation) to increase survival rates
o Chemotoxic effects are typically exerted on both healthy cells
and cancer cells
o o Nadir- the lowest point in blood count after chemo
 To reduce immunosuppression, when an individual has
combined therapy the drugs are chosen so that the nadirs
of the drugs do not occur at the same time
o Chemotherapy drugs: (effective by different means, do not need
to know names)
 Alkylating agents
 Antimetabolites
 Antimitotic agents/mitosis inhibitors
 Antitumor antibiotics
 Topoisomerase inhibitors
 Miscellaneous chemotherapeutic agents
 Hormone therapy
o Treatment factors:
 Dosage- determined by body surface area (height and
weight must be evaluated frequently)
 Scheduling- intent is to give healthy cells time to
recover, but not allow the cancer cells to recover
 Administration
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o Chemo drugs are vesicant agents, so preventing
extravasation is extremely important
-
-
Preventing Extravasation :
Results can include pain, infection and tissue loss
Reconstructive surgery is sometimes warranted for severe tissue damage
Monitor blood return at the access site
When Vesicants are part of therapy :
 Use of implanted port or central line to decrease extravasation risk is highly
recommended
 Nurse should still observe closely for any leakage, pain, or swelling
Oral anticancer drugs are just as toxic as patient as drug thru IV
o Healthcare provider safety:
 Specific protocol for handling chemotherapy drugs or
excreta from patients receiving IV chemotherapy
• Follow your agency policies

PPE: includes eye protection, masks, double gloves or chemo gloves, and
gown
“Anyone preparing, giving, or disposing of chemotherapy drugs or handling
excreta from patients within 48 hours of the patients’ receiving IV chemotherapy
must wear approved personal protective equipment (PPE). This equipment
includes eye protection, masks, double gloves or “chemo” gloves, and a
nonpermeable gown.”
•
o Protection from side effects:
 Risk for infection due to neutropenia (decreased WBCs)
o Filgrastim (Neupogen)- bone marrow simulant that increases
production of blood cells and improves survival rates in
individuals exposed to radiation
o Bone pain is a known side effect for filgrastim
 Anemia risk
o Erythropoiesis- stimulating agents (ESAs)
 Darbepoetin (Aranesp)
 Epoetin alfa (Epogen, Procrit)- used to treat anemia
in patients receiving chemotherapy or patients with
chronic kidney failure . for cancer that DON’T evolve
BONE CANCER
 Increase risk for heart attack, stroke, clots
 o Leukemias, lymphomas, and some head/neck cancers have
increased growth rate when ESAs are administered
Thrombocytopenia risk
 (Impaired clotting)
 Stimulation of plasma production
 Oprelvekin (Neuumega)- increases production of platelets,
but may also cause fluid retention (increases risk for heart
failure
and pulmonary edema)
dec bp
elevate HR
Pt need to weigh them daily ***
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Paper with time and date; b4 breakfast, same clothes, new onset weight need to call HCP
Mesna (Mesnex) – to reduce the risk of bleeding in the bladder (hemorrhagic cystitis)
 Chemotherapy-induced nausea and vomiting (CINV)
 Encourage eating meet w. dietitian
 manifest as anticipatory (before receiving the chemotherapy, often
triggered by thoughts, sights, and sounds related to the anticipated
chemotherapy), acute (within the first 24 hours after chemotherapy),
delayed (occurring after the first 24 hours), breakthrough (occurring
intermittently
 Acute CINV is the most common type
 Mucositis- inflammation of the mucous membranes
 Clean oral hygiene must be maintained. Use soft sponge dipped in
saine / water
Box 18.11 Patient and Family EducationMouth Care for Patients
With Mucositis
• Examine your mouth (including the roof, under the tongue, and
between the teeth and cheek) regularly.
• If sores or drainage are present, contact your cancer health care
provider.
• Brush the teeth and tongue with a soft-bristled brush or sponges at
least every 8 hours and after meals.
• Avoid the use of mouthwashes that contain alcohol.
• “Swish and spit” room-temperature tap water, normal saline, or salt
and soda water on a regular basis (at least four times a day) and as
needed according to changes in the oral cavity.
• Drink 2 or more liters of water per day if another health problem does
not require limiting fluid intake.
• Take all drugs, including antibiotics and drugs for nausea and
vomiting, as prescribed.
• Use topical and oral analgesic drugs as prescribed.
• Apply a water-based moisturizer to your lips as needed.
• Use prescribed “artificial saliva” or mouth moisturizers as needed.
• Avoid using tobacco or drinking alcoholic beverages.
• Avoid spicy, salty, acidic, dry, rough, or hard food.
• Use caution when drinking and eating hot foods to prevent burns.
• If you wear dentures, keep them clean, and make sure they fit well.
 Alopecia
 Regrowth 1 month after chemo. Grows different textures, color
 Cognitive changes
 Also known as “chemo Brian” short term often not permanent
 Chemotherapy induced peripheral neuropathy (CIPN)
 No know intervention to prevent
 Nursing Goal: prevent injury due to lose of sensation
 Patients with chemotherapy-induced peripheral neuropathy (CIPN)
report loss of sensation, especially in the lower extremities.
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Symptoms include numbness, tingling, neuropathic pain, and changes
in gait and balance.
Box 18.12 Patient and Family EducationChemotherapy-Induced
Peripheral Neuropathy
• Protect feet and other body areas where sensation is reduced; always
wear shoes with a protective sole.
• Be sure that shoes are well fitting to prevent creating sores or blisters
from friction.
• Inspect your feet daily (with a mirror, if needed) for open areas or
redness/hyperpigmentation.
• Avoid extremes of temperature; wear warm clothing in the winter,
especially over hands, feet, and ears.
• Test water temperature with a thermometer when washing dishes or
bathing. Use warm water rather than hot water (less than 105°F or
40.6°C).
• Use gloves when washing dishes or gardening.
• Foods and liquids that are too hot may cause burns.
• Get up slowly from a lying or sitting position. If you feel dizzy, sit
back down until the dizziness fades before standing; then stand in place
for a few seconds before walking or using the stairs.
• To prevent tripping or falling, look at your feet and the floor or
ground where you are walking to assess how the ground, floor, or step
changes.
• Avoid using area rugs, especially those that slide easily.
• Keep floors free of clutter that could lead to a fall.
• Use handrails when going up or down steps.
 Fatigue
 Need to balance rest and activity
• Immunotherapy- biological response modifiers (BRMs), modify a
patient’s biological response to tumor cells and can have direct
antitumor activity o Can interfere with cancer cell differentiation,
transformation, and metastasis o Can improve immune function
o Interleukins (ILs)- group of substances produced by the body that regulates inflammation

Helps the immune system cells identify/destroy abnormal cells

Being used to help treat certain cancers
o Interferons (IFNs)- cell produced proteins that are being used to treat certain
cancers
•
Photodynamic therapy- selective destruction of cancer cells via chemical reaction triggered by
types of light
•
Hormonal manipulation- changing usual hormone receptors
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o Some hormones make hormone-sensitive tumors grow more rapidly
 Decreasing the hormone amounts to hormone-sensitive tumors can slow cancer
growth rate
o Steroids, steroid analogues, and enzyme inhibitors
o Side effects:
 Can cause masculine effects in women
 Can cause feminine effects in men (facial hair thinning, body fat redistribution,
risk for osteoporosis, testicular atrophy)
 Androgens may cause hypercalcemia as well as liver dysfunction
 Increase risk for venous thromboembolism
Estrogen / progastrin
Fluid retention
Breast tenderness
Pt is a risk for thromboembolism
Men
Development of breast tissue (develop
from use to steroids
Bone loss
Testicular and Pino atrophy
TEACH PT OF ALL SIDE EFFECTS
Care of the patient with immunosuppression:
• Isolation- place client in a private room whenever possible
o Avoid crowds/large gatherings of people
• Hand hygiene and frequent bathing
• Use food safety when preparing meals
• Frequent vital signs
• IV care
o Should be assessed each time vital signs are taken
• Diet therapy
• Limit visitors
• Lab monitoring
• Take all drugs as prescribed
Box 18.7 Best Practice for Patient Safety and Quality CareCare of the Patient With Myelosuppression
and Neutropenia
• Place the patient in a private room whenever possible.
• Use good handwashing technique or alcohol-based hand rubs before touching the patient or any of the
patient’s belongings.
• Ensure that the patient’s room and bathroom are cleaned at least once each day.
• Monitor vital signs, including temperature, every 4 hours.
• Inspect the patient’s skin and mucous membranes for the presence of fissures and abscesses per
facility policy.
• Inspect IV sites for indications of infection.
• Change wound dressings daily or as ordered.
• Use strict aseptic technique for all invasive procedures.
• Promptly notify the primary health care provider if any area appears infected, and obtain order for
culture, per protocol.
• Encourage activity at a level appropriate for the patient’s current health status.
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• Keep frequently used equipment in the room for use with this patient only (e.g., blood pressure cuff,
stethoscope, thermometer).
• Visitors with signs or symptoms of illness should be restricted.
• Monitor the white blood cell count daily.
• Avoid the use of indwelling urinary catheters if possible. Provide perineal hygiene per protocol and at
least daily.
• Follow agency policy for restriction of fresh flowers and potted plants in the patient’s room.
Cancer complications:
• Sepsis- bloodstream infection, can result in septic shock (at risk due to decreased immune system
function)
• Disseminated intravascular coagulation (DIC)
o Dec BF to organs
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• Spinal cord compression- due to collapsing vertebrae due to osteoporosis or pressure from the
tumor
• Hypercalcemia- develops slowly, so the body has ample time to adjust to electrolyte changes,
therefore manifestations do not occur until serum calcium levels are very high (and phosphate
levels are very low)
• Superior vena cava (SVC) syndrome- compression of the superior vena cava by enlarged lymph
nodes or tumor growth o Lack of blood flow returning from the head/neck
o Early signs: tightness of shirt collar, orbital edema, redness of upper body, edema of arms
and hands
o Later stages: hypotension, decreased cardiac output, cyanosis, hemorrhage o Treatment:
patient may receive high dose radiation to upper torso, stent may be placed in the upper
vena cava to keep it open
•
Tumor lysis syndrome (TLS)- occurs when many cancer cells are destroyed quickly, so their
intracellular contents are released into the bloodstream faster than the body can eliminate them o
Can cause tissue damage, cardiac dysfunction, and acute kidney injury

Can have life threatening effects on the heart, kidneys, and CNS
o Serum potassium levels may increase along with hyperuricemia o Treatment:
hydration (a minimum of 3,000 mL) to flush the kidneys

Patients at risk should have consistent fluid intake throughout all
24 hours
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Alterations in oxygenation: Caring for the client with select respiratory alterations
Oxygen therapy- the goal is to use the lowest fraction of inspired oxygen for an acceptable blood oxygen
level without causing harmful side effects
• Oxygen is needed to sustain life
• Ventilation- the process of moving gases in and out of the lungs
• Diffusion- the exchange of respiratory gases at the alveoli/capillaries
• Perfusion- the ability of the cardiovascular system to pump oxygenated blood to the body, and
unoxygenated blood back to the heart
Lung structure and function:
• Lung volumes
o Tidal- the amount of air moved in and out of the lungs during inhalation and exhalation
while at rest
o Residual (RV)- the amount of air remaining in the lungs at the end of maximum
exhalation
 Increased in patients with COPD o Forced vital capacity (FVC)- the
maximum amount of air that can be exhaled as quickly as possible after
maximum expiration
 Indicates respiratory muscle strength and ventilatory reserve o FEV1records the maximum effort of air that can be exhaled in the first second of
expiration
 In general, 75-80 precent of lung volume should be exhaled in the
first second
• Pulmonary circulation- moves blood to and from the alveolar capillary membrane for gas
exchange
Regulation of respiration:
• Neural regulation- the central nervous system controls the respiratory rate, depth, and rhythm o
The cerebral cortex regulates the voluntary control of respiration
• Chemical regulation- maintains the rate and depth of respirations based on changes in the blood
concentrations of CO2 and O2, and in hydrogen ion concentration (pH) o Chemoreceptors sense
changes in the chemical content and stimulate the neural regulators to adjust
Abnormalities in respirations/oxygenation:
• Hypoxia- decreased oxygen delivery to the cells
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Atelectasis- alveolar collapse (if widespread, can lead to lung collapse) o Results in less surface
area for gas exchange
Dyspnea- difficulty breathing
Orthopnea- difficulty breathing when lying flat o Quantified by the number of pillows the patient
needs to be propped up on for comfortable breathing
Cheyne-Stokes respirations- respirations that wax and wane, followed by periods of apnea o
Potential causes: drug overdose, increased ICP, heart failure o Typically occurs directly before
death
Biot’s respirations- irregularly irregular breathing, series of normal respirations, then irregular
respirations, then apnea o The length of the cycle is variable
o Occurs in head and spinal trauma, meningitis/encephalitis, and brain abscesses
Kussmaul respirations- rapid deep breathing that is characteristic of metabolic acidosis
o Occurs in patients who are in diabetic ketoacidosis
Hypoxia- decreased arterial oxygen levels that leads to decreased oxygen delivery to the tissues,
organs, and cells o Most accurate way to assess oxygenation status: arterial blood gases or a
specimen of blood drawn from an artery (instead of a vein)
o Signs and symptoms:
 Low SpO2 (< 90%)
 Dyspnea
 Hyperventilation or hypoventilation
 Cyanosis
Circumoral cyanosis- occurs around the lips
In dark skinned clients: check mucous membranes, nail beds, and conjunctivae
o Severe hypoxia signs and symptoms:
 Cyanotic extremities
 Restlessness
 Diaphoresis
 Confusion, behavior changes
 Chest pain (if coronary ischemia is present)
 Clubbing (late sign of prolonged hypoxia)
Common causes of dyspnea:
• Respiratory:
o COPD
o Pneumonia o Pulmonary embolism (PE)
• Cardiac:
o Heart failure
o Coronary artery disease (CAD) angina
o Myocardial infarction (MI)
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Nursing process for respiratory clients:
• Assessment:
o In-depth history of client’s baseline and current cardiopulmonary function
 Dyspnea/SOB/SOA
 Fatigue
 Wheezing
 Respiratory infection
 Health risks
 Pain
 Cough
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•
Smoking (personal history, secondhand exposure)
 Vaping
 Allergies
 medications o Past impairments in circulatory or respiratory functioning o
Methods that a patient uses to optimize oxygenation o Review of drug, food, and
other allergies o Physical examination
 Inspection- skin and mucous membrane color, level of consciousness, breathing
patterns, chest wall movement, general appearance, circulation
 Palpation- chest, feet, legs, pulses
 Percussion- presence of abnormal fluid or air; diaphragmatic excursion
 Auscultation- normal and abnormal heart and lung sounds o Laboratory and
diagnostic tests (various diagnostic tests are used for assessing cardiopulmonary
functioning)
 Blood specimens, X-rays, tuberculin skin testing (TST), pulse ox, pulmonary
function testing (PFTs), thoracentesis, end tidal CO2/capnography
Nursing diagnosis:
o Activity intolerance o Ineffective breathing pattern o
Fatigue o Impaired gas exchange o Impaired verbal
communication o Ineffective airway clearance o Risk for
aspiration
o Ineffective health maintenance
Safety guidelines:
• Client with sudden changes in their vital signs, level of consciousness, or behavior may be
experiencing profound hypoxia
• Use caution when suctioning a patient with a head injury
• The routine use of normal saline instillation into the airway before ET or tracheostomy suctioning
is not recommended
• Do not strip or milk chest tubes
• The most serious tracheostomy complication is airway obstruction, which can result in cardiac
arrest
• Clients with COPD who are breathing spontaneously should never receive high levels of oxygen
therapy
• Use smoke detectors and carbon monoxide detectors
Care of patients with noninfectious respiratory problems:
Asthma- condition that occurs intermittently and causes bronchoconstriction, affects the airway not the
alveoli
• Airway obstruction occurs through inflammation
• Airway hyperresponsiveness leads to bronchoconstriction
• Classifications: mild, moderate, and severe
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•
•
•
Extrinsic asthma (allergic)- acute episodes triggered by a type 1 hypersensitivity reaction to an
inhaled allergen
Intrinsic asthma (non-allergic)- onset during adulthood, hyperresponsive tissue in the airway o
Stimuli include: respiratory infections, stress, exposure to cold, inhalation of irritants (ex.
Cigarette smoke), exercise, ASA/NASAIDs
Collaborative management:
o Assessment o History o Physical assessment/clinical manifestations o What are the
signs and symptoms?
Laboratory Assessment/Diagnosis:
o Arterial Blood Gases o Pulse oximetry
o Serum labs- WBC, immunoglobulins o Sputum culture o Peak flow measurements o
PFTs
 Forced vital capacity (FVC)
 Forced expiratory volume in first second (FEV1)
 FEV1/FEC
 Total lung capacity (TLC) o Chest X-ray
Interventions:
o Teaching for self-management
 Identify/avoid triggers
 Control symptoms o Personal medication therapy plan
 Long term control medications
 Quick relief mediations (short acting bronchodilators)
 Corticosteroids o Exercise and activity to promote ventilation and
perfusion
o Oxygen therapy via mask or nasal cannula to treat an acute asthma attack
Drug therapy:
o Based on step category for severity and treatment o Control therapy- formerly
preventive drugs
 Change airway responsiveness to prevent asthma attacks
Used every day, regardless of symptoms
o Quick-relief drugs- rescue drugs, stop the attack once it has started
 Client must always have these drugs available o Bronchodilators:
 short and long acting beta2 agonists
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
 Cholinergic antagonists
 Xanthine (ex. Aminophylline, theophylline) o Anti-inflammatory
agents:
•
 Corticosteroids
 NSAIDs
 Leukotriene modifiers
 Immunomodulators
Severe Asthma Exacerbation- severe, acute, life-threatening episode of airway obstruction o
Intensifies once it begins, often does not respond to common therapy o Patient can develop
pneumothorax and cardiac/respiratory arrest
o Treatment: IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen
Chronic Obstructive Pulmonary Disease (COPD)- includes emphysema and chronic bronchitis
• Characterized by alveolar hyperinflation and mucus hypersecretion o Typically occurs in older
adults
•
•
Tissue damage is not reversible; increases severity, eventually leading to respiratory failure
Emphysema- loss of lung elasticity, resulting in hyperinflation of the lung o Air trapping caused
by loss of elastic recoil in alveolar walls, overstretching, and enlargement of alveoli into bullae,
collapse of bronchioles
o Signs and symptoms:
 Dyspnea (SOB, SOA)
 Increased respiratory rate
 Increasing costal angle (where ribs connect with the sternum, as AP diameter
increases, so will the costal angle)
 Barrel chest
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•
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•
Chronic bronchitis- inflammation of bronchi and bronchioles caused by chronic exposure to
irritants (especially, but not exclusively tobacco smoke) o Causes inflammation, vasodilation,
congestion, mucosal edema, bronchospasm o Only affects airways (not alveoli)
o Production of large amount of mucus putting patients at risk for pneumonia and
infection
 Nursing diagnosis: ineffective airway clearing, impaired gas exchange o
Diagnosis: patient must have a cough with excessive mucous production for at least three
months
Complications of COPD:
o Hypoxemia/tissue anoxia
o Chronic CO2 retention, leading to respiratory acidosis o Respiratory infections o
Cardiac failure
 Cor pulmonale- alteration in the structure and function of the right ventricle
caused by issues with the lungs (causes right sided heart failure)
Typically caused by pulmonary hypertension or COPD • Physical assessment and clinical
manifestations:
o History
 Smoking history
Pack years: packs per day multiplied by number of years

Occupational history

Environmental exposures o General
appearance o Respiratory changes o Cardiac changes o
Dyspnea visual analog scale
Diagnostic assessment:
o Pulmonary function test, spirometry
o ABG values for alterations in oxygenation, ventilation, acid-base balance o Sputum
samples o CBC
o Hemoglobin and hematocrit
Polycythemia- compensation mechanism of increased RBCs/iron in patients with
chronic lung disease
o Serum electrolytes o Serum a-1 antitrypsin (AAT)
 Family history, relatively young client, severe COPD at a relatively young age o
Chest X-ray
Interventions/health promotion:
o Goals of treatment:
 Prevent infection
 Relieve bronchospasm
 Decrease mucosal edema
 Improve expectoration
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ADLs o Drug therapy:
Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
NSAIDs
Mucolytics o Nursing care:
Diaphragmatic breathing
Space out activities- rest
Keep environment clean
Nutrition
Use meds correctly
Ambulatory and home care
Teaching for self-management
Care of patients with infectious respiratory problems:
Influenza- highly contagious acute viral respiratory infection
• Severe headache, muscle ache, fever, chills, fatigue, weakness, anorexia
• Vaccination is recommended for all persons 6 months of age and older, with rare exception
• Antiviral agents may be effective if started within 24-48 hours of onset of symptoms
Pneumonia (PNU)- excess fluid in lungs resulting from inflammatory process (inflammation is triggered
by infectious organisms and inhalation of irritants)
• Various types:
o Community acquired pneumonia (CAP) o
Health care associated pneumonia (HCAP) o
Hospital acquired pneumonia (HAP) o
Ventilator associated pneumonia (VAP)
• Risk for aspiration
• Opportunistic infections: PCP, CMV • Laboratory and imaging assessment:
o Gram stain, culture and sensitivity (C&S) of sputum
o CBC
o ABGs
o Serum BUN and creatinine
o Electrolytes
o Chest x-ray (CXR) o Pulse ox o Bronchoscopy
• Nursing care:
o Maintain patent airway to promote gas exchange o Promote comfort- rest, conserve
energy, splint when coughing
o Medications- antibiotics as indicated, analgesics, antitussives (ex. Codeine, Tessalon,
hycodan)
o Teaching for self-management
 Vaccination for appropriate persons (adults greater than 65 and adults 19-64 with
certain risk factors)
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Pulmonary tuberculosis (TB)- highly communicable disease caused by Mycobacterium tuberculosis, the
most common respiratory infection in the world
• Transmitted via aerosolization o Increased incidence secondary to HIV infection
• Clinical manifestations:
o Progressive fatigue o Lethargy o Nausea o Anorexia o
Unplanned weight loss o Irregular menses o Low-grade
fever o Night sweats
o Cough with mucopurulent sputum and blood streaks
• Diagnostic assessment:
o Manifestation of signs/symptoms, patient history
o Nucleic acid amplification (NAA) test (results appear in about 2 hours)
 Should be performed on all patients with active signs/symptoms of TB and are
assumed to have TB
• Does not replace the need for AFB smear/culture
o Sputum culture for acid-fast bacillus (AFB) o Sputum culture of
M. tuberculosis o QuantiFERON- gold standard, blood test
o Tuberculin (Mantoux) skin test (TST)- injection given
intradermally into the forearms
 Must wait 48-72 hours to be read
 Induration of 10 mm or greater diameter means the patient is positive for TB
exposure or dormant disease
 False test results are possible:
• False positives- infection with non-TB mycobacterium, incorrect interpretation, incorrect antigen
used
• False negatives- cutaneous anergy, recent TB exposure, less than 6 months old, recent live virus
vaccination, very old TB exposure
• Interventions:
o Long term combination drug therapy with strict adherence (typically 6-9 months long) 
Rifampin- hepatotoxic drug, patient should not drink alcohol, needs liver panels
every month, take B vitamins
• Skin and urine may have a red or orange ting

Isoniazid (INH)
pyrazinamide (PZA)- patient needs to increase water intake to prevent
dehydration
 Ethambutol- patient needs to report visual changes to the HCP immediately o
Directly observed therapy (DOT, eDOT)- HCP watches the patient take their medicine
(can be in person or online) to prevent noncompliance o Negative
sputum culture means that the patient is no longer infection
• Lab tests to monitor:
o ALT- 4-36 units/L
o ALP- 30-120 units/L
o AST- 0-35 units/L
o Bilirubin- 0.3-1 mg/dL
Inhalation anthrax- bacterial infection caused by a gram-positive bacteria Bacillus anthracis (which can
survive as a spore)
28
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Accounts for less than 5% of anthrax cases, not spread by person-to person contact
Nearly 100% fatal without treatment
Occupational hazard of veterinarians, farmers, and others in frequent contact with animal wool,
hides, bone meal, and skin o Occurrence in other adults considered intentional act of terrorism o
Certain individuals are vaccinated
Symptoms may take up to 8 weeks to develop after exposure
Prodromal stage- early stage/incubation o Presents with fever, fatigue, mild chest pain, dry, harsh
cough, no indication of upper respiratory infection
o Mediastinal “widening” on chest x-ray
o Client may start to feel better with symptoms improved in 2-4 days
If the diagnosis is made and appropriate antibiotic therapy start in the early stage, likelihood of
survival is high
Fulminant stage (late stage)- begins after the client starts to feel better from prodromal symptoms
o Sudden onset of severe illness
o Presents with respiratory distress, hematemesis, dyspnea, diaphoresis, stridor (on both
inhalation and exhalation), chest pain, cyanosis
o Infection spreads to the blood, causing septic shock and hemorrhagic meningitis o
Death often occurs within 24-36 hours, even if IV antibiotics are started at this stage
Care of Clients with diabetes mellitus: Insulin physiology:
Types of diabetes:
• Type 1 diabetes (T1DM)- autoimmune disorder in which the body destroys beta cells, leading to
absolute insulin deficiency o Main signs: 3 Ps
 Polyuria- increased urination
 Polydipsia- increased thirst
 Polyphagia- increased hunger o Has a familial tendency and rapid onset
of symptoms is common o Can also lead to weight loss, fatigue, and increased
frequency of infections o Absence of insulin may lead to:
 Hyperglycemia
 Polyuria, polydipsia, polyphagia
29
 Ketone bodies (as the body begins to break down fats and muscle for
energy)
•
•
•
•
 Hypovolemia, hemoconcentration, hyper viscosity
 Hypoperfusion and hypoxia
 Acidosis
Compensation mechanism: Kussmaul respirations
Type 2 diabetes (T2DM)- ranges from insulin resistance with relative insulin deficiency to
secretory deficit with insulin resistance o Risk factors: obesity, sedentary lifestyle, poor diet,
familial tendency o Main signs: 3 Ps
 Polyuria- increased urination
 Polydipsia- increased thirst
 Polyphagia- increased hunger o Also causes fatigue and low energy
Maturity-onset diabetes of the young (MODY)- inherited form of diabetes, caused by a change in
one of the 11 genes that controls insulin o Autosomal dominant inheritance pattern
o More likely to affect adolescents and young adults, but may occur at any age
Gestational diabetes- glucose intolerance related to pregnancy, puts the mother at increased risk
for developing type 2 diabetes later in life
30
o A hormone produced by the placenta stops the body from being able to use glucose
properly
Other conditions that can result in hyperglycemia:
• Pancreatic disorders: pancreatitis, trauma, cancer, cystic fibrosis, hemochromatosis
• Endocrinopathies: acromegaly, Cushing’s disease, glucagonoma, pheochromocytoma,
hyperthyroidism, aldosteronism
• Drug or chemical induced hyperglycemia (often caused by Prednisone)
• Infections: congenital rubella, cytomegalovirus, human immunodeficiency virus
• Genetic syndromes associated with diabetes: Down Syndrome, Klinefelter syndrome, Turner’s
syndrome, Huntington disease and others
Diabetes assessment:
• Screening- for anyone over the age of 45 or anyone under the age of 45 who is overweight or has
risk factors (ex. Family history)
• Diagnostic tests:
o Fasting plasma glucose (FPG)- blood glucose level taken before the patient has had
anything to eat

Levels >126 mg/dL obtained on at least 2 occasions are diagnostic of
diabetes o Oral glucose tolerance test (OGTT)- used to diagnose pre-diabetes or
diabetes, determines how well the body uses glucose

Typically used to test pregnant women for gestational diabetes
• Ongoing assessment:
o Glycosylated hemoglobin (HbA1c)- standardized test the measures how much glucose
permanently attaches to the hemoglobin molecule and indicates the effectiveness of
blood glucose control measures
 tells us what average glucose level was in the last 120 days (because average
lifespan of RBC is 120 days) 
Target A1C levels:
• Normal: below 5.7%
• Between 7-8% for most clients with type 2 diabetes
• 6.5% or less is recommended to reduce the risk for long term complications
o Serum proteins and albumin
o Urine testing- determines if there are ketones/glucose in the urine
o Renal function- assessing if kidneys are still functioning (progressive diabetes can lead to
kidney failure)
Acute complications of diabetes:
• Diabetic ketoacidosis (DKA)- the absence of insulin causes the body to find alternate ways of
producing energy, patient will present with an acetone smelling breath (due to ketones) o More
common in individuals with type 1 diabetes o Related to dehydration and hyperglycemia o
Treatment:
 Maintain airway
 Restore fluid volume and maintain perfusion to core organs
 Treated with insulin (initially a bolus, then changed to a drip)
 Monitor for signs of hypokalemia (replete potassium with IV drip)
31
•
Hyperglycemia hyperosmolar state (HHS)- caused by insulin deficiency along with profound
dehydration o More common in individuals with type 2 diabetes
o Serum glucose levels become exceedingly high with little to no ketone formation
•
Hypoglycemic shock- when too much insulin causes blood glucose levels to drop o Can occur
from double doses of insulin or when pt receives insulin and doesn’t eat after
32
Chronic complications of diabetes:
• Macrovascular complications o Cardiovascular:
 Myocardial infarction
 Peripheral vascular disease (ischemia, gangrene) o Cerebrovascular
disease
 Increased risk for stroke (CVA)
 Most diabetic patients will die from a thrombotic event
 Increased risk for carotid atherosclerosis
• Microvascular complications:
o Diabetic retinopathy (eye and vision complications)
 Can lead to blindness
 Annual eye exams are essential o Diabetic peripheral neuropathy (nerve
dysfunction)
 Can cause cognitive dysfunction as well as erectile dysfunction
 Note: in addition to ischemia, there is also a metabolic abnormality that causes
degeneration of myelin, which is essential for conduction of nerve impulses
o Diabetic nephropathy (kidney dysfunction)
33
•
Infection- due to the influence of high blood sugars
Metabolic syndrome- previously called syndrome X, classified as the simultaneous presence of metabolic
factors known to increase the risk for developing type 2 diabetes and disease
Health promotion and maintenance:
• The control of diabetes and its complications is a major focus for health promotion activities •
Priorities:
o Glucose levels o Kidney function
o Neuropathy
o Lifestyle modifications (ex. Diet, physical activity)
Client with a diabetic condition:
• Etiologies, risk factors, comorbidities
• Assessment findings
• Diagnostic tests
• Nurse's role vs. Interdisciplinary team’s role
• Treatment/intervention priorities
• Teaching/community health resources
• Community resources
Treatment:
• Nutritional interventions (decreased sodium, more fruits and vegetables)
• Exercise
• Blood glucose monitoring (prevents complications)
• Stress management
• Medication therapies o Oral agents o Insulin
 Injection or pump
• Surgical intervention o Pancreas/kidney transplant (typically occur at the same time)
o Pancreatic islet cell transplantation- just approved by the FDA this year, donor pancreatic
islet cells are transplanted into the diabetic patient, which will begin producing insulin
and actively regulate blood glucose levels
 For type 1 diabetes patients
 Better outcomes in patients 35 years of age or older, lower pretransplant insulin
use
Patient education points:
• Insulin storage
• Dose preparation
• Syringes
• Blood glucose monitoring
• Infection control measures
• Diet therapy
• Foot care
Diabetic patient sick day rules:
• Notify HCP (primary or diabetes care) of illness
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Monitor blood glucose at least q4 hours
Test urine for ketones when blood glucose is greater than 240 mg/dL
Continue to take antidiabetic agents, unless directed otherwise
Prevent dehydration: drink 8-12 ounces of sugar free liquids every hour while awake o If blood
glucose is below target range, drink fluids with sugar
Continue to eat meals at regular times o If unable to tolerate solid food, consume more tolerable
foods and liquids equal to the CHO content of your usual meal
Call HCP if danger signs occur o Persistent nausea and vomiting o Moderate or large ketones
o Blood glucose stays elevated after two supplemental doses of insulin
o High temperature (>101.5), increasing temperature, or fever for longer than 24 hours
Treat symptoms (nausea, vomiting, diarrhea, fever) as instructed by diabetes HCP
Rest
Foot issues occurring in diabetics:
• Diabetic foot ulcers- may start small, but a significant cause of amputation and death for people
with diabetes o Half of diabetic patients who lose a leg will lose the other leg within 5 years o
Nursing care and teaching can help improve outcomes o Risks:
 Male sex
 Smoking
 History of diabetes for more than 10 years
 Poor blood glucose control
 Previous foot ulcer or amputation
 Other diabetic complications, such as peripheral neuropathy o Testing
sensation sites:
•
•
•
Diabetic neuropathy- affects half of all patients with diabetes, especially the feet (both large and
small fibers) o Symptoms: numbness, burning, tingling, itching, and pain
o Large fiber damage cases changes in vibratory perception, proprioception, and deep
tendon reflexes
o Autonomic neuropathy- reduces sweat glands and leads to dry, cracked, atrophic skin and
callus formation
Peripheral Arterial disease (PAD)- four times more prevalent in patient with diabetes in those
without it o Almost half of patients with diabetes for 20+ years have PAD, usually below knees
Charcot foot- progressive and degenerative arthropathy of the foot joints caused by neuropathy o
Typically starts with traumatic injury to the neuropathic foot o Chronic inflammation and bone
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remodeling cause the foot arch to collapse o Potential disorder of calcium and phosphate
metabolism are associated with renal disease o Arch becomes inverted (convex) and the thin skin
of the arch becomes vulnerable to ulceration
Foot trauma- repetitive stress is probably the most common cause of injury o Neuropathy causes
patients to be unable to feel injury to foot o Tell patients to stay off feet and inspect them daily
o Toenail clubbing, callus removal, and barefoot stubbing are all potential sources of injury
Foot assessment:
• Inspection:
o Assess for musculoskeletal abnormalities, such as limited joint mobility, prominent
metatarsal heads, and Charcot foot
o Look for cyanosis, dependent rubor, pallor, erythema, calluses, dryness, cracking, edema,
and ulcerations
o Assess skin temp and capillary refill time
 Note changes associated with chronic PAD (cool skin, decreased pedal hair, nail
atrophy)
• Palpation: o Femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally
• Distinguish between neuropathic and arterial ulcers o Diminished or absent dorsalis pedis and
posterior tibial pulses may indicate PAD
• Assessment:
o Examine patient’s footwear for pressure and worn spots o Test for
changes in foot sensation and proprioception (position sense) o Use
Semmes Weinstein monofilament test for sensory neuropathy
 Ankle/brachial index is easy to do but may be artificially high with diabetes
because of vessel calcification
 Toe/brachial index (TBI) is more reliable in these patients
• A TBI > 0.9 indicates that arterial flow is sufficient to heal a foot ulcer
o Documentation includes location, dimensions (including depth), undermining,
description of the ulcer base and peri-wound skin, exudate, and potential bone exposure
o Heel ulcers are more likely to lead to limb amputation
 Pressure is the most common cause of heel ulcers which can develop if a patient
is confined to their bed or wheelchair
 Typically occur on the medial, lateral, or posterior aspect of the heel
• Management of diabetic foot ulcers:
o Except for stable eschar or an uninfected heel ulcer, necrotic tissue and calluses must be
removed
o Callus is a warning sign of abnormal pressure
 It is best removed by a specialist using sharp debridement o Other necrotic
tissue can be removed by a sharp, enzymatic, or autolytic debridement, as chosen by the
wound care provider o Wet-to-dry gauze dressings are not recommended
o Grading classification systems include the Meggitt-Wagner Ulcer classification and the
University of Texas Staging system
• Dressing for foot ulcers:
o Protect the wound from trauma, prevent contamination, and maintain a moist wound bed
o Occlusive and semi-occlusive dressings- ensure clean, uninfected wounds with
minimal or no drainage
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Absorbent dressings- used for wounds with copious drainage that may benefit from
negative pressure wound therapy
o Silver impregnated dressings- used for infected or heavily colonized wounds o Other
options:
 Becaplermin gel for full thickness wounds with adequate blood supply
 Apligraf- a human skin substitute, indicated for full-thickness neuropathic foot
ulcers
Keeping pressure off:
o Teaching patients the use of crutches or a wheelchair or encouraging bed rest (if
indicated) with pressure relief
o Total contact casting contributes to healing in about 90% of ulcers vs. Removable
walking casts (61%)
o Walking braces with rocker bottom soles, half-sole shoes, and shoe cutouts
Fighting infections:
o Patients with diabetes are more prone to soft tissue and bone infections
 Difficult to treat and at risk for amputation o Susceptible to fungal
infections, soft tissue infections, deep space abscesses, and osteomyelitis
o Impaired immune responses and neuropathy make infection difficult to recognize o
Monitor serum blood glucose and white blood cell count for unexplained rise o Obtain
wound culture specimens after the surface is cleaned and debrided o Administer
antibiotics o Elderly patients may not have the usual symptoms of infection o Assessing
patients for cellulitis:
 >2 cm inflammation, lymphangitis, soft tissue necrosis, fluctuance, odor, signs of
gangrene or osteomyelitis
 Confusion occurs in older adults o Antibiotic loaded beads- made of bone
cement (polymethyl methacrylate) and used locally to treat infection in the
wound
 Bead removal may be painful
Surgical intervention o Indications include bone deformities
o PAD treatment may include arterial bypass, balloon angioplasty, or stent to improve
circulation and healing
o Orthopedic reconstructive surgery is indicated if deformity can’t be accommodated with
custom shoes or orthosis (brace)
Team approach:
o All patients with diabetes need an annual comprehensive foot examination o
Interdisciplinary foot care team can be effective
o Teach patient how to inspect his feet and shoes, what to watch for, and to report changes
to his healthcare provider
Meggitt-Wagner Ulcer Classification- grades are based on ulcer depth (does not consider
infection or ischemia) o 0- pre-ulceration lesions, healed ulcer, or bony deformity
o 1- superficial ulcer, no subcutaneous involvement
o 2- full-thickness ulcer, may expose bone, tendon, ligament, or joint capsule o 3- osteitis,
abscess, or osteomyelitis
o 4- gangrene of toe
o 5- gangrene of foot
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Cardiovascular System:
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Blood flow regulation:
• Stroke volume- amount of blood ejected from the left ventricle with each contraction
• Cardiac output- amount of blood ejected from the left ventricle each minute o Cardiac Output
(CO) = Stroke volume (SV) x heart rate (HR) o Normal CO for an average adult: 4-6 liters per
minute
• Pre-load- end diastolic volume
• Afterload- resistance to left ventricular ejection
Blood pressure- altered by cardiac output, blood volume/viscosity, peripheral resistance
• Systolic pressure- pressure exerted by blood that is ejected from the left ventricle
• Diastolic pressure- sustained pressure when the ventricle relaxes
• Pulse pressure- difference between SBP and DBP in mmHg o Causes of widening pulse pressure:
arteriosclerosis, low iron levels resulting in anemia, hyperthyroidism, increased ICP
• Mean arterial pressure (MAP)- average pressure in client’s arteries during one cardiac cycle, a
better determination of peripheral perfusion than solely systolic pressure o MAP = (2DBP +
SBP)/3
Cardiovascular assessment:
• Client history
• Family history and genetic risk
• Nutritional history
• Current health problems o Pain, discomfort
o Dyspnea (SOA, SOB), dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal
dyspnea (PND)
o Fatigue
o Palpitations o Edema o Syncope o Extremity pain
• Physical assessment:
o General appearance
 Skin- Cyanosis, Rubor
 Extremities- Clubbing, edema o Blood pressure:
 Hypotension or hypertension
 Orthostatic hypotension- change in pulse pressure of 20 or greater during
position changes
• Laboratory assessment:
o Troponin- troponin T and I, any rise in troponin is a sign of cardiac necrosis
 Helpful in determining cause in patients who have presented to the hospital hours
after first experiencing chest pain
o Creatinine kinase- specific to myocardial injury/necrosis o Myoglobin- less
clinically useful than troponin, also found in muscle cells o Serum lipids:
 Total cholesterol: < 200 mg/dL
 Triglycerides:
• Men: 40-160 mg/dL • Women: 35-135 mg/dL  HDL:
• Men > 45 mg/dL
• Women > 55 mg/dL
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 LDL: <130 mg/dL o Homocysteine- amino acid that is produced when
muscle breaks down o C-reactive protein- used for risk assessment for cardiac issues
o Microalbuminuria- urine test that is a marker for renal/epithelial disease o Blood
coagulation studies:
 PT: 11-12.5 seconds
 INR: 0.8-1.1
 PTT: 60-70 seconds
 APTT: 30-40 seconds
o ABG
o Erythrocyte count o Hemoglobin and hematocrit o Serum
electrolytes
 Hypo/hyperkalemia puts patient at risk for cardiac dysrhythmias
Diagnostic assessment:
o PA and lateral CXR o Angiography/arteriography o Cardiac catheterization o
Electrocardiography
o Electrophysiologic study (ESP)- intentionally producing dysrhythmias to determine what
medications can be used to treat them
o Stress test
o echocardiography
o Myocardial nuclear perfusion imaging o Psychosocial assessment
Heart failure- inability of the heart to work effectively as a pump
• Risk factors:
o Hypertension
o Coronary artery disease
o Cardiomyopathy
o Substance abuse (alcohol, prescribed drugs, illicit drugs)
o Valvular disease o Congenital defects
o Cardiac infections and inflammations
o Dysrhythmias o Diabetes mellitus o Smoking/tobacco
use o Family history o Obesity o Severe lung disease o
Sleep apnea o Hyperkinetic conditions
• Left sided heart failure- symptoms are local and related to decreased cardiac output and
pulmonary congestion o Decreased cardiac output results in:
 Weakness
 Fatigue
 Angina
 Dizziness
 Confusion, restlessness
 Oliguria during the day and nocturia at night
 Increased heart rate and palpitations
 Weak peripheral pulses
 Cool extremities
 Pallor o Pulmonary congestion:
 Hacking cough (worse at night)
 Dyspnea/SOB/SOA
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 Dyspnea on exertion (DOE)
 Increased respiratory rate
 Orthopnea (measured by number of pillows needed to sleep)
 Crackles or wheezes
 frothy, pink sputum
 S3/S4 summation gallop
Right sided heart failure- symptoms are related to systemic congestion o Distended jugular neck
veins (JVD) o Hepatomegaly and/or splenomegaly o Distended abdomen o Dependent edema o
Polyuria at night
o Weight gain
 Weight is the most reliable indicator of fluid retention or loss o Increased
blood pressure (from excessive volume) or decreased blood pressure (from failure)
o Swollen hands/fingers o Anorexia and nausea
Compensatory mechanisms:
o Sympathetic nervous system stimulation o Other renin-angiotensin system stimulation
o Chemical responses
 Atrial natriuretic peptide (ANP): 22-77 pg/dL
 B-type natriuretic peptide (BNP): <100 pg/dL
Critical value: > 400 pg/mL (heart failure is likely)
o Myocardial hypertrophy
Assessment of heart failure:
o Psychosocial assessment o Laboratory data
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Imaging o
Priority problems:
 Impaired gas exchange
 Decreased CO
 Fatigue/weakness
 Potential for pulmonary edema
Signs of worsening or recurrent heart failure:
o Weight gain (may be rapid)
o Decrease in exercise tolerance
o Cold symptoms
o Excessive awakening at night to urinate o Development of dyspnea/angina at rest o
Increased edema in feet/ankles
Care of clients with vascular problems:
Arteriosclerosis and atherosclerosis:
• Arteriosclerosis- thickening or hardening of arterial wall often associated with aging
• Atherosclerosis- type of arteriosclerosis involving formation of plaque within arterial wall o
Leading risk factor for cardiovascular disease
o Usually affects larger arteries (coronary artery beds, aorta, carotid and vertebral arteries,
renal, iliac, and femoral arteries)
o Risk factors:
 Nonmodifiable: age, sex, familial factors, racial/ethnic backgrounds
 Modifiable: obesity, sedentary lifestyle, exposure to cigarette smoke, diabetes
mellitus, poorly controlled hypertension, combination of oral contraceptives and
smoking, elevated triglycerides, low HDL, high LDL, excessive alcohol use,
high stress/poor coping skills
• Coronary artery disease- plaque development due to endothelial injury, lipid infiltration, aging,
thrombogenic, vascular dynamics, and inflammation o Elevated serum lipid levels are the first
major risk factor 
Total HDL ratio:
• <3.5 is optimal for men
• <3.0 is optimal for women  HDL/LDL ratio: 3:1
• Elevated ratios may protect against coronary artery disease
o Hypertension is the second major risk factor of coronary artery disease, it increases the
rate of atherosclerotic development
o Definition (for individuals 60 and younger):
 Systolic pressure > 140
 Diastolic > 90
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Interventions:
o Assess labs:
 Full lipid panel
 Homocysteine levels (expected range: 4-14 micromoles/liter)
 Highly sensitive C-reactive protein
Average cardiac risk: 1-3 mg/dL
High cardiac risk: > 3 mg/dL
o Lifestyle modifications
 Nutrition therapy
 Smoking cessation
 Exercise o Complementary and alternative therapies
o Drugs: statins, fibrinic acids, bile acid sequestrants, Ezetimibe
Hypertension- the second major risk factor of coronary artery disease, it increases the rate of
atherosclerotic development and results in damage to vital organs
• Definition (for individuals 60 and younger):
o Systolic pressure > 140 o Diastolic > 90
o Taken on at least 2 occasions, over several weeks
• Common risk factors: obesity, smoking, stress, family history
• Primary (essential) hypertension- occurs in patients greater than 60 years old or who are
postmenopausal o risk factors: family history of hypertension, physical inactivity, excessive
alcohol intake, hyperlipidemia, African-American ethnicity, high intake of sodium and caffeine,
reduced intake of K+, Ca+ or Mg+, overweight/obesity, smoking, stress
• Secondary hypertension- hypertension caused because of something else o Causes: renal disease,
primary aldosteronism, pheochromocytoma, Cushing’s syndrome, coarctation of the aorta, brain
tumors, encephalitis, pregnancy, medication
• Assessment:
o Client history (includes risk factor assessment) o
Physical assessment
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Psychosocial assessment
o Diagnostic assessment
Lifestyle modifications:
o Sodium restriction (salt substitute, seasoning mix?)
o Weight reduction o Reduce alcohol intake
o DASH diet (Dietary approaches to stop hypertension)
o Exercise o Decreased stress levels o Avoid
smoking
Drug therapy:
o Beta blockers o Renin
inhibitors o Central alpha
agonists o Alpha-adrenergic
agonists o Diuretics
o Calcium channel blockers o
ACE inhibitors
o Angiotensin II receptor
antagonists o Aldosterone
receptor antagonists
Drug therapy strategies:
o Strategy A- start 1 drug, titrate to maximum dose, then add second drug
o Strategy B- start 1 drug, then add second drug before achieving maximum dose of first
drug
o Strategy C- begins 2 drugs at the same time (as individual pills or as a combination pill)
 Initial combination therapy is recommended if the BP is greater than 20/20 mmHg
above goal
Peripheral arterial disease (PAD)- alters natural flow of blood through arteries and veins of peripheral
circulation
• A result of systemic atherosclerosis o Risk factors atherosclerosis apply to PAD
• Partial or total arterial occlusion decreases perfusion to the extremities • Increased risk for
developing chronic angina, myocardial infarction, CVA
• Physical assessment:
o Inflow disease- discomfort in lower back, buttocks, thighs o Outflow
disease- burning or cramping in calves, ankles, feet, or toes o
Intermittent claudication- muscle pain, cramping, or burning that
occurs with exercise/activity and is relieved by rest
o Sensation (pain, numbness, tingling) that occurs even at rest o Hair
loss
o Dry, scaly pale or mottled skin
o Thickened toenails o Severe arterial disease:
 Extremity is cold and gray blue/darkened
 Pallor may occur with extremity elevation
 Dependent rubor
 Muscle atrophy
• 6 Ps of arterial insufficiency:
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Pain
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Pallor o
Pulselessness o
Paresthesia o
Paralysis
o Poikilothermia (coolness)
Diagnostic assessments:
o Magnetic resonance angiography- may require the use of
contrast material and must be careful because the magnetic
field may cause some medical devices to malfunction
o Computed tomography angiography o Ankle-brachial index
(ABI)
 Expected ratio: 1.0-1.4
o Exercise tolerance testing o
Plethysmography
Management:
o Exercise and positioning o Promote vasodilation
o Drug therapy (antiplatelet agents) o
Percutaneous transluminal angioplasty (PCTA) o
Atherectomy
Acute peripheral arterial occlusion:
o Embolus- most common cause of occlusions
o May affect upper extremities, but most common in lower extremities o Drug therapy o
Surgical therapy
o Nursing care
Peripheral venous disease- characterized by thrombus formation, defective valves, and skeletal muscles
that do not contract to help pump blood in the veins
• Venous thromboembolism (VTE)
• Perdisoposing factors: open prostate surgery, knee replacement surgery, hip surgery
• Virchow’s triad: blood flow stasis, endothelial injury, hypercoagulability
• Conditions increasing risk: ulcerative colitis, cancer, immobility, oral contraceptives, sitting for
long periods of time
• Assessment:
o History:
 History of VTE
 Risk factors
 Padua Prediction score (PPS)- 1 point for each characteristic, 4 points or more
indicate a DVT is likely
• Active cancer
• Previous VTE
• Reduced mobility
• Known thrombophilia condition
• Recent (less than 1 month) trauma or surgery
• Older than 70
• Cardiac or respiratory failure
• Acute MI or ischemic stroke
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Acute infection or rheumatologic disorder
BMI > 30
Ongoing hormonal treatment
Physical assessment
 May be asymptomatic
 Calf or groin pain
 Sudden onset of unilateral swelling o Diagnostic assessments
 Venous duplex ultrasonography
 Doppler flow studies
 Impedance plethysmography
 MRI
 D-dime- assesses thrombin and plasma activity
Nursing diagnoses:
o Ineffective tissue perfusion related to disease process
o Risk for impaired tissue integriy o Risk for injury
Nonsurgical management:
o Patient education o Leg exercises
o Early ambulation o Adequate
hydration o Graduated compression
stockings o Sequential compression
devices o Venous plexus foot pump
o Anticoagulant therapy
Care coordination:
o Home education: educate patient on anticoagulant therapy o
Self-management education:
 Risk reduction
 Injection of low molecular weight heparin
 Avoid potentially traumatic situations
Venous insufficiency- result of prolonged venous hypertension, stretching veins and damaging valves
Varicose veins- distended protruding veins that appear darkened and tortuous
• Collaborative care:
o 3 Es: elastic compression hose, exercise, elevation of extremities o
Sclerotherapy- works best on small and medium veins
o Endovenous ablation (occludes veins) works better on medium to large
veins o Surgical removal of veins
Phlebitis- inflammation of superficial veins
• Management: warm compress, elastic stockings
• Complications: tissue necrosis, infection, increased risk of thrombosis, pulmonary embolism
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