Information ⬇
Synonym/Acronym
angiogram, arteriography.
Rationale
To visualize and assess internal organs/structures for abnormal or absent anatomical features, abscess, aneurysm, cancer or other masses, infection, or presence of disease.
Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered (e.g., clear liquids only for 2 hr), prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at https://pubs.asahq.org/anesthesiology/article/126/3/376/19733/.
Note: Protocols regarding the use of iodinated contrast medium in patients with impaired kidney function and who are receiving metformin or drugs containing metformin for type 2 diabetes may vary by facility; the drug may be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Kidney function should be assessed per facility protocol before use of metformin is resumed (e.g., Cr, eGFR, hydration, or clinical assessment).
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period.
Normal Findings
- Normal structure, function, and patency of organ vessels
- Contrast medium normally circulates throughout area of inquiry symmetrically and without interruption
- No evidence of obstruction, variations in number and size of vessels and organs, malformations, cysts, or tumors
Critical Findings and Potential Interventions ⬆ ⬇
- Abdominal abscess
- Abdominal aneurysm
- Pulmonary embolism
- Stroke
- Adrenal disease
Timely notification to the requesting health-care provider (HCP) of any critical findings and related symptoms is a role expectation of the professional nurse. A listing of these findings varies among facilities.
Overview ⬆ ⬇
(Study type: X-ray, special/contrast; related body system: Circulatory, digestive, endocrine, respiratory, urinary systems.)
Angiography provides x-ray visualization of organs and associated branches of the vasculature and organ parenchyma. A digital image is taken prior to injection of the contrast and then again after the contrast (e.g., iodinated contrast medium) has been injected through a catheter, which has been inserted into an artery (arteriography) or vein (venography). Fluoroscopy is used to guide catheter placement, and angiograms (high-speed x-ray images) provide images of the organ and associated vessels of interest that are displayed on a monitor and recorded for future viewing and evaluation. The x-ray equipment is mounted on a C-shaped arm with the x-ray device beneath the table on which the patient lies. Over the patient is an image intensifier that receives the x-rays after they pass through the patient. Digital subtraction angiography (DSA) is a computerized method of removing from the image undesired structures, such as bone, from the surrounding area of interest. By subtracting the preinjection image from the postinjection image, a higher-quality, unobstructed image can be created. Patterns of circulation, organ function, and changes in vessel wall appearance can be viewed to help diagnose the presence of vascular abnormalities, aneurysm, tumor, trauma, or lesions.
The catheter used to administer the contrast medium to confirm the diagnosis of organ lesions may be used to deliver chemotherapeutic drugs or different types of materials administered to stop bleeding. Catheters with attached inflatable balloons for angioplasty and wire mesh stents are used to widen areas of stenosis and to keep vessels open, frequently replacing surgery. Embolotherapy can also be accomplished through the same catheter when the site of bleeding or extravasation is located. Angiography is also valuable because other imaging studies cannot always visualize a tumor, especially if it is small. Angiography is one of the definitive tests for organ disease and may be used to evaluate chronic disease and organ failure, treat arterial stenosis, differentiate a vascular cyst from hypervascular cancers, and evaluate the effectiveness of medical or surgical treatment.
In addition to its other indications, adrenal angiography is used to accomplish adrenal venous sampling, which can be very challenging. Blood samples may be taken from the vein of each gland and the distal portion of the vena cava to assess cortisol and adrenocorticotropic hormone (ACTH) levels. The information is used to assist in determining a diagnosis of ACTH-independent Cushing syndrome (benign or malignant adrenal growth that secretes cortisol) or primary hyperaldosteronism (excessive adrenal gland production of aldosterone). The gold standard for distinguishing between a cortisol-secreting tumor and unilateral or bilateral adrenal hyperplasia is considered to be measurement of aldosterone/cortisol ratios taken from a series of samples during adrenal angiography. Cortisol levels will be elevated if related to Cushing syndrome. A ratio of greater than 4:1 is indicative of unilateral hyperplasia. Ratios between each gland are similar and usually less than 3:1 in the presence of bilateral hyperplasia. Obtaining the correct diagnosis from the angiogram is important because treatment for adrenal adenoma and unilateral adrenal hyperplasia is surgical removal of the affected adrenal gland, whereas bilateral adrenal hypertrophy is treated medically.
Carotid angiography evaluates blood vessels in the neck carrying arterial blood to the brain and is accomplished by the injection of contrast material into the carotid artery through a catheter that has been initially inserted into the femoral artery. For additional information, refer to the study titled “Cardiac Catheterization.”
Pulmonary angiograms are requested less frequently in favor of CT pulmonary angiograms, which are less invasive, faster, have fewer complications, and are of similar quality.
Peripheral angiogram evaluates peripheral arterial vessels of the extremities (e.g., legs, feet) for blockages.
Indications ⬆ ⬇
General
- Allow infusion of thrombolytic drugs into an occluded artery.
- Assist with angioplasty, atherectomy, or stent placement.
- Assist with the collection of blood and tissue samples for laboratory analysis.
- Detect and evaluate tumors before surgery or embolization, evidenced by arterial supply, extent of venous invasion, and tumor vascularity.
- Detect arterial occlusion, evidenced by a transection of the affected artery caused by trauma or a penetrating injury.
- Detect arterial or venous stenosis, evidenced by vessel dilation, collateral vessels, or increased vascular pressure.
- Detect absence of an organ or associated structure; arteriovenous fistula, aneurysms, congenital defects; emboli in vessels, or thrombosis.
- Differentiate between tumors and cysts.
- Evaluate chronic organ disease.
- Evaluate the vascular system of prospective organ donors before surgery.
- Evaluate organ transplantation for function or organ rejection.
- Evaluate placement of a shunt or stent.
Abdominal
- Detect abdominal aneurysm.
Adrenal
- Detect adrenal hyperplasia.
- Detect adrenal tumor.
- Evaluate medical therapy or surgery of the adrenal glands.
- Identify pheochromocytoma.
Carotid
- Assess risk of stroke.
- Determine the need for further treatment.
- Evaluate the degree of carotid artery blockage.
Lungs
- Detect anomalous pulmonary venous drainage and vascular changes associated with chronic obstructive pulmonary disease, blebs, and bullae.
- Determine the cause of recurrent or severe hemoptysis.
- Evaluate pulmonary circulation.
- Use hemodynamic measurements taken during pulmonary angiography to assist in the diagnosis of pulmonary hypertension and cor pulmonale.
Peripheral
- Evaluate for peripheral arterial disease (PAD).
Contraindications ⬆ ⬇
Pregnancy is a general contraindication to procedures involving radiation.
Conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium).
Although patients are asked specifically if they have a known allergy to iodine or shellfish (shellfish contain high levels of iodine), it has been well established that the reaction is not to iodine; an actual iodine allergy would be problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with moderate to marked renal impairment (glomerular filtration rate less than 30 mL/min/1.73 m2) or with conditions associated with preexisting renal insufficiency (e.g., chronic kidney disease, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs), because iodinated contrast is nephrotoxic.
Patients with moderate to marked renal impairment (glomerular filtration rate less than 30 mL/min/ 1.73 m2) and who are also taking metformin, which may put them at risk for development of drug-induced lactic acidosis, a dangerous and sometimes fatal adverse effect of metformin (related to renal impairment that does not support sufficient excretion of metformin).
Patients who are chronically dehydrated before the test, especially older adults and patients whose health is already compromised, because of their risk of contrast-induced acute kidney injury.
Patients with pheochromocytoma, because iodinated contrast may cause a hypertensive crisis.
Patients with bleeding disorders or receiving anticoagulant therapy, because the puncture site may not stop bleeding.
Interfering Factors ⬆ ⬇
- Gas or feces in the gastrointestinal (GI) tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure; barium studies should be performed more than 4 days before angiography.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Potential Medical Diagnosis: Clinical Significance of Results ⬆ ⬇
Abnormal Findings Related to
General
- Abscess or inflammation, as seen by edema in the area of the vessel
- Aneurysms, visualized by a bulging in a vessel
- Arteriovenous fistula or other abnormalities
- Cancer
- Congenital anomalies
- Cysts visualized by areas with a halo of contrast surrounding them or tumors, indicated by areas of increased density due to the vascularity that collects the contrast
- Trauma causing tears or other disruption, indicated by blood outside the vessel
- Vascular blockage, stenosis, dysplasia, or organ infarction, indicated by a narrowing or blocked artery
Abdomen
Adrenal
- Adrenal adenoma
- Bilateral adrenal hyperplasia
- Pheochromocytoma
Carotid
- Increased stroke risk related to occluded carotid artery
Kidneys
Lungs
- Bleeding caused by tuberculosis, bronchiectasis, sarcoidosis, or aspergilloma
- Pulmonary embolism (PE), acute or chronic, visualized as an area of interrupted opacity in the pulmonary artery
- Pulmonary sequestration
Peripheral
Nursing Implications ⬆
Potential Problems: Assessment & Nursing Diagnosis/Analysis
| Problems | Signs and Symptoms |
|---|
| Abdomen: Pain (related to blockage of blood flow secondary to plaque buildup) | Painful muscle cramping in legs, hips, thighs with activity; slow to heal wounds on feet and toes; gangrene; decreased temperature of lower leg/foot in comparison with the other leg/foot or rest of the body; nail or hair growth is poor on legs/toes; erectile dysfunction in diabetic men |
| Abdomen: Tissue perfusion (inadequate—related to plaque buildup, spasm, vasoconstriction, occlusion) | Lower extremity pain and cramping; pale, cool extremities; diminished pedal pulse; long capillary refill; toe numbness; shiny skin; hair loss; thick, discolored nails; arterial pulses are diminished or absent |
| Adrenal: Body image (related to increased androgen production, cortisol excess, altered protein metabolism, altered body fat distribution) | Abnormal hair growth, muscle and bone matrix wasting, moon-shaped face, obesity located in the trunk of the body, presence of a cervicodorsal lump, verbalization of negative feelings about body image, social withdrawal |
| Adrenal: Fluid volume (excess—related to water and sodium retention associated with excess cortisol) | Shortness of breath, tachycardia, hypertension, positive jugular vein distention, edema, electrolyte imbalance (potassium, sodium) |
| Carotid: Tissue perfusion (inadequate—related to blockage, hemorrhage, mass, edema, infection, plaque, atrophy, abscess, cyst, tumor) | Diminished or altered level of consciousness, expressive or receptive aphasia, loss of sensory functionality, slurred speech, difficulty swallowing, difficulty in completing a learned activity or in recognizing familiar objects (apraxia, agnosia), motor function deficits, spatial neglect, facial droop and/or varying degrees of flaccid extremities, pain, fever |
| Kidneys: Infection (related to obstruction, aneurysm, inflammation, cyst, anomaly, structural abnormality, abscess, inflammation, trauma, injury) | Positive culture, chills, elevated temperature, elevated WBC count, flank pain, hematuria, urinary frequency |
| Kidneys: Pain (related to infection, inflammation, obstruction, anomaly, structural abnormality, bleeding, infection, trauma) | Self-report of pain; facial grimace; crying; restlessness; diaphoresis; nausea; vomiting; guarding; social withdrawal; elevated blood pressure, heart rate, respiratory rate; pallor |
| Lungs: Breathing (related to fear, anxiety, pain, insufficient oxygenation, inflammation, infection, mass, embolus) | Shortness of breath; skin that is cool, clammy, and cyanotic; anxiety; chest pain; decreased oxygenation; abnormal blood gas; increased work of breathing (use of accessory muscles); increased respiratory rate |
| Lungs: Gas exchange (inadequate—related to obstruction, mass, infection, bleeding, embolus, tumor inflammation) | Difficulty breathing, shortness of breath (dyspnea), chest pain (pleuritic), diminished oxygenation, cyanosis, increased heart rate, increased respiratory rate, restlessness, anxiety, fear, adventitious breath sounds (rales, crackles), sense of impending death and doom, hemoptysis, abnormal arterial blood gas |
| Lungs: Pain (related to embolus, mass, inflammation, infection, malformations, tumor) | Self-report of pain, increased respiratory rate, increased heart rate, fear, anxiety, restlessness, crying, moaning |
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in assessing internal organs and other anatomical areas of interest.
- Review the procedure with the patient.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing) or to assess for impaired kidney function (serum Cr or eGFR) if use of iodinated contrast medium is anticipated. Pregnancy testing may be required.
- Advise that the procedure takes about 30 to 60 min and is usually performed in a radiology or vascular suite.
- Reducing health-care-associated infections is an important patient safety goal. A number of different safety practices will be implemented during the procedure. Hair near the catheter insertion site may be clipped or shaved and then cleaned with an antiseptic solution removing bacteria from the skin and reducing the risk for infection.
- There may be moments of discomfort or pain when the IV line or catheter is inserted allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medication. Contrast medium will be injected, by catheter, at a separate site from the IV line. A burning and flushing sensation may be felt throughout the body during injection of the contrast medium. There may be an urge to cough, flushing, nausea, or a salty or metallic taste.
- Explain how slow deep breaths can help with nausea during the procedure. Administer an ordered antiemetic as needed. Advise that an emesis basin will be available for use during the procedure, if necessary.
Procedural Information
- Policies regarding breastfeeding before and after an imaging procedure may vary among facilities. For additional information, see Appendix A: Patient Preparation Specimen Collection, subsection: Potential Contraindications and Complications Associated With Diagnostic Procedures.
- Note: The World Health Organization, Centers for Disease Control and Prevention, and Association of periOperative Registered Nurses recommend that hair not be removed at all unless it interferes with the incision site or other aspects of the procedure because hair removal by any means is associated with increased infection rates.
- Hair removal requires facilities to use a protocol that is based on scientific literature or the endorsement of a professional organization. Clipping immediately before the procedure and in a location outside the procedure area is preferred to shaving with a razor. Shaving can create a break in skin integrity and provide a way for bacteria on the skin to enter the incision site.
- Baseline vital signs are recorded and monitored throughout the procedure. Electrocardiographic electrodes are placed for cardiac monitoring to establish a baseline rhythm and identify any ventricular dysrhythmias. Peripheral pulses are marked with a pen before the venography, allowing for a quicker and more consistent assessment of the pulses after the procedure.
- Positioning is selected based on the safest and most effective site access and as directed by the HCP performing the procedure. Once positioned, a local anesthetic is injected at the site, and a small incision is made or a needle inserted under fluoroscopy. Instruction will be given to inhale deeply and hold breath while the x-ray images are taken, until directed to exhale.
- Contrast medium is injected then a rapid series of images is taken during and after the filling of the vessels to be examined. Delayed images may be taken to examine the vessels after a time and to monitor the venous phase of the procedure.
- Continuous monitoring is performed to assess for complications related to the procedure (e.g., allergic reaction, etc.). Once the study is completed, the needle or catheter is removed and a pressure dressing is applied over the puncture site.
- Protocols may vary among facilities.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Glucagon or an anticholinergic drug may be given to stabilize movement of the stomach muscles; peristaltic contractions (motion) may alter study findings.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure if bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information, see Appendix A: Patient Preparation Specimen Collection, subsection: Potential Contraindications and Complications Associated With Diagnostic Procedures.
- Report any reaction symptoms immediately to the HCP (difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, vomiting). Administer ordered antihistamines or prophylactic steroids if an allergic reaction occurs. Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation. Assess extremities for signs of ischemia or absence of distal pulse caused by a catheter-induced thrombus.
Note and report system-specific adverse effects; abdomen (GI) (nausea, vomiting, diarrhea, cramping), adrenal (hypertension associated with pheochromocytoma), brain (headache, confusion, dizziness, seizure), kidney (oliguria, hypertension, contrast-induced nephropathy), lung (respiratory) (laryngeal edema, bronchospasm, pulmonary edema).
Treatment Considerations
General
- Follow postprocedure vital sign and assessment protocol for the specific procedure.
- Monitor peripheral pulses as well as changes in the color or temperature of the skin around the insertion site that may be indicative of bleeding. Provide IV fluid to support blood pressure (rapid rate as appropriate) or blood transfusion as ordered, per clinical situation.
- Maintain bed rest in the supine position to prevent stress on the puncture site for 2 to 6 hr depending on the location of the insertion site.
Tissue Perfusion
- Facilitate management of inadequate tissue perfusion associated with abdominal disease.
- Interventions/actions related to inadequate tissue perfusion include the following: Mark and assess distal pulses (pedal, posterior tibial) using an ultrasound Doppler if unpalatable. Assess for extremity pallor, pain, coolness, pulselessness, paralysis. Keep extremities warm with socks, blankets. Facilitate gradual activity to promote extremity collateral circulation. Administer ordered analgesics, antiplatelets, cilostazol, and lipid-decreasing medications. Discuss treatment options as appropriate: stents, revascularization, and angioplasty.
Pain
- Facilitate management of pain associated with abdominal, kidney, and lung disease.
- Interventions/actions related to pain management include the following: Assess pain character, location, duration, intensity. Use an easily understood and culturally/age-appropriate pain-rating scale. Place in a position of comfort. Facilitate a calm, quiet environment. Administer ordered medications (e.g., antibiotics, analgesics). Consider alternative measures for pain management (e.g., imagery, relaxation, music).
Body Image
- Facilitate management of body image concerns associated with adrenal disease.
- Potential interventions related to body mage include the following: Assess for changes in physical appearance: moon face, muscle atrophy (thin extremities), obesity, red cheeks, buffalo hump, increased body hair, increased facial hair. Provide a nonjudgmental atmosphere to allow venting of feelings. Assess emotional response to physical changes and validate feelings. Assess coping mechanisms and facilitate by encouraging talking to others who have experienced these changes. Provide a referral to support groups. Support adjustments to changed appearance.
Fluid Volume
- Facilitate management of fluid volume excess associated with adrenal disease.
- Interventions/actions related to fluid volume excess include the following: Monitor and trend vital signs, especially heart rate and blood pressure. Assess for symptoms of circulatory fluid excess (e.g., edema, positive jugular vein distention, weight gain, shortness of breath, dyspnea, increased work of breathing, crackles on auscultation). Record daily weight. Monitor closely for potassium loss and sodium retention. Limit fluid intake. Facilitate low-sodium diet with sufficient potassium-rich foods. Administer ordered antihypertensive medications.
Tissue Perfusion
- Facilitate management of inadequate tissue perfusion associated with carotid disease.
- Interventions/actions related to inadequate tissue perfusion include the following: Monitor and trend vital signs and blood pressure (orthostatic). Assess for dizziness, capillary refill, and pedal pulses. Monitor level of consciousness and check skin temperature for warmth. Administer prescribed IV fluids and medications: thrombolytics (tissue plasminogen activator, alteplase), antiplatelet, antihypertensive, anticoagulant, osmotic diuretics, antipyretics, antibiotics, and oxygen. Monitor oxygenation with pulse oximetry; raise the head of the bed 30 degrees. Monitor and trend ECG.
Infection
- Facilitate management of infection associated with kidney disease.
- Interventions/actions related to infection management include the following: Encourage oral fluids if not contraindicated. Administer ordered parenteral fluids. Monitor and trend laboratory and diagnostic studies.
Pain
- Facilitate management of pain associated with kidney disease.
- Interventions/actions related to pain management include the following: Assess pain character, location, duration, intensity. Use an easily understood and culturally/age-appropriate pain-rating scale. Place in a position of comfort. Facilitate a calm, quiet environment. Administer ordered medications (e.g., antibiotics, analgesics). Consider alternative measures for pain management (e.g., imagery, relaxation, music).
Breathing
- Facilitate management of breathing associated with lung disease.
- Interventions/actions related to breathing include the following: Encourage the patient to cough and deep breathe, suction as needed, and prepare for intubation. Assess and trend breath sounds, work of breathing, and respirations (quality, rate, rhythm, depth). Monitor and trend ABG results; administer ordered oxygen. Monitor and trend oxygen saturation with pulse oximetry. Use coping mechanisms to decrease anxiety. Position patient to facilitate breathing, elevate the head of the bed, or bedrest as appropriate. Administer ordered analgesics.
Gas Exchange
- Facilitate management of inadequate gas exchange associated with lung disease.
- Interventions/actions related to inadequate gas exchange include the following: Assess respiratory status to establish a baseline (rate, rhythm, depth, work of breathing, use of accessory muscles, cyanosis). Administer ordered oxygen. Use pulse oximetry to maintain saturation at the medically specified level. Elevate the head of the bed to facilitate breathing and encourage drainage. Monitor and trend ABG results. Administer ordered medications, anticoagulants, antibiotics, bronchodilators, steroids, and diuretics. Pace activities to match patient’s breathing efforts, conserving oxygen consumption. Prepare for possible intubation.
Pain
- Facilitate management of pain associated with lung disease.
- Interventions/actions related to pain management include the following: Assess pain character, location, duration, intensity. Use an easily understood and culturally/age-appropriate pain-rating scale. Place in a position of comfort. Facilitate a calm, quiet environment. Administer ordered medications (e.g., antibiotics, analgesics). Consider alternative measures for pain management (e.g., imagery, relaxation, music).
Clinical Judgement
- Consider how fear and misunderstanding can misconstrue the value of adhering to therapeutic treatment recommendations in a multicultural setting. You must ensure the words you use fit the context of the patient’s individual situation and worldview to prevent clinical failure.
Follow-Up Evaluation and Desired Outcomes
- Understands the importance of maintaining bedrest for 4 to 6 hr after the procedure if ordered; recognizes the value of applying ordered cold compresses to the puncture site as needed to reduce discomfort or edema.
- Demonstrates correct assessment technique of the injection site (bleeding, hematoma formation, bile leakage, inflammation) and care of catheter insertion site.
- Acknowledges the importance of adhering to the therapy regimen; states significant adverse effects associated with the prescribed medication and the option for literature review provided by a pharmacist.
Abdomen
Adrenal
- Agrees that adequate rest and adherence to the recommended therapeutic regime are key to improving overall health; exhibits positive adaptation to changes in physical appearance and sexuality.
Carotid
Kidney
- Describes dietary and lifestyle changes that will facilitate renal health; acknowledges the importance of completing the prescribed antibiotic regime; demonstrates the correct technique to measure and record intake and output.
Lung
- Discusses the importance of remaining on bedrest to prevent oxygen desaturation with activity and the importance of keeping ordered oxygen in use; correctly states the reportable signs of bleeding (bleeding gums, black tarry stools, blood in urine, hematoma) if started on thrombolytics.