Cardiac Flashcards
Normal blood flow thru ♡
superior and inferior vena cava (deoxygenate blood) → RA → tricuspid valve → RV → pulmonary artery → lungs → pulmonary veins (oxygenated blood) → LA → mitral/bicuspid valve → LV → aorta → body systems
Preload
amount of blood returning to right side of heart and muscle stretch that the volume causes — (ANP released during stretch)
Afterload
• what is it?
• w/ HTN = more ____ = lead to what? because HIGH afterload = ↓ CO and ↓ forward flow (wears your heart out)
- pressure/”resistance” in aorta and peripheral arteries that LV has to pump against to get blood out
- HTN = more RESISTANCE = lead to HF and pulmonary edema (HIGH afterload = ↓ CO and ↓ forward flow — wears your heart out)
Stroke Volume
amount of blood pumped out of ventricles w/ each beat
Cardiac Output
• formula?
• ____ is dependent on adequate CO
• Cardiac output changes according to body’s ____
- CO = HR x SV
- Tissue perfusion
- body’s needs
Factors that affect Cardiac Output
• what 3 things? examples?
- HR and certain arrhythmias
- Blood volume
- -less volume = ↓ CO
- -more volume = ↑ CO - Decreased contractility
- -MI, meds, cardiac muscle disease
Patho of ↓ CO • will you perfuse properly? a. Brain: LOC? b. heart? c. lungs? d. skin? e. kidneys? f. peripheral pulses?
• ____ are no big deal UNTIL they affect your Cardiac Output
• NO
a. LOC ↓
b. chest pain
c. wet lung sounds; SOB
d. cold and clammy
e. UO ↓
f. weaker pulses
• Arrhythmias
3 Arrhythmias that are always a big deal
- V-fib
- Pulseless V-tach
- Asystole
Medications Effects on CO
Preload - vasodilate/diurese to ↓ preload
- Diuretics (furosemide)
2. Nitrates (nitroglycerin)
Medications Effects on CO
Afterload - vasodilate to ↓ afterload
- ACE inhibitors (enalapril, fosinopril, captopril)
- ARBs (losartan, irbesartan)
- Hydralazine
- Nitrates
Medications Effects on CO
Improve Contractility
- Inotropes (dopamine, dobutamine, milrinone)
Medications Effects on CO
Rate control
- Beta blockers (propranolol, metoprolol, atenolol, carvedilol)
- Calcium Channel Blockers (diltiazem, verapamil, amlodipine)
- Digoxin
Medications Effects on CO
Rhythm control
- Antiarrhythmics (Amiodarone)
Coronary Artery Disease (CAD)
• most common type of cardiovascular disease: broad term for _____ and _____
• chronic stable angina and acute coronary syndrome
Chronic Stable Angina Patho
- Intermittent ↓ blood flow to myocardium leads to? and then can lead to temporary what?
- what brings this pain? ____ O2 usually d/t ____
- What relieves the pain?
- ISCHEMIA; pain/pressure in chest
- LOW O2 d/t EXERTION
- rest and/or nitroglycerin SL
Nitroglycerin (Nitrostat): Sublingual • causes what? then causes ↓ \_\_\_\_ and \_\_\_\_; also causes what to increase blood flow to myocardium? • take 1 every \_\_\_\_ min x \_\_\_\_ doses • okay to swallow? • keep inside what? in what environment? • burn or fizz? • will get a what? • renew how often? spray? • after taking nitro, what to expect for BP to do?
- venous and arterial DILATION; ↓ PRELOAD and AFTERLOAD; also causes DILATION of CORONARY ARTERIES
- take 1 every 5 MINUTES x 3 DOSES
- DO NOT SWALLOW –needs to dissolve
- keep in DARK, GLASS BOTTLE; dry, cool
- burn or fizz –MAY OR MAY NOT HAPPEN
- will get a HEADACHE
- renew EVERY 6 MONTHS —-spray: 2 YEARS
- BP ↓
Algorithm for NItroglycerin
take 1 NTG SL –after 5 mins if chest pain/discomfort is unimproved/worsened – CALL 911!
Beta-Blockers for Prevention of Angina • examples? • what BBs do to BP, Pulse, myocardial contractility? • what BBs do to workload of heart? • what BBs block? • what happens to CO?
- propranolol (Inderal), metoprolol (Lopressor/Toprol XL), atenolol (Tenormin), carvedilol (Coreg)
- DECREASE BP, Pulse, myocardial contractility
- ↓ workload of heart
- block beta cells (receptor sites for catecholamines – epi, norepi)
- ↓ CO
Calcium Channel Blockers for Prevention of Angina • examples? • what CCB do to BP? • cause what in arterial system? • dilate \_\_\_\_ \_\_\_\_ • 2 benefits of CCB?
- nifedipine (Procardia XL), verapamil (Calan), amlodipine (Norvasc), diltiazem (Cardizem)
- ↓ BP
- vasodilation
- coronary arteries
- ↓ afterload and ↑ O2 to heart muscle
Acetylsalicylic acid (Aspirin) typical dose?
81 mg - 325 mg
Chronic Stable Angina Education • rest? • nutrition: avoid \_\_\_\_, eat what? • what to avoid that ↑ HR? • wait how long after eating to exercise? • what to wear in cold weather? why? • take \_\_\_\_ prophylactically • \_\_\_\_ cessation • lose \_\_\_\_ • avoid \_\_\_\_ exercise • reduce \_\_\_\_
- rest FREQUENTLY
- nutrition: avoid OVEREATING, eat LOW-FAT, HIGH FIBER
- EXCESS CAFFEINE OR ANY DRUGS that ↑ HR
- wait 2 HOURS after eating to exercise?
- DRESS WARMLY in cold weather? TEMP EXTREMES PRECIPITATE ATTACK
- take NITROGLYCERIN prophylactically
- SMOKING cessation
- lose WEIGHT
- avoid ISOMETRIC exercise (NO LIFTING WEIGHTS)
- reduce STRESS
Cardiac Catheterization Pre-procedure • ask if allergic to what? why? • check kidney function why? • what do PHP prescribe if client has kidney problems? why? what should the client expect when getting this?
- shellfish or iodine — iodine-based dye is used
- b/c dye is excreted thru kidneys
- acetylcysteine (Mucomyst) —helps protect kidneys — hot shot and palpitations
Cardiac Catheterization Post-procedure • monitor \_\_\_\_ • watch puncture site for what? • assess 5 Ps? • bed rest, flat, extremity straight for how many hours? • report \_\_\_\_ ASAP • IF client is on metformin (Glucophage) -- what to do with this med post procedure? we are worried of what?
- monitor VS
- bleeding and hematoma formation
- Pulselessness, Pallor, Pain, Paresthesia, Paralysis
- 4-6 hours
- Pain
- hold metformin for 48 hours post procedure — worried about kidneys
Unstable chronic angina = Impending ______
MI
Acute Coronary Syndrome/MI/Unstable Angina
PATHO
• Decreased blood flow to ____ → ____ and ____
• does the client have to be doing anything to bring this pain on?
• will rest or nitroglycerin (Nitrostat) relieve this pain?
- Decreased blood flow to MYOCARDIUM → ISCHEMIA and NECROSIS
- no
- no
Acute Coronary Syndrome/MI/Unstable Angina S/SX • pain described as? • women present with what s/sx? • #1 sign of MI in elderly? • skin? BP? • CO? • ECG changes? • Vomiting?
- pain as CRUSHING, elephant sitting on chest, pressure radiating to left arm and left jaw, N/V, pain between shoulder blades
- women - GI s/sx – epigastric discomfort, pain between shoulders, aching jaw or choking sensation
- SOB
- cold and clammy; BP ↓
- CO ↓
- ECG changes –lots of PVCs
- Yes, stimulation of vagus nerve
Triad of Symptoms in Women
- indigestion or feeling of fullness
- unsual fatigue
- inability to catch one’s breath
STEMI?
NSTEMI?
***WORRY ABOUT WHICH CLIENT?
STEMI
– ST-segment elevation MI – client is having a HEART ATTACK – goal is to get client to cath lab for PCI in <90 minutes!!
STEMI
Non-ST segment elevation MI – less worrisome
WORRY ABOUT STEMI CLIENT
MI Lab work - CPK-MB • Cardiac specific \_\_\_\_ • \_\_\_\_ w/ damage to cardiac cells • elevates within \_\_\_\_ hours; peaks in \_\_\_\_ hours
- TROPONIN
• ____ specificity to myocardial damage
• elevates within ____ hours; remains elevated up to ____ weeks - MYOGLOBIN
• Increases within ____ hour; peaks in ____ hours
• ____ results are a good thing - which cardiac biomarker is the most sensitive indicator for an MI?
- which enzymes or biomarkers are most helpful when the client delays seeking care?
- biomarker
- INCREASE
- elevates within 3-6 HOURS —- peak: 12-24 HOURS
- HIGHLY specific cardiac biomarker
- elevates within 3-4 HOURS — elevates up to 3 WEEKS
- 1 HOUR; peak: 12 HOURS
- negative
- troponin
- troponin
MAJOR ARRHYTHMIAS
• what untreated arrhythmias will put client at risk for SUDDEN DEATH?
- tx for V-Fib?
- if defib doesn’t work, what’s 1 st med or vasopressor to give?
- what’s an antiarrhythmic and is used when V-fib and pulseless VT are resistant to treatment, also for fast arrhythmias
- antiarrhythmic drugs given to prevent a second episode of V-fib?
- Lidocaine toxicity: any ____ changes
- 1sst antiarrhythmic of choice? important SE? why?
• Pulseless V-tach, V-Fib, Asystole
- Defibrillation “Defib the V-fib!”
- EPI
- amiodarone (Cordarone)
- Amiodarone or Lidocaine
- NEURO changes
- amiodarone (Cordarone); hypotension; lead to further arrhythmias
MI Treatment
• MONA?
• postition? why?
- oxygen, chewable aspirin, nitro, morphine (2mg at a time)
* head up — ↓ workload on heart and ↑ CO
Thrombolytics
• goal?
- medications examples?
- how soon after onset of myocardial pain should these drugs be administered? within ____ HOURS
- Stroke: _____ IS BRAIN
- major complication?
- obtain what history?
- contraindications?
- during and after administration we take _____ precautions
- draw blood when starting IV’s to decrease what?
- what about ABGs? why?
• DISSOLVE CLOT that’s blocking blood flow to heart muscle = ↓ size of infarction
- alteplase (t-PA), tenecteplase (TNKase, one time push), reteplase (Retavase), streptokinase
- within 6 - 8 HOURS
- TIME IS BRAIN
- BLEEDING
- bleeding hx
- intracranial neoplasm, intracranial bleed, suspected aortic dissection, internal bleeding (= CAUSE MASSIVE HEMORRHAGE)
- bleeding precautions
- number of puncture sites
- no; artery is going to BLEED
Bleeding Precautions
• watch for?
• use what?
- Watch for bleeding gums, hematuria, black stools
* use electric razor, soft toothbrush, no IMs
MEDS REQUIRING BLEEDING PRECAUTIONS
ALL ANTICOAGULANTS!!!
abciximab, acetaminophen, acetylsalicylic acid, apixaban, clopidrogel, dabigatran, enoxaparin sodium, eptifibatide, heparin rivaroxaban, warfarin
PCI (PERCUTANEOUS CORONARY INTERVENTIONS)
• including interventions such as?
• major complication of angioplasty?
• if any problems occur → go to ____
• chest pain after procedure–what to do?
• anti-platelet meds?
• PTCA (percutaneous transluminal coronary angioplasty) and stents • MI • go to SURGERY • call PHP bc REOCCLUDING!
• acetylsalicylic acid (Aspirin); clopidogrel (Plavix); prasugrel (Effient); abciximab (ReoPro IV); eptifibatide (Integrilin IV)
CABG (Coronary Artery Bypass Graft) • what is it? • scheduled or emergency procedure? • used for? • the \_\_\_\_ main coronary artery supplies the entire left ventricle • \_\_\_\_main coronary artery occlusion... Think: \_\_\_\_ or Widow Maker
- open heart surgery
- both
- multiple vessel disease or left main coronary artery occlusion
- left
- left; sudden death
Cardiac Rehab • \_\_\_\_ cessation • activity? • diet changes? • exercises to avoid? • valsalva? straining? suppository? docusate (Colace)? • when can sex be resumed? • safest time of day for sex? • best exercise for MI client? • teach s/sx of HF, which are?
• SMOKING cessation
• activity? INCREASE GRADUALLY
• diet changes? LOW FAT, LOW SALT, LOW CHOLESTEROL
• exercises to avoid? NO ISOMETRIC EXERCISES (↑ workload of heart)
• valsalva? straining? suppository? docusate (Colace)? NO TO ALL OF IT
• when can sex be resumed? clients w/o complications – 1 WEEK TO 10 DAYS; or can walk/go upstair w/o SOB
• safest time of day for sex? IN THE MORNING (8-9 AM)
• best exercise for MI client? WALKING
• teach s/sx of HF, which are?
–weight gain, ankle edema, SOB, confusion
HF causes
result from cardiomyopathy, valvular heart disease, endocarditis, acute MI, HTN
Left-sided HF
• blood is not moving ____ into aorta and out to body….goes backward into the ____
• s/sx
• forward; lungs • pulmonary congestion dyspnea cough blood tinged frothy sputum restlessness -- hypoxia 1st sign tachycardia S3 (ventricular gallop, lub-dub-dub) orthopnea nocturnal dyspnea
Right-sided HF
• blood is not moving ____ into the ____….goes backward into the _____ system
• s/sx
• forward; lungs... venous system • distended neck veins edema enlarged organs weight gain ascites
Systolic HF
heart can’t contract and eject
Diastolic HF
ventricles can’t relax and fill
HF Diagnosis
a. BNP
• secreted by ____ in heart when what are increased
• ____ indicator
• can be ____ for HF when CXR does not indicate a problem
• if client is on nesiritide (Natreco), what to do with before drawing a BNP?
b. CXR
enlarged ____, pulmonary ____
c. Echocardiogram
looks at what of the heart? give info about?
d. NY Heart Association Functional Classification of Persons w/ HF:
Class 1-4 — which is the WORST?
a. BNP • ventricular tissues in heart when ventricular volumes and pressure ↑ • sensitive • positive • turn it off 2 hours prior
b. CXR
enlarged HEART, pulmonary INFILTRATES
c. Echocardiogram
pumping action or ejection fraction of heart —backflow and valve disease
d. class 4 is the worst!
Swan-Ganz (Pulmonary Artery) catheter
floated into the right side of heart and pulmonary artery–provides hemodynamic pressures, CO, and access to mixed venous blood sampling
Arterial lines
• most common site?
• provides what? allows for repeated collection of what?
- radial artery
* provides continuous intra-arterial BP; repeated ABGs (prevent injury to client)
HF Treatment: ACE Inhibitors • these are the \_\_\_\_ for HF • suppress what? • prevent conversion of? • results in?
- drug of choice for HF
- Renin Angiotensin System (RAS)
- Angiotensin I to Angiotensin II
- arterial vasodilation and ↑ SV
HF Treatment: ARBs
• block what?
• cause a ______ in arterial resistance and ____ BP
- Angiotensin II receptors
* ↓ arterial resistance, ↓ BP
HF Treatment: Beta Blockers
• considered as? prescribed in additon to?
• relax the? and decreases what?
• ACE inhibitors and ARBs block _____ = we lose _____ and _____ and retain ____
• why a client w/ HF will be sent home on ACE inhibitors–why?
- first-line therapy; ACE inhibitors
- vessels; ↓BP, ↓ afterload, ↓ workload on heart
- block aldosterone; lose sodium and water; retain potassium
- these drugs ↓ workload on heart by preventing vasoconstriction (↓ afterload) = ↑ CO and keep blood moving forward
HF Treatment: Digoxin (Lanoxin) ACTIONS • monitor for \_\_\_ in elderly • uses? • often given in combination with what meds? • contraction? • HR? • CO? • kidney perfusion?
- drug toxicity
- SINUS RHYTHM or A-Fib and has chronic HF
- ACE inhibitors, ARBs, Beta Blocker, Diuretics
- contraction IMPROVES (STRONGER)
- HR lower
- CO ↑
- kidney perfusion ↑
HF Treatment: Digoxin (Lanoxin) NURSING CONSIDERATIONS • would diuresis be a good thing or bad thing? • digitalizing dose mean? • how do you know it's working?
• s/sx of toxicity–early? late?
- before administering, do what? hold if?
- Monitor ____
• what electrolyte when it’s low cause the most trouble? why?
- good thing!
- loading dose
- CO ↑
• early – anorexia, N/V
late – arrhythmias and vision changes (yellow halo
• check apical pulse (hold if <60 bpm)
- electrolytes
- POTASSIUM — hypokalemia + digoxin = DRUG TOXICITY
HF Treatment: Diuretics
• med examples
• action
• when do you give diuretics?
- furosemide (Lasix), hydrochlorthiazide (HCTZ), bumetanide (Bumex), hydrochlorothiazide/triamterene (Dyazide), spironolactone (Aldactone)
- decreases preload
- morning
HF Treatment: IV Inotropes
examples?
• milrinone (Primacor), dobutamine
HF Treatment: Vasodilators
examples?
• nitroprusside (Nipride), neseritide (Natrecor)
HF Treatment: Non-med
• what diet? decreases what? helps with?
• watch for?
• what can contain a lot of sodium?
- elevate ____
- weigh daily and report a gain of ______
- Report s/sx of recurring ______
- low sodium diet; ↓ fluid retention; helps ↓ preload
- salt substitutes (has lots of potassium!)
- canned/processed foods and OTC meds
- elevate HOB
- 2-3 lbs (1-2 kgs)
- failure
Fluid retention - think _____ problems first
heart
Pacemakers
• what’s your “natural” pacemaker called? it sends out what?
• if HR drops 60 or below = CO?
• what is pacemaker used for?
- SA node or sinus node; sends out impulses that makes heart contract
- ↓ CO
- increase HR w/ symptomatic bradycardia
Pacemaker may be temporary or permanent?
• always worry if HR drop below the _______
• what maintain a certain minimal HR depending on settings?
- a ____ pacemaker kicks in only when the client needs it
- _____ rate pacemakers fire at a ____ rate constantly
- it’s okay for rate to increase but never _____
- always worry if the rate _____ below the set rate
BOTH; temporary (invasive or non-invasive) and permanent
- set rate
- set rate
- demand pacemaker
- fixed
- decrease
- drops
Post-procedure care (permanent pacemakers)
• monitor the?
• most common complication?
• immobilize the ____
• how to prevent frozen shoulder?
• kee the client from raising arm higher than what?
- incision and ECG for malfunction
- Electrode displacement (wires pull out)
- arm
- assisted passive ROM
- keep client from raising the arm higher than shoulder height
Pacemakers: S/SX of Malfunction
• is it possible that no contraction will follow the stimulus? called what?
- is it possible for pacemaker to fire at inappropriate times? called what?
- what can cause any malfunction?
- -pacemaker may not be ______ correctly
- -electrodes can _____
- -battery may be ____
• watch for any sign of what?
- loss of capture
- failure to sense
- programmed; dislodged; depleted
- ↓ CO or ↓ rate
Pacemaker Client Education/Teaching • Check \_\_\_ daily • wear what? • Avoid \_\_\_\_\_\_\_ fields • Avoid what dx procedure?
- pulse
- ID card or bracelet
- electromagnetic fields (cell phones, large motors)
- MRI
Pulmonary Edema Risks Any person: • receiving IVFs really \_\_\_\_ • very \_\_\_ and very \_\_\_\_ • history of what diseases?
- FAST
- young, old
- heart or kidney
Pulmonary Edema Patho
• fluid is backing up into ____ — heart is unable to move the volume ____
• usually occurs when?
- lungs; forward
* at night when client goes to bed
Pulmonary Edema S/SX
- sudden onset
- breathless
- restless/anxious (think hypoxia)
- SEVERE HYPOXIA
- productive cough (pink frothy sputum)
Pulmonary Edema Treatment:
• Non-med
• position? improves what? promotes ____ of blood in lower extremities
• prevention – check what and avoid what?
• Oxygen (high flow O2) – monitor O2 sat and keep
>90%
• Upright position; legs down — improves CO —- promotes POOLING of blood
• check lung sounds and avoid FVE
Pulmonary Edema Treatment: Diuretics
• furosemide: causes what? dose? to prevent?
• bumetanide: given how? dose?
- diuresis and vasodilation = reduces preload — 40 mg IV push SLOWLY over 1-2 minutes to prevent HYPOTENSION and OTOTOXICITY
- given IV push or continuous IV infusion to provide rapid fluid removal —- 1-2 mg IV push given over 1-2 minutes
Pulmonary Edema Treatment: Nitroglycerin IV
• Vasodilation = ____ afterload
• _____ afterload = ____ CO because why?
- ↓ afterload
* ↓ afterload = ↑ CO — heart is pumping against less pressure and more blood can move forward
Pulmonary Edema Treatment: Morphine
• dose? decrease what?
• 2 mg IV push for vasodilation; ↓ preload and afterload
Pulmonary Edema Treatment: Nesiritide (Natrecor) • synthetic version of? • route? short or long term? • not be given more than \_\_\_\_ hours • action?
- synthetic BNP
- IV infusion; short term therapy
- 48 hours
- vasodilates veins and arteries and has a diuretic effect
Cardiac tamponade
Patho
• blood, fluid, or exudates have leaked into _____ resulting in what?
• causes?
- pericardial sac; compression of heart
* MV collision, RV biopsy, MI, pericarditis, hemorrhage post CABG
Cardiac tamponade S/SX • CO • CVP • BP • heart sounds • neck veins • pressures in all 4 chamber are \_\_\_\_\_\_\_\_ • shock? • \_\_\_\_\_ pulse pressure
- CO ↓ (LV being squeezed)
- CVP ↑
- BP ↓ (CO is dropping)
- heart sounds – MUFFLED/DISTANT
- neck veins DISTENDED
- pressures in all 4 chamber are THE SAME
- shock? YES
- NARROWED pulse pressure
Cardiac tamponade
Treatment
• To remove blood from around the heart?
• procedure? monitor what after?
- Pericardiocentesis — insert needle into pericardial sac and remove fluid
- Surgery — monitor UO
Arterial Disorders Patho • if you have \_\_\_\_\_ in one place, you have it everywhere • medical emergency if you have what? • client will report what? • extremity temp? • no \_\_\_\_\_ pulse • more symptomatic where? • what's the hallmark sign? what is it? • arterial blood isn't getting to the \_\_\_\_\_\_ → what sx? • paint rest means what?
Treatment
• If you elevate the extremity, would pain increase or decrease?
• treated with what?
• if you have ATHEROSCLEROSIS in one place, you have it everywhere
• medical emergency - ACUTE ARTERIAL OCCLUSION
• client will report NUMBNESS and PAIN
• extremity temp? COLD
• no PALPABLE pulse
• more symptomatic where? LOWER EXTREMITIES
• what’s the hallmark sign? what is it? INTERMITTENT CLAUDICATION; pain when walking
• arterial blood isn’t getting to the TISSUES →
coldness, skin/nail changes, ulcerations
• paint rest means SEVERE OCCLUSION
tx
• increase — we DANGLE ARTERIES
• angioplasty or endarterectomy
Venous Disorders • arteries carry \_\_\_\_ blood; veins carry \_\_\_\_ blood • what can occur? • could develop what? • tx?
- oxygenated; deoxygenated
- inflammation and chronic ulcers
- DVT
- absorbent dressing on wound; compression
we _____ veins
we ____ arteries
we ELEVATE veins
we DANGLE arteries
Chronic Arterial Insufficiency Symptoms • Pain • Pulses • Color • Temp • Edema • Skin changes • Ulceration • Gangrene • Compression
- Pain — INTERMITTENT CLAUDICATION
- Pulses — ↓ or ABSENT
- Color — PALE WHEN ELEVATED; RED W/ LOWERING OF LEG
- Temp — COOL
- Edema — ABSENT OR MILD
- Skin changes — THIN, SHINY, LOSS OF HAIR OVER FOOT/TOES, NAIL THICKENING
- Ulceration — IF PRESENT, WILL INVOLVE TOES OR AREAS OF TRAUMA ON FEET (PAINFUL)
- Gangrene — MAY DEVELOP
- Compression — NOT USED
Chronic Venous Insufficiency Symptoms • Pain • Pulses • Color • Temp • Edema • Skin changes • Ulceration • Gangrene • Compression
- Pain — NONE TO ACHING PAIN, depending on dependency of area
- Pulses — NORMAL (may be difficult to palpate d/t edema)
- Color — NORMAL (may see petechiae or brown pigmentation with chronic condition)
- Temp — NORMAL
- Edema — PRESENT
- Skin changes — BROWN PIGMENTATION AROUND ANKLES, POSSIBLE THICKENING OF SKIN, SCARRING MAY DEVELOP
- Ulceration — IF PRESENT, WILL BE ON SIDES OF ANKLES
- Gangrene — DOES NOT DEVELOP
- Compression — USED
