Polish up on client care

occlusion at another site. Warn him against

wearing constrictive clothing. These measures
enable the client to join actively in his care, and
allow him to make more informed decisions
about his health status.

DIAGNOSTIC TEST RESULTS

Arteriography reveals vasospasm.
Plethysmography reveals intermittent
vessel occlusion.

NURSING DIAGNOSES
Teaching topics
Explanation of the disorder and treatment
options
Medications and possible adverse effects
Performing proper foot care
Recognizing signs of arterial occlusion
Modifying risk factors

Ineffective tissue perfusion: Peripheral

Risk for injury
Risk for peripheral neurovascular
dysfunction
Acute pain
Chronic pain

59

Hmmm
Vasodilators are
typically used only
in severe cases of
Raynauds disease
because the adverse
effects of these
drugs may
be more bothersome
than the disease
itself.

TREATMENT

Raynauds disease
Raynauds disease is characterized by episodic vasospasm in the small peripheral
arteries and arterioles, precipitated by
exposure to cold or stress. This condition
occurs bilaterally and usually affects the
hands or, less often, the feet.
Raynauds disease is most prevalent in
women, particularly between puberty and age
40. A benign condition, it requires no specific
treatment and has no serious sequelae.
Raynauds phenomenon, however, a condition often associated with several connective
tissue disorders such as scleroderma,
systemic lupus erythematosus, and polymyositis has a progressive course, leading to
ischemia, gangrene, and amputation. Differentiating the two disorders is difficult because
some clients who experience mild symptoms
of Raynauds disease for several years may
later develop overt connective tissue disease
most commonly scleroderma.

CAUSES
Unknown (most probable theory involves
an antigen antibody immune response)

ASSESSMENT FINDINGS
Numbness and tingling that are relieved
by warmth
Sclerodactyly, ulcerations, or chronic
paronychia (in longstanding disease)
Typically, blanching of skin on the fingers,
which then becomes cyanotic before changing to red (after exposure to cold or stress)

313419NCLEX-RN_Chap03.indd 59

Activity changes: avoidance of cold

Smoking cessation (if appropriate)
Surgery (used in fewer than one-quarter of
clients): sympathectomy

Drug therapy
Calcium channel blockers: diltiazem (Cardizem), nifedipine (Procardia)
Vasodilator: phenoxybenzamine (Dibenzyline)

INTERVENTIONS AND RATIONALES

Warn against exposure to the cold. Tell
the client to wear mittens or gloves in cold
weather and when handling cold items or
defrosting the freezer to prevent vasospasm,
which causes onset of symptoms.
Advise the client to avoid stressful situations and to stop smoking to prevent exacerbation of symptoms.
Instruct the client to inspect the skin frequently and to seek immediate care for signs
of skin breakdown or infection to prevent complications.
Teach the client about drugs, their use,
and their adverse effects to prevent further
complications.
Provide psychological support and reassurance to allay the clients fear of amputation and
disfigurement.

Teaching topics
Modifying risk factors, including smoking
cessation, if appropriate
Preventive measures such as avoiding cold
and stress

4/8/2010 7:01:51 PM