THROMBOANGIITIS OBLITERANS

BUERGERS disease is a rare disease characterized by a combination of acute inflammation and thrombosis (clotting) of the arteries and pains in the hands and feet. The obstruction of blood vessels in the hands and feet reduces the availability of the blood to the tissues, causes pain and eventually damages or destroys the tissue. It often leads skin ulcerations and gangrene of fingers and toes. Rarely in advance stages of the disease, it may affect vessels in other parts of the body.

Buergers disease affects approximately six out of every 10,000 people. It almost always affects men, ranges 20-40, who smoke or chew tobacco. Recently, however, more women and men over the age of 50 have been diagnosed with buergers disease. This disorder is still very uncommon in children, but it may occur in those with autoimmune disease. Buergers disesase is greatly associated with heavy to moderate tobacco use, both cigarette and smokeless.

PATHOPHYSIOLOGY There are two types of factors that we may considered:

Predisposing factor Smoking Obesity Precipitating factor Age Lifestyle Occupation When this two factors united, it can form a specific chemical. One of the chemicals that we can get on smoking is the nicotine. Nicotine has a substance called neutrophil polymorphs. This substance can filled the blood vessels that can cause inflammation. This condition can be painful, and patients extremities can be numb and when it is severe it can result to ulcer.

Predisposing Factors: Smoking Obesity

Precipitating Factors: Age Occupation Lifestyle

Inhalation of nicotine from

tobacco
Exacerbation of the patient due to remission and resumption of smoking

Releasing the antibodies by polyphenol from nicotine

Inflammation of the specific areas

Presence of the endothelium

on the inflamed areas

Leads to thrombosis and obliteration of lumen

Decrease blood supply to the small arteries and midsized

Scarring and fibrosis of the affected toes/fingers

Presence of all clinical manifestations

GANGRENE

BUERGERS DISEASE

CLINICAL FINDINGS 1. Pain 2. Numbness 3. Tingling 4. Burning 5. Paresthesias 6. Cold feet 7. Foot discoloration 8. Poor leg and hand circulation 9. Intermittent claudation 10. Persistent ischemia of one or more digits of the fIngers. 11. Cold sensitivity 12. Pulsations in the posterior tibials and dorsalis pedis arteries are weak or absent. 13. Cramps in the feet or legs after exercise. 14. Extremities maybe abnormally red. 15. Extremities maybe cyanotic. 16. The hands or feet may show enlarge. 17. Fred tender blood vessels. 18. Ulceration 19. Gangrene

NURSING CARE OF CLIENTS WITH BUERGERS DISEASE A. ASSESSMENT Buergers disease is often masked by a wide variety of other diseases that cause dimished blood flow to the hands and feet. Because of this, other disorder must be ruled out with aggressive evaluation. Blockage of blood vessels in the hands and feet caused by buergers disease maybe detected by one of the following methods: Angiography of the upper and lower extremities. Arteriography Doppler ultrasound Biopsy of the blood vessels-final confirmation of the diagnosis Venous duplex scanning. Plethysmographic examination Venography Ventilation-perfusion scanning Lumbar sympathetic block-a test used to evaluate peripheral Exercise test- determine the amount of activity possible before the onset of intermittent claudation.

B. NURSING DIAGNOSES 1. Pain 2. Impaired skin integrity 3. Altered tissue perfusion 4. Anxiety 5. Body image disturbance 6. Impaired physical mobility 7. Activity intolerance 8. Health seeking behaviors 9. Fluid volume deficit 10. Altered health maintenance

C. NURSING INTERVENTIONS 1. Smoking cassation 2. Producing vasodilation (calcium channel blockers or prozosine; re--gional sympathetic ganglionaectomy) 3. Relieving pain 4. Improving peripheral circulation- elevating the head of the bed or assuming a seating position with the feet resting on the floor. 5. Trauma to the extremities must be avoided.

6. The use of neutral soaps and body lotion prevents drying and cracking of skin. 7. Fingernails and toe nails should be carefully trimmed. 8. Good nutrition promotes healing and prevents tissue breakdown 9. Physical exercise 10. Control weight 11. Well fitting shoes and slippers should be worn to prevent foot injury and blisters. 12. Patients should take low cholesterol and low fat diet. 13. Vitamins B and C and adequate protein are necessary. 14. Self care program should be planned with the patient. 15. Long term care of the feet and legs is prime importance in the prevention of trauma, ulceration and gangrene COMPLICATIONS Ulceration Gangrene Edema of the legs Leg blood clots Changes in the nails and skin appears. Segmental thrombophlebitis affects the smaller veins. Inflammatory lesions are usually noted.

D. EVALUATION AND OUTCOMES 1. Demonstrate an increase in arterial blood supply to extremities 2. Exhibit extremities warm to touch. 3. Has improved color of extremities(is free of rubor and cyanosis) 4. Experience decrease muscle pain with exercise. 5. Demonstrate palpable peripheral pulses. 6. Elevate lower extremities as prescribed. 7. Avoid prolonged standing or sitting. 8. Has decreased edema in extremities. 9. Increases walking time. 10. Protects extremities from exposure to cold. 11. Does not smoke. 12. Uses stress management program to minimize emotional upset. 13. Wears none constricting clothing. 14. Avoid leg crossing 15. Take medication as prescribed. 16. Is free of pain.

RAYNAUDS DISEASE Raynauds disease or primary Raynauds disease is an intermittent spasm of the digital arteries and arterioles resulting in decreased circulation to the fingers and toes. The cause of the condition is unknown but seems to be related to vasopastic disorders, a disturbance with the innervations of the sympathetic nervous system and angiography complications. During a spasm that lasts approximately 15 minutes, the fingers become pale and cyanotic. As the circulation returns to the fingers, the fingertips become reddened and the person experiences a tingling or throbbing pain in the fingers. The episode may last t0 1-2 hours. Symptoms usually occur when the person is exposed to cold or experiences emotional stress. Gangrene is not common but can occur in the fingertips if the disease has been longstanding. Ulcerations can also occur and are difficult to heal because of decreased circulation in the fingers. The condition is called Raynauds phenomenon or secondary Raynauds phenomenon when it is associated with connective tissue or collagen vascular disease, medications or occupational trauma. Raynauds symptoms may occur 10 years before the related disease is diagnosed. A 2-year history of signs and symptoms with no evidence of underlying disease, especially an autoimmune disease, is necessary for a diagnosis of Raynauds disease. Sometimes a disease, condition, or other factor causes Raynaud's. This type of Raynaud's is called Raynaud's phenomenon or secondary Raynaud's. Primary Raynaud's is more common and tends to be less severe than secondary Raynaud's. In both types of Raynaud's, even mild or brief changes in temperature can cause Raynaud's attacks. For example, taking something out of the freezer or being exposed to temperatures below 60 degrees Fahrenheit can cause your fingers to turn blue.

Figure A shows arteries in the fingers (digital arteries) with normal blood flow. The inset image shows a cross-section of a digital artery. Figure B shows fingertips that have turned white due to blocked blood flow. Figure C shows narrowed digital arteries, causing blocked blood flow and blue fingertips. The inset image shows a cross-section of a narrowed digital artery.

What Causes Raynaud's? Often, the cause of Raynaud's isn't known. This type of Raynaud's is called Raynaud's disease or primary Raynaud's. Causes of Secondary Raynaud's Many things can cause secondary Raynaud's. Examples include: Diseases and conditions that directly damage the arteries or damage the nerves that control the arteries in the hands and feet Repetitive actions that damage the nerves that control the arteries in the hands and feet Injuries to the hands and feet Exposure to certain chemicals Medicines that narrow the arteries or affect blood pressure Diseases and Conditions Secondary Raynaud's is linked to diseases and conditions that directly damage the arteries. The disorder also is linked to diseases and conditions that damage the nerves that control the arteries in the hands and feet. Scleroderma and lupus are two examples of conditions that can cause Raynaud's. About 9 out of 10 people who have scleroderma have Raynaud's. About 1 out of 3 people who has lupus has Raynaud's. Other examples of diseases and conditions that can cause Raynaud's include: Rheumatoid arthritis Atherosclerosis Blood disorders such as cryoglobulinemia and polycythemia Sjgren's syndrome, dermatomyositis and polymyositis

PATHOPHYSIOLOGY

Precipitaing

Factors Emotional sensitivity/stress Cold environment

Raynauds attack

Constriction of blood vessels due to cold (vasospasm)

Decreased blood supply

Pain and discomfort

Presence of symptoms

Discoloration of the fingers/toes

RAYNAUDS PHENOMENON

MEDICAL MANAGEMENT Raynaud s phenomenon is treated conservatively. The client is assessed regularly for symptom of autoimmune disease. If the symptoms of raynaud s are due to a vasopastic disease. Relief is best achieved with medication. PHARMACOLOGICAL MANAGEMENT Nifedipine- may take medication 1-2 hours before engaging in an outdoor activity during cold weather. Iloprost- aid in healing finger ulcers, a prostaglandin which is given intravenously Ciprofloxacin- antibiotic HEALTH PROMOTION Client is encouraged to avoid exposure to cold, repetitive hand movements and stressful situations. Client is encouraged to quit smoking and avoid secondary smoke as nicotine is a potent vasoconstriction. NURSING DIAGNOSES & NURSING INTERVENTION Altered tissue perfusion related to vasospasm of peripheral arteries. Encourage the client to use caution when engaging in an activities that may cause a cut or scratch as healing may be impaired because of decreased circulation. Acute pain related to decreased circulation in digits, Teach client to keep the indoor temperature at a comfortable level to avoid ischemic attacks.