115-NCLEX-RN Review Made Incredibly Easy, Fifth Edition (Incredibly Easy...

Polish up on client care 59

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.

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

Raynauds disease

Raynauds disease is characterized by epi-sodic 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 con-dition often associated with several connective tissue disorders such as scleroderma, systemic lupus erythematosus, and poly myo-sitis has a progressive course, leading to ischemia, gangrene, and amputation. Differ-entiating 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 chang-ing to red (after exposure to cold or stress)

DIAGNOSTIC TEST RESULTS Arteriography reveals vasospasm. Plethysmography reveals intermittent vessel occlusion.

NURSING DIAGNOSES Ineffective tissue perfusion: Peripheral Risk for injury Risk for peripheral neurovascular dysfunction Acute pain Chronic pain

TREATMENT 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 (Card-izem), nifedipine (Procardia) Vasodilator: phenoxybenzamine (Diben-zyline)

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 situa-tions and to stop smoking to prevent exacerba-tion of symptoms. Instruct the client to inspect the skin fre-quently and to seek immediate care for signs of skin breakdown or infection to prevent com-plications. Teach the client about drugs, their use, and their adverse effects to prevent further complications. Provide psychological support and reassur-ance 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

HmmmVasodilators 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.

313419NCLEX-RN_Chap03.indd 59313419NCLEX-RN_Chap03.indd 59 4/8/2010 7:01:51 PM4/8/2010 7:01:51 PM

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