Orthopedic Nursing Orthopedic Nursing

Raynaud’s Disease Raynaud’s Disease (Raynaud’s Phenomenon)(Raynaud’s Phenomenon)

DefinitionDefinition

• Raynaud's diseaseRaynaud's disease is a condition of is a condition of the circulation that affects blood the circulation that affects blood supply to the skin and causes the supply to the skin and causes the extremities of the body to lose feeling extremities of the body to lose feeling and become numb. and become numb. 

• Paroxysmal pallor and coldness of the Paroxysmal pallor and coldness of the extremities.extremities.

Synonyms Synonyms

• Raynaud's phenomenonRaynaud's phenomenon• vasoconstrictionvasoconstriction• scleroderma scleroderma • lupuslupus• microcirculation microcirculation

Two ClassificationTwo Classification

• Primary Raynaud's phenomenonPrimary Raynaud's phenomenon or or idiopathic is considered the more common, idiopathic is considered the more common, milder condition. There is no underlying milder condition. There is no underlying disease associated with the primary disease associated with the primary classification. About 75% of all cases classification. About 75% of all cases diagnosed occur in women between 15 and diagnosed occur in women between 15 and 40 years old. 40 years old.

• Secondary Raynaud's phenomenonSecondary Raynaud's phenomenon is less is less common, but is considered the more serious common, but is considered the more serious of the two classifications. It is associated with of the two classifications. It is associated with an underlying disease, most commonly, one an underlying disease, most commonly, one of the connective tissue diseases of the connective tissue diseases

Predisposing Factors Predisposing Factors

The risk factors include:The risk factors include:• Smoking Smoking • Working with vibrating machinery - the Working with vibrating machinery - the

fingers may go into spasm. This is due to fingers may go into spasm. This is due to an intermittent lack of blood supply to the an intermittent lack of blood supply to the fingers. fingers.

• Emotional distress-Emotional distress-• Exposure to the coldExposure to the cold• Women affected more often than menWomen affected more often than men

Signs and Symptoms Signs and Symptoms • People with Raynaud's (primary or secondary) People with Raynaud's (primary or secondary)

have attacks in response to have attacks in response to cold or cold or emotional stressemotional stress. The attacks can affect the . The attacks can affect the fingers and toesfingers and toes, and , and rarely the nose, rarely the nose, ears, nipples, or lipsears, nipples, or lips. The affected body . The affected body parts will usually have two or more of the parts will usually have two or more of the following changes:following changes:

• Look Look palepale due to lack of blood flow due to lack of blood flow • Look Look bluishbluish due to a lack of oxygen due to a lack of oxygen • Feel Feel numb, cold, or painfulnumb, cold, or painful • Redden and throb or tingle as blood returns to Redden and throb or tingle as blood returns to

the affected area the affected area

Pathophysiology Pathophysiology Precipitating Factors SmokingWorking with vibrating machineryEmotional distressExposure to the coldWomen affected more often than men

Stress

Digital artery contraction spasm

Occlusion of arteries

Predisposing Factors

Age - between 15 and 40 years old. Gender- Women are mostly affectedClimate- winter Cold

exposure

Tissue ischemia(s/s: Blanching of the digits, burning, throbbing pain, swelling

of the area)

Tissue hypoxia

Tissue necrosis

Tissue ulceration

Gangrene

Diagnostic Test Diagnostic Test

Diagnostic tests which doctors use to assess Diagnostic tests which doctors use to assess Raynaud's phenomenon include the:Raynaud's phenomenon include the:

• Antinuclear Antibody (ANA) lab testAntinuclear Antibody (ANA) lab test -- are are unusual antibodies, detectable in the blood, unusual antibodies, detectable in the blood, that have the capability of binding to certain that have the capability of binding to certain structures within the nucleus of the cells.structures within the nucleus of the cells.

• Erythrocyte Sedimentation Rate (ESR) Erythrocyte Sedimentation Rate (ESR) blood testblood test - - This blood test determines This blood test determines the rate at which red blood cells settle the rate at which red blood cells settle to the bottom of a tube. A faster-than-to the bottom of a tube. A faster-than-normal rate may signal an inflammatory normal rate may signal an inflammatory or autoimmune disease. or autoimmune disease.

Diagnostic TestDiagnostic Test

• Nailfold Capillaroscopy TestNailfold Capillaroscopy Test – – A drop of oil is A drop of oil is put on the nailfolds and then looked at under put on the nailfolds and then looked at under a magnifying glass to see whether there are a magnifying glass to see whether there are changes in the capillaries which are changes in the capillaries which are indicative of connective tissue disease. indicative of connective tissue disease.

• Cold Stimulation TestCold Stimulation Test - A heat sensor is taped to - A heat sensor is taped to your fingers and the temperature is recorded. Your your fingers and the temperature is recorded. Your hand is then immersed in ice water for hand is then immersed in ice water for 20 seconds20 seconds. . Then it is removed from the bath and the Then it is removed from the bath and the temperature recorded every 5 minutes until your temperature recorded every 5 minutes until your finger temperature is the same as it was before the finger temperature is the same as it was before the bath. This bath. This test should nottest should not be performed if you be performed if you have a have a finger infection or problems with the finger infection or problems with the blood supply to your fingers.blood supply to your fingers.

Diagnostic Criteria Diagnostic Criteria The diagnostic criteria used to diagnose The diagnostic criteria used to diagnose

primary Raynaud's phenomenonprimary Raynaud's phenomenon include: include:• Periodic vasospastic attacks ofPeriodic vasospastic attacks of pallor pallor

(whiteness) or (whiteness) or cyanosiscyanosis (blueness) (note: (blueness) (note: some doctors include the additional criterion some doctors include the additional criterion of the presence of these attacks for at least 2 of the presence of these attacks for at least 2 years)years)

• Normal Normal nailfold capillary patternnailfold capillary pattern• NegativeNegative antinuclear antibody test (ANA) antinuclear antibody test (ANA)• Normal Normal erythrocyte sedimentation rate (ESR)erythrocyte sedimentation rate (ESR)• Absence of pitting scars or ulcers of the Absence of pitting scars or ulcers of the

skinskin, or , or gangrene gangrene (tissue death) in the (tissue death) in the fingers or toesfingers or toes

Diagnostic CriteriaDiagnostic Criteria

The diagnostic criteria used to diagnose The diagnostic criteria used to diagnose Secondary Raynaud's phenomenonSecondary Raynaud's phenomenon include: include:

• Periodic vasospastic attacks of Periodic vasospastic attacks of pallorpallor (whiteness) and (whiteness) and cyanosiscyanosis (blueness) (blueness)

• AbnormalAbnormal nailfold capillary pattern nailfold capillary pattern• PositivePositive antinuclear antibody test (ANA) antinuclear antibody test (ANA)• AbnormalAbnormal erythrocyte sedimentation rate (ESR) erythrocyte sedimentation rate (ESR)• Presence of pitting scars or ulcers of the Presence of pitting scars or ulcers of the

skinskin, or gangrene in the fingers or toes, or gangrene in the fingers or toes

NursingNursing Management Management

• The client is encouraged to avoid exposure to The client is encouraged to avoid exposure to coldcold..

• Avoid repetitive hand movements and stressful Avoid repetitive hand movements and stressful situations. situations.

• Quit smoking and avoids secondary smoke as Quit smoking and avoids secondary smoke as nicotinenicotine is is potent vasoconstrictorpotent vasoconstrictor. .

• Stress management techniques ex. Stress management techniques ex. biofeedbackbiofeedback • Assist in alleviating some distress from the Assist in alleviating some distress from the

condition.condition.

MedicalMedical Management Management

• Assessed regularly for symptoms of Assessed regularly for symptoms of autoimmune autoimmune diseasesdiseases. .

• Medication is administered if the symptoms are Medication is administered if the symptoms are due to vasospastic disease.due to vasospastic disease.

• BiofeedbackBiofeedback allows clients to allows clients to voluntarily voluntarily control the temperature of their handscontrol the temperature of their hands..

• Avoiding particular Avoiding particular stimuli (cold, tobacco)stimuli (cold, tobacco) that that provoke provoke vasoconstrictionvasoconstriction..

• Calcium channel blockers- Calcium channel blockers- The first choice drugs The first choice drugs for Raynaud's in Scleroderma patients. for Raynaud's in Scleroderma patients.

• Vasodilators- Vasodilators- Some doctors prescribe a Some doctors prescribe a vasodilator (a drug that relaxes blood vessels), vasodilator (a drug that relaxes blood vessels), such as such as nitroglycerine nitroglycerine cream. You put the cream cream. You put the cream on your fingers to help heal skin ulcers. on your fingers to help heal skin ulcers.

Pharmacological Pharmacological Management Management • Nifedipine (Procardia, Adalat):Nifedipine (Procardia, Adalat): calcium channel calcium channel

blockers Nifedipine was found to reduce the: Frequency blockers Nifedipine was found to reduce the: Frequency of ischemic episodes of ischemic episodes

Nursing considerations :Nursing considerations : Don't give immediate-release Don't give immediate-release form within 1 week of acute MI or in acute coronary form within 1 week of acute MI or in acute coronary syndrome. Monitor blood pressure regularly, especially in syndrome. Monitor blood pressure regularly, especially in patients who take beta blockers or antihypertensive. patients who take beta blockers or antihypertensive. Watch for symptoms of heart failure.Watch for symptoms of heart failure.

• Captopril (Capoten)Captopril (Capoten) - ACE inhibitors- ACE inhibitorsIndications:Indications: Hypertension,Diabetic nephropathy Hypertension,Diabetic nephropathyNursing considerationsNursing considerations::• Monitor patient's blood pressure and pulse rate Monitor patient's blood pressure and pulse rate

frequently. frequently. • Alert: Elderly patients may be more sensitive to drug's Alert: Elderly patients may be more sensitive to drug's

hypotensive effects. hypotensive effects. • Assess patient for signs of angioedema. Assess patient for signs of angioedema. • Drug causes the most frequent occurrence of cough, Drug causes the most frequent occurrence of cough,

compared with other ACE inhibitors. compared with other ACE inhibitors.

Pharmacological Pharmacological ManagementManagement

• Diltiazem hydrochloride (Cardizem)-Diltiazem hydrochloride (Cardizem)- slow channel blocker or calcium antagonist

Indications:Indications: indicated for the treatment of hypertension. It may be used alone or in combination with other antihypertensive medications.

Nursing considerationsNursing considerations • Patients controlled on drug alone or with other drugs Patients controlled on drug alone or with other drugs

may be switched to Cardizem LA tablets once a day may be switched to Cardizem LA tablets once a day at the nearest equivalent total daily dose. at the nearest equivalent total daily dose.

• Monitor blood pressure and heart rate when starting Monitor blood pressure and heart rate when starting therapy and during dosage adjustments. therapy and during dosage adjustments.

• Maximum antihypertensive effect may not be seen Maximum antihypertensive effect may not be seen for 14 days. for 14 days.

Pharmacological Pharmacological ManagementManagement

• Verapamil (Calan) Verapamil (Calan) calcium channel blockerscalcium channel blockersIndications:Indications: Vasospastic angina (Prinzmetal's or Vasospastic angina (Prinzmetal's or variant angina); classic chronic, stable angina variant angina); classic chronic, stable angina pectoris; chronic atrial fibrillation, To prevent pectoris; chronic atrial fibrillation, To prevent paroxysmal supraventricular tachycardia , paroxysmal supraventricular tachycardia , Supraventricular arrhythmias.Supraventricular arrhythmias.

Nursing considerations Nursing considerations • Patients with severely compromised cardiac function Patients with severely compromised cardiac function

or those receiving beta blockers should receive or those receiving beta blockers should receive lower doses of this drug.lower doses of this drug.

• Instruct patient to take oral form of drug exactly as Instruct patient to take oral form of drug exactly as prescribed. prescribed.

• Tell patient that long-acting forms shouldn't be Tell patient that long-acting forms shouldn't be crushed or chewed. crushed or chewed.

Pharmacological Pharmacological ManagementManagement

• Medication that aids in healing finger ulcers Medication that aids in healing finger ulcers are iloprost a are iloprost a prostaglandinprostaglandin which is which is given IV and given IV and Ciprofloxacin (Cipro),Ciprofloxacin (Cipro), an an antibiotic.antibiotic.

• Chemotherapy drugs such as Chemotherapy drugs such as Bleomycin Bleomycin Sulfate (Blenoxane)Sulfate (Blenoxane) and and CisplatinCisplatin, also , also cause secondary Raynaud’s disease.cause secondary Raynaud’s disease.

Surgical ManagementSurgical Management• Nerve surgery.Nerve surgery. Through small incisions in the Through small incisions in the

affected hands or feet, a doctor strips away these tiny affected hands or feet, a doctor strips away these tiny nerves around the blood vessels. The surgery, called nerves around the blood vessels. The surgery, called sympathectomy, may reduce the frequency and sympathectomy, may reduce the frequency and duration of attacks, but it's not always successful. duration of attacks, but it's not always successful.

• Chemical injection.Chemical injection. Doctors can inject chemicals to Doctors can inject chemicals to block sympathetic nerves in affected hands or feet. block sympathetic nerves in affected hands or feet. You may need to have the procedure repeated if You may need to have the procedure repeated if symptoms return or persist. symptoms return or persist.

• Amputation.Amputation. Sometimes, doctors need to remove Sometimes, doctors need to remove tissue damaged from a lack of blood supply. This may tissue damaged from a lack of blood supply. This may include amputating a finger or toe affected by include amputating a finger or toe affected by Raynaud's in which the blood supply has been Raynaud's in which the blood supply has been completely blocked and the tissue has developed completely blocked and the tissue has developed gangrene.gangrene.

ReferencesReferences• Brunner and Suddarth’s Textbook of Medical-Surgical Brunner and Suddarth’s Textbook of Medical-Surgical

Book 11th edition vol. 1, page 1003-1004.Book 11th edition vol. 1, page 1003-1004.• Psychopathophysiology Manual, Mr. Jerome C. Bajao, Psychopathophysiology Manual, Mr. Jerome C. Bajao,

class 2007, page 59.class 2007, page 59.Internet: Internet: • http://http://en.wikipedia.org/wiki/Raynaud's_diseaseen.wikipedia.org/wiki/Raynaud's_disease• http://www.sclero.org/medical/symptoms/raynauds/http://www.sclero.org/medical/symptoms/raynauds/

diagnosis.htmldiagnosis.html• http://www.feelgoodhealth.co.za/http://www.feelgoodhealth.co.za/

circulation_help_reynauds.htmcirculation_help_reynauds.htm• http://www.mayoclinic.com/health/raynauds-disease/http://www.mayoclinic.com/health/raynauds-disease/

DS00433/DSECTION=2DS00433/DSECTION=2• http://arthritis.about.com/cs/raynauds/a/Raynauds.htmhttp://arthritis.about.com/cs/raynauds/a/Raynauds.htm• http://health.yahoo.com/lupus-diagnosis/antinuclear-http://health.yahoo.com/lupus-diagnosis/antinuclear-

antibodies-ana/healthwise--hw2297.htmlantibodies-ana/healthwise--hw2297.html• http://www.nhlbi.nih.gov/health/dci/Diseases/http://www.nhlbi.nih.gov/health/dci/Diseases/

raynaud/ray_diagnosis.htmlraynaud/ray_diagnosis.html• http://www.itmonline.org/journal/arts/raynauds.htmhttp://www.itmonline.org/journal/arts/raynauds.htm