A client with Raynaud’s disease is experiencing an acute attack. The nurse should anticipate which of the following assessment findings?
1. Involuntary muscle contractions and twitching
2. Unilateral facial weakness and drooping mouth
3. Numbness and tingling of fingers and blanching of the skin at the fingertips
4. Photophobia
Raynaud’s disease ( Review)
Description
Raynaud’s disease is vasospasm of the arterioles and arteries of the upper and lower extremities.
Vasospasm causes constriction of the cutaneous vessels.
Attacks are intermittent and occur with exposure to cold or stress.
Affects primarily fingers, toes, ears, and cheeks
Assessment
Blanching of the extremity, followed by cyanosis during vasoconstriction
Reddened tissue when the vasospasm is relieved
Numbness, tingling, swelling, and a cold temperature at the affected body part
Interventions
Monitor pulses.
Administer vasodilators as prescribed.
Instruct the client regarding medication therapy.
Assist the client to identify and avoid precipitating factors such as cold and stress.
Instruct the client to avoid smoking.
Instruct the client to wear warm clothing, socks, and gloves in cold weather.
Advise the client to avoid injuries to fingers and hands.