Raynaud’s Disease

RAYNAUD’S DISEASE

Raynaud’s disease is a form of intermittent arteriolar vasocon-striction that results in coldness, pain, and pallor of the fingertips or toes. The cause is unknown, although many patients with the disease seem to have immunologic disorders. Symptoms may result from a defect in basal heat production that eventually decreases the ability of cutaneous vessels to dilate. Episodes may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age, and it occurs more frequently in cold climates and during the winter.

The term Raynaud’s phenomenon is used to refer to localized, intermittent episodes of vasoconstriction of small arteries of the feet and hands that cause color and temperature changes. Gener-ally unilateral and affecting only one or two digits, the phenom-enon is always associated with underlying systemic disease. It may occur with scleroderma, systemic lupus erythematosus, rheuma-toid arthritis, obstructive arterial disease, or trauma.

The prognosis for Raynaud’s disease varies; some patients slowly improve, some become progressively worse, and others show no change. Ulceration and gangrene are rare; however, chronic dis-ease may cause atrophy of the skin and muscles. With appropri-ate patient teaching and lifestyle modifications, the disorder is generally benign and self-limiting.

Clinical Manifestations

The classic clinical picture reveals pallor brought on by sudden vasoconstriction. The skin then becomes bluish (cyanotic) due to pooling of deoxygenated blood during vasospasm. As a result of exaggerated reflow (hyperemia) due to vasodilation, a red color is produced (rubor) when oxygenated blood returns to the digits after the vasospasm stops. The characteristic sequence of color change of Raynaud’s phenomenon is described as white, blue, and red. Numbness, tingling, and burning pain occur as the color changes. The involvement tends to be bilateral and symmetric.

Medical Management

Avoiding the particular stimuli (eg, cold, tobacco) that provoke vasoconstriction is a primary factor in controlling Raynaud’s dis-ease. Calcium channel blockers may be effective in relieving symptoms. Studies indicate that nifedipine (Procardia, Adalat) is an effective calcium channel blocker for treating an acute episode of vasospasm (Kaufman et al., 1996). Sympathectomy (inter-rupting the sympathetic nerves by removing the sympathetic ganglia or dividing their branches) may help some patients.

Nursing Management

The nurse teaches patients to avoid situations that may be stress-ful or unsafe. Stress management classes may be helpful. Expo-sure to cold must be minimized, and in areas where the fall and winter months are cold, the patient should remain indoors as much as possible and wear layers of clothing when outdoors. Hats and mittens or gloves should be worn at all times when outside. Fabrics specially designed for cold climates (eg, Thinsulate) are recommended. Patients should warm up their vehicles before get-ting in so that they can avoid touching a cold steering wheel or door handle, which could elicit an attack. During summer, a sweater should be available when entering air-conditioned rooms.

Concerns about serious complications, such as gangrene and amputation, are common among patients. However, these con-sequences are uncommon. Patients should avoid all forms of nicotine; the nicotine gum or patches used to help people quit smoking may induce attacks.

Patients should be careful about safety. Sharp objects should be handled carefully to avoid injuring the fingers. Patients should be informed about the postural hypotension that may result from medications, such as calcium channel blockers, used to treat Raynaud’s disease. The nurse also discusses safety precautions related to alcohol, exercise, and hot weather.