Page 1721 - Saunders Comprehensive Review For NCLEX-RN

l. Instruct the client about proper foot care
and measures to prevent ulcer
formation.
m. Assist the client in modifying lifestyle
to prevent further plaque formation.
n. Following arterial revascularization,
monitor for a sharp increase in pain,
because pain is frequently the first
indicator of postoperative graft
occlusion. If signs of graft occlusion
occur, notify the PHCP immediately.

B. Raynaud’s disease

1. Description
a. Raynaud’s disease is vasospasm of the
arterioles and arteries of the upper and
lower extremities.
b. Vasospasm causes constriction of the
cutaneous vessels.
c. Attacks occur with exposure to cold or
stress.
d. Affects primarily fingers, toes, ears, and
cheeks
2. Assessment
a. Blanching of the extremity, followed by
cyanosis from vasoconstriction
b. Reddened tissue when the vasospasm
is relieved
c. Numbness, tingling, swelling, and a
cold temperature at the affected body
part
3. Interventions
a. Monitor pulses.
b. Administer vasodilators as prescribed.
c. Instruct the client regarding medication
therapy.
d. Assist the client to identify and avoid
precipitating factors such as cold and
stress.
e. Instruct the client to avoid smoking.
f. Instruct the client to wear warm
clothing, socks, and gloves in cold
weather.
g. Advise the client to avoid injuries to
fingers and hands.

C. Buerger’s disease (thromboangiitis obliterans)

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