BUERGER’S AND RAYNAUD’S DISEASESBy: Wenda Lyn V. Castro Definition: Buerger’s disease also known as thromboanginitis obliterans is a rare disease characterized by a combination of acute inflammation and thrombosis (clotting) of the arteries and pains in the hands and feet. The obstruction of blood vessels in the hands and feet reduces the availability of blood to the tissues. It often leads to skin ulcerations and gangrene of fingers and toes. Raynaud's is a rare disorder that affects the arteries. The disorder is marked by brief episodes of vasospasm (narrowing of the blood vessels) that occurs as a result of exposure to cold and emotional stress. Vasospasm of arteries reduces blood flow to the fingers and toes that result in coldness, pain and pallor of the fingertips or toes. Causes or Etiology: The basic causes of Buerger’s and Raynaud’s diseases are unknown. Buerger’s disease typically occurs between the ages of 20 to 40 years and rare in women. Incidences regarding the disease are strongly associated with cigarette smoking and do not occur with those individuals who are non-smokers. On the other hand, Raynaud’s disease is most common in women between 16 to 40 years of age and occurs more frequently in cold climates and during the winter. Also, many patients with the disease seem to have immunologic disorders (scleroderma, systemic lupus erythematosus, rheumatoid arthritis, obstructive arterial disease). Classifications/Types: Raynaud’s disease: 1. Primary Raynaud’s – more common and tends to be less severe 2. Secondary Raynaud’s or Raynaud Phenomenon – Secondary Raynaud's is linked to diseases and conditions that directly damage the arteries or damage the nerves that control the arteries in the hands and feet. Scleroderma and lupus are two examples of conditions that are linked to Raynaud's. About 9 out of 10 people who have scleroderma have Raynaud's. About 1 out of 3 people who has lupus has Raynaud's. Clinical Manifestations: Buerger’s disease: • Pain • Numbness, tingling, burning • Paresthesias • Cold feet • Foot discoloration • Poor hand and leg circulation • Intermittent claudication • Persistent ischemia of one or more digits of the fingers • Cold sensitivity • Pulsations in the posterior tibial and dorsalis pedis arteries are weak or absent • • • Cramps in the feet or legs after exercise Extremities maybe abnormally red or cyanotic The hands or feet may be enlarge Raynuad’s disease: The disorder is characterized by three color changes (white, red and blue). • Pallor – brought on by sudden vasoconstriction • Cyanotic (bluish purple) – skin then becomes bluish due to pooling of oxygenated blood during vasospasm. • Rubor (red) – as a result of exaggerated reflow (hyperemia) due to vasodilation, a red color is produced when oxygenated blood returns to the digits after the vasospasm stops. (Numbess, tingling and burning pain occurs as the color changes. The involvement tends to be bilateral and symmetric.) Risk Factors/Predisposing Factors: Buerger’s disease: • Predisposing factors: 1. Smoking 2. Obesity • Precipitating factor 1. Age (20 to 40 years of age) 2. Lifestyle 3. Occupation Raynaud’s disease: • Primary Raynaud’s 1. Gender. About 80 percent of people who have primary Raynaud's are women. 2. Age. Primary Raynaud's usually develops before the age of 30. 3. Family history. Primary Raynaud's may occur in members of the same family. 4. Living in a cold climate. Cold temperatures can trigger Raynaud's attacks. • Secondary or Raynaud Phenomenon 1. Age. Secondary Raynaud's usually develops after the age of 30. 2. Certain diseases and conditions. For examples, diseases that directly damage the arteries or damage the nerves that control the arteries in the hands and feet may cause secondary Raynaud's. 3. Injuries to the hands or feet. 4. Exposure to certain workplace chemicals, such as vinyl chloride (used in the plastics industry). 5. Repetitive actions with the hands, such as typing or using vibrating tools. 6. Certain medicines, such as migraine, cancer, cold/allergy, or blood pressure medicines. 7. Smoking. 8. Living in a cold climate. Pathophysiology: Buerger’s disease Thromboangiitis Obliterans (Buerger’s disease), which tends to occur in young men who are heavy cigarette smokers, is an inflammatory disease of the peripheral arteries. The inflammatory lesions are accompanied by thrombi and sometimes by vasospasm of arterial segments. Inflammation, thrombus formation, and vasospasm can eventually occlude and obliterate portions of small and medium-sized arteries in the feet and sometimes in the hands. Typically affected are the digital, tibial and plantar arteries of the feet and the digital, palmar, and ulnar arteries of the hands. The disease is sometimes associated with inflammation of adjacent veins and nerves. The pathogenesis of Buerger’s disease is unknown. The chief symptom of Buerger’s disease is pain and tenderness of the affected part. Clinical manifestations are caused by sluggish blood flow and include rubor (redness of the skin), which is caused by dilated capillaries under the skin, and cyanosis, which is caused by blood that remains in the capillaries after its oxygen has diffused into the interstitium. Chronic ischemia causes the skin to thin and become shiny, and the nails to become thickened and malformed. In advanced disease, ischemia resulting from vessel obliteration can cause gangrene. Raynaud’s disease: Raynaud phenomenon and Raynaud’s disease are both characterized by attacks of vasospasm in the small arteries and arterioles of the fingers, and, less commonly, the toes. Although the clinical manifestations of the phenomenon and disease are the same, their causes differ. Raynaud phenomenon is secondary to systemic diseases, particularly collagen vascular disease (scleroderma), pulmonary hypertension, thoracic outlet syndrome, myxedema trauma, serum sickness or long-term exposure to environmental conditions such as cold or vibrating machinery in a workplace. Raynaud’s disease, however, is a primary vasospastic disorder of unknown origin. Raynaud’s disease tends to affect young women and to consist of vasospastic attacks triggered by brief exposure to colds or by emotional stress. Genetic predisposition may play a role in its development. The clinical manifestations of the vasospastic attacks of either disorder are changes in skin color and sensation caused by ischemia. Vasospasm occurs with varying frequency and severity and causes pallor, numbness, and the sensation of cold in the digits. Attacks tend to be bilateral, and manifestations usually begin at the tips of the digits and progress to the proximal phalanges. Sluggish boold flow resulting from ischemia may cuase the skin to appear cyanotic. Rubor follows as vasospasm ends and the capillaries become engorged with oxygenated blood. Rubor often is accompanied by throbbing and paresthesias. Skin color returns to normal after the attack, but frequent, prolonged attacks interfere with cellular metabolism, causing the skin of the fingertips to thicken and the nails to become brittle. In severe, chronic Raynaud phenomenon or disease, ischemia can eventually cause ulceration and gangrene. Complications of Buerger’s and Raynaud’s disease: • • • Ulceration Gangrene Leg blood clots • • Changes in the nails and skin appears Inflammatory lesions are usually noted Diagnostic tests: Buerger’s disease: • Blood tests Blood tests to look for certain substances can rule out other conditions that may cause similar signs and symptoms. For instance, blood tests can help rule out scleroderma, lupus, blood clotting disorders and diabetes, along with other diseases and conditions. Nursing Responsibilities: Before: 1. Monitor vital signs 2. Refer to the chart to know whether the patient is in NPO order or not After: 1. Check vital signs 2. Assess patient’s level of consciousness 3. Assess patient’s condition • The Allen's test A simple test called the Allen's test is performed to check blood flow through the arteries carrying blood to your hands. In the Allen's test, you make a tight fist, which forces the blood out of your hand. The doctor presses on the arteries at each side of your wrist to slow the flow of blood back into your hand, making your hand lose its normal color. Next, you open your hand and your doctor releases the pressure on one artery then the other. How quickly the color returns to your hand may give a general indication about the health of your arteries. Slow blood flow into your hand may indicate a problem, such as Buerger's disease. Nursing Responsibilities: Before: 1. Inform patient regarding the test to be done 2. Ask the patient to cooperate to achieve successful findings After: 1. Document findings. • Angiogram An angiogram, also called an arteriogram, helps doctors see the condition of the arteries. Doctors inject dye into an artery and then take X-rays or other types of images. Images show any blockages in the artery. The doctor may order arteriograms be performed on both of the arms and legs — even if a client don't have signs and symptoms of Buerger's disease in all of the limbs. Buerger's disease almost always affects more than one limb, so even though the client may not have signs and symptoms in the other limbs, this test may detect early signs of vessel damage. Nursing Responsibilities: Before: 1. Inform the client regarding NPO order 2. Assess for a potential allergy to the contrast dye 3. Obtain health history about allergies to sea foods and iodine 4. Obtain Vaseline VS 5. Consent signed After: 1. Bed rest until VS are stable 2. Monitor especially peripheral pulses 3. Apply pressure dressing or ice over the puncture site to prevent bleeding 4. Immobilize affected extremity in extension to promote adequate circulation 5. Monitor extremities for color, temperature and tingling Raynaud’s disease: Cold Stimulation Test A cold stimulation test can be used to trigger Raynaud's symptoms. For this test, a small device that measures temperature is taped to your fingers. Your hands are then exposed to cold—they're usually briefly put into ice water. Your hands are then removed from the cold, and the device measures how quickly your fingers return to their original temperature. If you have Raynaud's, it may take more than 20 minutes for your fingers to return to their original temperature. Nursing Responsibilities: Before: 1. Describe the procedure to the client and explain the reason for the test. 2. Assure the patient that the procedure is safe. After: 1. Document findings. 2. Extend results and findings to the patient. • Nailfold Capillaroscopy Your doctor may do a test called nailfold capillaroscopy. For this test, your doctor puts a drop of oil at the base of your fingernail. He or she then looks at your fingernail under a microscope. If your doctor sees abnormal arteries, it may mean you have a disease linked to Raynaud's, such as scleroderma. Nursing Responsibilities: Before: 1. Explain procedure to the patient. 2. Tell the patient who will perform the procedure and where it will be done. After: 1. Document findings • Erythrocyte Sedimentation Rate (ESR) The ESR is s sensitive but nonspecific test that is frequently the earliest indicator of disease when other chemical or physical signs are normal. This is done to aid detection and diagnosis of occult diseases such as tuberculosis, tissue necrosis or connective tissue disease. Nursing Responsibilities: Before: 1. Explain that this test evaluates the condition of RBCs. 2. Inform the patient that the test requires blood sample After: 1. If a hematoma develops at the venipuncture site, applying warm compress soaks eases discomfort. • Antinuclear antibodies (ANA) test A positive test for the presence of these antibodies — produced by your immune system — indicates a stimulated immune system and is common in people who have connective tissue diseases or other autoimmune disorders. Nursing Responsibilities: Before: 1. Explain that this test evaluates the immune system and that further testing is required for accurate diagnosis. 2. Check the patient’s medication history for drugs that may affect test results, such as isoniazid, hydralazine, and procainamide. After: 1. If a hematoma develops at the venipuncture site, applying warm compress soaks eases discomfort. Medical and Surgical Management: The main objectives in managing Buerger’s and Raynaud’s diseases are to improve circulation to the extremities, prevent the progression of the disease and protect the extremities from trauma and infection. Non- invasive interventions include: • Advice patient to completely stop using tobacco because symptoms are often relieved by cessation of tobacco use. • Encourage patient to attend smoking-cessation programs. Daily counseling sessions and other activities helps patient deal with the cravings for cigarettes and to help you learn to live tobacco-free. • Encourage patients to take care of their fingers and toes. • Check the skin on arms and legs daily for cuts and scrapes. • Clean any cuts with water and cover them with a clean bandage. Keep an eye on any cuts or scrapes to make sure they're healing. If they get worse or heal slowly, see the doctor promptly. • Elevate the head of the bed to or assuming a seating position with the feet resting on the floor to help improve peripheral circulation. • Educate the patient that the use of neutral soaps and body lotion prevents drying and cracking of skin • Encourage patient to exercise, control weight and eat nutritious foods (low cholesterol and low fat diet) to promote healing and prevent tissue breakdown • Tell patient to avoid exposure to cold and protect the extremities from trauma and injury by wearing adequate clothing, wearing gloves when handling frozen foods, and wearing socks during cold climate. • Discus importance of reducing emotional stress • Avoid drugs that can cause vasoconstriction, such as contraceptive pills, beta blockers and ergotamines. Invasive interventions include: Below-knee of above-knee amputation – removal of a body part, usually an extremity. Nursing Responsibilities: 1. The nurse determines whether the patient has a network of family and friends to assist with ADLs. 2. The nurse ensures that the patient has the knowledge and ability to assess for any postoperative complications such as infection and decreased blood flow. 3. Maintain a positive attitude so that the patient can adjust to the amputation more readily and actively participate in the rehabilitative plan, learning how to modify activities and how to use assistive devices for ADL’s and mobility. • Sympathectomy – a surgical interruption of part of the sympathetic nerve pathways to relieve chronic pain or to promote vasodilation in vascular diseases. The sheath around an artery carries the sympathetic nerve fibers that control constriction of the vessel. Removal of the sheath causes the vessel to relax and allows more blood to pass through it. •