Raynaud’s Disease

Definition
 Is avasospastic disorder causing discoloration of the fingers, toes, and
occasionally other areas. This condition can also cause nails to become brittle
with longitudinal ridges. Named for French physician Maurice Raynaud (1834–
1881), the phenomenon is believed to be the result of vasospasms that decrease
blood supply to the respective regions. Emotional stress and cold are classic
triggers of the phenomenon.
 It comprises both Raynaud's disease (also known as "Primary Raynaud's
phenomenon" where the phenomenon is idiopathic, and Raynaud's
syndrome (secondary Raynaud's), where it is caused by some other instigating
factor. Measurement of hand-temperature gradients is one tool used to
distinguish between the primary and secondary forms.
 It is possible for the primary form to progress to the secondary form.
In extreme cases, the secondary form can progress to necrosis or gangrene of
the fingertips.
 Raynaud's phenomenon is an exaggeration of vasomotor responses to cold or
emotional stress. More specifically, it is a hyperactivation of the sympathetic
system causing extreme vasoconstriction of the peripheral blood vessels, leading
to tissue hypoxia. Chronic, recurrent cases of Raynaud phenomenon can result
in atrophy of the skin, subcutaneous tissues, and muscle. In rare cases it can
cause ulceration and ischemic gangrene.

Prevalence:

 The phenomenon is more common in women than men, with the Framingham
Study finding that 5% of men and 8% of women suffer from it.
Epidemiology:

It is important to distinguish Raynaud's disease from syndrome. In order

to diagnose these two forms of Raynaud's, a doctor may look for signs
of arthritis or vasculitis, and may conduct a number of laboratory tests.

Primary Raynaud's (disease)

Raynaud's disease, or "Primary Raynaud's", is diagnosed if the symptoms

are idiopathic, that is, they occur by themselves and not in association with other
diseases. Some refer to Primary Raynaud's disease as "being allergic to coldness".
It often develops in young women in their teens and early adulthood. Primary
Raynaud's is thought to be at least partly hereditary, although specific genes have
not yet been identified.

Smoking worsens frequency and intensity of attacks, and there is a hormonal

component. Caffeine also worsens the attacks. Sufferers are more likely to
have migraine and angina than controls.

B. Secondary Raynaud's (syndrome)

Raynaud's syndrome, or "Secondary Raynaud's", occurs secondary to a wide

variety of other conditions. Secondary Raynaud's has a number of associations:

 Connective tissue disorders:

 scleroderma[8]
 systemic lupus erythematosus
 rheumatoid arthritis
 Sjögren's syndrome
 dermatomyositis
 polymyositis
 mixed connective tissue disease
 cold agglutinin disease
 Ehlers-Danlos Syndrome
 Eating disorders
 anorexia nervosa
 Obstructive disorders
 atherosclerosis
 Buerger's disease
 Takayasu's arteritis
 subclavian aneurysms
 thoracic outlet syndrome
 Drugs
 Beta-blockers
 cytotoxic drugs - particularly chemotherapeutics and most
especially bleomycin
 ciclosporin
 ergotamine
 sulfasalazine
 anthrax vaccines whose primary ingredient is the Anthrax Protective
Antigen
 Occupation
 jobs involving vibration, particularly drilling suffer from Vibration white
finger
 exposure to vinyl chloride, mercury
 exposure to the cold (e.g. by working packing frozen food)
 Others
 hypothyroidism
 cryoglobulinemia
 malignancy
 reflex sympathetic dystrophy
 carpal tunnel syndrome
 Magnesium Deficiency
 Erythromelalgia, (the opposite of Raynaud's, with hot and warm
extremities) often co-exists in patients with Raynaud's)[9]
It is important to realize that Raynaud's can herald these diseases by periods of more
than 20 years in some cases, making it effectively their first presenting symptom. This
can be the case in the CREST syndrome, of which Raynaud's is a part.

Patients with Secondary Raynaud's can also have symptoms related to their underlying
diseases. Raynaud's phenomenon is the initial symptom that presents for 70% of
patients with scleroderma, a skin and joint disease.

When Raynaud's phenomenon is limited to one hand or one foot, it is referred to as

Unilateral Raynaud's. This is an uncommon form, and it is always secondary to local or
regional vascular disease. It commonly progresses within several years to affect other
limbs as the vascular disease progresses.[10]

Diagnostic Examination:

A careful medical history will often reveal whether the condition is primary or secondary.
Once this has been established, an examination is largely to identify or exclude possible
secondary causes.

 Digital artery pressure: pressures are measured in the arteries of the fingers
before and after the hands have been cooled. A decrease of at least 15 mmHg is
diagnostic (positive).
 Doppler ultrasound: to assess blood flow.
 Full blood count: this can reveal a normocytic anaemia suggesting the anaemia
of chronic disease or renal failure.
 Blood test for urea and electrolytes: this can reveal renal impairment.
 Thyroid function tests: this can reveal hypothyroidism.
 An autoantibody screen, tests for rheumatoid factor, Erythrocyte sedimentation
rate and C-reactive protein, which may reveal specific causative illnesses or a
generalised inflammatory process.
 Nail fold vasculature: this can be examined under the microscope.
 Nail Fold capillaroscopy
- Nailfold capillaroscopy (study of capillaries under a microscope) can help
the doctor distinguish between primary and secondary Raynaud's phenomenon.
During this test, the doctor puts a drop of oil on the patient's nailfolds, the skin at the
base of the fingernail. The doctor then examines the nailfolds under a microscope to
look for abnormalities of the tiny blood vessels called capillaries. If the capillaries are
enlarged or deformed, the patient may have a connective

 ANA
- The antinuclear antibody test (ANA) test determines whether the body is
producing special proteins (antibodies) often found in people who have connective
tissue diseases or other autoimmune disorders. Patients with these connective tissue
diseases or other autoimmune disorders, make antibodies to the nucleus, or
command center, of the body's cells. These antibodies are called antinuclear
antibodies and are tested for by placing a patient's blood serum on a microscope
slide containing cells with visible nuclei. A substance containing fluorescent dye is
added which binds to the antibodies. Under a microscope the abnormal antibodies
can be seen binding to the nuclei.

 ESR
- The erythrocyte sedimentation rate (ESR) is a diagnostic test for
inflammation. The erythrocyte sedimentation rate (ESR) test is a measure of
inflammation in the body and tests how fast red blood cells settle out of unclotted
blood by measuring the rate at which the red blood cells fall to the bottom of a tube
over time. An increased sedimentation rate corresponds to increased non-specific
inflammation in the body. It is often called a "sedrate" for short.
Symptoms:

The condition can cause pain within the affected extremities, discoloration (paleness)
and sensations of cold and/or numbness. This can often be distressing to those who are
not diagnosed, and sometimes it can be obstructive. If someone with Raynaud's is
placed in too cold a climate, it could potentially become dangerous.

The symptoms include several cyclic color changes:

1. When exposed to cold temperatures, the blood supply to the fingers or

toes, and in some cases the nose or earlobes, is markedly reduced; the skin
turns pale or white (called pallor), and becomes cold and numb.
2. When the oxygen supply is depleted, the skin colour turns blue
(called cyanosis).
3. These events are episodic, and when the episode subsides or the area is
warmed, the blood flow returns and the skin colour first turns red (rubor), and
then back to normal, often accompanied by swelling and tingling.

All three colour changes are observed in classic Raynaud's. However, not all patients
see all of the aforementioned colour changes in all episodes, especially in milder cases
of the condition. Symptoms are thought to be due to reactive hyperemias of the areas
deprived of blood flow.

In pregnancy, this sign normally disappears due to increased surface blood flow.
Raynaud's has also occurred in breastfeeding mothers, causing nipples to turn white and
become extremely painful.[5] Nifedipine, a calcium channel blocker and vasodilator was
recommended to increase blood flow to the extremities and noticeably relieved pain to
the breast, in an extremely small study group.
Anatomy and Physiology

In people with Raynaud's, blood flow is more strongly reduced in response to cold
temperatures than in people without the disorder. When Raynaud's is severe (which is
uncommon), exposure to cold for as little as 20 minutes can cause major tissue
damage.

The blood vessels of people with Raynaud's also physically overreact to stressful
emotions. It is normal during times of psychological stress for the body to release
hormones that narrow its blood vessels. But for people with Raynaud's, this squeezing of
blood vessels is stronger. This results in less blood reaching fingers, toes, and
sometimes other extremities.
Three layers of the arteries and veins
 Tunica Intima

 Tunica Media

 Tunica Adventitia

Lumen-cavity of the blood vessels

Arteries-thicker than veins it is more elastic and can contract than veins
Arterioles-small arteries that delivers blood to the capillaries
Capillaries-connects arterioles with Venules and allows the exchange of gases, wastes,
and nutrients between blood and the tissue cells.
Venules -small vessels that connects the capillaries to veins
Veins-have more fibrous tissues and they have internal valves to ensure blood flow in
one direction
Venous sinuses -veins with thin walls.
 Pathophysiology

Predisposing Factors: Precipitating Factors:

Female Cold temperature, pollution
15 – 25 years of age Lifestyle: Smoking
Occupational Trauma

Digital Artery
Spasm/Constriction

Occlusion in the arteries

Impaired blood circulation

Tissue Hypoxia

Tissue Ischemia

Skin discoloration, cyanosis, pain, tingling with burning

pain

Raynaud’s Disease
 Untreated: Infection
Treated: Amputation

Septicemia

Management

A. Surgical Management:
 Symphatectomy
- is a surgical procedure that destroys nerves in the sympathetic nervous
system. The procedure is done to increase blood flow and decrease long-
term pain in certain diseases that cause narrowed blood vessels. It can also be used
to decrease excessive sweating. This surgical procedure cuts or destroys the
sympathetic ganglia, collections of nerve cell bodies in clusters along the thoracic or
lumbar spinal cord.
 Amputation for gangrenous tissue
- An amputation usually refers to the surgical removal of the whole or part of
an arm/hand or a leg/foot. Amputation of a toe or leg is one of the oldest surgical
procedures.
 Nerve surgery
B.Non Surgical
 Calcium channel blockers
 Alpha-adrenergic blocking agents
 Calcium antagonist to dilate peripheral vessels

Nursing Intervention:
 Kept hands warm
 Teach effects of nicotine
 Teach ways to avoid exposure to cold
 Wear adequate clothing
 Wear gloves when handling frozen foods
 Caution when cleaning refrigerator
 Wear socks during cold climate
 Discuss imporatance of reducing emotional stress
Discharge Planning

 Medication
-As prescribed by the physician
-Vasodilator

 Exercise
-Ambulate as tolerated

 Treatment
-Avoid triggers
-Gradual cessation of smoking

 Health teaching
-Discuss the etiology of the condition
-Ways to avoid exposure to cold

 Outpatient Care
-Follow up checkups as indicated by the physician.

 Diet
-Diet as tolerated
 Spiritual
-Continue Religious practices