Buerger’s Disease Nursing Care

 

Nursing Diagnosis

Acute Pain / Chronic Pain related to vasospasm / reperfusion disorders, ischemic / tissue damage.

Goal

Pain is reduced and tissue damage is not widespread.

Nursing Intervention
  • Record the characteristics of pain and paresthesias.
    • Rationale: Knowing the pain level.
  • Check the patient’s vital signs.
    • Rationale: To monitor the general state of the client.
  • Discuss with the patient, how and why the pain inflicted.
    • Rationale: That patients understand how to process pain.
  • Help the patient identify trigger factor or situation example: smoking, exposure to cold and how to handle.
    • Rationale: That patients understand the factors that influence pain.
  • Encourage the use of stress management techniques, entertainment activities.
    • Rationale: Used to divert the attention of the client.
  • Soak the affected area in warm water.
    • Rationale: Warm water will make the blood vessels will dilate and blood flow.
  • Give the room a warm, draft-free air, for example ventilation, air-conditioning, keep doors closed as indicated.
    • Rationale: Avoid infection and keep the air hot.
  • Monitor drug effects and action.
    • Rationale: Determine the level of effectiveness of the drug.
  • Collaboration: the medications as indicated, prepare surgical intervention when necessary.
    • Rationale: Administration of drugs to relieve pain.
Nursing Diagnosis

Ineffective Tissue Perfusion is related to cessation of arterial blood flow

Nursing Intervention
  • Observation of skin color on the sick.
    • Rationale: To see cyanosis or redness of the skin.
  • Note the decrease in pulse.
    • Rationale: Identify the severity of the cessation of arterial blood flow.
  • Evaluation of pain sensation parts, for example: sharp / shallow, hot / cold.
    • Rationale: Knowing levels, flavors, and forms of pain.
  • View and examine the skin for ulceration, lesions, gangrene area.
    • Rationale: Seeing how big a part that had gangrene.
  • Recommended for proper nutrition and vitamins.
    • Rationale:Proper nutrition and vitamin requirements are complete will increase the body’s immune system.
  • Collaboration: the medications as indicated (vasodilator), example: drainage lesions for culture or sensitivity.
    • Rationale: Giving obta vasodilator make the arteries dilate and blood flow.
Nursing Diagnosis

Knowledge Deficit: the need to learn about the condition, treatment needs related to lack of knowledge / resources are not familiar with, wrong perception / misunderstood.

Nursing Intervention
  • Provide information to patients about the disease.
    • Rationale: Increase patients’ knowledge about the disease.
  • Encourage clients to ask questions about the disease.
    • Rationale: Knowing the client’s level of curiosity about the disease.
  • Instruct to avoid exposure to cold.
    • Rationale: Cold temperatures make the constriction of the blood vessels and will aggravate the blockage of blood flow.
  • Preserve the environment at a temperature above 20.9 C eliminate cold flow.
    • Rationale: Hot temperature makes blood vessels to maintain a state of dilatation.
  • Discuss the possibility of moving to a warmer climate.
    • Rationale: Avoid the severity of which will happen.
  • Emphasize the importance of stopping smoking, provide information on local clinics / support group.
    • Rationale: That patients know and understand that smoking is a major contributing factor to the occurrence trombongitis.
  • Help the patient to create a method to avoid or alter discuss stress relaxation techniques.
    • Rationale: Distraction and relaxation techniques to make the patient more calm in responding.
  • Emphasize the importance of viewing each day and do the right skin care.
    • Rationale: Avoid skin injury.
Nursing Diagnosis

Anxiety related to the action procedure to be performed

Nursing Intervention
  • Describe the action procedure to be performed.
    • Rationale: Increase patients’ knowledge about action procedure.
  • Explain the importance of actions to be taken.
    • Rationale: In order for patients to understand why the need for that action.
  • Observation of vital signs.
    • Rationale: Knowing the general state of the client.
  • Give comfort to the patient.
    • Rationale: Patients will feel calm and do not worry with action procedures to be performed.
  • Reassure the patient that the action to be performed is the best course of action.
    • Rationale: Reduce the level of anxiety on the client.
  • Reassure the patient that the procedure acts to be performed safely.
    • Rationale: Reduce negative thinking about an act procedures.
  • Collaboration with physicians for the provision of drugs.
    • Rationale: To create a calm and reduce anxiety levels.