Question

A nurse assesses a 40-year-old female client with Raynaud's phenomenon involving her right hand. The nurse records the information in the progress notes, as shown. From these findings, what should the nurse first instruct the client how to manage?

1. acute pain.
2. numbness.
3. lack of circulation.
4. potential for skin breakdown.

Answer 1

The nurse should first instruct the client on how to manage the potential for skin breakdown associated with Raynaud's phenomenon, as this poses an immediate threat of long-term complications.

Step-by-step explanation:

Raynaud's phenomenon is characterized by episodes of reduced blood flow to the fingers and toes, usually in response to cold or stress, leading to symptoms such as skin color changes, numbness, and acute pain. Given the case where the client exhibits symptoms like swelling and loss of skin and nails, the nurse should prioritize preventing potential for skin breakdown. This is because damaged tissues are more susceptible to infection and further complications. Instructions to the patient should include avoiding temperature extremes, stress management, wound care, and possibly wearing protective gloves to minimize trauma and maintain skin integrity.

Circulatory issues like lack of circulation and numbness are also significant but secondary to immediate skin protection. Managing acute pain is important for the client's comfort, but it does not pose an immediate threat as potential skin breakdown does in terms of leading to long-term complications.