The nurse is assessing the client following the transfusion of 2 units of packed RBCs.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding click on the finding again

 

Laboratory Results

1800

• WBC count 6700/mm3 15.000 to 10.000/mm
• Hemoglobin 12 g/dl (14 to 18 g/dL)
• Hematocrit 36% (40% to 52%)

Vital Signs

1800

• Blood pressure 112/74 mm Hg
• Heart rate 95/min
• Respiratory rate 18/
• Temperature 37.5°C (95°F)
• Oxygen saturation 100% via 2 L/min nasal cannula

 

Rationale:

A. Provide information about stress management.: Stress is a major trigger for vasospastic episodes in Raynaud’s disease because it increases sympathetic nervous system activity, causing further arterial constriction. Stress-reduction techniques such as deep breathing, biofeedback, or relaxation exercises helps reduce the frequency and severity of attacks.

B. Administer epinephrine for acute episodes.: Epinephrine causes vasoconstriction, which would worsen Raynaud’s symptoms by further reducing blood flow to the extremities. During an acute episode, warming the affected areas and avoiding additional vasoconstrictors is essential. Epinephrine is not indicated as a treatment and can intensify ischemic discomfort

C. Maintain a cool temperature in the client's room.: Cold temperatures are one of the most common triggers for vasospasm in Raynaud’s disease. A cool environment increase the likelihood of an episode by promoting peripheral vasoconstriction. The nurse should provide a warm environment and encourage protective clothing to maintain circulation.

D. Give a glucocorticoid steroid twice per day.: Steroids are not a standard treatment for Raynaud’s because the condition is related to vasospasm rather than inflammatory processes. Routine steroid use would expose the client to unnecessary adverse effects without addressing the underlying problem. Management strategies focus instead on warmth, lifestyle modification, and vasodilator medications when needed.

Rationale:

A. "Taking disulfiram is an alternate therapy instead of joining Alcoholics Anonymous.": Disulfiram is a pharmacologic aid and should be used in combination with counseling or support groups like Alcoholics Anonymous. It is not a standalone treatment and does not replace behavioral therapies.

B. "I should avoid products containing alcohol, like mouthwash, while taking this medication.": Disulfiram causes a severe reaction when alcohol is ingested, even in small amounts found in products like mouthwash or cough syrup. Avoiding all alcohol-containing products demonstrates correct understanding of safety precautions while taking this medication.

C. "Disulfiram is mainly used for people who are at a high risk for a relapse of drinking alcohol.": Disulfiram is primarily used to maintain abstinence by causing unpleasant reactions with alcohol, but it is not limited to clients at high risk of relapse. It is important for all clients on disulfiram to understand adherence and alcohol avoidance.

D. "My sensitivity to alcohol will go away 24 hours after I stop taking this medication.": Disulfiram’s effects persist for up to 14 days after discontinuation, not just 24 hours. The client must continue to avoid alcohol for a longer period even after stopping the medication to prevent adverse reactions.