Monday, September 6, 2010

Lydia Hall's Care, Core, and Cure Theory in Patient with Thromboangiitis Obleterans (Buerger's Disease)

Rationale of the Study

Buerger’s disease also known as Thromboangiitis Obliterans is a rare arterial vascular disease characterized by acute inflammatory lesions and occlusis thrombosis of the small and medium arteries and veins. The legs, feet, upper limbs. (Canobbio, 2006; Black and Hawks, 2005). The distal tips of hands and feet are pale, but as the disease progresses, the hands and feet become reddened when held in a dependent position (White, 2000; White and Duncan, 2002).

This disorder occurs in 6 of every 10,000 people. Incidence is highest among males aged 20 to 40 who have history of smoking or chewing tobacco. Recently has been increasing in prevalence in women. Although the classic patient is a heavy smoker, there may be association with passive exposure to smoke. More recent have revealed a notable increase in the number of women affected, with 8 to 23%. Because there has been a significant increase in the use of tobacco by women over the past several decade (Rajagopalan et. al., 2004; Beers, 2003). It is associated with a 30% of major amputation rate over 5-20 years (Cuschiere, 2003).

Tobacco is a slow, insidious, but most malignant poison. In whatever form it is used, it tells upon the constitution; it is all the more dangerous because its effects are slow and at first hardly perceptible. It excites and the paralyzes the nerves. Among children and youth the use of tobacco is working untold harm. The unhealthful practices of past generations affect the children and youth of today (White, 2001).

A growing number of young Filipinos are picking up smoking despite new restrictions on tobacco advertising, according to a nationwide study. Based on health report in 2005, there are 20 million of Filipinos who are smoking. Four million youth, aged between 11 and 19, are smokers, said the 2007 survey commissioned by the World Health Organization and the health department. The youth group made up 23 percent of all Filipino smokers, compared to about 18 percent in 2005. "This 23 percent could further increase in a matter of three years," said Maricar Limpin, a doctor who leads an anti-smoking lobby, Framework on Tobacco Control of the Philippines Alliance (Varona, 2009).

Government data shows smoking is linked to five of the top 10 leading causes of deaths in the Philippines, where up to 35 percent of the country's 89 million people are tobacco users ( It is interesting to know the leading disease and health condition that kill Filipinos everyday. Based from the Department of Health’s Health Statistics and was updated last January 2007 that the second Philippines’ top killer is the Vascular System Disease. It is closely related to the number one top killer which is the Heart Disease. The disease that affect the circulatory system or the blood vessels may include periphery artery disease, all types of aneurysms and dissections, atherosclerosis, Buerger’s Disease, Raynaud’s phenomenon, and arterial embolism and thrombosis (

Considering the figures that were stated, it is evident that Buerger’s disease is indeed rising in the Philippines that needs to be addressed early, especially since the disease is highly preventable through proper health teaching, education and by living a healthy lifestyle. With proper handling and adherence to the management program of the disease, complication and debilitating conditions can also be prevented in order to promote a quality of life that could be beneficial not only to the patient, but also to the community.

As a result of this study, a holistic care management can be proposed which would be used in managing a patient with Buerger’s disease and preventing such complication.

The researcher is a registered nurse, a volunteer public health nurse at Rural Health Unit II in Lipata, Minglanilla, Cebu, and was trained as an orthopedic nurse at Vicente Sotto Memorial Medical Center in Ward VIII for three (3) months. Qualified by his experience and educational background, the researcher is highly competent in conducting a case study that would benefit not only the client but the family and the community as a whole.

During the researcher’s exposures and experiences, the researcher saw the suffering of the client so as the family or significant others in giving care. The researcher saw the struggle and regret of the client, which can be prevented by stopping the cigarette smoking. Acknowledging the fact that the disease is increasing statistically, still the people are unaware of the disease.

Lydia Hall’s Nursing Model is believed to be applicable to the patient suffering from Buerger’s disease. By making this study, buerger’s disease will be minimal or under control case in the country, and the nurse will be guided on how to handle and deliver a holistic quality nursing care to the client.
Theoretical Background

This study is anchored on Lydia Hall’s Care, Core, and Cure Model. Care alludes to the hands on intimate bodily care of the client implies a comforting, nurturing relationship. Core involves the therapeutic use of self in communicating with the patient. The nurse reflects questions appropriately and helps the client clarify motives and goals facilitating the process of increasing the client’s awareness. Cure is the aspect of nursing involved with administration of medication and treatments. The nurse functions in this role as an investigator. The major outcome of nursing care is rehabilitation and feelings of self-actualization by the patient (Taylor, Lillis, and LeMone, 2005; Basavanthappa, 2007).

According to Tomey and Alligood (2002) Hall sees that nursing can and should be professional, that patients should be cared for only by a professional registered nurse who can take total responsibility for the care and teaching of the clients. The professional nurse functions most therapeutically when patients have entered the second stage of their hospital stay. The second stage is the recuperating, or non acute, phase of illness. The first stage of illness is a time of biological crisis, with nursing being ancillary to medicine. After the crisis period, the patient is more able to benefit and learn from the teaching that nurses can offer.

Potter (2004) pointed that Teaching presents correct principles, procedures and techniques of the health care to clients and informs clients about their health status. As nursing responsibility, teaching is implemented in all health care settings. The nurse is responsible for assessing the learning needs of clients and is accountable for the quality of education delivered.

Nursing is complex. The patient is complex. Not only is the patient a human being, bringing the influences of his or her culture and environment, but the patient may be suffering from an illness that medicine is still struggling to understand and treat. The nurse giving the care is also a unique human being, interacting with the patient in a complex process of teaching and learning. Nursing expertise centers around the body, because Hall viewed the patient as composed of Body, Pathology, and Personality. The uniqueness of nursing lies not only in knowing bodily care, but also in knowing how to modify these process and treatment and amend them in line with the personality of the patient (Tomey and Alligood, 2002).

Client achieves their maximal potential through a learning process, therefore the chief therapy they need is teaching. Rehabilitation is a process of learning to live within limitations. Physical and mental skills must be learned, but a prerequisite is learning about oneself as a person, becoming aware of feelings and behaviors, and clarifying motivations. Hall believed that the professional nurse, educated in communication skills, could best facilitate the teaching-learning process (Tomey and Alligood, 2002).

Hall was not pleased with the concept of team nursing. She said, “Any career that is defined around the work that has to be done, is a trade.” She vehemently opposed the idea of anyone other than educated, professional nurses taking direct care of patients and she decried the fact that nursing has trained non-professionals to function as practical nurses so professional nurses function as practical doctors (Tomey and Alligood, 2002).
Llyod (2007) pointed that it is an organizational system in which nurses carry out individual assessments of the clients’ needs and is basic on the relationship between specific nurse and specific client. It encourages professionalism in nursing practice. It also improves the quality of care and increases satisfaction of clients and nurses.

There are two phases of medical care practiced in medical centers: (1) biological crises and (2) evaluative medicine. The biological crises phase involves intensive medical and diagnostic treatment of the patient. The evaluative medicine phase follows and generally, it is the time when the patient is observed to appraise whether he or she is meeting the doctor’s goals (Tomey and Alligood, 2002).

Hall proposed that the nursing functions differ, using the three interlocking circles to represent aspects of the patient. She labeled the circles as the body (the care), the disease (the cure), and the person (the core). Nurses function in all three circles but to different degrees. They also share the circles with other providers. Hall believed that professional nursing care hastened recovery and that as less medical care was needed, more professional nursing care and teaching were necessary.

Hall viewed illness and rehabilitation experiences in which the nurse’s role was to guide and teach the client through personal care giving (Ellis and Hartley, 2004).

Care. The care circle represents the nurturing component of nursing and is exclusive to nursing. Nurturing involves using the factors that make up the concept of mothering (care and comfort of the person) and provide for teaching-learning activities (George, 2001).

The professional nurse provides care to the body of the client and will help the client to his activities of daily living such as eating, bathing, eliminating, and dressing. In providing the care, the main goal of the nurse is to provide comfort to the patient.

In providing care for a patient at the basic need level presents the nurse and patient with opportunity for closeness. As closeness develops, the patient can share and explore feelings with the nurse. The opportunity to explore feelings represents the teaching-learning aspect of nurturing.

George (2001) said that when functioning in the care circle, the nurse applies knowledge of the natural and biological sciences to provide a strong theoretical base for nursing implementations. In interactions with the patient the nurse’s role needs to be clearly define. A strong theory base allows the nurse to maintain a professional status rather than a mothering status, while at the same time incorporating closeness and nurturance in giving care. The patient views the nurse as a potential comforter, one who provides care and comfort through the laying on of hands.

Core. The core circle of the client care based in the social sciences, involves the therapeutic use of self, and is shared with other members of the health team. The professional nurse, by developing an interpersonal relationship with the client, is able to help the patient verbally express feelings regarding the disease process and its effects. Through such expression the patient is able to gain self-identity and further develop maturity. Hall (1965) says to look at an listen to self is often too difficult without the help of a significant figure (nurturer) who has learned how to hold up a mirror and sounding board to invite the behaver to look and listen to himself. If he accepts the invitation, he will explore the concerns in his acts and as he listen to his exploration through reflection of the nurse, he may uncover in sequence his difficulties, the problem area, his problem, and eventually the threat which is dictating his out-of-control behavior.

The professional nurse, by use of the reflective technique (acting as a mirror for the client), helps the patient look at and explore feelings regarding his or her current health status and related potential changes in lifestyle. The nurse uses a freely offered closeness to help the patient bring into awareness the verbal and nonverbal messages being into sent to others. Motivations are discovered through the process of bringing into awareness the feelings being experienced. With this awareness the patient is now able to make conscious decisions based on understood and accepted feelings and motivations. The motivation and energy necessary for healing exist within the patient, rather than in the health care team (George, 2001).

Cure. The cure circle of client care is based in the pathological and therapeutic sciences and is shared with other members of the health team. The professional nurse helps the client and family through the medical, surgical, and rehabilitative prescriptions made by the physician. During this aspect of nursing care, the nurse is an active advocate of the patient.

George (2001) The nurse’s role during the cure aspect is different from the care circle because many of the nurse’s actions take on a negative quality of avoidance of pain rather than a positive quality of comforting. This is negative in the sense that the client views the nurse as a potential cause of pain, one who is involved in such actions as administering injections, versus the potential comforter who provides care and comfort.
Hall places the motivation and energy needed for healing within the client. This aspect of her theory influences the nurse’s total approach to the five phases of the nursing process; assessment, diagnosis, planning, implementation, and evaluation.

George (2001) said that he assessment phase involves the collections of date about the health status of the individual. According to hall, the process of data collection is directed for the benefit of the patient rather than for the benefit of the nurse. Data collection should be directed toward increasing the patient’s self-awareness. Through use of observation and reflection, the nurse is able to assist the client t in becoming aware of both verbal and nonverbal behaviors. In the individual, increased awareness of feelings and needs in relation to health status increases the ability for self-healing.

The assessment phase also pertains to guiding the patient through the cure aspect of nursing. The health team collects biological data (physical and laboratory) to help the client and family understand and progress through the medical regimen.

During this phase the nurse determines the client’s learning need and readiness to learn. The nurse then interpret the data to formulate nursing diagnoses reflecting the identified needs.

The second phase is the nursing diagnosis, or statement of the patient’s need or problem area. How a nurse envisions the nursing role influences the interpretation of assessment data and conclusions reached. Viewing the patient as the power of self-healing directs conclusions differently than if the healing power rests in the physician or nurse. The patient is the one in control, the one who identifies the need (George, 2001).
Planning involves setting priorities and mutually establishing patient—centered goals. The client decides what is of highest priority and also what goals are desirable.

The core is involved in planning. The role of the nurse is to use reflection to help the client become aware of and understand needs, feelings, and motivations. Once motivations are clarified, Hall indicates that the client is the best person to set goals and arrange priorities. The nurse seeks to increase patient awareness and to support decision making based on the client’s new level of awareness. The nurse works with the client to help keep the goals consistent with the medical prescription. The nurse needs to draw on a knowledge base in the social and scientific areas to present the client with creative alternatives from which to choose (George, 2001; Basavanthappa, 2007).

Implementation involves the actual institution of the plan of care. This phase is the actual giving of nursing care. In the care and core circles, the nurse works with the patient, helping with bathing, dressing eating, and other care and comfort needs. The professional nurse uses a “permissive nondirective teaching-learning approach” to implement nursing care, thus helping the patient reach the established goals. This include “helping the patient with his feelings, providing requested information and supporting patient-made decisions” the nurse also helps the patient and family to help them understand and implement the medical plan (George, 2001; Basavanthappa, 2007).

Evaluation is the process in which the nurse will check if the goals are met or not. It is phase that the nurse will decide if the things that are done to the client is effective and successful. Timby (2009) and Smith (2007) although this is considered the last step, the entire process is ongoing. During this phase, nurse compares the actual to the expected outcomes or selected alternative plans of action when expected outcomes are not met.
Lydia Hall’s nursing theory has a limitation of its application to the patient care. The first of these areas is the stage of illness. Hall applies her ideas of nursing to a patient who has passed the acute stage of biological stress- that is, the patient who is experiencing the acute stage of illness is not included in Hall’s approach to nursing care. However, it is possible to apply the care, core, and cure ideas to the care of those who are acutely ill. The acutely ill individual often needs care in relation to basic needs, as well as core awareness of what is going on and, in cure understanding of the plan of medical care (George, 2001).

Another limitation of the theory is the age of the client. Hall refers the adult client in the second stage of their illness, thus limiting all younger clients. However, it would be possible to apply Hall’s theory with younger individuals. Certainly adolescents younger than age 16 are capable of seeking self-identity.

A third limiting factor is the description of how to help a person toward self-awareness. The only tool to be used is “reflection” in therapeutic communication; the emphasis of reflection arises from the belief that both the problem and the solution lie in the individual and that the nurse’s function is to help the individual find them. There are some techniques can also be use like active listening and nonverbal support, may also be used to facilitate the development of self-identity.

Fourth, the family is mentioned only in the cure circle. This means that the nursing contact with the families is used only in regard to the patient’s own medication care. It does not allow for helping a family increase awareness of family’s self.

Lastly, Hall’s theory relates only to those who are ill. This w9ould indicate no nursing contact with the healthy individuals, family, or communities, and it negated the concept of health maintenance and health care to prevent illness (George, 2001).

Although the study is anchored mainly on Lydia Hall’s Care, Core, and Cure model, but other theories were also used in support to support the study.

Undan (2004) further points out that from the theory of Faye Glenn Abdellah, defined nursing as service to individual and families. She conceptualized nursing as an art and a science that mold the attitudes, intellectual competencies and technical skills of the individual nurse into the desire and ability to help people, sick or well, and cope with their health needs.
Jean Watson’s theory of human caring in nursing proposes human caring as the moral ideal of nursing. In her definition for nursing consists of transpersonal human-to-human attempts to protect, enhance and preserve humanity by helping a person find meaning in illness, suffering, pain, and existence. Nurses participate in human caring to protect, enhance, and preserve humanity by assisting individuals to find meaning in illness, pain, and existence and to help others gain self knowledge, self-control, and self-healing. Watson’s conceptualizations of caring embody the essence of professional nursing practice. The nurses assist patients to find meaning in their existence, patient’s gain self-knowledge, self-control, self-love, choice, and self-determination in health decisions and lifestyle management. She articulates a holistic viewpoint of patient care (Rice, 2006; Hood, 2006).

Virginia Henderson’s theory, believed that the unique function of the nurse is to assist the individual, sick and well, in the performance of those activities contributing to health or its recovery the nurse would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. Henderson defined the patient as someone who needs nursing care (McEwen and Wills, 2007).

Cardiovascular System

The main functions of the cardiovascular system are the (1) rapid transport of nutrients (Oxygen, amino acid, glucose, fatty acids, water, etc) and waste product. (2) Hormonal control, by transporting hormones to their target organs, and by secreting its own hormones (e.g. atrial natriuretic peptide). (3) Temperature regulation, by controlling heat distribution between the body core and the skin. (4) reproduction, by producing erection of the penis. (5) Host defense, transporting immune cells, antigen and other mediator (e.g. antibodies) (Fagan, 2002; Ehrlich and Schroeder, 2005).

The heart and circulatory system make up your cardiovascular system. The heart works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from your heart to the rest of your body through a complex network of arteries, arterioles, and capillaries. Blood is returned to the heart through venules and veins. If all the vessels of this network in your body were laid end-to-end, they would extend for about 60,000 miles (more than 96,500 kilometers), which is far enough to circle the earth more than twice! (;

The circulatory system carries blood to all part of the human body. The one that carry the oxygenated blood away from the heart are the arteries, and the one that carry a poor oxygenated blood back to the heart are the veins

In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich blood back to your heart (Alforn and Hill, 2003).
In the diagram, the vessels that carry oxygen-rich blood are colored red, and the vessels that carry oxygen-poor blood are colored blue.

There were twenty (20) major arteries make a path through the tissues in the body, they will branch in a smaller arteries called the arterioles. Arterioles further branch into capillaries, where the oxygen and nutrients exchange is taking place (Schunke, 2006). Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to your heart to pick up oxygen. It serves as the communicator between the arteries and the veins. In addition to being the transporters of blood products, capillaries allow for waste products to enter. In this way they perform an important function because waste is ultimately transported out of the body through this interchange (www.wisegeek).

Arterial walls are composed of elastic tissue and smooth muscle. It is their elastic nature and the presence of substantial muscle tissue that allows them to expand and contract as the heart beats. This allows them to even out the increase in pressure caused by each beat (

Veins are thinner walled than arteries and have less elastic tissue, and much, much less smooth muscle tissue. Instead, veins make use of valves and the muscle contraction of your body's major skeletal muscles to squeeze blood along. This is the reason one asked to get up and walk around on a long plane flight—to prevent blood from pooling in the legs. As a side note, the lack of muscle in the walls of veins makes them more susceptible to bleeding when injured since there is no muscle to clamp down (

Blood is essential to transport oxygen and nutrients to the tissues; carbon dioxide and other waste product of the cell metabolism to the excretory organs; and leukocytes, hormones, and anti-bodies to various locations in the body. The volume of blood which varies with the size of the individual, is about five (5) quarts in the average man. Almost half of the blood consists of cellular elements; red cells, white cells, and platelets suspended in a viscous fluid called blood plasma. But in addition to the water, plasma contains salts, sugar (glucose), and other substances. And, most important, plasma contains proteins that carry important nutrients to the body’s cells and strengthen the body’s immune system so it can fight off infection (Crowley, 2009).

Blood is actually a tissue. It is thick because it is made up of a variety of cells, each having a different job. In fact, blood is actually about 80% water and 20% solid. We know that blood is made mostly of plasma (contains a variety of proteins and many other small molecules and ions). But there are 3 main types of blood cells that circulate with the plasma (Wilhelm. et. al., 2001).
• Platelets, which help the blood to clot. Clotting stops the blood from flowing out of the body when a vein or artery is broken. Platelets are also called thrombocytes.
• Red blood cells, also called as the erythrocyes which carry oxygen. Of the 3 types of blood cells, red blood cells are the most abundant. In fact, a healthy adult has about 35 trillion of them. The body creates these cells at a rate of about 2.4 million a second, and they each have a limited life span of about 100 to 120 days (Marieb, 2006).
• White blood cells, ward off infection. These cells, which come in many shapes and sizes, are vital to the immune system. When the body is fighting off infection, it makes them in ever-increasing numbers. Still, compared to the number of red blood cells in the body, the number of white blood cells is low. Most healthy adults have about 700 times as many red blood cells as white ones. White blood cells are also called leukocytes. Types of white blood cells are the neutrophil, eosinophil, basophil, monocytes, B and T lymphocyes (Gordon and Golany, 2006;

Pathophysiology of Buerger's Disease


Smoking is very closely related to Buerger's disease and smoking history is one of the critera for diagnosing the disease. In general if the patient absolutely abandons smoking the course of the disease will be invariably benign, but if smoking continues any treatment will ultimately be futile. Though "passive smoking" has adverse effect on cardiovascular system, non smokers should never develop the disease. Active smokers can be identified by measuring levels of nicotine, the major metabolite of nicotine in urine. Since all smokers do not develop the disease an immunopathogenesis is considered probable. It has been proposed in Japanese that presence of a gene linked to some HLA antigens might control the susceptibility to the disease (

Most patients with Buerger’s are heavy smokers, but some cases occur in patients who smoke “moderately”; others have been reported in users of smokeless tobacco. It has been postulated that Buerger’s Disease is an “autoimmune” reaction (one in which the body’s immune system attacks the body’s own tissues) triggered by some constituent of tobacco (

Mogotlane (2005) said that nicotine in cigarette acts as a vasoconstrictor so there will be less oxygen supply to the extremities, and in addition, is thought to alter the surface properties of platelets so that they become more stick, increasing the risk of clots formation causing further damage.

Although this condition is different from atherosclerosis, Buerger’s disease in older patients may also be followed by atherosclerosis of the larger vessels after involvement of the smaller vessels. The patient’s ability to walk may be severely limited. Patients are at higher risk for non healing wounds because of impaired circulation (Smeltzer and Bare, 2004).

Onset of the disease is gradual and first occurs in the feet or hands. Inflammation occurs in small and medium-sized arteries and veins near the surface of the limb. In advanced cases, blood vessels in other parts of the body may be affected. There is a progressive decrease in the blood flow to the affected areas. The pulse in arteries of the feet is weak or undetectable. The lack of blood flow can lead to gangrene, which is decay of tissue due to restricted blood supply (Zhang, 2008).

Symptoms. The thromboangiitis obliterans (Buerger’s disease presents with a triad of symptoms and signs: digital arteries occlusion, Raynaud’s phenomenon, and migrating superficial vein thrombophlebitis (Lilly, 2007).
Early symptoms include decrease in the blood supply (arterial ischemia) and superficial (near the skin surface) phlebitis. The main symptom is pain in the affected areas is the outstanding manifestation. A cold sensitivity in the hands with color changes, similar to that seen in Raynaud's disease, can develop and may be another early manifestation. In this case, the hands turn color--white, blue, and then intense rubor or reddish blue discoloration (Zhang, 2008; Smeltzer and Bare, 2004).

Claudication type of pain is common with pain in the arch of the foot. Various types of paresthesias may occur. Pulsations in the posterior tibial and dorsalis pedis arteries are weak or absent. In advance cases, the extremities may be abnormally red or cyanotic, particularly when dependent (Black and Hawks, 2005).

Diagnostic Test for Buerger's Disease


Leslie (2004) said that no Formal set of diagnostic studies exist to determine if the patient has Buerger’s disease. It can be a diagnosis of exclusion after a complete history taking and physical examinations have been performed. The commonly followed diagnostic criteria are below although the criteria tend to differ slightly from author to author.

1.) Typically between 20-40 years old and male, although recently females have been diagnosed. 2.) Current (or recent) history of tobacco use. 3.) Presence of distal extremity ischemia In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischemia or ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene) documented by noninvasive vascular testing such as ultrasound. 4.) Exclusion of other autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests. 5.) Exclusion of a proximal source of emboli by echocardiography and arteriography. 6.) Consistent arteriographic findings in the clinically involved and noninvolved limbs.

Buerger’s disease can be mimicked by a wide variety of other diseases that cause diminished blood flow to the extremities. These other disorders must be ruled out with an aggressive evaluation, because their treatments differ substantially from that of Buerger’s Disease. For Buerger’s there is no treatment known to be effective.

Diseases with which Buerger’s Disease may be confused include atherosclerosis (build–up of cholesterol plaques in the arteries), endocarditis (an infection of the lining of the heart), other types of vasculitis, severe Raynaud’s phenomenon associated with connective tissue disorders (e.g., lupus or scleroderma), clotting disorders of the blood, and others (Domingo, 2007).

Angiograms of the upper and lower extremities can be helpful in making the diagnosis of Buerger’s disease. In the proper clinical setting, certain angiographic findings are diagnostic of Buerger’s. These findings include a corkscrew appearance of arteries that result from vascular damage, particularly the arteries in the region of the wrists and ankles. Angiograms may also show occlusions (blockages) or stenoses (narrowings) in multiple areas of both the arms and legs. The changes are particularly apparent in the blood vessels in the lower right hand portion of the picture (the ulnar artery distribution) (

In order to rule out other forms of vasculitis (by excluding involvement of vascular regions atypical for Buerger’s), it is sometimes necessary to perform angiograms of other body regions (e.g., a mesenteric angiogram).

Skin biopsies of affected extremities are rarely performed because of the frequent concern that a biopsy site near an area poorly perfused with blood will not heal well (

Doppler ultrasonography can detect the direction, velocity, and turbulence of blood flow. May show diminished circulation in the peripheral vessel (

Plethysmoghraphy is a test used to measure changes in blood flow or air volume in different parts of the body. It may be done to check for blood clots in the arms and legs, or to measure how much air you can hold in your lungs. It detects decreased circulation in the peripheral vessels (

Arteriography on the other hand is a common procedure done by injecting a dye by x-ray into the bloodstream. Then X-ray pictures are taken and studied to see if arteries are damaged. It locates lesions and rules out atherosclerosis (

The Allen's test the doctor may conduct a simple test called the Allen's test to check blood flow through the arteries carrying blood to his/her hands. In the Allen's test, onemake a tight fist, which forces the blood out of your hand. The doctor presses on the arteries at each side of his/her wrist to slow the flow of blood back into the hand, making his/her hand lose its normal color. Next, the client will open his hand and the doctor releases the pressure on one artery then the other. How quickly the color returns to the hand may give a general indication about the health of arteries. Slow blood flow into hand may indicate a problem, such as Buerger's disease (

Blood Test. A deficient in protein C or protein S, or even anti-thrombin III may also be associated with venous or arterial; occlusion and leads to rejection of the diagnosis ( is also performed to identify other causes of narrowed or blocked arteries, such as inflammation of blood vessels due to autoimmune disorder. Such procedure include the erythrocyte sedimentary rate (ESR) and tests for C-reactive protein, which is produced only when inflammation is present (Beers, 2004).

Urinalysis creatinemia (The presence of excessive creatine in the blood) and studies of urinary sedimentary and proteinuria (albuminuria or urine albumin—is a condition in which urine contains an abnormal amount of protein) demonstrate the absence of renal damage suggestive of autoimmune diseases (; www. medical-dictionary. The free ; ).

Medical and Nursing Intervention, Prevention Complication, and Prognosis

Medication Treatment.

Vasodilators such as phenoxybenzamine. Vasodilators are given in Buerger’s disease to increase the lumen of the arteries and improve the flow of blood to the legs.

Nonsteroidal anti-inflammatory and opioids are given to the client to provide comfort form the pain in the affected part. These medications are particularly useful not only because they help decrease pain, but they also help control swelling and inflammation (

Anti-coagulants such as coumarin, dipyramidole and aspirin, 325 mg PO (by mouth), are used to prevent clot formation in the affected vessels. In addition to relieving pain and reducing inflammation (

Calcium Channel blockers such as nifedipine. Calcium-channel blockers are used to
produce vasodilatation in the affected blood vessels. It also act by relaxation of the smooth muscle of the arterial wall (Katzong, 2007).

Statins lower cholesterol level in the blood resulting in an increased clearance in the bloodstream, which reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with Buerger’s disease (Stump, 2008).

Surgical Management

Surgical Bypass of the larger blood vessel in the affected limb may be carried out in the severe cases of the disease to improve circulation. Lumbar sympathectomy in which the sympathetic nerve supply to the blood vessels of the legs is cut, indicated for relief of intractable rest pain and healing of refractory ulcers, often in conjunction with digital amputation.

Local debridement may be used to remove local areas gangrene. Local care is the other main component. Amputation may be required if gangrene is persistent and for patients with severe rest pain

Nursing Management

Non-pharmacological measures in the treatment for Buerger’s disease are directed towards improving blood flow to the affected area and exacerbating factors (Lippincott Williams & Wilkins, 2006).

Positioning. Let the client lie on the bed and elevate the legs for 1-2 minutes or until they blanch. Then let the patient sit on the side of the bed and hold the feet down until become pink. Let the client do this 5 times each, 3 times a day.
Instruct the client no to sit for long periods of time without getting up and walking. Sleep on the firm mattress. Never cross the legs of the knee (Ferrell, 2004).

Clothing. Items of clothing that constrict the circulation must be avoided and the limbs should be kept warm while avoiding direct exposure to heat, as cold may
precipitate vasoconstriction.

Prevention. Peripheral vascular disease is related to the avoidance of the risk behavior, smoking cessation, elimination of chewing tobacco, and marihuana, and avoidance of nicotine replacement and exposure to second-hand smoking (Levy, et al, 2005).

Weight. Must be controlled. Body Mass Index (BMI) can be used to indicate if you are overweight, obese, underweight or normal. Because of these problems, this body mass index calculator shows extra statistics to help patient to be informed and judge the body compared to others of the same height and age. The patient should have an average range from 18.5 – 24.9 (;

Exercise. A special exercise program can be developed to improve the efficiency of the blood supply to the legs. Regular exercise, especially walking is a good preventive measure because exercise improves the circulation generally (Mogotlane, 2005).

Buerger-Allen exercises consist of elevating them at that angle for 2 to 3 minutes.

The legs are then lowered to a dependent position until they become red and supported at that level for 5 to 10 minutes. The legs then placed flat on the bed with the client in a supine position for 10 minutes. The exercises are repeated as tolerated by the client (White, 2000).

Diet. Must have a food preparation should provide complete nutrient as well as supplies carbohydrates, proteins, fats, vitamins, minerals and fiber in their normal proportions. It is the basis for all diet modifications (Varona, 2003).
B vitamins they help blood circulation and are needed for good metabolism. This family of vitamins aids the body with stress and its effects.

Essential fatty acids helpful in improving blood circulation, good for the heart and cardiovascular health. Fatty acids are found in omega fatty acids from fish oil, flax seed oil, and borage seed oil.

Coenzyme Q10 improves circulation, some supplements will include reishi mushroom which helps boost the immune system as well.

Multi-vitamin and Mineral supplement contains B vitamins, vitamin E , calcium, zinc, and magnesium, which all are helpful in both the treatment and prevention of Buerger's disease as well as promote good circulation health. Nutrients in a daily supplement are required for good general health and well being (

Zinc, Calcium, Magnesium, Vitamin A, and Carotenoids helps circulation and to protect arteries from stress caused by sudden blood pressure changes, women often are low in calcium but need the other vitamins and minerals to properly absorb the calcium into their body (

Local wound care. Limited debridement, appropriate dressings, and IV antibiotics for cellulites. Moisturation of non ulcerated skin to prevent from drying.

Foot and toe care. Taking care of the toe and foot is very important to the client with Buerger’s disease. It helps prevent wounds or foot ulcers from becoming infected and painful or resulting to gangrene. Foot ulcers require meticulous care. Such care is needed to treat infection, to protect the skin from further damage, and to enable the person to continue to walk (Beers, 2004).

Low blood flow to the extremities means the body cannot resist infection as easily. Small cuts and scraped can easily turn into serious infections. Clean any cuts with water and cover with a clean bandage. Keep an eye on any cuts or scrapes to make sure they are healing well. If it get worse or heal slowly contact the physician promptly (

Inspect the feet daily for cracks, sores, corns, calluses, erythema, discoloration, or trauma, using mirrors as necessary for adequate visualization, wash feet daily with mild soap and warm water; check water temperature with water thermometer or elbow, dry the foot gently and thoroughly, use a lubricant, such as lanolin, for dry skin, or use moisturizer to soften it and avoid putting lotion between toes.
Use unmedicated power to keep the feet dry, prevent ingrown toenails. Cut toenails straight across and not too short. (A podiatrist may have to cut the nails; tell the podiatrist that peripheral arterial disease is present). Have a podiatrist treat corns or calluses.

Change socks and stockings daily and shoes often to prevent infection from moisture or dirt, wear loose wool socks to keep the feet warm, do not wear tight garters or stockings with tight elastic tops, wear shoes that fit well and have wide toe spaces and do not wear open shoes or walk barefoot.

Alternate between at least two pairs of properly fitted shoes to avoid potential for pressure points that can occur by wearing one pair only, ask the podiatrist about a prescription for special shoes if the feet are deformed, do not use hot water bottles for heating pads, attend to any foot injury immediately, and seek medical attention to avoid any potential complication and do not go barefoot indoors and outdoors (Swearingen, 2002; Beers 2004).

Emotional Support. Provide an emotional support. If necessary, refer the client for psychological counseling to help cope with restrictions imposed by this chronic disease. If the client undergone amputation, assess rehabilitative need, especially regarding changes in body image. Refer to the physical therapists, occupational therapist, and social service agencies, as needed (Lippincott Williams & Wilkins, 2009).

Spiritual. Care is important in dealing of clients with any kind of disease.

Promoting peace of mind and a sense of wholeness and well-being. Some client adhere to specific beliefs and ideals as a way of life, and these carry over into the most basic aspects of health and illness.(Mauk & Schmidt, 2004).

Encourage the client to allocate time for prayer and meditation each day and give Bile verse such as Jeremiah 33:3 (King James Version) “Call unto me, and I will answer thee, and show thee great and mighty things, which thou knowest not” and James 5:15 (King James Version) “And the prayer of faith shall save the sick, and the Lord shall raise him up; and if he have committed sins, they shall be forgiven him”.

Complication. Without smoking cessation, Buerger’s disease progresses inexorably through an obliterative vascular process, leading to coolness of the digits, hands, and feet; paresthesias; intermittent claudication symptoms; skin ulcerations over the fingers and toes; and gangrenous infarctions of the extremities. Once established, the disease may be maintained by even small exposures to tobacco (even smokeless tobacco or second-hand smoke). Failure to stop smoking is associated with a dramatic increase in the risk of limb loss by amputation. (Papadakis, 2006; Imboden, 2007).

Prognosis. If smoking cessation can be achieved, the outlook fro the disease may be better than in patients with premature peripheral vascular disease. If smoking cessation is not achieved then the prognosis is generally poor, with amputation of the affected part is the eventual outcome. (McPhee, 2008; More than 90% of the patients who quit smoking avoid amputation (Papadakis, 2006).

Buerger's is not immediately fatal, but life-shortening. Death rate has not been consistently shown as higher in patients who do not cease smoking but for this and other health concerns quitting is highly recommended. Female patients tend to show much higher longevity rates than men (

Prevention. Smoking is the only known causative agent for this disease and should be avoided and also nicotine products . Avoid cold temperature and other condition that reduce circulation to the hands and feet. (; Papadakis, 2006).

Quit Smoking. Decide to quit smoking – the power of will is very important, the most hard days after smoking is the first three (3) days, think about some issues like: The future for itself and loved ones, Cost lots of money, shortens man’s life span, health problems (throat cancer, lung cancer, emphysema, hardening of the arteries, slowing of mental activity, cholesterol build up and blood pressure problems).

Learn to depend on prayers, carry some Bible promises like Philippians 4:13 – “I can do all things through Christ which strengtheneth me” and 1 Corinthians 15:57 – “But thanks be to God, which giveth us the victory through our Lord Jesus Christ”.
Believe that these promises were written just for you and your need, just now. Repeat them all.

Get rid of all tobacco products, including ash trays and all the rest, stay away from other smokers as much as possible for the next few weeks. Two or even three times a day, take a warm bath for 15 – 20 minutes at a time. Relax and enjoy it. This will help soak the poisons out quicker.

Do deep breathing exercise every time you crave to smoke. Slowly take in as much air then exhale slowly. Repeat saying “I choose not to smoke”. Go out in an open air and breathe deeply. There is energy in fresh air; and it is helping to clean out
Drink at least 6 – 8 glasses of water daily. Do this between meals. This helps flush out poisons, take no alcoholic beverages, none at all. They will cloud the mind, weaken the power of will, and could lead to smoking again. Eat lots of fresh fruits and vegetables. Especially oranges, the vitamin C in oranges help destroy the poisons in the body, lessening the craving.

Walk outdoors for 15-30 minutes after each meal, breathing deeply going out. Don’t sit after a meal; for this is the time a person wants to smoke. The craving for a smoke only last for 3-5 minutes; then it returns later for another 3-5 minutes. As the time passes, it gets easier to resist the urge. Open up the curtains, raise the windows, and let the purifying sunlight and air. There is tobacco odor all over the house. Get it out. It is very important.

Avoid mustard, spices, pepper, vinegar, ketchup, hot sauce, chili, and hoarseradish. These foods tend to arouse craving, skip all sweets, pastries, cake, ice cream, and chocolate during the first 10 days. Avoid rich, sugar-heavy desert. A lot of sugar in the diet makes a person more jumpy and irritable. This is because it steals B vitamins and minerals, especially calcium. Calcium helps strengthen and calm the nerves.

Heavy smokers often like spiced foods; they frequently eat a heavy meat diet, plus gravies, fried foods, and other rich foods. Avoid them, do not use fish, fowl, meat, tea, coffee, or cola beverages. The uric acid, ammonia, purines, and other wastes in meat is what gives it that special flavor. It stimulates the nerves increases the craving for nicotine and alcohol. The caffeine in tea, coffee, and cola drinks can so trigger the nerves that, in matter of minutes, a person will have an uncontrollable desire to light up.

Carrot sticks or raw celery at the close of a meal will lessen the craving to smoke. Chewing raisins help somewhat. Carry a small package of raisins in the pocket. Hot water with lemon juice is helpful. Go on a fast for a day or two a time, drinking only hot water and lemon juice. That will clean the poisons out the fastest. Remember the quicker they eliminated, the quicker the craving will go. Keep positive. Keep busy doing something. Keep praying. Keep thanking God. Keep thinking of the brighter future of you and your loved ones Ferrel, 2004.

Nursing Care Plan : Identified Nursing Problem: Impaired Physical Mobility related to activity intolerance, musculoskeletal impairment, limited strength, and pain/discomfort.

Scientific Basis:

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative state involve some degree of immobility (e.g., leg fracture, trauma).

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobility joint, and gait changes affecting balance can significantly compromise the mobility of older clients.

Mobility is paramount if the older clients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Older client are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment.

Gulanick, 2007

Intervention and Rationale

I: Assess for impediments to immobility.
R: Identify the specific cause guides design of an optimal treatment plan.

I: Assess the client’s ability to perform ADLs effectively and safely on a daily basis using an appropriate assessment tool, such as the functional independence measures (FIM).
R: Restricted movement affects the ability to perform most ADLs. A variety of assessment tools are available, depending on the clinical setting. Such tools provide objective data for baselines.

I: Assess ability to ability to perform ROM to all joints.
R: This provides baseline measurement for future evaluation and guides therapy. Testing by a physical therapist may be needed.

I: Assess the client’s and caregiver’s knowledge of immobility and it’s implications.
R: Even the clients who are temporarily immobile are at risk for effects of immobility such as skin breakdown, muscle weakness, thrombophlebitis, constipation, pneumonia, and depression.

I: Assess for developing thrombophlebitis (e.g., calf pain Homan’s sign, redness, localized swellings, and rise in temperature).
R: Bed rest or immobility promotes clot formation.

I: Assess skin integrity. Check for sign of redness and tissue ischemia.
R: Regular examination of the skin (especially over bonny prominences) will allow for prevention or early recognition and treatment of pressure sores.

I: Monitor input and output record and nutritional pattern. Assess nutritional needs as they relate to immobility.
R: Pressure sores develop more quickly in clients with nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or rehabilitative program.

I: Assess elimination status (e.g., usual pattern, present patterns, signs of constipation).
R: Immobility promotes constipation.

I: Assess emotional response to disability or limitation.
R: Acceptance of temporary or more permanent limitations can vary widely among individuals. Each person has his or her own definition of acceptable quality of life.

I: Evaluate need for home assistance.
R: Obtaining appropriate assistance for client can ensure safe and proper progress of activity.

I: Evaluate the safety of the immediate environment.
R: Obstacles such as throw rugs, can further impede one’s ability to ambulate safely.

I: Encourage and facilitate early ambulation and other ADLs when possible. Assist in initial change: dangling legs, sitting in chair, ambulation.
R: The sooner the client becomes mobile, the less chance that debilitation will occur.

I: Provide positive reinforcement during activity.
R: Clients may be reluctant to move or initiate new activity due to fear of falling. A positive approach allows the learner to feel good about learning accomplishments.

I: Allow the client to perform tasks at his own rate. Do not rush the client. Encourage independent activity as able and safe.
R: Health care team and family care givers are often in hurry and do more for clients than needed, thereby slowing the client’s recovery and reducing his self-esteem.

I: Encourage to turn every 2 hours as needed.
R: Turning the clients optimizes circulation to all tissue and relieves pressure.

I: Perform passive or active ROM exercise to all extremities.
R: Exercise promotes increased venous return, prevents stiffness, and maintain muscle strength and endurance. To be most effective, all joints should be exercised to prevent contractures.

I: Encourage resistance training exercise using light weights when appropriate.
R: Research supports that strength training and other forms of exercise in older adults can preserve the ability to maintain independent living status and reduce risk of falling.

I: Encourage liquid intake of 2000 to 3000 ml/day unless contraindicated.
R: Liquids optimize hydration status and prevent hardening of the stool.

I: Teach energy-saving techniques.
R: These optimize the client’s limited reserves.

I: Assist the client in accepting limitations. Emphasize abilities.
R: Quality of life is influenced by a variety of factors that can extend beyond only physical function.
I: Explain progressive activity to the client. Help the client or caregivers establish reasonable and obtainable goals.
R: Information promotes awareness of the treatment plan. Setting small, attainable goals help increase self-confidence and promotes adherence.

I: Instruct the client or caregivers regarding hazards of immobility. Emphasize importance of measures such as position change, ROM, coughing, and exercise.
R: Information enables the client to assume some control over rehabilitation process.

I: Reinforce principles of progressive exercise, emphasizing that joints are to be exercised to the point of pain, not beyond.
R: “no pain, no gain” is not always true.

I: Instruct the client and family regarding the need to make the home environment safe.
R: A safe environment will help prevent injury related to falls.

Gulanick, 2007; Doenges, et al, 2002; Kruse, et al, 2003

Nursing Care Plan: Non-Compliance with treatment regimen related to low socio-economic status, difficulty in understanding the disease.

Scientific Basis:

Adherence is the extent to which an individual’s behavior taking medications, following diets, or making lifestyle changes coincides with medical or health advice. Degree of adherence may range from disregarding every aspect of the recommendations to following the total therapeutic plan.

Factors influencing the compliance of the patient are motivation to become well, degree of lifestyle change necessary, perceived severity of the health care problem, value place on reducing the threat of illness, difficulty in understanding and performing specific behaviors, degree of inconvenience of the illness itself or of the regimens, beliefs that the prescribed therapy or regimen will or will not help, specific cultural heritage that may make adherence difficulty, degree of satisfaction and quality type of relationship with the health care provider and overall cost of prescribed therapy.

Preventing illness may not have as high priority among as generating and maintaining the income, even when prevention is priority. The poor may not have be able to afford regular medical examination, housing or nutritious food that promotes health. It is important to them to work than to lose a day’s pay visiting the physician. Reliance on public assistance and inability to afford health care insurance limit both low income person’s access to health care and the type of care available.

Berman, et al, 2002

Intervention and Rationale
I Assess client reason for non-compliance, health beliefs and cultural influence.
R: Listening to client’s reason may identify concerns and help to establish a plan of care.

I: Determine family’s knowledge of illness and treatment. Taught them the illness and purpose of the treatment regimen.
R: Compliance is increased by knowledge to the therapeutic regimen.

I: Assess the possible contributing factors leading to non-compliance.
R: A client who is noncompliant is expressing a need; the behavior has meaning and helps patient meet their needs.

I: Assess financial resources and refer to social services as necessary.
R: Inability to afford health care is a major contributing factor in noncompliance.

I: Avoid using threats, pressure and inappropriate fear of arousal to increase compliance.
R: These measures are unethical and generally ineffective.

I: Develop a therapeutic relationship based on active listening.
R: Compliance is increased when the family feels that the health care provider is interested in genuinely cares how the family is doing.

I: Consult with primary practitioner regarding the possibility of exemplifying the health care regimen so that it is more easily fits into client’s lifestyle.
R: The more the complex the regimen, the less likely they will follow it.

I: Encourage significant and family to follow treatment regimen as much as possible despite financial constraints.
R: For effectiveness of pharmacological treatment and use for good of the patient.

I: Discuss non-compliance with instruction and programs with SO.
R: To determine rationale for assistance.

I: Provide accurate information about the treatment regimen: present clear understanding of the drugs positive effect, explain how the medication works and why it helps, etc. at the patient’s ability.
R: Individuals who perceive a relationship between their actions and outcomes want a great deal of information about their illness and treatment in order to control the disease. Other who do not necessary rely on internal cues will comply more with the prescribed regimen when the information is presented accurately by a professional they believe to be an authority.

I: Make a compliance contract with client review it periodically.
R: Often clients will be more compliant initially but as time lapses and the condition becomes chronic, compliance tends to decrease.

I: Note length of illness.
R: Clients tend to become passive and dependent in long-term, debilitating illnesses.

I: Be aware of nurse/ healthcare provider’s attitudes and behaviors toward the client.
R: Some care providers may be enabling client whereas others’ judgmental attitudes any impede treatment progress.

I: Develop therapeutic nurse-client relationship.
R: Promotes trust, provides atmosphere in which client and significant other(s) can freely express views and concerns.

I: Explore client’s involvement in or lack of mutual goal setting.
R: Patient will be more likely to follow through on goals he/she participated in developing.

I: Review treatment strategies. Identify which interventions in the plan of care are most important in meeting therapeutic goals and which are least amenable to compliance.
R: Sets priorities and encourages problem solving areas of conflict.

I: Provide for continuity of care in and out of the hospital/ care setting, including long-range-plans.
R: Supports trust and facilitates progress toward goals.

I: Have client paraphrase instructions/ information heard.
R: Helps validate client’s understanding and reveals misconceptions.

I: Accept the client’s choice/ point of view, even if it appears to be self-destructive. Avoid confrontation regarding beliefs.
R: To maintain open communication.

I: Establish graduate goals or modified regimen as necessary e.g. patient to stop smoking cigarette.
R: May improve quality of life, encouraging progression to more advanced goals.

I: Develop a system for self-monitoring. Share data pertinent to client’s condition e.g. laboratory results blood pressure.
R: Provide sense of control and enables client to follow own progress and to assist with making choices.

I: May use of social workers, government welfare agencies, government officials and resources to assist the family in their financial problem.
R: They can provide support and assist in financial arrangement by allocating amount from government and other charitable agencies.

Doenges, et al, 2006; Gulanick, 2007; Kruse, et al. 2003