Ateneo de Zamboanga University

College of Nursing
NURCO-2

Name: __________________________________ Date: ______________

Section: ___________________ Delivs # ____________

Concept/s: ________________________________________________________

CARPAL TUNNEL SYNDROME

The most common of the nerve entrapment syndromes, carpal tunnel syndrome
(CTS), results from compression of the median nerve at the wrist within the carpal
tunnel. This nerve passes through the carpal tunnel, along with blood vessels and
flexor tendons, to the fingers and thumb. The compression neuropathy causes
sensory and motor changes in the hand, especially the palm and middle finger.

Causes (Risk Factors):

● Dislocation or subluxation of ● Pregnancy

the carpus ● Menopause
● Fractures or skewed ● Obesity
consolidation of the distal ● Kidney failure
radius ● Hypothyroidism
● Wrist arthrosis, inflammatory ● Use of oral contraceptives
arthritis, and infectious ● Congestive heart failure
arthritis ● Diabetes
● Acromegaly ● Alcoholism
● Cysts or tumors within the ● Vitamin deficiency or
tunnel toxicity
● Exposure to toxins

Patho-physiology

Carpal Tunnel Syndrome (CTS) results from a combination of compression and

traction on the median nerve. Increased pressure leads to obstruction of venous
outflow, edema, and impaired microcirculation, compromising nerve function.
Lesions on the myelin sheath and axon cause inflammation, disrupting normal
protective functions. Wrist movements and repeated traction worsen the
dysfunctional environment, exacerbating nerve injury. Inflammation of flexor
tendons can also compress the median nerve. Sensory fibers are typically affected
first, followed by motor fibers, and autonomic nerve fibers may also be impacted.

Assessment Findings (Subjective & Objective)

Subjective findings: include pain, numbness, and tingling in the hand, particularly
at night, with a potential weakness in gripping objects.

Objective signs: involve positive Tinel's and Phalen's tests, altered sensation in
the median nerve distribution, muscle atrophy at the base of the thumb, and a
positive median nerve compression test. Both subjective and objective
assessments are crucial for diagnosing carpal tunnel syndrome.

Diagnostic Test Findings (Imaging or Scan & Laboratory Test)

● Electrodiagnostic Tests:
 ○ Nerve Conduction Studies (NCS): Measures the speed and strength
of electrical signals as they travel along the nerves. NCS can help
identify nerve damage and quantify its severity.
○ Electromyography (EMG): Records the electrical activity in
muscles, helping to evaluate the health of muscles and the nerves
controlling them.
● Imaging:
○ Ultrasound: Can assess the anatomy of the carpal tunnel,
identifying any abnormalities, such as swelling of the median
nerve.
○ Magnetic Resonance Imaging (MRI): Provides detailed images of
soft tissues and can help rule out other conditions that may mimic
CTS.
● Laboratory Tests:
○ Generally, CTS is a clinical diagnosis, and routine lab tests are not
specific for its confirmation.
○ Blood tests may be ordered to rule out conditions like rheumatoid
arthritis or diabetes, which can contribute to nerve compression.

Interventions/Management (Surgical Procedures, Treatments, Medications)

Non-Surgical Interventions:
● Wrist Splints: Wearing a splint at night helps keep the wrist in a
neutral position, reducing pressure on the median nerve.
● Activity Modification: Avoiding activities that exacerbate
symptoms and taking breaks during repetitive hand use can help
alleviate pressure on the nerve.
● Physical Therapy: Stretching and strengthening exercises may be
prescribed to improve flexibility and reduce symptoms.
● Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Medications
like ibuprofen can help alleviate pain and inflammation.
​ Corticosteroid Injections:
● Injecting a corticosteroid into the carpal tunnel can provide
temporary relief by reducing inflammation around the median
nerve.
​ Surgical Interventions:
● Carpal Tunnel Release Surgery: In cases where symptoms are
severe or do not respond to conservative measures, surgical release
of the transverse carpal ligament is performed to relieve pressure
on the median nerve.
● Endoscopic Surgery: An alternative to traditional open surgery, this
minimally invasive procedure involves using a small camera to
guide the surgeon in releasing the carpal ligament.
​ Medications:
● Antidepressants (e.g., amitriptyline) and Anticonvulsants (e.g.,
gabapentin): These medications may be prescribed to help manage
pain associated with nerve compression.
​ Lifestyle and Ergonomic Modifications:
● Advising patients on proper ergonomics and hand positioning
during activities to minimize strain on the wrist and prevent
symptom exacerbation.

Nursing Responsibilities
​ Assessment:
● Conduct a thorough patient history and physical examination to
assess symptoms and functional limitations.
● Perform neurovascular assessments, including Tinel's and Phalen's
tests.
 ​ Education:
● Provide patient education on CTS, its causes, and symptom
management strategies.
● Instruct on proper use of wrist splints and the importance of
activity modification.
​ Collaboration:
● Collaborate with other healthcare professionals, such as physical
therapists or occupational therapists, to optimize patient care.
​ Monitoring:
● Monitor and document patient response to interventions, including
medication effectiveness and changes in symptoms.
​ Medication Administration:
● Administer prescribed medications, such as NSAIDs or
corticosteroid injections, as per physician orders.
​ Postoperative Care:
● If surgery is performed, provide postoperative care, including
wound care, pain management, and monitoring for complications.
​ Patient Advocacy:
● Advocate for patient needs, including pain management,
accommodations at work, and follow-up care.
​ Promoting Self-Care:
● Encourage and support patients in implementing self-care
strategies, such as hand exercises and ergonomic adjustments.
​ Documentation:
● Maintain accurate and thorough documentation of assessments,
interventions, and patient responses.

Complications
CTS may lead to irreversible median nerve damage, resulting in permanent
impairment and disability. Muscle weakness and atrophy at the base of the thumb
can cause reduced dexterity. Patients affected by this condition may also suffer
from chronic wrist and hand pain, potentially progressing to the development of
complex regional pain syndrome.
The most frequent complication of carpal tunnel surgery is the development of a
neuroma in the palmar cutaneous branch of the median nerve. Patients may also
experience hypertrophic scars, joint stiffness, dysesthesias, and incomplete
resolution of their symptoms.
https://www.ncbi.nlm.nih.gov/books/NBK448179/

Questions:
1. A client tells the nurse that she experiences pain and numbness in the
fingers when typing on a computer keyboard. Which action will help the
nurse assess for Phalen’s sign?
A. Having the client hold both wrists in acute flexion with the dorsal
surfaces touching for 60 seconds
B. Having the client hold both hands above her head with her arms
straight for 30 seconds
C. Having the client extend her wrists while the nurse provides
resistance
D. Tapping gently over the median nerve in the wrist
Rationale: A. Acute wrist flexion places pressure on the inflamed median nerve,
causing the pain and numbness of carpal tunnel syndrome (Phalen’s sign).
Holding the hands above the head with arms straight for 30 seconds is not an
assessment technique. Tapping gently over the median nerve tests for Tinel’s sign,
which is another sign of carpal tunnel syndrome. Placing the wrists in extension
against resistance tests the strength.

2. A 45-year-old teller presents with numbness in her hands after being at

work for a few hours. The symptoms are worsening with time and she
describes a burning sensation on the palmar surface of the first 3 digits,
which is worse at night. On physical examination Phalen and Tinnel's tests
are positive. Which of the following is consistent with advanced disease?
A. Loss of sensation in the ring and little fingers bilaterally.
B. Decreased range of motion in the little finger.
C. Weakness of abduction of the little finger.
D. Difficulty in flexing the index and middle fingers at the
metacarpophalangeal joints.

Rationale: D. In advanced cases, there is the involvement of first and second

lumbricals, which function to flex the index and middle fingers at the
metacarpophalangeal joints and extend interphalangeal joints of the same digits.

3. Carpal tunnel syndrome can paralyze which of the following muscles?

A. Adductor pollicis and 2 medial lumbricals
B. Abductor pollicis and 2 lateral lumbricals
C. Lateral one and 2 medial lumbricals
D. Palmar and dorsal interossei

Rationale: B. Carpal tunnel syndrome (CTS) results from compression of the

median nerve at the wrist. Symptoms include numbness, muscle weakness, and
paresthesias which are often worse at night. Median nerve compression can cause
paralysis of the two lateral lumbricals and the abductor pollicis.
Electromyography and nerve conduction studies are the gold standard for carpal
tunnel syndrome diagnosis. Other clinical or special exams do not confirm CTS
but do assist in ruling out other diagnoses and prompt the electromyography and
nerve conduction studies.

4. You are providing nursing care for a patient with carpal tunnel syndrome
(CTS) who is preparing for surgery. Which intervention should you
delegate to the nursing assistant?
A. Immediately after surgery, the patient will no longer need
assistance.
B. Pain and numbness will be experienced for several days to weeks.
C. After surgery, the pain and paresthesia will no longer be present.
D. After surgery, the dressing will be large with dots of drainage
Rationale: B. Post-operative pain and numbness occur for a longer period of time
with endoscopic carpal tunnel release than with the open procedure. Patients often
need assistance post-operatively, even after they are discharged.

5. You are providing nursing care for a patient with carpal tunnel syndrome
(CTS) who is preparing for surgery. Which intervention should you
delegate to the nursing assistant?
A. Test the patient for painful tingling in the four digits of the hand.
B. Initiate placement of a splint for immobilization during the day.
C. Assist the patient with daily self-care measures such as bathing and
eating.
D. Assess the patient’s wrist and hand for discoloration and brittle
nails.
Rationale: C. Placing a splint for the first time is appropriate to the scope of
practice for physical therapists. Assessing and testing for paresthesia are not
within the scope of practice for nursing assistants. Assistance with activities of
daily living is within the scope of practice for a nursing assistant. Focus:
Delegation/supervision

6. You observe the nursing assistant performing all of these interventions for
the patient with CTS. Which action requires that you intervene
immediately?
A. Provide warm water and assist the patient with a bath.
B. Remind the patient not to lift very heavy objects.
C. Replace the patient’s splint in hyperextension position.
D. Arrange the patient’s lunch tray and cut the meat.
Rationale: C. When a patient with CTS has a splint used for immobilization of the
wrist, it is placed either in the neutral position or in slight extension. The other
interventions are correct and are within the scope of practice for a nursing
assistant. Nursing assistants may remind patients about elements of their care
plans such as avoiding heavy lifting. Focus: Delegation/supervision

7. You are preparing the post-operative CTS patient for discharge. Which
information is important to provide to this patient?
A. Notify the physician immediately for any pain or discomfort.
B. Hand movements will be restricted for 4 – 6 weeks after surgery.
C. Frequent pain medication dosages will no longer be necessary.
D. The surgical procedure is a cure for CTS.
Rationale: B. Hand movements, including heavy lifting, may be restricted for 4- 6
weeks after surgery. Patients experience discomfort for weeks to months after
surgery. Surgery is not always a cure. In some cases, CTS may recur months to
years after surgery.

8. The patient is scheduled for endoscopic carpal tunnel release surgery in

the morning. What key point will you be sure to teach the patient?
A. Pain and numbness will be experienced for several days to weeks.
B. Immediately after surgery, the patient will no longer need
assistance.
C. After surgery, the pain and paresthesia will no longer be present.
D. After surgery, the dressing will be large with dots of drainage
Rationale: A. Post-operative pain and numbness occur for a longer period of time
with endoscopic carpal tunnel release than with the open procedure. Patients often
need assistance post-operatively, even after they are discharged. The dressing
from the endoscopic procedure is usually very small and there should not be a lot
of drainage.

9. The nurse is conducting a discharge teaching regarding the prevention of

further problems to a client who undergone surgery for carpal tunnel
syndrome of the right hand. Which of the following instruction will the
nurse includes?
A. Do manual stretching exercise during breaks.
B. Learn to type using your left hand only.
C. Avoid carrying heavy things using the right hand.
D. Avoid typing in a long period of time.
Rationale: A. Manual stretching exercises will assist in keeping the muscles and
tendons supple and pliable, reducing the traumatic consequences of repetitive
activity.

10. Of the following common problems of the upper extremities, which results
from entrapment of the median nerve at the wrist?
 A. Impingement syndrome
B. Ganglion
C. Dupuytren’s contracture
D. Carpal tunnel syndrome
Rationale: Carpal tunnel syndrome is commonly due to repetitive hand activities.
A ganglion, a collection of gelatinous material near the tendon sheaths and joints,
appears as a round, firm, cystic swelling, usually on the dorsum of the wrist.
Dupuytren’s contracture is a slowly progressive contracture of the palmar fascia.
Impingement syndrome is associated with the shoulder and may progress to a
rotator cuff tear.

https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/ca
rpal-tunnel-syndrome/

Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN,

PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A
Nursing
Therapeutics Manual, 2007 3rd ed