Aurelio Lyca Mae M.

BSN III-D

CARPAL TUNNEL SYNDROME

PROFRESSIVE CASE ANALYSIS

You are the nurse-on-duty at the medical OPD today.

Ms. Xandra Y. Zobel (XYZ) is a 50-year-old female municipal clerk, married, who
comes to the clinic due to pain and numbness of the right hand. According to the patient,
her condition started 3 days ago while she was at work. She relates, “Bigla met lattan nga
nagsakit ken nagbibineg daytoy imak. Kaado iti ubrami ngamin didiay opisina ta
masungadan iti election. Nagado ti pakamakam ni bossko nga computer works”

XYZ claims that “Medyo lumteg ti sakitna daytoy imak no ibaliwko iti posisyonna.”
She mentions that she has been taking Doloneurobion 1 tablet PO 3x a day as suggested by
her friend to ease the pain and promote hand sensation; however she says, “Saanmet unay
effective.” She also takes Tylenol 650 mg when the pain intensifies especially at night which
offers mild relief.

The patient is a known diabetic for 5 years and is taking metformin 500 mg/tab, 1
tablet PO twice a day. She denies any history of cardiovascular diseases, recent infection
and trauma to the affected hand.

XYZ’s medical condition is confirmed: Carpal Tunnel Syndrome. She shares that she
smoked and took oral contraceptive pills during her reproductive years and comments,
“Daytoy siguro nasakitko ket epekto daydi ado a tawen a pinagsigarilyo’k ken pinagtumarko
iti contraceptive pills.” She then asks the nurse, “Kasanoakpay nga makatrabaho iti nasayaat
ket agsakitmet daytoy imakun no kasta nga kaado iti ubra?”
Question 1: Identify data in the scenario that can be causes/reasons of concern for the
nurse. Explain how each data can be a cause/reason of concern.

Diabetes

The patient is a known diabetic for 5 years. The relationship between diabetes and
CTS is complicated, but carpal tunnel syndrome is generally believed to be more common in
individuals with diabetes, even those without diabetic nerve complications. Carpal tunnel
syndrome is widely reported in up to between 15-20% per cent of people with diabetes,
with research suggesting the link between diabetes and carpal tunnel syndrome could be
due to excessively high blood sugar levels. This can result in carpal tunnel tendons becoming
glycosated, which occurs when glucose attaches to the tendon proteins and restricarpal
tunnel syndrome their ability to move freely (Diabetes UK, 2019).

Age

The patient is currently 50 years old. The peak age range for development of carpal
tunnel syndrome (CTS) is 45-60 years and only 10% of patients with CTS are younger than 31
years (Ashworth, 2022).

Occupation

The patient is a municipal clerk and working hardly due to the upcoming election.
Production type jobs that include an assembly line or repeated movement can cause a
worker to sustain an injury such as carpal tunnel. For example, an office worker who is on
the computer for eight-plus hours each day operating a mouse may develop the syndrome.
Moreover, due to the repetitive use of her hand contributed to the cause why the patient is
experiencing pain and numbness of her right hand. When holding equipment or devices in
the hand for an extended period of time can also lead to pain and suffering. In order to
support my claims, repetitive hand use and wrist motions or activities over a prolonged
period of time may aggravate the tendons in the wrist, causing swelling that puts pressure
on the nerve (OrthoInfo, 2021)
 Sex

Women are three times more likely than men to develop carpal tunnel syndrome.
Perhaps this is due to hormonal changes that could affect fluid retention, especially during
pregnancy or menopause. Swelling can reduce available space in the carpal tunnel and
compress the median nerve (National Institutes of Health, 2020).

Oral Contraceptive Pills

The patient took oral contraceptive pills during her reproductive years. Side effects
of combined oral contraceptive pill can disrupt the hormonal balance and for the long-term
it is can cause carpal tunnel syndrome (London Neurosurgery Partnership, 2020).

Smoking

The patient smokes earlier in her life. Smoking is a carpal tunnel risk factor and can
make the condition worse because it affects the supply of oxygen to the median nerve.
Nicotine causes blood vessels to become smaller. When this happens, there is less blood to
carry oxygen around the body. Reduced blood flow and less oxygen supply affects the very
small blood vessels at the fingertips the most. It can also affect the larger blood vessels that
bring oxygen to bone, nerves, tendons, and muscles (American Society for Surgery of the
Hand, 2021).

Question 2: What additional data do you need to elicit from XYZ to complete your
assessment and confirm the diagnosis of the patient’s condition? Explain significance of
the data.

History of Present Illness

Accurate patient history should be obtained. Several broad questions may solicit
reports of hand numbness or hand/wrist pain and/or symptoms. These include

a. Duration: How long have the symptoms been present?

b.
Severity/character: How severe are the symptoms? When do symptoms occur (eg, nighttime)?
Describe symptom quality (eg, tingling, burning, aching). Is the numbness/tingling
intermittent or persistent? What improves (eg, shaking the hand, holding hand down, warm
water) or exacerbates (eg, driving, holding a telephone, using vibratory tools) symptoms?
c. Location/radiation: What is the location of the pain and/or numbness? Are the symptoms in
the median nerve distribution of the hand(s)? If the symptom is not focal, does it radiate to
a specific area of the body? Are there any other associated symptoms (eg, numbness in the
feet; symptoms in the neck, shoulder, and more proximal in the arm; weakness, clumsiness,
dropping things)?
d. Pace of illness: Is the problem getting better, worse, or staying the same? If it is changing,
what has been the rate of change?
e. Previous treatment: What has been done and what makes it better?
f. Lifestyle and activities: What hand activities are common for the patient (eg, hobbies,
occupation)? Are there functional limitations due to these symptoms?

Obtaining a history relating to CTS serves to assist in diagnosing the disease and
planning appropriate treatment options. Symptoms such as numbness along the distribution
of the median nerve, increasing symptoms at night when sleeping, improvement of
symptoms by shaking the hand, and symptom exacerbation when driving or holding a
telephone are classic symptoms that in combination may be highly suggestive of CTS.

Identification of the location and radiation of symptoms may exclude or include

other diagnoses, such as proximal nerve compression syndrome, that may mimic CTS.
Having these associated symptoms may alert the physician to look for diagnoses other than
CTS.

The symptoms of CTS may vary on a daily basis. Understanding the disease
progression can be helpful in determining the appropriate diagnosis and treatment plan. For
symptoms that are not increasingly severe but vary periodically, conservative management
may be helpful in diagnosis. Moreover, understanding patient response to previous
treatment may verify the diagnosis of CTS and may support patient progression.

Physical Examination

 Examine the neck, arms, wrists, and hands, comparing the strength and appearance
of both sides.
 Check the thumb for strength and movement by watching patient grip or pinch an
object.

Specific Physical Examination are also the following:

Tinel's sign test

Taps the inside of the patient wrist over the median nerve. If the patient feels tingling,
numbness, "pins and needles," or a mild "electrical shock" sensation in the hand when
tapped on the wrist, she may have carpal tunnel syndrome.

Phalen's sign test

Let the patient hold her arms out in front of her and then flex her wrists, letting her hands
hang down for about 60 seconds. If she feels tingling, numbness, or pain in the fingers
within 60 seconds, she may have carpal tunnel syndrome.

Two-point discrimination test

Let the patient close her eyes and then uses small instruments, such as the tips of two
opened paper clips, to touch two points (fairly close together) on her hand or finger.
Typically, she would feel separate touches if the two points are at least 0.5 cm (0.2 in.)
apart. In severe carpal tunnel syndrome, she may not be able to tell the difference between
the two touches, so it may feel as though only one place is being touched.

Question 3: How would you react to the patient’s comment? Please state of evidence to
support your reaction
“Daytoy siguro nasakitko ket epekto daydi ado a tawen a pinagsigarilyo’k ken pinagtumarko
iti contraceptive pills.”

I agree that use of contraceptive pills and smoking can be factor why is she
experiencing such conditions. Side effects of combined oral contraceptive pill can disrupt
the hormonal balance and for the long-term it is can cause carpal tunnel syndrome (London
Neurosurgery Partnership, 2020). Moreover, based from an article from the University of
Iowa Healthcare (2019) numbness, tingling, weakness of arms or legs are associated warning
signs of taking contraceptive pills. Smoking is also a carpal tunnel risk factor and can make
the condition worse because it affects the supply of oxygen to the median nerve (American
Society for Surgery of the Hand, 2021). Nicotine causes blood vessels to become smaller.
When this happens, there is less blood to carry oxygen around the body. Reduced blood
flow and less oxygen supply affects the very small blood vessels at the fingertips the most. It
can also affect the larger blood vessels that bring oxygen to bone, nerves, tendons, and
muscles. Also, the possibility of neuropathic pain increases as the duration of smoking and
addiction level increases (Celik et al., 2017).

Question 4: How would you respond to the patient’s concern? Formulate nursing problem
to address his concern.

*NCP and Drug Study by cluster

Question 5: Share evidence-based practice in promoting the client’s understanding of the

disease process.

The evidenced-based practice is titled “The Patient Perspective on Shared Decision

Making in Carpal Tunnel Syndrome” by Kortlever et. al. (2019). The purpose is to understand
the patient perspective on which decisions should be shared during the course of treatment
for carpal tunnel syndrome.

P- Patients (age 18 years or greater) with a diagnosis of carpal tunnel syndrome

I- More surgeon involvement in decision making

C- Less surgeon involvement in decision making

O- Activate healthier patient behaviors and mindset, and optimize stewardship of resources

Clinical Question:

Among patients (age 18 years or greater) with a diagnosis of carpal tunnel syndrome, does
more surgeon involvement in decision making activate healthier patient behaviors and
mindset, and optimize stewardship of resources compared to less surgeon involvement in
decision making?

Interventions that improve a patient's understanding of the problem and their

options might reduce surgeon-to-surgeon variation, activate healthier patient behaviors and
mindset, and optimize stewardship of resources while improving quality of care. Patients
with carpal tunnel syndrome (CTS) have more uncertainty about which course of action to
take (so-called decision conflict) than hand surgeons. We studied patient preferences
regarding shared decision making (SDM) for different parts of the treatment for CTS. We
assessed the following hypotheses: (1) Younger age does not correlate with a preference for
greater involvement in decisions; (2) Demographic and socioeconomic factors are not
independently associated with (A) preferences for decision making (separated into
preoperative, operative, postoperative, and the full SDM scale) and (B) the Control
Preference Scale; (3) the SDM scale does not correlate with the Control Preference Scale.

They prospectively invited 113 new and postoperative patients with CTS to
participate in the study. They recorded their demographics and they completed the SDM
scale and the Control Preference Scale.
 The full SDM scale and all subsets showed a patient preference toward sharing the
decisions for treatment with the surgeon with a moderate tendency toward patients
wanting more surgeon involvement in decision making. On multivariable analysis, having
commercial insurance compared with Medicare was independently associated with a
preference for less surgeon involvement (ie, higher SDM scores) in decision making
(regression coefficient, 0.60; 95% confidence interval, 0.03-1.2).

Patients with CTS generally prefer to share decisions with their surgeon with a
tendency for more surgeon involvement especially in the operative and postoperative
period. Decision aids and preference elicitation tools used to ensure diagnostic and
treatment decisions for CTS that are aligned with patient preferences are needed. Future
studies might address the routine use of these tools on patient outcomes.

References:

American Society for Surgery of Hand. (2022). Cigarettes And Hand Conditions.
https://www.assh.org/handcare/condition/how-cigarettes-affect-your-hands/

Ashworth, N. L. (2022). Carpal Tunnel Syndrome.

https://emedicine.medscape.com/article/327330-overview#a6
Brutas, J. P. (2022). Treating carpal tunnel without surgery.
https://www.tunnelcarpienmd.com/en/non-surgical-treatment/

Calandruccio, J. H., & Thompson, N. B. (2018). Carpal Tunnel Syndrome: Making Evidence-
Based Treatment Decisions. The Orthopedic clinics of North America, 49(2), 223–229.
https://doi.org/10.1016/j.ocl.2017.11.009

Diabetes Co. UK (2006). Carpal Tunnel could predict diabetes.

https://www.diabetes.co.uk/news/2006/aug/carpal-tunnel-could-predict-
diabetes.html

Keith, M. W., Masear, V., Chung, K., Maupin, K., Andary, M., Amadio, P. C., Barth, R. W.,
Watters, W. C., 3rd, Goldberg, M. J., Haralson, R. H., 3rd, Turkelson, C. M., & Wies, J.
L. (2009). Diagnosis of carpal tunnel syndrome. The Journal of the American
Academy of Orthopaedic Surgeons, 17(6), 389–396.
https://doi.org/10.5435/00124635-200906000-00007

National Institutes of Health. (2020). Carpal Tunnel Syndrome Fact Sheet.

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/
Carpal-Tunnel-Syndrome-Fact-Sheet