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CARPAL TUNNEL SYNDROME

It is a condition that involves compression of the media nerve beneath the transverse carpal ligament
with in the narrow, confines of the carpal tunnel located in the wrist.

Carpal tunnel syndrome is the most common compression neuropathy.

Causes

i. Pressure from trauma or oedema caused by inflammation of the tendon.


ii. Neoplasm
iii. Rheumatoid synovial disease.
iv. The syndrome is also seen during the pre-menstrual period, pregnancy and menopause, in
diabetes mellitus, thyroid dysfunction and conditions associated with increased fluid retention.
v. Occupation that requires continuous wrist movement e.g butchers, dentists, seamstress,
machine operators.

Clinical presentation

i. Weakness especially the thumb


ii. Burning pain (causalagia) and numbness
iii. Impaired sensation in the distribution of media nerve
iv. Numbness and tingling sensation may awaken the patient at night.
v. Holding the wrist in acute flexion for 60 seconds will produce tingling and numbness over the
distribution of the median nerve.ie the palmar surface of the thumb, the index finger, middle
finger and part of the ring finger termed as the phalens sign

vi. Taping gently over the area of the median nerve many reproduce paresthesia a situation known
as Tinels sign.
vii. In late stages, there is atrophy of the thenar muscles around the base of the thumb resulting the
recurrent pain and eventually loss of function of the affected hand.

Management of carpal tunnel syndrome

i. The goal is to relieve the underlying cause of the nerve compression.


ii. The symptoms can be relieved by stopping the aggravating movement by hand and wrist at
rest by immobilizing them in a hand splint.
iii. In cases of inflammation a corticosteroid can be injected into the carpal tunnel, it provides a
short term relief e.g about 6 months.
iv. The patient should be warned about impaired sensation during this period and therefore avoid
hazards which can cause thermo injuries.
v. If there is persistent symptoms, the median nerve can surgically be decompressed by dividing
the carpal ligament under regional anaesthesia procedure done in OPD.
vi. The cardiovascular status should be evaluated after the procedure and patient informal about
self-assessment at home.
vii. Nursing intervention includes relief of pain, support and protection of the injured joint.

Rehabilitation

i. After reduction and immobilization, motion is usually restricted.


ii. A careful regulated rehabilitation program can prevent development of contractures, this is
done through gentle ROM (range of motion) which are started when the joint is stable and
well supported.
iii. The joint should not be stretched beyond its limits.
iv. An exercise program slowly and methodically restores the joint to its ROM without causing
another dislocation.
v. The patient should gradually return to normal activities.

Investigations

i. X-ray can show the extent of shifting of involved structures.


ii. Joint aspiration to establish presence of hemarthrosis or fat cells, which indicate probable
intra-articular fracture.

Complications

i. Open joint fractures


ii. Intra-articular fractures
iii. Fracture dislocation
iv. Avascular necrosis
v. Damage to the adjacent vascular tissue.
AMPUTATION

Introduction

With advanced techniques on surgery, many amputees have since the last 20 years been able to return to
productive work and satisfying social roles. There have been major advances to surgical amputation
techniques, prosthetic design and rehabilitation program. The increasing number of patients who need
amputation due to increasing RTAs and vascular impairing medical conditions especially in middle and older
age groups.

Definition

It is cutting or removal of a limb or part of a limb or any part projecting from the body.

CLINICAL INDICATIONS

1. It depends on the underlying disease or trauma


2. Circulatory impairment resulting from;
i. Peripheral vascular disorder
ii. Traumatic or thermo injuries
iii. Malignant tumours
iv. Uncontrolled/ widespread infection of the extremity e.g gas gangrene, osteomyelitis
v. Congenital disorders

The clinical manifestations for such conditions to call for an amputation include;
i. Loss of sensation
ii. Inadequate circulation
iii. Pallor
iv. Local or systemic manifestations of infection.
v. Although pain is usually present, it is not the primary indication for amputation.

DIAGNOSTIC STUDIES FOR AMPUTATION/ASSESSMENT FOR AMPUTATION


The possibility of revascularization surgery rather than amputation can be assessed on the basis of
vascular studies.
1. Assess for
i. Physical appearance of soft tissues
ii. Skin temperature
iii. Sensory function
iv. Presence of peripheral pulses
2. Arteriography/ venography
3. Thermography
4. Transcutaneous ultrasound Doppler readings
5. WBC- increase indicate presence of infection
GOAL OF AMPUTATION
Is to preserve extremity length and function while removing all infected pathologic or ischaemic
tissue in an effort to improve possibility of prosthetic, cosmetic and functional satisfaction

TYPES OF AMPUTATION
It depends on the reason for surgery and includes
Open amputation
It leaves a surface on the residual limb that is not covered with skin. This type of surgery is
indicated for actual or potential infection. It is usually covered later by a second surgery or by
skin traction surrounding the residual limb termed as a guillotine amputation.

1. Closed amputation
It is performed to create a weight bearing residual limb/ stump. An anterior skin flap with
dissected soft tissue padding covers the bonny part of the residual limb.
2. Disarticulation
Is an amputation through a joint.

3. Asymes amputation
It is a form of disarticulation of the ankle joint

PRE OPERATIVE MANAGEMENT

i. A constant anxiety about healing of the amputation flaps in tissues which are obviously
depleted of supply is the major concern and therefore critical thinking in decision making
is vital.
ii. The higher the level of amputation such as the midthigh, the better chances of healing but
rehabilitation is much more difficult.
iii. The nurse should take time in giving the appropriate information to the patient and family
about the following;
Level of amputation
The type of surgical dressing to be applied
The type of prosthesis planned
iv. The patient should be taught the exercises of the of the upper extremity e.g pushups in
bed or wheel chair to promote the arm strength, this will help in later crutch walking and
gait training.
v. Patient should be explained the general post-operative care including; positioning,
support and residual limb care.
vi. If compression bandage is to be used after surgery, the patient should be instructed about
its purpose and how it will be applied.
vii. If an immediate prosthesis is planned, general ambulation program should be discussed.
viii. The patient should be warned about phantom limb sensation so that the experience post
operatively do not cause anxiety. Phantom sensation include
Feelings of coldness and heaviness
Cramping
Shooting
Burning or crushing pain
Patient knows the limb is off but still feels the pain it.

ix. As patient recovers, phantom pain subside but can be chronic, phantom pain occur in
80% post amputation.

POST-OPERATIVE MANAGEMENT
i. General post-operative care depends on the general state of health, the reason for
amputation and the patients age.
ii. An older patient needs special monitoring of respiratory status.
iii. A victim of motor-vehicle accident need careful monitoring of neurologic symptoms and
signs.
iv. Emergency amputation following RTA need monitoring for post-traumatic stress disorder
because he had no time to be prepared.
v. Prevention and detection of complications are important nursing responsibilities.
vi. Careful monitoring for signs of haemorrhage including vital signs
vii. Aseptic technique during dressing is vital in prevention of wound infection
viii. Special care of the stamp include;
ix. Avoid injury to the stamp
x. The stamp must be dressed and wrapped in crepe bandage
xi. Prevent flexion deformity of the hip by avoiding placing a pillow behind the stump.
xii. Remove drain tube if present within 24-48 hours.
xiii. Exercise the stump on the 2nd day
xiv. Early ambulation on crutches and fitting of a prosthesis.
xv. Remove skin sutures on the 10th day
xvi. If an immediate prosthesis has been applies, the nurse must monitor vital signs to rule out
haemorrhage in case it occurs.
xvii. Before settling the patient at home, circumstances at home should be investigated to
adopt the physical changes necessary for a smooth return and maximum independence e.g
bars in toilet, ramp to get in house or wheel chair, correct height of bed etc
COMPLICATIONS
1. Reactionary haemorrhage with in the first 12 hours. It is rare, surgery may be done to stop
it.
2. Secondary haemorrhage, common on 7-10 days. It is associated with inflammation or
ischemia of tissues adjacent to the wound. Treat the infection or ischemia if it is the cause.

3. Ischaemia of the stamp. The blood supply to the muscle or skin at the distal end of the stamp
may be inadequate, causing failure to healing of part or the whole wound.
Management is by surgical excision of the dead tissue or re amputation at the higher level
4. Infection. It is more common in diabetic patients. The stump becomes painful, swollen, red
and hot. It may be necessary to open the wound and excise dead tissue to provide adequate
drainage.
5. Phantom pain. The patient may complain of pain in the foot or hand that has been removed.
It goes slowly or may be chronic. Re assure the patient about it.

6. Amputation stamp neuroma. This is a painful condition in which one of the nerve ends,
remaining as a result of amputation becomes swollen or tethered in the scar. It is managed by
avoiding local pressure or excision of the area.

Assignment
Read on location and description of amputation sites of the upper and lower limbs

NURSING DIAGNOSIS FOR AMPUTATION


i. Disturbed body image related to amputation manifested by abnormal gait or obvious
loss of a limb.
ii. Impaired mobility related to amputation manifested by abnormal gait or walking on
crutches or wheel chair.
iii. Impaired skin integrity related to immobility or improper fitted prosthesis
iv. Altered comfort related to amputation as verbalized by patient I feel the same pain as
though I still have the lost/ removed limb
v. Potential for anxiety related to loss of a limb, fear of poor recovery, and uncertainty of
how to survive or perform activities of daily living.