Nursing Guide to Carpal Tunnel Syndrome: Nursing Diagnosis, Interventions, & Care Plans

Carpal Tunnel Syndrome Etiology and Epidemiology 

Carpal tunnel syndrome is a common nerve entrapment condition typically caused by a compression of the median nerve, where it runs through the tunnel at the wrist (Wright & Atkinson, 2019). Carpal tunnel syndrome (CTS) can be acute or chronic. 

Carpal tunnel syndrome occurs three times more frequently in women than men, and the average age of occurrence is between the ages of 40 and 60 (DynaMed, 2018). CTS accounts for approximately 90% of entrapment neuropathies. Pregnant women are commonly affected by CTS due to swelling in the blood vessels, which can cause compression of the carpal tunnel. 

The primary risk factors for CTS include: 

• Increased BMI
• Repetitive hand or wrist motions
• Perimenopause
• Rheumatoid arthritis
• Distal upper extremity tendinopathies
• Work or recreational activities that involve:
  • Gardening
  • Assembly work
  • Computer work
  • Vibration
  • Forceful grip or exertion 

Less common risk factors for CTS include: 

• Dialysis
• Fibromyalgia
• Varicosis
• Distal radius fracture 

Carpal tunnel syndrome is caused by increased pressure inside the carpal tunnel (DynaMed, 2018). The causes of the increased pressure may be related to one of the following: 

• Inflammatory response
  • Tenosynovitis
  • Hypertrophic synovium
  • Trauma to the median nerve
• Anatomic
  • Conditions causing modification to carpal tunnel walls
  • Abnormalities in the carpal or radius bones
  • Anomalous flexor tendons
  • Proximal lumbrical muscle insertion
  • Changes in thickness or forearm fascia stiffness
  • Median nerve arterial hypertrophy
• Intratunnel tumors or lesions
• Systemic conditions
  • Obesity
  • Inflammatory arthritis
  • Pregnancy
  • Hypo/hyperthyroidism
  • Chronic kidney disease
  • Amyloidosis
  • Scleroderma
  • Systemic lupus erythematosus
  • Multiple myeloma
  • Sarcoidosis
  • Acromegaly
  • Infection 

Carpal Tunnel Syndrome Diagnosis 

Individuals with CTS usually present with tingling or a burning pain distal to the wrist (DynaMed, 2018). The affected area below the wrist usually includes the thumb, index and middle finger, and medial or radial half of the ring finger. The individual may exhibit decreased strength when gripping or pinching. Symptoms of CTS are usually increased at night when the person is sleeping due to flexion of the wrist. 

The initial history should include: 

• The onset of signs and symptoms, such as when pain and numbness started
• What activities does the person’s lifestyle include that may be repetitive
• Range of motion, deformities, swelling, or atrophy of affected wrist
• Weight and body mass index (BMI) 

Diagnostic testing can include (Wright & Atkinson, 2019): 

• Electromyography (EMG) studies, especially if considering surgical intervention
• Carpal tunnel ultrasound to determine contributing factors 

Carpal tunnel syndrome is often related to a person’s work. To establish CTS as a work-related injury, there must be three specific criteria met (Wright & Atkinson, 2019): 

• Workplace exposure to activities that are known to contribute to carpal tunnel syndrome
• A positive diagnosis of carpal tunnel syndrome from a medical provider
• At least 50% of contributing factors are related to workplace activity 

Management 

After a diagnosis of CTS, treatment is dependent upon the severity. Less invasive treatment methods for CTS, such as splinting, can be managed by the primary care provider (Wright & Atkinson, 2019). Splinting should be started immediately and encouraged during sleep and activity involving the affected wrist. Non-steroidal anti-inflammatory medications (NSAIDs) are administered to reduce inflammation. For pregnant females, NSAIDs are eliminated from the treatment plan. 

If CTS is moderate to severe, individuals should be referred to an orthopedic surgeon for treatment. Surgery may be needed depending upon how acute the onset and how severe the CTS is. The orthopedic surgeon may use a combination of splinting and corticosteroid injections for moderate CTS. 

Conservative treatments are always attempted first for mild to moderate cases of CTS. If the treatments are not effective at relieving symptoms, then surgery is required. 

A carpal tunnel release surgery has shown to have superior outcomes. The transverse carpal ligament is released, minimizing pressure within the tunnel and decompressing the median nerve.

Carpal Tunnel Syndrome Nursing Care Plan

Nursing Considerations 

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for carpal tunnel syndrome are listed below. 

Assessment 

Assess signs and symptoms, such as: 

• Positive Tinel’s sign (increased paresthesia when tapping on tendon sheath)
• Positive Phalen test (increased symptoms with palmar flexion for one minute)
• Pain in affected hand/wrist
• Swelling in affected wrist/hand
• Decreased circulation in affected or operative hand (discoloration, cool temperature, missing or weak pulse)
• Decrease in ability to complete activities of daily living
• Motor changes of the affected extremity, such as weakness
• Sleep disturbance related to pain
• Repetitive motion activity 

Nursing Diagnosis/Risk For 

• Acute pain related to compression of the median nerve, as evidenced by (Phelps, 2021a):
  • Verbalizing pain
  • Guarding or splinting of the affected limb
  • Limited movement of the affected limb
• Risk for peripheral neurovascular dysfunction, as evidenced by (Phelps, 2021b):
  • Postoperative swelling causing decreased blood flow
  • Loss of sensation to affected extremities
• Impaired physical mobility, as evidenced by (Phelps, 2021c):
  • Mobility limited by splint use
  • Fear of pain when using the affected limb
• Sleep deprivation as evidence by (Phelps, 2021d):
  • Increased pain during the night 

Carpal Tunnel Syndrome Interventions 

• Monitor pain level.
• Monitor for changes in numbness or function.
• Monitor for adverse effects of NSAID therapy (GI distress, bleeding, or increased creatinine level).
• Monitor neurovascular changes of the affected extremity.
• Administer NSAIDs or analgesic medication, as needed, and monitor their effectiveness.
• Apply wrist splint and watch for circulation problems related to splint.
• Apply a cold compress to decrease pain and swelling.
• Instruct individual not to flex the wrist and how to avoid flexion.
• Instruct and assist the individual with range of motion (ROM) exercises.
• Promote independence through activities of daily living completion.
• Promote a well-balanced diet.
• Encourage relaxation techniques to reduce stress and relieve tension.
• Encourage the individual to talk about their fears and pain.
• Assist individual with performing rehabilitative therapy, as needed.
• Allow adequate time to complete activities of daily living.
• Elevate affected limb to reduce swelling.
• Instruct individual on proper placement of splint and how to check circulation while wearing it. 

Expected Outcomes 

• Shows no evidence of nerve damage
• Maintains circulation to affected extremities
• Demonstrates proper splint placement and usage
• Exhibits no symptoms of neurovascular damage 

Patient/Caregiver Education 

• Condition, treatment, and expected outcomes
• Analgesic use as needed
• Application of splint in correct location and when to use
• Ways to prevent recurrence of CTS
• Importance of wearing the splint while sleeping and performing activities
• Notify healthcare provider or seek immediate medical for:
  • Conservative nonsurgical treatment
  • If symptoms worsen
  • If symptoms affect your ability to work
  • Weakness, numbness or tingling in fingers or thumb
  • Difficulty holding objects
• Surgical treatment
  • Redness, swelling, or draining at incision site
  • Severe pain or swelling of wrist/hand/arm
  • Sudden loss of sensation in hand or fingers
  • Discoloration of hand/fingers
  • Fever >101.5°F
• Recommended follow-up with healthcare provider

Content Release Date

4/1/2022

Content Expiration

12/31/2027

Course Contributor 

The content for this course was revised by Kathleen Koopmann, RN, BSN, PCCN. Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner. 

Resources 

• Carpal Tunnel Syndrome Prevention Tips. Fairview Health Services. https://www.mhealthfairview.org/conditions/Carpal-Tunnel-Syndrome

References 

• DynaMed. (2018). Carpal tunnel syndrome. https://www.dynamed.com/condition/carpal-tunnel-syndrome 
• Phelps, L. L., (2021a) Sparks and Taylor’s nursing diagnosis pocket guide (4th ed., pp. 396- 398). Wolters Kluwer. 
• Phelps, L. L., (2021b) Sparks and Taylor’s nursing diagnosis pocket guide (4th ed., pp. 376- 378). Wolters Kluwer. 
• Phelps, L. L., (2021c) Sparks and Taylor’s nursing diagnosis pocket guide (4th ed., pp. 352- 354). Wolters Kluwer. 
• Phelps, L. L., (2021d) Sparks and Taylor’s nursing diagnosis pocket guide (4th ed., pp. 542- 544). Wolters Kluwer. 
• Wright, A. R., & Atkinson, R. E. (2019). Carpal tunnel syndrome: An update for the primary care physician. Hawai'i Journal of Health & Social Welfare, 78(11 Suppl 2), 6–10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874691/