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The private detective Salahadin came to the hotel, where his friend stayed. The whole day Sahaladin was waiting for his friend in his office, but he did not come. The thing is that he had been murdered in his room. The police group were working in the hotel, when the detective arrived. They did not allow him to come to the corpse. There was inspector Ahmed, who was Salahadin's friend. He gave the access to the crime scene for the detective.
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Macmillan Readers level - Intermediate. A book for reading and listening that can be used both for self-studying and while working with the class. Macmillan Readers, Adapted audiobook. Level 4. Retold by John Escott.
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Barbara K Miller, RN Margaret Gregory, RN Carpal tunnel syndrome Although carpal tunnel syndrome (CTS) is a common disorder, for many years it was relatively unknown and either misdiagnosed o r minimally treated. But recently, CTS has been more readily recognized by health care professionals leading to earlier diagnosis and conservative treatment. When CTS becomes chronic or no longer responds to palliative treatment, surgical intervention is needed. Most patients will be treated in outpatient surgery, but some will be hospitalized. In either setting, the perioperative nurse makes a nursing assessment and teaches patients about what to expect postoperatively and what they can do to help their recovery. This article provides current information on the etiology, medical and surgical treatment, and nursing as- sessments and interventions for patients with carpal tunnel syndrome. The syndrome is a combination of symptoms resulting from a restriction of the median nerve in the wrist. The carpal tunnel is located on the palmar aspect of the wrist (Fig 1). Normally four superficial flexors, four deep flexors, and the median nerve pass through the carpal tunnel. The restriction interferes with smooth movement of the median nerve, producing sensory loss in the thumb, index finger, second finger, and inner aspect of the third finger on the affected side. This is the median nerve distribution area. In chronic or long-term CTS, the whole hand may develop paresthesia. In most cases, CTS affects the dominant hand. A recent study of 169 individuals with CTS revealed that hand dominance was Barbara K Miller, RN, MS, is an assistant professor at Arizona State University College of Nursing, Tempe. She earned a master's degree in education from the University of Akron, Ohio. As a graduate of the Massillon (Ohio) City Hospital School of Nursing, Miller earned a bachelor's of science in nursing from the University of Akron. Barbara K Miller Margaret Gregory Margaret Gregory, RN, BSN, is a staff nurse at the Scottsdale (Ariz) Memorial Hospital Outpatient Surgical Center. With a diploma from Good Samaritan Hospital School of Nursing, Phoenix, Gregory earned a BS from Arizona State University College of Nursing. AORN Journal, September 1983, Vol38, No 3 626 Flg 1 Views of carpal funnel ulnar nerve flexor tendons of fingers carpal transverse carpal ligament ti innal flexor tendoins and tend 'S. a significant factor. In addition, 119 of the participants had bilateral involvemerit.' Etiology. Tissue swelling in the carpal tunnel or fibrosis of the flexor synovials are considered the most common causes of CTS. Endocrine abnormalities 528 are common conditions accompanying CTS as are pregnancy, menopause, or taking oral contraceptives. More recently, there have been reports of patients on hemodialysis who have CTS2 These conditions support the theory that fluid retention may cause chronic AORN Journal, September 1983, Vol 38, No 3 swelling of tissue in the carpal tunnel, and even though the carpal tunnel is open ended, it is restricted by firm boundaries of ligaments and bone. A hobby or occupation may accentuate or create compression of the median nerve. CTS is more prevalent where there is a constant flexion of the wrists for a prolonged period, consequently typists, hairdressers, butchers, truck drivers and persons who knit have a greater tendency for CTS. A literature review of the last five years of published research reports indicates that persons of every age may be affected with the highest percentage in the over 40 age bracket and a fairly equal number according to sex. These reports, however, may misrepresent the actual age of the person with CTS. A young person with CTS symptoms may not consider the signs alarming or incapacitating enough to seek professional advice. Also, it should be noted that many health professionals are only now becoming informed of this syndrome, and therefore CTS could have been misdiagnosed or its symptoms disregarded. Reports of acute CTS resulting from burns, spontaneous hemorrhage, infection in the forearm and hand, or frac- With long-term CTS, signs of atrophy are often present. ~~ tures of the digital radius are relatively rarea4Bauman suggests that these reports of CTS do not distinctly differentiate between nerve contusion and acute nerve compression. Signs and symptoms. CTS symptoms vary, and in the early stages, they may 630 be intermittent and nonspecific. The most common symptom is nocturnal paresthesia or dysesthesia of the affected hand. The person awakens during the night with numbness, tingling, and coldness of the hand. Minutes after moving or rubbing, these symptoms usually disappear. They may reoccur during the night. Patients have reported they have awakened several times during a night thinking they were lying on their arm or their sleeping position accentuated the symptoms. When these symptoms interfere with sleep on a regular basis or when the symptoms disrupt normal daytime activities, persons often seek professional advice. One study of 15 persons with CTS indicated that nocturnal paresthesia, and hypoesthesia occurred for a mean duration of 30 months before the individual sought con~ultation.~ The symptoms of CTS may become more severe if untreated, consequently, hypoesthesia in the median nerve distribution becomes more pronounced, and pain radiates throughout the hand. The fourth and fifth finger are in the ulnar nerve distribution, and the ulnar nerve is covered by a position of the volar carpal tunnel. When tenosynovitis accompanies CTS, the ulnar nerve is affected.6Muscle weakness may occur. Diagnostic tests. Two of’ the most common tests are the wrist-flexion and the wrist percussion test. The Phalen’s wrist fexion test is accomplished by holding the arms in a vertical position and allowing both hands to drop in a flexion position for 30 to 60 seconds. If paresthesia occurs over the median nerve distribution, the test is positive. Symptoms occurring in less than 30 seconds indicate severe involvement. The second test, known as Tinel’s test, is accomplished by gently tapping the area of the median nerve on the wrist with the wrist in neutral position. If a tingling sensation occurs over the me- AORN Journal, September 1983, Vol38, N o 3 dian nerve distribution area, the test is positive. Percussion must be gentle because strenuous percussion may cause a reaction even with a normal hand. Other diagnostic tests that may be used are passive hyperextension of the affected wrist or inflating a sphygmomanometer cuff (tourniquet test) above the patient’s systolic pressure for 1to 2 minutes. The latter test is less significant than the former, however, both may increase pain and paresthesia due to ischemia to the median nerve. Other tests that may be done are nerve conduction times and electromyography. Electromyography may be done on the surface impulses and on the deep muscles. For the deeper muscles, needles are introduced to determine muscle relaxation. With these tests, a mathematical compilation of time conduction and velocity conduction is determined. Most hand specialists believe that the Tinel and Phalen tests along with the subjective symptoms are the most important criteria to diagnose carpal tunnel ~ y n d r o m e .In ~ one study of 48 hemodialysis patients, all the subjective symptoms of nocturnal paresthesia, numbness in the median nerve distribution, and hand pain were predominant, CTS is associated with deficiency of vitamin B6. but positive Phalen and Tinel tests were not common. The explanation suggested was that these patients had preexisting peripheral neuropathy and thus, additional criteria had to be considered.8 When CTS has been present for a long time, assessment will show atrophy of the thenar eminence because of decreased motor function of the median nerve. If only one hand is involved, a comparison of the muscles ofboth hands may give evidence of the flattened thenar eminence. Patients with long-term symptoms may have swelling or a mass on the palmar aspect of the wrist near the ulnar nerve by the carpal tunnel. To differentiate carpal tunnel syndrome from other entities, an accurate neurological examination must be done. These other entities include generalized peripheral neuropathy, cervical radiculopathy, thoracic outlet syndrome, and lateral epicondylitis. Palliative treatment. Before atrophy of the thenar eminence, treatment of CTS may be simple. If the cause is occupational or due to a repetitive activity, then a plaster splint or a canvas splint may be prescribed. If the symptoms are nocturnal, a canvas splint may be worn only at night to prevent hyperextension or prolonged flexion. Studies are being conducted to ascertain the value of Pyridoxine (vitamin Ek).One study of 22 patients with carpal tunnel syndrome demonstrated that it was associated with a deficiency of vitamin Be. The required dietary allowance (RDA) is 2 mg daily. Participants were given 100 mg of vitamin Bs daily, and by the eleventh week, they demonstrated definitive clinical improvement.Y Another palliative treatment is the administration of medications such as phenylbutazone to reduce the inflammatory process. Because these medications can cause blood dyscrasia and are contraindicated with many other disorders, such as peptic ulcer, cardiovascular disease, and renal impairment, this treatment is becoming infrequent. The injection of a steroid preparation into the central portion of the flexor tendon mass provides some temporary relief. & 532 AORN Journal, September 1983, Vol38, N o 3 Those patients with mild symptoms for less than one year get the most benefit from this approach.1° Other medications, such as nonsteroid antiinflammatory agents and diuretics, may be used if the symptoms are mild, of short duration, and are expected to abate. For example, if the person plans to discontinue the use of oral contraceptivesor is able to avoid repetitive activity or has an endocrine abnormality that can be corrected, the use of these drugs with the use of a splint may correct the syndrome. When immobilization, medications, and restriction of activities do not correct the syndrome or when atrophy of the thenar eminence is noted, the usual treatment is surgery. Surgical treatment and nursing interventions. Carpal tunnel surgery may require an overnight hospital stay for patients who have a higher than normal surgical risk because of, for example, health problems. Also, the patient having bilateral carpal tunnel surgery may be hospitalized. The trend, however, is to perform this surgery in an outpatient setting. Although admitting procedures may differ in outpatient surgery departments, the perioperative nurse’s goal is A radio headset may relax patients during the surgery. ~ ~~ to prepare the patient for what he will experience, The patient is admitted approximately one hour before the scheduled surgery time. This allows for the patient t o be admitted, change clothes, and receive an explanation of the procedure before signing the opera536 tive permit. Taking an accurate assessment and history will help the nurse use an individualizedplan for this patient. Preoperative instruction includes an explanation of the anesthesia used and the postoperative expectations. All of the information conveyed to the patient is documented so discharge instructions can be reinforced after surgery. Most patients do not receive a preoperative medication unless they are extremely anxious. The nurse can encourage the patient to use relaxation techniques. One effective relaxation measure is having the patient listen to an AM-FM radio with a headset just before the induction of local or regional anesthesia and during the surgery. This diverts the patient from the OR noises. The type of anesthesia may be selected by the surgeon or by the surgeon and the patient. In outpatient surgery, a local or regional block is used most frequently. The operative time is approximately one-half hour. The surgical procedure releases the pressure on the median nerve in the carpal tunnel. One of the important factors concerning the surgical procedure is for the surgeon to visualize the carpal tunnel sufficiently, so that the median nerve and the palmar cutaneous branches may be seen to protect them from injury. Also, exposing the area allows the surgeon to see if any other abnormalities are present. The s-shaped incision is the most common and preferred by many hand specialists because it permits adequate visibility. The incision extends into the palm and past the peripheral branching of the median nerve. According to Sandzen, the curvilinear incision avoids scar contracture.ll Postoperatively, the wrist is immobilized to prevent flexion. Stabilization of the wrist enhances wound healing by preventing edema and/or the formation AORN Journal, September 1983, Vol38, No 3 of a hematoma. In a published report of two cases of complications of postoperative CTS, the patients stated the initial dressings were small, and consequently the wrists were not immobilized and wrist flexion occurred.12Most hand specialists consider splinting of the wrist important for uncomplicated healing. When the wrist is splinted in a 45”extension, finger movement does not put pressure on tendons within the carpal tunnel, and finger movement is facilitated. Discharge planning should include all instructions and expectations concerning the postoperative period. The information should be written so the patient may refer to the instructions at home. Manipulation of the fingers on the affected hand is an important aspect of the instructions for discharge. Initially, the patient is encouraged to do passive exercises and then active exercises of the fingers. The patient should also be cautioned to observe the color and temperature of the fingers for at least 24 to 48 hours. Any coldness of the hand or change in color of the fingers should be reported. Postoperatively, the hand is to be elevated above the level of the heart for 24 to 48 hours. This helps venous return, and thus reduces swelling and pain. A sling facilitates this precaution. The nurse explains the physiological basis for this to encourage the patient to follow the instructions. Reduction of swelling also decreases pain. Patients are told they will have some pain when the anesthesia dissipates, and an analgesic should be taken to relieve any throbbing pain. Usually the pain lasts only 24 hours, and some patients do not have any pain. The preoperative assessment should have given information concerning whether the patient is taking any other medication that may interfere or interact with the prescribed analgesic. The time the splint is worn varies from 10 to 14 days. The hand may be wrapped in gauze and covered by an elastic bandage that serves as a compression dressing. Postoperative teaching includes instructing the patient to keep the bandage and incision dry. The patient may be given suggestions or techniques to make compliance easier. The stitches are usually removed when the splint is removed. After removal of the splint, however, heavy lifting with the affected hand may be contraindicated for several months, and the patient may wear a canvas splint during activity as a reminder not to lift or carry objects. Women are encouraged to use shoulder strap purses, and all patients should carry objects in their arms rather than their hands. Mobility of the hand progresses in the postoperative period, and the patient is reminded that normal sensation returns slowly. It may be a year before normal sensation returns. In some cases, the middle finger numbness continues longer. Preoperative pain is usually relieved, however, complete relief may take several weeks to months. Some patients use relaxation methods and techniques of imagery to facilitate healing and return of normal sensation. 0 Notes 1. Leon Reinstein, ”Hand dominance in carpal tunnel syndrome,” Archives of Physical Medicine Rehabilitation 62 (May 1981) 202-203. 2. S K Halter et al, “Carpal tunnel syndrome in chronic renal dialysis patients,”Archives of Physical Medicine Rehabilitation 62 (May 1981) 197-201. 3. B K Miller, “Hands that hurl less,” American Journal of Nursing 79 (February 1979) 266-267. 4. Thomas D Bauman et al, “The acute carpal tunnel syndrome,” Clinical Orthopedics and Related Research 156 (May 1981) 151-156. 5. R H Gelberman et al, “The carpal tunnel syndrome: A study of carpal canal pressures,”Journal of Bone and Joint Surgery 63 (March 1981) 380383. 6. Sigurd C Sandzen, Jr, “Carpal tunnel syndrome,“ American Family Physician 24 (November d+ AORN Journal, September 1983, Vol38, No 3 537 1981) 190-204. 7. Ibid. 8. Halter et al, “Carpal tunnel syndrome.’’ 9. John Ellis et al, “Clinical results of a crossover treatment with pyridoxine and placebo of the carpal tunnel syndrome,” American Journalof Clinictll Nutrition 32 (October 1979) 2040-2046. 10. Gelberman et al, ”The carpal tunnel syndrome.” 11. Sandzen, “Carpal tunnel syndrome.” 12. Allan E Inglis, “Two unusual operative complications in the carpal-tunnel syndrome: A report of two cases,” Journal of Bone and Joint Surgery 62 (October 1980)1208-1209. Taking a look at nursing’s image The National League for Nursing (NLN), like AORN, wants to improve the way the public and other health professionals perceive nurses. On the final day of the NLN convention, John Pollock, PhD, president of Research & Forecasts, Inc, a division of Rudder, Finn, & Rottman, a public relations agency, discussed what it takes to be regarded as a mature profession. He then suggested ways nurses could achieve this status. This public relations agency is working with NLN to develop a five-year campaign to improve nursing’s image. The requirements for a mature profession have a historical basis, according to Pollock. A mature profession is a full-time activity, and there should be a sense of a calling. Pollock said, “The profession should be more than just a pay check.” Mature professions have cohesive organizations and high educational standards. “The standards are based on theory. A theoretical basis is what separates a profession from a trade. A trade, no matter how complex, is primarily learned on the job,” Pollock said. There is an element of service in a mature profession. “Nursing doesn’t have any problem there,” he said. But, a mature profession is also autonomous, and “nursing constantly struggles with that.” Admitting that he tends to talk only about why nursing’s image is not better, he suggested three ways to improve the situation. First, he called for a national study on how the public perceives nurses. Pollock said, “These sorts of studies tend to reveal a few surprises that can be most helpful.” His second suggestion was to make 540 known achievements that are directly related to nursing action. “Make lots of noise and use the strength of the group,” he said. Allen ’s responsibilities as program specialist Janice Allen, RN, MS, assumed the position of program specialist in the AORN Education Department in June. Among her responsibilities,Allen will be the staff consultant to the Research Committee. She will also assist in designing, implementing, and evaluating continuing education activities. In addition, Allen will assist in organizing educational sessions for AORN’s annual Congress. The 1984 AORN Congress will be March 4 to 9 in Atlanta. Allen was an assistant professor at the University of Arizona College of Nursing, Tucson. From 1974 to 1981, she was assistant supervisor of operating room education for the Arizona Health Sciences Center, Tucson. She earned her master’s degree from the University of Arizona, Tucson, and a bachelor’s degree from the University of Colorado, Denver. AORN Journal, September 1983, Vol38, N o 3 ![]() Comments are closed.
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