A patient with De Quervain's tenosynovitis presents with worsening symptoms despite initial conservative management. What is the most appropriate nursing intervention to prioritize at this time?

B) Recommend the application of a thumb spica splint to immobilize the thumb and wrist.

A) Educate the patient on the importance of complete rest and avoiding all thumb movements.

B) Recommend the application of a thumb spica splint to immobilize the thumb and wrist.

C) Encourage the patient to increase the frequency of NSAID use to manage pain.

D) Suggest the initiation of physical therapy exercises to improve range of motion.

A 32-year-old violinist presents with worsening De Quervain's tenosynovitis despite conservative treatment. Which nursing intervention is most appropriate to implement next to address both her physical symptoms and mental well-being?

B) Educate the patient on the use of a thumb spica splint to immobilize the affected area.

A) Increase the dosage of NSAIDs to manage pain more effectively.

B) Educate the patient on the use of a thumb spica splint to immobilize the affected area.

C) Refer the patient to a counselor for stress management and relaxation techniques.

D) Advise the patient to apply heat to the affected area to improve circulation and reduce stiffness.

A patient with persistent localized inflammation, crepitus, and limited range of motion in the thumb has been treated with corticosteroid injections and immobilization. Which nursing intervention is most appropriate to address her ongoing symptoms and support her recovery?

B) Educate the patient on the importance of adhering to the thumb spica splint to reduce inflammation.

A) Encourage the patient to increase thumb exercises independently to improve range of motion.

B) Educate the patient on the importance of adhering to the thumb spica splint to reduce inflammation.

C) Advise the patient to apply heat therapy to improve circulation and reduce swelling.

D) Suggest the patient decrease mental health support sessions to focus more on physical therapy.

A patient receiving treatment for localized inflammation in her thumb returns for a follow-up, reporting persistent swelling, warmth, and limited range of motion despite initial treatment. Which nursing intervention is most appropriate to support the patient's recovery and address her concerns about continuing her performance schedule?

D) Coordinate with the physiotherapist and counselor to adjust the rehabilitation and stress management plan.

A) Encourage continued use of the thumb spica splint and rest the affected hand completely.

B) Recommend increasing the frequency and intensity of physical therapy sessions immediately.

C) Suggest using over-the-counter anti-inflammatory medications in addition to prescribed treatments.

D) Coordinate with the physiotherapist and counselor to adjust the rehabilitation and stress management plan.

A patient with persistent wrist inflammation and a small synovial cyst is being considered for a minor surgical procedure. Which nursing intervention is most appropriate to support the patient in preparing for this procedure while addressing her concerns about recovery time and professional commitments?

B) Collaborate with the healthcare team to adjust the patient's rehabilitation program to minimize time away from work.

A) Educate the patient about the surgical procedure and emphasize the importance of post-operative rest.

B) Collaborate with the healthcare team to adjust the patient's rehabilitation program to minimize time away from work.

C) Encourage the patient to postpone the procedure until she feels less anxious about her professional commitments.

D) Inform the patient that surgical intervention is the only option for effective treatment.

A patient with persistent inflammation in the wrist is found to have a thickened tendon sheath and a small synovial cyst. The healthcare team is considering a minor surgical procedure to alleviate symptoms. What should the nurse prioritize in the patient's care plan to optimize her recovery and address her concerns?

B) Focus on a balance between rehabilitation exercises and rest to enhance tendon glide.

A) Encourage immediate surgical intervention to prevent further tendon damage.

B) Focus on a balance between rehabilitation exercises and rest to enhance tendon glide.

C) Advise discontinuation of splinting to promote natural wrist movement.

D) Emphasize the importance of anxiety management techniques exclusively.

A patient with a synovial cyst causing radial nerve irritation presents with morning stiffness, swelling, and tingling in her thumb and index finger. Which nursing intervention is most appropriate to address her current symptoms while awaiting definitive treatment?

B) Educate the patient on performing nerve gliding exercises to alleviate nerve compression.

A) Encourage the patient to avoid using the affected hand to prevent further nerve damage.

B) Educate the patient on performing nerve gliding exercises to alleviate nerve compression.

C) Apply a warm compress to the affected wrist to reduce inflammation and improve circulation.

D) Instruct the patient to elevate the affected wrist above heart level to reduce swelling.

A patient with a synovial cyst compressing the radial nerve is scheduled for surgical excision. Prior to surgery, what is the most important nursing intervention to optimize the patient's hand function and recovery?

B) Encourage the patient to perform strength-building exercises for the hand and forearm.

A) Educate the patient about post-operative pain management strategies.

B) Encourage the patient to perform strength-building exercises for the hand and forearm.

C) Instruct the patient to avoid all use of the affected hand to prevent further injury.

D) Advise the patient to apply warm compresses to the hand to reduce swelling.

A patient with a synovial cyst causing radial nerve compression is being prepared for a surgical excision. Which nursing intervention is most critical in the pre-operative phase to ensure optimal outcomes for this patient?

C) Ensure the patient understands the potential risks of delaying the surgical intervention.

A) Educate the patient about the importance of immobilizing the wrist post-surgery.

B) Reinforce the rehabilitation plan focusing on strength-building exercises for hand muscles.

C) Ensure the patient understands the potential risks of delaying the surgical intervention.

D) Monitor the patient's vital signs closely to detect any signs of systemic infection.

Dequervains - Nursing Case Study

Pathophysiology

• Primary mechanism: De Quervain's tenosynovitis involves inflammation of the sheath (synovium) surrounding the abductor pollicis longus and extensor pollicis brevis tendons at the wrist, leading to pain and swelling.

• Secondary mechanism: Repetitive thumb or wrist movements can exacerbate the inflammation by increasing friction and stress on these tendons, causing further irritation and functional impairment.

• Key complication: If untreated, the condition may lead to restricted movement and chronic pain, significantly impacting the ability to perform daily tasks involving grip and thumb extension.

Patient Profile

Demographics:

34-year-old female, professional violinist

History:

• Key past medical history: Mild carpal tunnel syndrome, anxiety disorder

• Current medications: Ibuprofen as needed, sertraline 50 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Pain and swelling near the base of the thumb, worsening over the past few weeks

• Key symptoms: Difficulty gripping objects, tenderness along the thumb side of the wrist, occasional tingling in the thumb and index finger

• Vital signs: Blood pressure 138/90 mmHg, heart rate 98 bpm, respiratory rate 18 breaths per minute, temperature 99.1°F

Section 1

Change in Patient Status:

Over the next two weeks, the patient returns to the clinic with worsening symptoms. Despite adhering to a regimen of rest, ice application, and nonsteroidal anti-inflammatory drugs (NSAIDs), she reports an increase in pain intensity, now rated as 8 out of 10 on the pain scale. The swelling has persisted and is now accompanied by noticeable warmth and redness over the affected area. She also describes a new sensation of locking or catching when moving her thumb, leading to further difficulty in performing her daily violin practice and affecting her professional commitments.

Physical examination reveals increased tenderness along the first dorsal compartment of the wrist, with palpable crepitus during thumb movement. Finkelstein's test, which involves ulnar deviation of the wrist while the thumb is flexed within the palm, elicits severe pain, confirming the suspicion of De Quervain's tenosynovitis. Furthermore, there is a decrease in range of motion, particularly in thumb abduction and extension, indicating a potential progression to a more chronic phase of the condition.

These developments necessitate a reassessment of the current management plan. The escalation of symptoms suggests the need for a more aggressive therapeutic approach, potentially involving a corticosteroid injection to reduce inflammation or consideration of a splint to immobilize the thumb and wrist. The patient’s anxiety disorder may also be contributing to elevated stress and muscle tension, exacerbating her symptoms, warranting a holistic approach to her treatment plan that includes counseling or relaxation techniques. The clinical team must balance the necessity to alleviate her physical symptoms while ensuring her mental well-being and ability to continue her career as a violinist.

Section 2

Following the decision to adopt a more aggressive therapeutic approach, the patient receives a corticosteroid injection at the site of inflammation, and a thumb spica splint is applied to immobilize the thumb and wrist. Additionally, a referral is made to a physiotherapist specializing in hand therapy to develop a tailored rehabilitation program. The patient is also encouraged to engage in stress-reduction techniques and is referred to a counselor to address her anxiety, aiming to decrease stress-related muscle tension that may be exacerbating her symptoms.

Two weeks later, the patient returns for a follow-up appointment. She reports a slight reduction in pain, now rating it as 6 out of 10, and less frequent episodes of locking in the thumb. However, she continues to experience significant swelling and warmth in the area, and the range of motion remains limited. The patient expresses concern about her ability to maintain her performance schedule, noting that even minimal use of her thumb during practice sessions results in discomfort. Upon examination, while the tenderness has slightly decreased, there is still palpable crepitus and persistent redness over the first dorsal compartment.

Vital signs are stable, with no signs of systemic infection, but the continued localized inflammation raises the suspicion of a potential secondary complication, such as tendon sheath thickening or synovial cyst formation. The clinical team decides to conduct an ultrasound to assess for these complications, which may require further intervention if present. Additionally, the care plan includes ongoing evaluation of her mental health support, recognizing the integral role it plays in her overall recovery and professional life. This comprehensive approach aims to address both the physical and psychological aspects of her condition, promoting a more effective and sustainable path to recovery.

Section 3

During the follow-up visit, the clinical team proceeds with an ultrasound examination to investigate the persistent inflammation in the patient's wrist. The ultrasound reveals notable thickening of the tendon sheath around the first dorsal compartment, along with a small synovial cyst adjacent to the affected tendons. This finding explains the ongoing swelling and limited range of motion, suggesting that the initial conservative interventions may need to be adjusted. The presence of the cyst, although not significantly large, indicates a more complex inflammatory process than initially anticipated.

In light of these findings, the healthcare team discusses the potential for a minor surgical procedure to aspirate the cyst and relieve pressure on the tendons. The patient expresses concern about the recovery time associated with any surgical intervention, given her professional commitments. However, she acknowledges the need for a more definitive solution to prevent further impairment. The team emphasizes the importance of continued adherence to the splinting regimen and physiotherapy to maintain joint stability and function, and they explore the option of modifying her rehabilitation program to include specific exercises aimed at improving tendon glide and reducing edema.

Meanwhile, the patient's mental health support is reassessed. The counselor notes an improvement in her anxiety levels, likely due to a combination of stress-reduction techniques and an increased understanding of her condition. This improvement is crucial, as it positively influences her ability to cope with the physical challenges. The team plans to reassess her response to these combined interventions in another follow-up, ensuring that both her physical and mental health needs are being adequately addressed. With a comprehensive plan in place, the patient feels cautiously optimistic about her recovery path, understanding the need for a balanced approach that respects her career demands while prioritizing her long-term health.

Section 4

Two weeks after the adjustment in her treatment plan, the patient returns for a follow-up visit. She reports some improvement in pain levels but continues to experience significant swelling and stiffness in her wrist, particularly in the morning. Upon examination, the clinical team notes mild erythema and warmth over the first dorsal compartment, suggestive of ongoing inflammation. Her range of motion remains limited, with difficulty in thumb abduction and extension. The patient also mentions a new tingling sensation in her thumb and index finger, raising concerns about potential nerve involvement or compression.

Vital signs are stable, with a blood pressure of 118/78 mmHg, heart rate at 72 bpm, and temperature at 98.6°F. To further explore the cause of the new symptoms, an electromyography (EMG) study is ordered, which reveals mild irritation of the radial nerve. This finding suggests that the synovial cyst may be exerting pressure on the nerve, contributing to the patient's sensory changes. The team discusses these results with the patient, highlighting the need to address the cyst more definitively to prevent further nerve involvement and functional impairment.

Given these developments, the clinical team revisits the surgical option, now placing greater emphasis on the potential benefits of cyst aspiration or excision to alleviate nerve pressure. They also explore the possibility of a corticosteroid injection to reduce inflammation and swelling while awaiting the surgical decision. Meanwhile, the patient's rehabilitation program is adjusted to include nerve gliding exercises to mitigate the risk of further nerve damage. The patient acknowledges the importance of this proactive approach and agrees to proceed with the recommended interventions, understanding that addressing the cyst and nerve involvement is crucial for her overall recovery and return to full function.

Section 5

Two weeks following the initiation of the adjusted treatment plan, which included the corticosteroid injection and nerve gliding exercises, the patient returns for another follow-up. She reports a moderate reduction in swelling and a slight improvement in thumb mobility, but the tingling sensation in her thumb and index finger persists, now occasionally radiating to the middle finger. Upon examination, the erythema and warmth over the first dorsal compartment have decreased slightly, yet the range of motion in her wrist remains limited, particularly in thumb abduction and extension. The clinical team notes a mild decrease in grip strength, raising concerns about the ongoing impact of the cyst and nerve involvement on her hand function.

Vital signs are reassuring, with a blood pressure of 120/80 mmHg, heart rate at 74 bpm, and temperature at 98.4°F. However, the persistence of sensory changes prompts the team to order a follow-up ultrasound to assess the size and positioning of the synovial cyst. The ultrasound reveals that the cyst has not significantly decreased in size, reinforcing the likelihood that it is the primary source of radial nerve compression. In light of these findings, the team emphasizes the importance of proceeding with a more definitive surgical intervention, specifically cyst excision, to alleviate pressure on the radial nerve and prevent further functional decline.

The patient, understanding the potential risks of delaying surgery, agrees to schedule the procedure. Meanwhile, her rehabilitation plan is further adjusted to incorporate strength-building exercises for the muscles of the hand and forearm to preserve function and improve post-operative recovery. This proactive approach is crucial in ensuring optimal outcomes and highlights the importance of timely surgical intervention alongside conservative management strategies.