Nursing care plan for post operation carpal tunnel release?

Patient: 62-year-old female status post carpal tunnel release of the right wrist.

Medical Diagnosis: Carpal Tunnel Syndrome

Nursing Diagnosis: Acute pain related to surgical incision and edema as evidenced by patient report of 4/10, guarding behavior, and restlessness.

Patient Goals:

- Patient will report pain level of 3 or less by the end of the shift

- Patient will demonstrate relaxation techniques to reduce anxiety and improve mobility by the end of the shift

- Patient will actively participate in exercises to promote ROM and strength by the end of the shift

Nursing Interventions:

1. Pain Management:

- Assess pain level frequently using a 0-10 scale.

- Administer prescribed pain medication as ordered.

- Elevate the affected limb to reduce edema and pain.

2. Promoting Relaxation:

- Provide the patient with a quiet, calm environment.

- Teach and encourage relaxation techniques such as deep breathing exercises and guided imagery.

- Help the patient to find a comfortable position that reduces pain and promotes relaxation.

3. Range of Motion and Strengthening Exercises:

- Consult with physical or occupational therapist for specific exercises.

- Gently encourage active ROM exercises of the fingers, wrist, and forearm within pain limits.

- Assist with passive ROM exercises if needed.

- Instruct the patient on isometric strengthening exercises for the affected muscles.

4. Wound Care and Infection Prevention:

- Monitor the surgical incision for signs of infection (eg, redness, drainage, or increased pain).

- Perform gentle dressing changes as prescribed. Reinforce the importance of keeping the wound clean and dry.

5. Patient Education:

- Educate the patient on the importance of following post-operative instructions, including activity restrictions and wound care.

- Provide information on carpal tunnel syndrome, including causes, risk factors, and prevention strategies.

Evaluation:

- Patient's pain level was reduced from 4/10 to 1/10 as evidenced by verbal report and improved mobility.

- Patient demonstrated relaxation techniques and reported feeling less anxious.

- Patient actively participated in ROM and strengthening exercises without significant discomfort.