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NURSING PROCESS:THE PATIENT IN A CAST
Before the cast is applied, the nurse completes an assessment of the patient’s general health, presenting signs and symptoms, emo-tional status, understanding of the need for the cast, and condi-tion of the body part to be immobilized in the cast. Physical assessment of the part to be immobilized must include assessment of the neurovascular status (neurologic and circulatory func-tioning) of the body part, degree and location of swelling, bruis-ing, and skin abrasions.
Based on the assessment data, major nursing diagnoses for the pa-tient with a cast may include the following:
· Deficient knowledge related to the treatment regimen
· Acute pain related to the musculoskeletal disorder
· Impaired physical mobility related to the cast
· Self-care deficit: bathing/hygiene, feeding, dressing/groom-ing, or toileting due to restricted mobility
· Impaired skin integrity related to lacerations and abrasions
· Risk for peripheral neurovascular dysfunction related to phys-iologic responses to injury and compression effect of cast
Based on the assessment data, potential complications that may develop include the following:
· Compartment syndrome
· Pressure ulcer
· Disuse syndrome
The major goals for the patient with a cast include knowledge of the treatment regimen, relief of pain, improved physical mobil-ity, achievement of maximum level of self-care, healing of lacer-ations and abrasions, maintenance of adequate neurovascular function, and absence of complications.
Before the cast is applied, the patient needs information con-cerning the pathologic problem and the purpose and expectations of the prescribed treatment regimen. This knowledge promotes the patient’s active participation in and adherence to the treat-ment program. It is important to prepare the patient for the ap-plication of the cast by describing the anticipated sights, sounds, and sensations (eg, heat from the hardening reaction of the plaster). The patient needs to know what to expect during appli-cation and that the body part will be immobilized after casting (Chart 67-1).
The nurse must carefully evaluate pain associated with muscu-loskeletal problems, asking the patient to indicate the exact site and to describe the character and intensity of the pain to help de-termine its cause. Most pain can be relieved by elevating the in-volved part, applying cold as prescribed, and administering usual dosages of analgesics.
Pain associated with the disease process (eg, fracture) is fre-quently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, inter-mittent application of cold. Ice bags (one-third to one-half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent the cast.
Pain may be indicative of complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of cold if prescribed, and usual dosages of analgesics. Severe pain over a bony prominence warns of an impending pressure ulcer. Pain decreases when ul-ceration occurs. Discomfort due to pressure on the skin may be relieved by elevation that controls edema or by positioning that alters pressure. It may be necessary, however, to modify the cast or to apply a new cast.
Every joint that is not immobilized should be exercised and moved through its range of motion to maintain function. If the patient has a leg cast, the nurse encourages toe exercises. If the pa-tient has an arm cast, the nurse encourages finger exercises.
Before the cast is applied, it is important to treat skin lacerations and abrasions to promote healing. The nurse thoroughly cleans the skin and treats it as prescribed. Sterile dressings are used to cover the injured skin. If the skin wounds are extensive, an alternative method (eg, external fixator) may be chosen to immobilize the body part. While the cast is on, the nurse observes the patient for systemic signs of infection, odors from the cast, and purulent drainage staining the cast. It is important to notify the physician if any of these occurs.
Swelling and edema are natural responses of the tissue to trauma and surgery. The patient may complain that the cast is too tight. Vascular insufficiency and nerve compression due to unrelieved swelling can result in compartment syndrome. The nurse monitors circulation, motion, and sensation of the affected extremity, assessing the fingers or toes of the casted extremity and comparing them with those of the opposite extremity. Normal findings include minimal swelling, minimal discomfort, pink color, warm to touch, rapid capillary refill response, normal sen-sations, and ability to exercise fingers or toes. The nurse encour-ages the patient to move fingers or toes hourly when awake to stimulate circulation.
It is important to perform frequent, regular assessments of neurovascular status. Early recognition of diminished circulation and nerve function is essential to prevent loss of function. As-sessment data including progressive unrelieved pain, pain on passive stretch, paresthesia, motor loss, sensory loss, coolness, paleness, slow capillary refill, and sensation of tightness indicate potential compartment syndrome. The nurse adjusts the extrem-ity so that it is no higher than heart level to enhance arterial per-fusion and control edema and notifies the physician at once.
Compartment syndrome occurs when there is increased tissue pressure within a limited space (eg, cast, muscle compartment) that compromises the circulation and the function of the tissue within the confined area. To relieve the pressure, the cast must be bivalved (cut in half longitudinally) while maintaining align-ment, and the extremity must be elevated no higher than heart level (Chart 67-2). If pressure is not relieved and circulation is not restored, a fasciotomy may be necessary to relieve the pressure within the muscle compartment. The nurse closely monitors the patient’s response to conservative and surgical management of compartment syndrome. The nurse records neurovascular re-sponses and promptly reports changes to the physician.
Pressure of the cast on soft tissues may cause tissue anoxia and pressure ulcers. Lower extremity sites most susceptible to pressure are the heel, malleoli, dorsum of the foot, head of the fibula, and anterior surface of the patella. The main pressure sites on the upper extremity are located at the medial epicondyle of the humerus and the ulnar styloid (see Fig. 67-1).
Usually, the patient with a pressure ulcer reports pain and tightness in the area. A warm area on the cast suggests underly-ing tissue erythema. The area may break down. The drainage may stain the cast and emit an odor. Even if discomfort does not occur with tissue breakdown and necrosis, there may still be extensive loss of tissue. The nurse must monitor the patient with a cast for pressure ulcer development and report findings to the physician.
To inspect the pressure area, the physician may bivalve the cast or cut an opening (window) in the cast. If the physician elects to create a window to inspect the pressure site, a portion of the cast is cut out. The affected area is inspected and possibly treated. The portion of the cast is replaced and held in place by an elastic com-pression dressing or tape. This prevents the underlying tissue from swelling through the window and creating pressure areas around its margins.
While in a cast, the patient needs to learn to tense or contract muscles (eg, isometric muscle contraction) without moving the part. This helps to reduce muscle atrophy and maintain muscle strength. The nurse teaches the patient with a leg cast to “push down” the knee and teaches the patient in an arm cast to “make a fist.” Muscle-setting exercises (eg, quadriceps-setting and gluteal-setting exercises) are important in maintaining muscles essential for walking (Chart 67-3). Isometric exercises should be performed hourly while the patient is awake.
Self-care deficits occur when a portion of the body is immobi-lized. The nurse encourages the patient to participate actively in personal care and to use assistive devices safely. The nurse must assist the patient in identifying areas of self-care deficit and in developing strategies to achieve independence in activities of daily living (ADLs) (Chart 67-4). The patient’s participation in planning and accomplishing ADLs is an important aspect of self-care, independence, maintaining control, and avoiding untoward psychological reactions, such as depression.
When the cast is dry, the nurse instructs the patient as follows:
· Move about as normally as possible, but avoid excessive use of the injured extremity and avoid walking on wet, slippery floors or sidewalks.
· Perform prescribed exercises regularly, as scheduled.
· Elevate the casted extremity to heart level frequently to pre-vent swelling.
· Do not attempt to scratch the skin under the cast. This may cause a break in the skin and result in the formation of a skin ulcer. Cool air from a hair dryer may alleviate an itch.
· Cushion rough edges of the cast with tape.
· Keep the cast dry but do not cover it with plastic or rubber, because this causes condensation, which dampens the cast and skin. Moisture softens a plaster cast. (A wet fiberglass cast must be dried thoroughly with a hair dryer on a cool setting to avoid skin problems.)
· Report any of the following to the physician: persistent pain, swelling that does not respond to elevation, changes in sensation, decreased ability to move exposed fingers or toes, and changes in skin color and temperature.
· Note odors around the cast, stained areas, warm spots, and pressure areas. Report them to the physician.
· Report a broken cast to the physician; do not attempt to fix it yourself.
The nurse prepares the patient for cast removal or cast changes by explaining what to expect (Chart 67-5). The cast is cut with a cast cutter, which vibrates. The patient can feel the vibration and pressure during its use. The cutter does not penetrate deeply enough to hurt the patient’s skin. The cast padding is cut with scissors.
The casted body part is weak from disuse, is stiff, and may ap-pear atrophied. There may be extreme stiffness even after only a few weeks of immobilization. Therefore, support is needed when the cast is removed. The skin, which is usually dry and scaly from accumulated dead skin, is vulnerable to injury from scratching.
The skin needs to be washed gently and lubricated with an emol-lient lotion.
The nurse and physical therapist teach the patient to resume activities gradually within the prescribed therapeutic regimen. Exercises that are prescribed to help the patient regain joint motion are explained and demonstrated. Because the muscles are weak from disuse, the body part that has been casted cannot withstand normal stresses immediately. In addition, the nurse teaches the patient who has noticeable swelling of the affected extremity after the cast is removed to continue to elevate the ex-tremity to control swelling until normal muscle tone and use are reestablished.
Expected patient outcomes may include:
1) Understands the therapeutic regimen
a) Elevates affected extremity
b) Exercises according to instructions
c) Keeps cast dry
d) Reports any problems that develop
e) Keeps follow-up clinic or physician appointments
2) Reports less pain
a) Elevates extremity that is in the cast
b) Repositions self
c) Uses occasional oral analgesic
3) Demonstrates increased mobility
a) Uses assistive devices safely
b) Exercises to increase strength
c) Changes position frequently
d) Performs range-of-motion exercises of joints not in the cast
4) Exhibits healing of abrasions and lacerations
a) Demonstrates no local signs of infection (ie, local dis-comfort, purulent drainage, cast staining, or odor from cast)
b) Demonstrates no systemic signs or symptoms of infection
c) Demonstrates intact skin when cast is removed
5) Maintains adequate neurovascular function of affected extremity
a) Exhibits normal skin color and temperature
b) Experiences minimal swelling
c) Exhibits satisfactory capillary refill on testing
d) Demonstrates active movement of fingers or toes if they are not casted
e) Reports normal sensations in casted body part
f) Reports that pain is controllable
6) Exhibits absence of complications
a) Demonstrates normal neurovascular status of casted extremity
b) Develops no pressure ulcers
c) Exhibits minimal muscle wasting
7) Participates in self-care activities
a) Performs hygiene and grooming activities indepen-dently or with minimal assistance
b) Performs ADLs independently or with minimal assistance
c) Adheres to prescribed exercise regimen.
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