Specific Cast Management Considerations
The patient whose arm is immobilized in a cast must readjust to many routine tasks. The unaffected arm must assume all the upper extremity activities. The nurse, in consultation with an occupational therapist, suggests devices designed to aid one-handed activities. The patient may experience fatigue due to modified activities and the weight of the cast. Frequent rest pe-riods are necessary.
To control swelling, the nurse elevates the immobilized arm. When the patient is lying down, the arm is elevated so that each joint is positioned higher than the preceding proximal joint (eg, elbow higher than the shoulder, hand higher than the elbow).
A sling may be used when the patient ambulates. To prevent pressure on the cervical spinal nerves, the sling should distribute the supported weight over a large area and not on the back of the neck. The nurse encourages the patient to remove the arm from the sling and elevate it frequently.
Circulatory disturbances in the hand may become apparent with signs of cyanosis, swelling, and an inability to move the fin-gers. One serious effect of impaired circulation in the arm is Volkmann’s contracture, a form of compartment syndrome. Contracture of the fingers and wrist occurs as the result of ob-structed arterial blood flow to the forearm and hand. The patient is unable to extend the fingers, describes abnormal sensation (eg, unrelenting pain, pain on passive stretch), and exhibits signs of diminished circulation to the hand. Permanent damage develops within a few hours if action is not taken.
This serious complication can be prevented with nursing sur-veillance and proper care. The nurse makes frequent neurovascular checks. Compartment syndrome is managed in part by bivalving (cutting) the cast to release constricting cast and dress-ings. A fasciotomy may be necessary to improve vascular status.
The application of a leg cast imposes a degree of immobility on the patient. The cast may be a short leg cast, extending to the knee, or a long leg cast, extending to the groin. The fresh cast must be handled in a manner that will not cause denting or disruption of the cast.
The nurse supports the patient’s leg on pillows to heart level to con-trol swelling and applies ice packs as prescribed over the fracture site for 1 or 2 days. The patient is taught to elevate the casted leg when seated. The patient should also assume a recumbent position sev-eral times a day with the casted leg elevated to promote venous re-turn and control swelling.
The nurse assesses circulation by observing the color, temper-ature, and capillary refill of the exposed toes. Nerve function isassessed by observing the patient’s ability to move the toes and by asking about the sensations in the foot. Numbness, tingling, and burning may be caused by peroneal nerve injury from pressure at the head of the fibula.
When the cast is hard and dry, the nurse teaches the patient how to transfer and ambulate safely with assistive devices (eg, crutches, walker). The gait to be used depends on whether the pa-tient is permitted to bear weight. If weight bearing is allowed, the cast is reinforced to withstand the body weight. A cast boot, worn over the casted foot, provides a broad, nonskid walking surface.
Casts that encase the trunk (body cast) and portions of one or two extremities (spica cast) require special nursing strategies. Body casts are used to immobilize the spine. Hip spicas are used for some femoral fractures and after some hip joint surgeries, and shoulder spica casts are used for some humeral neck fractures.
Nursing responsibilities include preparing and positioning the patient, assisting with skin care and hygiene, and monitoring for cast syndrome. Explaining the procedure helps reduce the pa-tient’s apprehension about being encased in a large cast. The nurse reassures the patient that several people will provide care during the application, that support for the injured area will be adequate, and that care providers will be as gentle as possible. Medications for pain relief and relaxation administered before the procedure enable the patient to cooperate during application of the cast.
Cracking or denting of the cast is prevented by supporting the patient on a firm mattress and with flexible, waterproof pillows until the cast dries. The nurse positions the pillows next to each other, because spaces between pillows allow the damp cast to sag, become weak, and possibly break. A pillow is not placed under the head and shoulders of a patient in a body cast while the cast is drying, because doing so causes pressure on the chest.
The nurse turns the patient as a unit toward the uninjured side every 2 hours to relieve pressure and to allow the cast to dry. It is important to avoid twisting the patient’s body within the cast. Suf-ficient personnel (at least three people) are needed when the pa-tient is turned so that the fresh cast can be adequately supported with the palms of the hands at vulnerable points (ie, body joints) to prevent cracking. The nurse encourages the patient to assist in the repositioning, if not contraindicated, by use of the trapeze or bed rail. A stabilizing abduction bar incorporated into a spica cast should not be used as a turning device. The nurse adjusts the pil-lows to provide support without creating areas of pressure.
The nurse turns the patient to a prone position, twice daily if tolerated, to provide postural drainage of the bronchial tree and to relieve pressure on the back. A small pillow under the abdomen enhances comfort. The nurse can either place a pillow lengthwise under the dorsa of the feet or allow the toes to hang over the edge of the bed to prevent the toes from being forced into the mattress.
The nurse inspects the skin around the edges of the cast fre-quently for signs of irritation. The nurse can inspect some of the skin under the cast by pulling the skin taut and using a flashlight.
The skin can be bathed and massaged by reaching under the cast edges with the fingers.
The perineal opening must be large enough for hygienic care. To protect the cast from soiling, the nurse can insert clean dry plastic sheeting under the cast and over the cast edge before elim-ination by the patient. Usually, fracture bedpans are easier for pa-tients with a hip spica cast to use than regular bedpans.
Patients immobilized in large casts may develop cast syndrome —psychological and physiologic responses to the confinement. The psychological component is similar to a claustrophobic re-action. The patient exhibits an acute anxiety reaction character-ized by behavioral changes and autonomic responses (eg, increased respiratory rate, diaphoresis, dilated pupils, increased heart rate, el-evated blood pressure). The nurse needs to recognize the anxiety re-action and provide an environment in which the patient feels secure.
The physiologic cast syndrome responses (superior mesenteric artery syndrome) are associated with immobility in a body cast. With decreased physical activity, gastrointestinal motility de-creases, intestinal gases accumulate, intestinal pressure increases, and ileus may occur. The patient exhibits abdominal distention, abdominal discomfort, nausea, and vomiting. As with other in-stances of adynamic ileus, the patient is treated conservatively with decompression (nasogastric intubation connected to suc-tion) and intravenous fluid therapy until gastrointestinal motil-ity is restored. If the cast restricts the abdomen, the abdominal window must be enlarged. After the ileus resolves and bowel sounds resume, the patient gradually resumes an oral diet. Rarely, the distention places traction on the superior mesenteric artery, reducing the blood supply to the bowel. The bowel may become gangrenous, which requires surgical intervention. The nurse monitors the patient in a large body cast for potential cast syn-drome, noting bowel sounds every 4 to 8 hours, and reports dis-tention, nausea, and vomiting to the physician.
The patient with a body or spica cast is often cared for in the home. The nurse teaches family members how to care for the pa-tient, which includes providing hygienic and skin care, ensuring proper positioning, preventing complications, and recognizing symptoms that should be reported to the health care provider.