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.
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