CARE OF PATIENTS WITH CASTS AND TRACTION One of the most important responsibilities of nurses is to understand the basic

procedures involved in the care of their patients. Throughout their career, nurses encounter a variety of patients with different diseases and/or injuries. Nurses must rely on the knowledge they possess regarding the care and treatment of these varying diseases and injuries when managing their patients. It is important for nurses to know why casts are used, the materials they are made of, and the application and removal processes. More importantly, nurses need to be aware of proper cast care in order to accurately educate their patients and maintain their health. In this article, we will briefly describe the casting process, materials that are frequently used, methods for cast removal, and the potential life-threatening complications that can be associated with casting and immobilization. What Is a cast? A cast is a supportive structure that surrounds an injured body part to protect, immobilize, and promote healing (Rouzier, 2009). Casts can also be used to treat and help to correct certain congenital deformities such as clubfoot, hip displacement, and spinal deformities. If a cast is necessary, the style and materials used will be determined by an orthopaedic physician and/or a nurse practitioner. Casting materials consist of fiberglass or plaster and the choice of material is dependent on several factors. Materials When selecting the material to be used for the casting process, there are various factors that can influence the decision. For instance, fiberglass is the most common material that is used, but may not be readily available in all settings and in all locations around the world. Plaster, however, is the cheapest material to use and is more available. We have included the three major types of materials that are used for casting with important points to keep in mind, while selecting the best option for each patient (Smeltzer, Care, Hinkle, & Cheever, 2008). PLASTER

allows the skin to "breathe." The downside of plaster lies in its setting time. Plaster requires at least 24 hours to reach "hard" set that can be inconvenient for the patient (Walsh, 2009). FIBERGLASS

Fiberglass is the most common casting material and usually the preferred method of immobilization. It has the versatility of plaster but is significantly lighter in weight. Fiberglass has the benefit of reaching full rigidity within minutes. It is stronger and more durable than plaster and does not soften when wet. Fiberglass is also porous, which diminishes the risk of skin problems, making fiberglass the preferred material for long-term casting (Smeltzer et al., 2008). WATERPROOF

Waterproof casting material is designed to get wet in a shower or pool. This particular kind of material is ideal for athletes and children, especially in the summer months (DeRosa, 2006; Shannon, DiFazio, Kasser, Karlin, & Gerbino, 2005). The liner that is used with the waterproof material dries quickly and the skin remains healthy and intact. The Casting Process When applying a cast, it is very important to remember to always immobilize the joint above and below the fracture. The extremity that is going to be casted should be supported and positioned before beginning the process. It should be determined first whether the extremity will be cast in the position of comfort, flexion, or extension. The patient should also be draped and the extremity should be clean and dry. The first thing that is put on the patient is stockinette, which should be measured to fit the extremity, allowing for extra material on either end to fold over the first layer of casting material. Next, four layers of webril should be applied to the patient's extremity. The webril should be an appropriate width for the size of the patient and should be wrapped from distal to proximal. Extra material should also be placed over any bony prominences. The four layers of padding have been proven to decrease the incidence of cast saw burns during the removal process (Walsh, 2009; see Figure 1). Then, the casting material should be chosen, whether it be plaster or fiberglass, and the appropriate width should also be considered. The casting material

Plaster is the traditional material used for casts. It is considered the most versatile of the splinting materials, is completely moldable, and can withstand considerable forces. Plaster is also a permeable material that

should be applied evenly on the extremity, distal to proximal. If fiberglass is used, one layer of white should be used first, folding over the edges of the stockinette to provide smooth edges and decrease skin irritation. If available, the patient may be given a choice of color or pattern. When all of the material has been applied to the affected extremity, remove any particles of casting material from the surrounding skin. It is very important to support the extremity during hardening, using palms only, no fingertips. Pressing on the cast with fingertips can create pressure points inside the cast and cause pain and loss of sensation for the patient (see Figure 2 and Figure 3). The materials will begin to harden within minutes. Support the cast on a firm and smooth surface; do not rest the cast on a hard surface or sharp edges. Be sure to promote drying by leaving the cast uncovered and exposed to the air; fans can be used to increase airflow and facilitate the drying process (Smeltzer et al., 2008).

Some patients may report that this casting material is not as comfortable as traditional because of the lack of padding. Also, the cost of the waterproof is substantially more than plaster or fiberglass. However, many patients may prefer the lightweight material that will allow them to be more active while healing takes place and even be willing to pay the extra charges for the convenience (Dubowitz & Miller, 2003). Assessment The nurse must complete an assessment of the patient's general health, emotional status, understanding of the need for the cast, and condition of the body part before a cast is applied. Physical assessment of the body part to be immobilized must include assessment of neurovascular status, degree and location of swelling, bruising, and skin abrasions (Smeltzer et al., 2008). SKIN

It is important to note that this is a general summary. The casting process will vary in each institution and around the world, depending on agency policy and available materials. Wrapping a Waterproof Cast The steps included in wrapping a waterproof cast are different from the steps for a regular cast. First, there is only one layer of padding and it is made of gore procel material overlapping each layer by half (Dubowitz & Miller, 2003). The adhesive side is away from the skin. This padding needs to be light enough to let water flow through easily (see Figure 4). The second difference is that there is a strip of cutting guard tape applied over the padding to the areas that the cast will be cut for bivalve and removal. This tape extends beyond the edge of the fiberglass casting material and is exposed for identification upon removal. Third, this tape is used to protect the skin from heat and friction of the cast saw upon removal (Haley, DeJong, Ward, & Kragh, 2006). Note that this type of cast is designed to get wet (i.e., shower and swim). The liner dries quickly, the skin remains healthy, and hygiene is improved along with patient comfort. This is especially useful for athletes and children during summer months (DeRosa, 2006; Shannon et al., 2005). The caution about using this material is that it is not wrapped with multiple layers and needs to have skin protection for removal. There is also a plastic "Zip-strip" that can be slid under the cast if the cutting tape is not used.

Assessment of the patient's skin should include assessing for edema, ecchymosis, lacerations, and/or abrasions as well as temperature and color of the injured body part. It is important to inspect for lacerations, ecchymosis, evidence of decreased circulation, or inflammation because they all influence nursing management of casting (Smeltzer et al., 2008). NEUROVASCULAR Neurovascular assessment of a patient should include the basic CSM checks, for or circulation, sensation, and motion checks. When assessing circulation, it is important to note the color and temperature of the skin as well as capillary refill. While assessing motion, it is important to note any weakness or paralysis of the injured body part. While assessing sensation, it is important to monitor any paresthesia, unrelenting pain, pain on passive stretch, and absence of feeling in the affected extremity. The nurse should monitor CSM of the fingers or toes of the cast extremity in comparison with the opposite extremity and any change should be noted and reported. Assessment of the five P's is crucial: pain, pallor, pulselessness, paresthesia, and paralysis (Smeltzer et al., 2008).

COMPARTMENT SYNDROME

Compartment syndrome occurs when there is increased tissue pressure in a limited space that compromises circulation and function of the tissue within a confined area, i.e., muscle fascia. The nerves and blood vessels within this confined space are compressed leading to problems with blood flow and damage of the muscle and nerves. The human body contains 46 anatomic compartments, 36 of which are located in the extremities. If a patient is experiencing compartment syndrome, they will experience the five P's: pain on passive stretch, paresthesia along dermatomal patterns, paralysis of the affected limb, pulselessness, and pallor of the extremity (Walsh, 2009). The pain is usually more severe than would normally be expected in this particular patient. However, patients with nerve damage may not even experience pain with compartment syndrome but will show sensory symptoms and signs of ischemia. Sensory symptoms are often experienced early, and once nerve ischemia occurs, it is almost never fully restored (McQueen, Christie, & Court-Brown, 1996). To relieve the pressure in the compartment, the cast must be bivalved, while maintaining the alignment of the extremity. Bivalving requires making a longitudinal cut to divide the cast in half to inspect the skin and relieve pressure. The extremity must then be elevated no higher than the heart to maintain arterial perfusion. If this does not relieve the pressure and restore circulation, a fasciotomy may be necessary. The fasciotomy will relieve the pressure in the compartment and prevent further tissue death and nerve ischemia. It is very important for the nurse to closely monitor this patient and perform frequent neurovascular checks (Smeltzer et al., 2008). Delay in treatment can be due to the lack of experience or confidence, but it can have devastating effects including contracture, infection, and even amputation (McQueen et al., 1996). SUPERIOR MESENTERIC ARTERY SYNDROME Superior mesenteric artery syndrome (cast syndrome) is specifically the physiologic factor associated with immobilization from a body cast. Abdominal distention can cause added pressure on the superior mesenteric artery that reduces blood supply to the bowel. If this occurs, the bowel can become gangrenous and will require surgical intervention and resection. The nurse taking care of a patient in a body cast needs to be sure to assess bowel sounds every 4-8 hr, report distention, nausea, and vomiting for immediate intervention (Smeltzer et al., 2008). CLAUSTROPHOBIA

Claustrophobia is most commonly seen in patients who require casting of a large area, i.e., body or spica casts. It is very important for the nurse to explain the casting procedure to the patient thoroughly to promote understanding and reduce anxiety. Be sure to administer pain and antianxiety medications as necessary prior to cast application (Smeltzer et al., 2008). Cast Removal Before beginning the process, it is important to inform the patient of the procedure. Be sure to explain that the cast saw uses an oscillating blade and will not cut the skin. If the patient is especially anxious, demonstrate on the bedding that the saw does not cut, but vibration will be felt. Next, bivalve the cast using linear movements of the blade and be sure not to drag the saw as this can cause burns. The linear movements prevent burns from prolonged contact of the saw to cast (see Figure 5 and Figure 6). Then cut the padding with trauma shears to ensure that the patient's skin will not be cut. As the extremity is being removed, be sure to support it and examine the skin. It is important to teach the patient to avoid rubbing and scratching the skin as this can damage the newly exposed skin. Also, be sure to teach the patient to control swelling by elevating the extremity, no higher than the heart (Smeltzer et al., 2008).

Conclusion We have offered a general overview of the casting process in this article. It is important to note that casting is not an exact science and will vary in different facilities and around the world, depending on policies and available materials. Nurses should be sure to become familiar with their agency's policies before caring for patients with casts. Cast Care at Home * To prevent pain and swelling, follow the acronym RICER-Rest I-Ice CCompression E-Elevation (no higher than heart level) * Take pain killers as prescribed by your physician or nurse practitioner * Report pain unrelieved by elevation and pain killers

* To control itching tap a pen on the outside of the cast or use a hair dryer on cool setting to blow cool air into the cast (NEVER insert an object into the cast) * When bathing, wrap the edges of the cast with a towel and cover the entire cast with a plastic bag, secure with tape or elastic bands (your local pharmacy may carry cast bags). * If your cast gets wet, report immediately to physician or nurse practitioner. * If your limb is in a cast, make sure that each day you are able to: 1. Lift your thumb or great toe 2. Spread your fingers or toes 3. Touch your fingers to your thumb (arm casts only) 4. Press and hold finger or toenail and release, nail should return to pink color within 2 seconds * If you are unable to do any of these activities, contact your physician or nurse practitioner IMMEDIATELY.

McQueen M. M., Christie J., Court-Brown C. M. (1996). Acute compartment syndrome in tibial diaphyseal fractures. The Journal of Bone and Joint Surgery, 78(1), 95-98. [Context Link] Rouzier P. (2009). "Cast care." McKesson provider technologies. Retrieved July 28, 2009, from http://www.summitmedicalgroup.com/library/sports_health/cast_care/[Contex t Link] Shannon E. G., DiFazio R., Kasser J., Karlin L., Gerbino P. (2005). Waterproof casts for immobilization of children''s fractures and sprains. Journal of Pediatric Orthopedics, 25(1), 56-59. [Context Link] Smeltzer S. C., Bare B. G., Hinkle J. L., Cheever K. H. (2008). Textbook of medical-surgical nursing (11th ed.). Philadelphia: Lippincott, Williams & Wilkins. [Context Link] Walsh C. R. (2009). Sign off on casting. OR Nurse, 3(5), 45-51. [Context Link]

Note. From Textbook of Medical-Surgical Nursing (11th ed.), by S. C. Smeltzer, B. G. Bare, J. L. Hinkle, and K. H. Cheever, 2008, Philadelphia: Lippincott Williams & Wilkins. REFERENCES DeRosa R. (2006). A sporting chance. Functional casting keeps athletes in the game. The Journal, 10(1), 4-5. [Context Link] Dubowitz G., Miller D. M. (2003). Cast adrift: Gortex cast liners allow greater patient activity. Wilderness and Environmental Medicine, 14(3), 167-168. [Context Link] Haley C. A., DeJong E. S., Ward J. A., Kragh J. F, Jr. (2006). Waterproof cast liner versus cotton cast liner: A randomized, prospective comparison. American Journal of Orthopedics, 35(3), 137-140. [Context Link]