ASSISTING WITH A CAST APPLICATION Purpose: To support and protect injured bones and soft tissue, reducing pain,

swelling, and muscle spasm, maintains alignment and prevents movement of the bones while it heals. Special Considerations: Before and after cast application: 1. Assess for signs of restricted circulation 2. Take the clients pulse rate, respiratory rate, and blood pressure Administer ordered analgesics before cast application Before cast is applied, remove clothing from the body area and rings from fingers of the affected limb Ensure safe storage of the clients valuables Wash the skin area to receive the cast and dry it thoroughly if ordered Stabilize and support the limb appropriately during cast application. Remove excess cast material from clients skin after application. Document assessment and interventions.

Equipment: Rolls of cast materials Plastic lined bucket of water at the prescribed temperature: 1. Tepid water for Plaster of Paris and water activated 2. Cool water at 26 C (80 F) for polyester and cotton cast or A thermostatically controlled hydro collator or a boiler or cooking pot with a temperature- regulating thermometer for a thermoplastic cast. 3. Stockinet Cotton sheet wadding or padding Felt padding (optional) PROCEDURE 1. Explain the procedure to the client, including the length of time the cast material requires for drying. Explain that the cast may feel warm during and after the application

Plaster Splints (optional) Moisture- resistant drapes Rubber gloves Plastic aprons Water- soluble lubricant Plaster knife Large bandage scissors Pillows Damp cloth 5 4 3 2 1

RATIONALE Different cast materials require different drying times. Pressure may cause a wet cast to change shape. The cast material gives off heat as they set.

PROCEDURE 2. Provide an analgesic as ordered

RATIONALE This procedure is optional. If pain is anticipated, the patient should also be informed. To reduce pain. To provide comfort

3. Assist the client into a comfortable sitting or lying position

4. Remove clothing from the body area and rings from fingers of the affected limb and give them to a family member or store safely in a locked safe.

Clothes may not be removed over a cast. Rings may interfere with the circulation of a swollen extremity

5. Support the part to receive the cast

To prevent accidental drop of affected extremity

6. Wash the skin area, and dry it thoroughly, if ordered. If there is no open wound, powder may be applied.

To remove dirt and debris from the skin

7. Provide stockinet of the correct size if used, and cut it several inches longer than the length of the extremity so that it will extend beyond the plaster edges. Then roll the stockinet to facilitate application. 8. Provide sheet wadding and felt pads as needed. Usually 2- 3 layers are applied.

Application of a stockinet prevents folds or creases that could irritate the skin

Provides padding to bony prominences and prevents direct contact of casting material to skin.

9. Provide gloves for the physician prior to application of the cast material 10. Hand the physician the casting material or place the material within the physicians reach. Preparation of cast material varies depending on the type of casting material used 11. Squeeze a generous amount of water-soluble lubricant on the physicians gloves as requested

Protects the hand from irritation or tacky resin

Provides systematic an easier application of the cast.

Lessens the tack on the physicians gloves when molding the cast

PROCEDURE 12. Support the limb while the physician applies the stockinet, padding, and cast material. With one hand, grasp the clients toes for a leg cast or fingers for an arm cast, and with the other hand support beneath the limb areas on which the physician is not working. 13. After the cast is applied, pull the stockinet out over the proximal and distal cast opening edges, while the physician secures it in place with one or two layers of cast material.

RATIONALE Failure to support the limb in one position could produce wrinkles on the inside of the cast and can cause pressure areas.

To cover rough edges

14. Remove any excess cast material deposited accidentally on the clients skin.

Cast material is mostly easily removed while it is still wet.

15. Assess the client with special reference to the cast.

Discomfort, chilling, pain may be present after cast application

16. Provide firm support for the cast.

To prevent deformity of wet cast.

17. Gather and dispose the used materials appropriately

Plaster of Paris and some plastics can obstruct plumbing and should be disposed of in a waste container.

18. Document

A nursing responsibility. Do after care.

CLIENT CARE IMMEDIATELY AFTER A CAST APPLICATION

Equipment: Soft, pliable pillows PROCEDURE 1. Assess the toes and fingers for nerve or circulatory impairments every 30 mins for several hours following application and then every 3 hours for the first 24-48 hours or until all signs and symptoms of impairment are negative 2. Immediately after the cast is applied, place it on pillows. Avoid using plastic or rubber pillows. RATIONALE Rapid swelling under a cast can cause neurovascular problems. 5 4 3 2 1

Pillows provide even pressure and support the curves of the cast and promote venous return, decreasing the possibility of swelling. Plastic and rubber pillows do not allow the heat of a drying cast to dissipate and causes discomfort.

3. Support the cast in the palms of your hands rather than your fingertips

Prevents dents in unset plaster and subsequent skin pressure areas. Prevents deformity

4. Control swelling by elevating arms or legs on pillows or, for leg fracture, by elevating the foot of the bed

Swelling can cause neurovascular impairments

5. Report excessive swelling and indications of neurovascular impairments to the physician or nurse in charge.

Bivalving might be necessary

6. Apply ice packs to a hip spica cast

To control perineal edema

7. Expose the cast to the circulating air 8. Check agency policy about the recommended turning frequency for clients with different kinds of cast

To facilitate drying of the cast Frequent turning promotes even drying of the cast

PROCEDURE 9. Avoid the use of artificial means to facilitate drying. This means including fans, hairdryers, infrared lamps, and electric heaters

RATIONALE Artificial methods dry the outer surface of the cast while the inner part remains soft and spongy

10. Monitor drainage for 24-72 hours after surgery. Outline the stained area every 8 hours.

To determine further bleeding

11. Never ignore any complaints of pain, burning or pressure. If patient is unable to communicate, be alert to changes in temperament, restlessness, or fussiness.

To monitor for signs of compartment syndrome or other complications

12. Give pain medications selectively

Pain medications may mask symptoms

13. Do not disregard the cessation of persistent pain or discomfort complaints

Cessation of complaints can indicate a skin slough. When a skin slough occurs, superficial skin sensation is lost and the client no longer feels pain.

14. Document

A nursing responsibility. Do after care.

CONTINUING CARE FOR CLIENTS WITH CASTS

Special Considerations: Remove crumbs of plaster from the skin, petal rough cast edges. For bed- confined patients, provide skin care over all bony prominences and turn the clients at least every 4 hours Keep the cast clean and dry Encourage clients to move toes or fingers of the casted extremity frequently Provide necessary instructions about cast care, ways to move safely, activity allowed, exercises, elevating the involved extremity, signs of neurovascular problems, ways to handle itching Equipment: Rubbing alcohol Mineral, olive, or baby oil to apply to the skin after cast removal Adhesive tape Scissors PROCEDURE 1. Wash crumbs of plaster from the skin with a damp cloth and feel along the cast edges or areas that press into the clients skin. It may be necessary to use a duck billed cast bender to bend cast edges that may irritate the skin

Damp washcloth for Plaster of Paris Warm water and a mild soap for synthetic casts Pillows Fracture pan 5 4 3 2 1

RATIONALE As plaster of Paris dries, small bits of plaster frequently break off from its rough edges. If they fall inside the cast, they can cause discomfort.

2. Cover rough edges of the cast when it is dry. If the stockinet has not been used to line the cast, petal the edge with small strips of adhesive tape. 3. Check the cast daily for foul odors

To prevent further damage to the skin

May indicate skin excoriation from pressure or an infected area beneath the cast

4. Discourage the patient from using long sharp objects to scratch under the cast

These objects can break the skin and cause an infection, since bacteria flourish in the warm, dark, moist environment under the cast

PROCEDURE 5. When cast is removed, dry, flaky and encrusted skin is observed, remove this debris gently and gradually by: a. Apply oil (mineral, olive, or baby) b. Soak the skin with warm water and dry it c. Caution the client not to rub the area too vigorously d. repeat steps a and b for several days Keeping the Cast Clean and Dry 6. Tub baths and showers are contraindicated. POP cast is kept clean by wiping it with a damp cloth. Place a bib or towel over a body cast to catch spills. If a spill does wet the cast, allow the area to air dry. 7. Use a fracture bedpan for people with long leg, hip spica, or body casts.

RATIONALE Vigorous rubbing can cause bleeding or excoriation. Gradual removal of skin exudates avoids skin irritation

Casts that become wet soften, and their function is impaired

The flat end placed correctly under the clients buttocks lessens the chance of spillage and minimizes the amount of lifting required by the client and/or the nurse.

8. Before placing the client on the bed pan, tuck plastic or other waterproof material around the top of a long leg cast or in around the perineal cutout. Remove plastic when elimination is completed 9. For people with long leg casts, keep the cast supported on pillows while the client is on bed pan.

If left in place, waterproof material makes the cast edge airtight and prevents evaporation of perspiration, which is irritating to the skin.

If the cast dangles, urine may run down the cast

10. For clients with hip spica casts, support both extremities and the back on pillows so that they are as high as the buttocks

This prevents urine from running back into the cast

PROCEDURE 11. When removing the bedpan, hold it securely while the client is turning or lifting the buttocks. After removing the bedpan, thoroughly clean and dry the perineal area

RATIONALE This prevents dripping and spilling

12. Synthetic casts: Synthetic casts can be cleaned readily and may, with the physicians permission, be immersed in water if polypropylene stockinet and padding were applied. a. Wash the soiled area with warm water and a mild soap b. Thoroughly rinse the soap from the cast c. Dry thoroughly to prevent skin maceration and ulceration under the cast. d. If the cast is immersed in water, the cast and underlying padding and stockinet must be dried thoroughly. First blot excess water from the cast with a towel. Then use a handheld blow-dryer on the cool or warm setting, directing the air stream in a sweeping motion over the exterior of the cast for about 1 hour or until the client no longer feels a cold clammy sensation like that produced by a wet bathing suit.

This drying procedure is essential to prevent skin maceration and ulceration

Turning and Positioning Clients 13. Place pillows in such a way that: a. Body parts press against the cast edges as little as possible. b. Toes, heels, elbows, etc., are protected from pressure against bed surface. c. Body alignment is maintained

To maintain body alignment and prevent skin breakdown

PROCEDURE 14. Plan and implement a turning schedule incorporating all possible positions.

RATIONALE Repositioning prevents pressure areas

Exercise 15. Unless contraindicated, encourage active ROM exercises for all joints on the affected extremities, as well as on the joints proximal and distal to the cast

Exercise prevents joint stiffness and muscle atrophy

16. Encourage the client to move the toes and/or fingers of the casted extremity as frequently as possible.

Moving these extremities enhances peripheral circulation and decreases swelling and pain.

17. With the physicians approval, teach isometric (muscle setting) exercises.

Isometric exercises will minimize muscle atrophy in the affected limb

18. Teach isometric exercises on the clients unaffected limb before the person applies it to the affected limb. Demonstrate muscle palpation while the client is carrying out the exercise.

Palpation enables the person to feel the changes that occur with muscle contraction and relaxation

19. Document assessments and nursing implementations on the appropriate records.

A nursing responsibility. Do after care.

TRACTION CARE Purpose: To apply a continuous pulling force to an extremity or body part, maintain its alignment, and prevent infection Guidelines: All traction should have a counter traction to prevent the client from being pulled by the force of traction against the pulleys or the bed, thus negating the traction To apply and maintain the correct amount of traction, all traction weights should be hanging freely and the ropes should not touch any part of the bed. The traction force should follow an established line of pull. The line of pull determines the position and alignment of the body as prescribed by the physician Traction should always be applied while the client is in proper body alignment in a supine position

Equipment: Protective skin devices, e.g. heel protectors Trapeze Rubbing alcohol

Antiseptic agent Sterile gauze dressing Picking forceps

PROCEDURE 1. Inspect the traction apparatus regularly, whenever you are at the bedside or at prescribed intervals, such as every 2 hours 2. Provide protective devices and measures to safeguard the skin. E.g. heel protectors, pillows, etc) massage the skin. 3. Maintain the client in supine position unless there are other orders 4. Provide a trapeze to assist the client to move and lift the body for back care if the person is unable to turn, e.g., if the client

RATIONALE Any articles that impinge on the traction can negate its effectiveness To prevent skin breakdown

Changing position can change the body alignment and the amount of force supplied by the traction To assist the client during ambulation

has balanced suspension traction PROCEDURE 5. Do not remove skeletal and adhesive skin traction. RATIONALE A reduced fracture for example, can become malpositioned if traction is removed. 5 4 3 2 1

6. Non adhesive skin traction is intermittent and can be removed; check agency policy about any orders required. Remove weights first; then unwrap the bandage and provide skin care. Rewrap the limb and slowly reattach the weights

To keep the underlying skin clean and to remove soil, debris and microorganisms.

7. Provide pin site care and this varies with different hospital protocols. Carefully inspect the site Use sterile technique Remove crusts with a rolling technique Cover sites with a sterile barrier Determine the frequency of care by the amount of drainage

Regular inspection of the pin site ensures early detection of minor infections, e.g., serosanguinous drainage, crusting, swelling and erythema. Sterile technique helps protect the client from infections. Removing all crusted secretions permits the pin site to drain freely.

8. Teach client deep breathing and coughing.

To prevent hypostatic pneumonia

9. Teach the client appropriate exercises

To maintain and develop muscle tone, prevent muscle atrophy, and promote blood circulation.

10. Document

A nursing responsibility. Do after care.