Nursing Care of patient during cast application

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Purpose of cast:

1. immobilize injured extremity to protect it from further injury.

2. provide alignment for bone fragment during healing process.

3. promote comfort.

Types of cast:

1. plaster of Paris.

2. synthetic.

The type of cast material selected depend depend on number of cast changes anticipated and the type of musculoskeletal injury.

Plaster of paris:

Composed of open-weave cotton roll or strip covered with calcium sulfate crystals when moistened with water, this material mold easily but drying may require 24 hours for regular arm cast.

This cast is heavier that synthetic cast and should not predisposed to water after application.

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Synthetic cast:

Composed of open-weave fiberglass tape covered with polyurethane resin that activated with water and dry within 15 minutes these cast are radiolucent and waterproof, it is also available in different colors.

These casts are more expensive than plaster cast.

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Assessment:

1. assess factors that may affect wound healing, such as diabetes, poor nutritional status, or steroid medication use.

Rational: when there is risk of slower healing, additional nutritional supplement is required.

2- assess clients ability to cooperate and level of understanding concerning the casting procedure.

Rational: sudden movement during procedure could cause injury.

3- Inspect condition of skin that will be under the cast- specifically note any areas of skin breakdown, rashes present or incisional wound.

Rational: provides baseline for skin condition.

4. assess neurovascular status of the area to be casted.

Specifically note presence or absence of motor and sensory function, skin color, temperature, and capillary refill (pain, presthesia, pale, pulseless, paralysis)

5- Pay attention to tissue distal to cast.

Rational: changes in neurovascular status may occur after casting, so its important to take baseline neurovascular changes before cast application.

5. assess client pain status using a scale of 0 to 10.

6. consult the physician to determine the extent to which client will be able to use the casted body part.

Rational: determine the extent to which self care will be required.

Equipment:

# plaster cast:

– plaster rolls 2,3,4, or 6 inch.

– padding material.

– Clean gloves, apron.

– plastic- lined bucket or basin.

– cart, chair and fracture table scissors.

– paper or plastic sheets.

# synthetic cast:

– synthetic rolls.

– pail with water to damp in rolls.

– padding materials.

– cast cutter to trim edge of cast.

Implementation for care of the client during cast application:

1. prepare needed equipment.

2. hand washing.

3. explain the procedure.

4. adjust the bed to appropriate level, lower side rails.

5. provide adequate lightening.

6. provide privacy .

7. administer analgesics before cast application 20 to 30 minutes before cast application.

Rational: reduces pain during cast application provide optimal analgesic effect.

8. wear gloves.

Rational: synthetic cast can leave glue like material on the hands which could cause allergy.

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9. assist physician in positioning client and injured extremity as desired, depending on type of cast to be used and area to be casted.

Rational: the part to be casted must be supported and in optimal alignment.

10. prepare the skin that will be enclosed in the cast. Change any dressing if present and cleanse the skin with mild soap and water.

Rational: assist in maintaining skin integrity.

Note: clients with skin damage may not be candidate for casting.

11. assist with application of padding material around body part to be casted, avoid wrinkles or uneven thicknesses.

Rational: decrease complication to the skin and prevents pressure points under the cast.

12. hold body part or parts to be casted or assist with preparation of casting materials.

Rational: support body part may require application of slight manual traction.

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a. plaster cast:

Mark the end of the roll by folding one corner of the material under it self. Hold plaster roll under water in a basin until bubbles stop then squeeze slightly and hand roll to person applying the cast.

Rational:

Once the end dampened in water it may be difficult to find.

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b. synthetic cast:

Submerge cast roll in lukewarm water for 10 to 15 seconds, squeeze to remove excess water.

Rational: submersion in water will initiate the chemical reaction which will result in the hardening of the cast.

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13. continue to hold the body part as necessary as the cast is applied, and supply necessary equipment And compress it gently with hands.

Rational: positioning cast help maintain alignment,

Thickness of plaster cast determine its strength, compression promote bonding and strength of cast layers.

14. provide walking heel, brace to stabilize the cast as requested by physician

Rational: braces incorporated into a cast assist in joint motion and mobility.

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15. assist with finishing the cast by folding the edge of the stockinette down over the cast to provide a smooth edge, unroll a dampened plaster roll over the stockinette to hold in place.

Rational: smooth edges decrease the chance for skin irritation or tissue injury.

16. using scissors, trim the cast around the fingers , toes, or the thump as necessary, remove and discard gloves and perform hand hygiene.

Rational: the cast should not restrict joint movement or restrict circulation.

17. depending on the tissue to be casted, elevate the casted tissue to the level of the heart by pillows or sling, air dry the cast, if ice ordered apply it to the side of the cast not on the top.

Rational: elevation enhance venous return and decrease edema, covering the cast delay drying.

18. inform client to notify caregivers of any alteration in sensation, numbness, tingling, unusual pain, or inability to move fingers or toes in affected extremity.

Rational: edema within a casted extremity causes pressure on nerves, blood vessels, and muscle tissues. This lead to neurovascular deficit, compartment syndrome and necrosis of tissue.

19. using palm of hands to support casted areas, assist client with transfer to stretcher or wheelchair for return to unit. Or prepare for discharge . Use additional personnel to transfer client safely if needed.

Rational: to maintain principles of safe transport.

20. review all home care instructions with the client and significant others.

21. explain to the client the need to keep cast exposed until drying is complete, use elevation or ice.

Rational: cast must dry from inside out, elevation and ice decrease edema.

22. have client turn every 2-3 hours, do not rest heel over bed or pillow.

Rational: to prevent continuous pressure to one area.

Cast care instructions:

1st 24 hours:

– follow physician instructions.

– keep the cast and extremity elevated 1st 48 hours.

– put ice first 24 hours beside cast not on the top.

– move body part above and below cast regularly or do massage to improve circulation.

– avoid handling cast in 1st 24 hours.

– use fan placed 18 to 24 inches to help cast for drying and dont cover the cast.

– never insert any subject inside the cast for any purpose.

Caring for plaster cast:

– avoid wetting the cast.

– cover cast in plastic when bathing.

– do not trim cast edges.

Synthetic cast:

– its water proof and can become wet if there is no incision under it.

– you can clean the cast with mild soup and water.

– you can rinse inside of your cast with warm water using a flexible shower head.

– when wetting cast dry it with towel and hair drayer on low setting, dont cover the cast if wet.

Skin care:

– inspect skin condition around the cast.

– do not insert any object inside the cast.

– you can use lotion on areas out side the cast not inside.

Activity:

– do not walk on a leg cast for the first 48 hours.

– use a sling for casted arm to promote support and comfort.

Contact the doctor if:

– you have pain, burning or swelling.

– feel a blister or sore developing inside the cast.

– experience numbness or persistent tingling.

– your cast become badly soiled.

– the cast break, cracks, develop soft spots.

– the cast become too loose.

– develop skin problem at the cast edges.

– develop fever or foul odor under the cast.

– If you have any questions regarding the treatment.

Evaluation:

1. inspect area distal to cast for capillary refill.

2. palpate temperature around the cast assessing for hot spot which may indicate infection.

3. palpate pulse distal to the cast.

4. inspect condition of the cast.

5. observe for edema.

6. observe client for signs of anxiety.

Recording and reporting:

– record cast application, condition of the skin, status of circulation and motion of distal parts.

– record instructions given to client and family.

– report abnormal findings from neurovascular checks, report signs and symptoms of compartment syndrome immediately.

Cast removal

Care of client during cast removal:

Assessment:

1. assess the clients understanding and ability to cooperate with cast removal

Rational: cast removal may require a cast saw, client need to understand that saw is noisy but do not cut the skin.

2. assess client readiness for cast removal ( physicians order, x ray examination, physical findings.

3. ask if client feel itching or burning below the cast

Rational: skin dryness or irritation normally present.

Equipment:

– cast saw.

– plastic sheet or paper.

– cold water enzyme wash

– skin lotion.

– basin, water, wash cloth, towels.

– scissors.

– eye protection (goggles) for client and nurse.

Procedure:

1. prepare needed equipment.

2. hand washing.

3. explain the procedure.

4. adjust the bed to appropriate level, lower side rails.

5. provide adequate lightening.

6. provide privacy .

7. assist with positioning the client.

Rational: to prevent accidental injury to skin during cast removal.

8. describe the sensation of vibration caused by cast saw during cast removal and the generation of heat.

Rational: to decrease client level of anxiety.

9. describe that skin under the cast will be dry and scaly, and muscle atrophy from disuse.

10. describe the loud noise caused by cast saw.

11. apply gloves and googles to prevent injury from cast saw.

12. stay with the client and explain the progress of the procedure as cast and underlying padding removed.

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13. inspect tissues underlying the cast after removal.

Rational: areas of irritation or breakdown may require treatment.

14. if skin intact apply water enzyme wash if available and leave it for 15-20 minutes, or mild soap and water could also be used but do not scrub the skin.

Rational: enzyme wash assist in dissolving dead tissue.

15. gently wash the extremity.

Rational: vigorous scrubbing damage delicate tissues.

16. pat extremity to dry, remove gloves, wash hands, apply lotion to client skin.

Rational: lotion moisturize dry skin.

17. after cast removal, explain and write ot skin care procedure for the client.

18. obtain physician order to perform active and passive ROM and clarify level of activity allowed.

Rational: after immobilization, the involved joints and muscles will be weak, and ROM may be limited. Activity is resumed slowly to avoid re injury.

19. assist in transfer of client for return to unit or discharge.

20. instruct client to observe for swelling and to continue to elevate the extremity to control swelling.

21. return patient to comfortable position.

22. dispose used supplies and equipments.

23. wash hands.

Report and record:

– record cast removal, condition of skin under the cast, skin care interventions, name of person removed the cast.

– record instructions given to client and family.

Patient instruction after cast removal include:

– elevate the extremity to decrease edema by pillows or chair.

– regular use of moisturizers for dry scaly skin.

– instruct client not to remove scaly skin by rubbing.

– teach client to ambulate slowly and carefully until muscle strength regained.

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