Managing a patient in cast

Cast >it is a rigid device applied to immobilize the injured bones and promote healing. >it is applied to immobilize the joint above and below the fractured bone so that the bone will not move during healing. >these are applied on clients who have relatively stable fractures. Types of casts Short-arm cast Long-arm cast Short-leg cast Long-leg cast Walking cast Body cast Guidelines for applying a cast Nursing action 1. Support extremity or body part to be casted. Guidelines for applying a cast Nursing action 2. Position and maintain part to be casted in position indicated by physician during casting procedure. Guidelines for applying a cast Nursing action 3. Drape patient. Rationale Avoids undue exposure; protects other body parts from contact with casting materials. Rationale Facilitates casting; reduces incidence of complications (eg, malunion, nonunion, contracture) Rationale It minimizes movement; maintains reduction and alignment; increases comfort Shoulder spica cast Hip spica cast Double hip spica cast Casting materials Plaster Nonplaster

Guidelines for applying a cast Nursing action 4. Wash and dry part to be casted. Rationale Reduces incidence of skin breakdown

Guidelines for applying a cast Nursing action 5. Place knitted material (eg, stockinette) over part to be casted. 1. Apply in smooth and nonconstrictive manner 2. Allow additional material Guidelines for applying a cast Nursing action 6. Wrap soft, nonwoven roll padding smoothly and evenly around part. 1. Use additional padding over bony prominences to protect superficial nerves (eg, head of fibula and olecranon process) Guidelines for applying a cast Nursing action 7. Apply plaster or nonplaster casting material evenly on body part 1. Choose appropriate width of bandage 2. Use continous motion, maintaining constant contact with body part 3. Use additional casting materials (splints) at joints and at points of anticipated cast stress Guidelines for applying a cast Nursing action 8. Finish cast 1. Smooth edges >Trim and reshape with cast knife and/or cutter Rationale Creates smooth, solid, well-contoured cast Facilitates smooth application Creates smooth, solid, immobilizing cast Shapes cast properly for adequate support Strengthens cast Rationale Protects skin from pressure of cast Protects skin at bony prominences Protects superficial nerves Rationale Protects the skin from casting materials. Protects skin from pressure Folds over edges of cast when finishing application; creates smooth, padded edge; protects skin from abrasion

Rationale Guidelines for applying a cast Nursing action 9. Remove particles of casting materials from skin

Protects skin from abrasionAllows full range of motion of adjacent joints

Rationale Prevents particles from loosening and sliding underneath cast

Guidelines for applying a cast Nursing action 10. Support cast during hardening 1. Handle hardening cast with palms of hands 2. Support cast on firm, smooth surface 3. Do not rest cast on hard surfaces or on sharp edges 4. Avoid pressure on cast Guidelines for applying a cast Nursing action 11. Promote drying of cast. 1. Leave cast uncovered and exposed to air 2. Turn patient every 2 hours supporting major joints 3. Fans may be used to increase air flow and speed drying. Rationale Facilitates drying. Rationale Casting materials begin to harden in minutes. Maximum hardness of nonplaster cast begins in minutes. Maximum hardness of plaster cast occurs with drying ( 24 to 72 hours, depending on environment and thickness of cast) Avoids denting of cast and development of pressure areas.

Procedure for bivalving a cast With a cast cutter, a longitudinal cut is made to divide the cast in half. The underpadding is cut with scissors. The cast is spread apart with cast spreaders to relieve pressure and to inspect and treat the skin without interrupting the reduction and alignment of the bone.

After the pressure is relieved, the anterior and posterior parts of the cast are secured togethr with an elastic compression bandage to maintain immobilzation. To control swelling and promote circulation, the extremity is elevated ( but no higher than the heart level, to minimize the effect of gravity on perfusion of the tissues). Preventing complications of immobility based on the system

Cardiovascular Complication >Orthostatic hypotension >Deep vein thrombosis and pulmonary embolism >Increased workload on heart Nursing intervention Exercises Plantarflexion and dorsiflexion foot exercises Quadriceps and gluteal setting exercises Frequent turning Slow mobilization No pillows behind the knees Antiembolism stockings

Respiratory Complication >Decreased chest expansion >Accumulation of secretions in respiratory tract Nursing intervention Frequent turning Encourage frequent coughing and deep breathing

Integumentary Complication Breakdown of skin integrity (abrasions, decubitus ulcer) caused by friction, pressure, or shearing force Nursing intervention Frequent turnig and repositioning Regular inspection of skin for signs of pressure Gentle massage of skin, especially over bony prominences

Gastrointestinal Complication Constipation Nursing intervention Frequent movement and turning in bed Increase fluid intake Adequate dietary intake with increase in high-fiber foods Use of stool softeners and laxatives as ordered

Musculoskeletal Complication Atrophy and weakness of muscles Contractures Demineralization of bones (osteoporosis) Nursing intervention Exercises Encourage participation in adl as much as possible Proper positioning and repositioning of joints

Urinary Complication Increased calcium excretionfrom bone destruction (calculi formation) Increased urine ph (alkaline) Stasis of urine in kidney and bladder Urinary infection Nursing intervention Increased fluid intake Decrease in calcium intake, especially milk and milk products Use of acid-ash foods Use of commode if possible

Neurologic Complication Sensory deprivation and isolation Nursing intervention Frequent contact by staff Orienting measures (clock, calendar) Diversional acitivities (tv, radio, hobbies) Inclusion of client in decision-making activities

Cardiovascular Complication Orthostatic hypotension Deep-vein thrombosis and pulmonary embolism Increased workload on the heart Nursing intervention Active or passive rom exercises The patient with splints or braces The patient with an external fixator

Managing the patient in traction

Traction Is the applicationof a straightening or pulling force to return or maintain the fractured bones in normal anatomic position. Types of traction 1. Straight or running traction 2. Balanced suspension traction Straight traction The pulling force is applied in a straight line to the injured body part resting on the bed Bucks traction It is the most common type of straight traction. The lower portion of the injured extremity is placed in a cradle-like sleeve. This sleeve is harnessed to itself and a weight is hung from the bottom of the traction frame. It is a form of skin traction. Skin traction Advantage: the relative ease of use and ability to maintain comfort Disadvantage: the weight required to maintain normal body alignment or fracture alignment cannot exceed the tolerance of the skin, about 6 lb per extremity. Balanced suspension traction It involves more than one force of pull. Several forces work in unison to raise and support the clients injured extremity off the bed and pull it in a straight fashion away from the body. Balanced suspension traction Advantage: it increases mobility without threatening joint continuity Disadvantage: the increased use of multiple weights makes the client more likely to slide in the bed. Types of traction 1. Skin traction 2-3.5 kg 2. Skeletal traction 3. Balanced suspension traction 7 -12 kg 4. Thomas splint and pearson attachment 5. Manual traction

Types of skin traction 1. Bucks extension traction 2. Russel traction 3. Cervical traction 4. Pelvic traction- 4.5-9 kg Manual traction The hand directly applies the pulling force Skeletal traction it is the application of a pulling force through placement of pins into the bone. the client receives a local anesthetic , and the pin is inserted in a twisting motion into the bone this type of traction should be applied in a sterile condition because of the risk of infection One or more pulling force is may be applied

Skeletal traction Advantage: more weight can be used to maintain the proper anatomic alignment if necessary Disadvantage: increased anxiety, increased risk of infection, increased discomfort Managing the patient in undergoing orthopedic surgery Joint replacement Total hip replacement Orthopedic surgeries Open reduction Internal fixation Arthroplasty Hemiarthroplasty Joint arthroplasty or replacement Total joint arthroplasty or replacement Meniscectomy Amputation Bone graft

Tendon transfer Fasciotomy Joint replacement Total hip replacement Methods for avoiding hip dislocation after surgery Keep the knees apart at all times Put a pillow between the legs when sleeping. Never cross the legs when seated. Avoid bending forward when seated in a chair. Avoid bending forward to pick up an object on the floor. Use a high-seated chair and a reaised toilet seat. Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes.