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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 CASTLONG-ARM CASTSHORT-LEG CASTLONG-LEG CASTWALKING CAST
BODY CASTSHOULDER SPICA CAST
HIP SPICA CASTDOUBLE HIP SPICA CAST
CASTING MATERIALS
PLASTERNONPLASTER
GUIDELINES FOR APPLYING A CAST
NURSING ACTION1. SUPPORT
EXTREMITY OR BODY PART TO BE CASTED.
RATIONALEIT MINIMIZES MOVEMENT; MAINTAINS REDUCTION AND ALIGNMENT; INCREASES COMFORT
GUIDELINES FOR APPLYING A CAST
NURSING ACTION2. POSITION AND
MAINTAIN PART TO BE CASTED IN POSITION INDICATED BY PHYSICIAN DURING CASTING PROCEDURE.
RATIONALEFACILITATES CASTING; REDUCES INCIDENCE OF COMPLICATIONS (eg, MALUNION, NONUNION, CONTRACTURE)
GUIDELINES FOR APPLYING A CAST
NURSING ACTION3. DRAPE PATIENT.
RATIONALEAVOIDS UNDUE
EXPOSURE; PROTECTS OTHER BODY PARTS FROM CONTACT WITH CASTING MATERIALS.
GUIDELINES FOR APPLYING A CAST
NURSING ACTION4. WASH AND DRY
PART TO BE CASTED.
RATIONALEREDUCES INCIDENCE OF SKIN BREAKDOWN
GUIDELINES FOR APPLYING A CAST
NURSING ACTION5. PLACE KNITTED
MATERIAL (eg, stockinette) OVER PART TO BE CASTED.1. APPLY IN SMOOTH
AND NONCONSTRICTIVE MANNER
2. ALLOW ADDITIONAL MATERIAL
RATIONALEPROTECTS 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
GUIDELINES FOR APPLYING A CAST
NURSING ACTION6. 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)
RATIONALEPROTECTS SKIN FROM
PRESSURE OF CASTPROTECTS SKIN AT
BONY PROMINENCES
PROTECTS SUPERFICIAL NERVES
GUIDELINES FOR APPLYING A CAST
NURSING ACTION7. APPLY PLASTER OR
NONPLASTER CASTING MATERIAL EVENLY ON BODY PART1. CHOOSE APPROPRIATE
WIDTH OF BANDAGE2. USE CONTINOUS
MOTION, MAINTAINING CONSTANT CONTACT WITH BODY PART
3. USE ADDITIONAL CASTING MATERIALS (SPLINTS) AT JOINTS AND AT POINTS OF ANTICIPATED CAST STRESS
RATIONALECREATES SMOOTH, SOLID,
WELL-CONTOURED CASTFACILITATES SMOOTH
APPLICATIONCREATES SMOOTH, SOLID,
IMMOBILIZING CASTSHAPES CAST PROPERLY
FOR ADEQUATE SUPPORT
STRENGTHENS CAST
GUIDELINES FOR APPLYING A CAST
NURSING ACTION8. FINISH CAST
1. SMOOTH EDGES2. TRIM AND
RESHAPE WITH CAST KNIFE AND/OR CUTTER
RATIONALEPROTECTS SKIN
FROM ABRASIONALLOWS FULL
RANGE OF MOTION OF ADJACENT JOINTS
GUIDELINES FOR APPLYING A CAST
NURSING ACTION9. REMOVE
PARTICLES OF CASTING MATERIALS FROM SKIN
RATIONALEPREVENTS
PARTICLES FROM LOOSENING AND SLIDING UNDERNEATH CAST
GUIDELINES FOR APPLYING A CAST
NURSING ACTION10. SUPPORT CAST
DURING HARDENING1. 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
RATIONALECASTING 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.
GUIDELINES FOR APPLYING A CAST
NURSING ACTION11. PROMOTE DRYING OF
CAST.1. LEAVE CAST UNCOVERED AND EXPOSED TO AIR2. TURN PATIENT EVERY 2 HOURS SUPPORTING MAJOR JOINTS3. FANS MAY BE USED TO INCREASE AIR FLOW AND SPEED DRYING.
RATIONALEFACILITATES DRYING.
PROCEDURE FOR BIVALVING A CAST
THE FOLLOWING PROCEDURE IS FOLLOWED WHEN A CAST IS BIVALVED.
• 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).
CARE OF THE PATIENT WITH A BODY OR SPICA CAST
NURSING ACTION1.
RATIONALE
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
TRACTIONIS 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
BUCK’S 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 COMFORTDISADVANTAGE: THE WEIGHT REQUIRED TO MAINTAIN NORMAL BODY ALIGNMENT OR FRACTURE ALIGNMENT CANNOT EXCEED THE TOLERANCE OF THE SKIN, ABOUT 6 lb PER EXTREMITY.
IN SKIN TRACTION, REMOVEWEIGHTS ONLY WHEN INTERMITTENT SKIN TRACTIONHAS BEEN ORDERED TO ALLEVIATE THE MUSCLE SPASM.
BALANCED SUSPENSION TRACTION
IT INVOLVES MORE THAN ONE FORCE OF PULL. SEVERAL FORCES
WORK IN UNISON TO RAISE AND SUPPORT THE CLIENT’S 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 CONTINUITYDISADVANTAGE: 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 kg2. SKELETAL TRACTION
3. BALANCED SUSPENSION TRACTION – 7 -12 kg
4. THOMAS SPLINT AND PEARSON ATTACHMENT
5. MANUAL TRACTION
TYPES OF SKIN TRACTION
1. BUCK’S EXTENSION TRACTION
2. RUSSEL TRACTION3. CERVICAL TRACTION4. PELVIC TRACTION- 4.5-9
kg
IN SKIN TRACTION, FREQUENTLY ASSESS SKIN FOR EVIDENCE OF PRESSURE, SHEARING OR PENDING SKIN BREAKDOWN.
IN SKIN TRACTION, PROTECT PRESSURE SITES WITH PADDING AND PROTECTIVE DRESSINGS AS INDICATED.
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
• IN SKELETAL TRACTION, NEVER REMOVE THE WEIGHTS.• MAY REQUIRE MORE FREQUENT ANALGESIC ADMINISTRATION.
SKELETAL TRACTION
ADVANTAGE: MORE WEIGHT CAN BE USED TO MAINTAIN THE PROPER ANATOMIC ALIGNMENT IF NECESSARYDISADVANTAGE: INCREASED ANXIETY, INCREASED RISK OF INFECTION, INCREASED DISCOMFORT
• FREQUENT SKIN ASSESSMENTS SHOULD INCLUDE PIN CARE PER POLICY.• REPORT SIGNS OF INFECTION AT THE PIN SITES.
ASSIST IN REPOSITIONING. THE AREA OF THE FRACTURE MUST BE STABILIZED WHEN THE CLIENT IS REPOSITIONED.
MAINTAIN THE LINE OF PULL:A. CENTER THE CLIENT ON THE BED.B. ENSURE THAT WEIGHTS HANG FREELY AND DO
NOT TOUCHTHE FLOOR.
PERFORM NEUROVASCULAR ASSESSMENTS FREQUENTLY.
DO NOT WEDGE THE CLIENT’S FOOT OR PLACE IT FLUSH WITH THE FOOT-BOARD OF THE BED.
MANAGING THE PATIENT IN UNDERGOING
ORTHOPEDIC SURGERY
JOINT REPLACEMENTTOTAL HIP REPLACEMENT
ORTHOPEDIC SURGERIES
OPEN REDUCTIONINTERNAL FIXATION
ARTHROPLASTYHEMIARTHROPLASTY
JOINT ARTHROPLASTY OR REPLACEMENTTOTAL JOINT ARTHROPLASTY OR
REPLACEMENTMENISCECTOMY
AMPUTATIONBONE GRAFT
TENDON TRANSFERFASCIOTOMY
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.