Before the cast is applied, the nurse completes an assessment of the patient’s general health, presenting signs and symptoms, emotional status, understanding of the need for the cast, and condition of the body part to be immobilized in the cast.
NURSING PROCESS:THE PATIENT IN A CAST Before the cast is applied, the nurse completes anassessment of the patient’s general health, presenting signs and symptoms,emo-tional status, understanding of the need for the cast, and condi-tion ofthe body part to be immobilized in the cast. Physical assessment of the part tobe immobilized must include assessment of the neurovascular status (neurologic and circulatory func-tioning) ofthe body part, degree and location of swelling, bruis-ing, and skin abrasions. Based on the assessment data, major nursing diagnoses forthe pa-tient with a cast may include the following: ·Deficient knowledge related tothe treatment regimen ·Acute pain related to themusculoskeletal disorder ·Impaired physical mobilityrelated to the cast ·Self-care deficit:bathing/hygiene, feeding, dressing/groom-ing, or toileting due to restrictedmobility ·Impaired skin integrityrelated to lacerations and abrasions ·Risk for peripheralneurovascular dysfunction related to phys-iologic responses to injury andcompression effect of cast Based on the assessment data, potential complicationsthat may develop include the following: ·Compartment syndrome ·Pressure ulcer ·Disuse syndrome The major goals for the patient with a cast includeknowledge of the treatment regimen, relief of pain, improved physicalmobil-ity, achievement of maximum level of self-care, healing of lacer-ationsand abrasions, maintenance of adequate neurovascular function, and absence ofcomplications. Before the cast is applied, the patient needs informationcon-cerning the pathologic problem and the purpose and expectations of theprescribed treatment regimen. This knowledge promotes the patient’s activeparticipation in and adherence to the treat-ment program. It is important toprepare the patient for the ap-plication of the cast by describing theanticipated sights, sounds, and sensations (eg, heat from the hardeningreaction of the plaster). The patient needs to know what to expect duringappli-cation and that the body part will be immobilized after casting (Chart67-1). The nurse must carefully evaluate pain associated withmuscu-loskeletal problems, asking the patient to indicate the exact site and todescribe the character and intensity of the pain to help de-termine its cause.Most pain can be relieved by elevating the in-volved part, applying cold asprescribed, and administering usual dosages of analgesics. Pain associated with the disease process (eg, fracture)is fre-quently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into thetissues can frequently be controlled by elevation and, if prescribed,inter-mittent application of cold. Ice bags (one-third to one-half full) orcold application devices are placed on each side of the cast, if prescribed,making sure not to indent the cast.Assessment
Diagnosis
NURSINGDIAGNOSES
COLLABORATIVEPROBLEMS/POTENTIAL COMPLICATIONS
Planning and Goals
Nursing Interventions
EXPLAININGTHE TREATMENT REGIMEN
RELIEVINGPAIN
Pain may be indicative of complications. Pain associatedwith compartment syndrome is relentless and is not controlled by modalities suchas elevation, application of cold if prescribed, and usual dosages ofanalgesics. Severe pain over a bony prominence warns of an impending pressureulcer. Pain decreases when ul-ceration occurs. Discomfort due to pressure onthe skin may be relieved by elevation that controls edema or by positioningthat alters pressure. It may be necessary, however, to modify the cast or toapply a new cast.
IMPROVINGMOBILITY
Every joint that is not immobilized should be exercisedand moved through its range of motion to maintain function. If the patient hasa leg cast, the nurse encourages toe exercises. If the pa-tient has an armcast, the nurse encourages finger exercises.
PROMOTINGHEALING OF SKIN ABRASIONS
Before the cast isapplied, it is important to treat skin lacerations and abrasions to promotehealing. The nurse thoroughly cleans the skin and treats it as prescribed.Sterile dressings are used to cover the injured skin. If the skin wounds areextensive, an alternative method (eg, external fixator) may be chosen toimmobilize the body part. While the cast is on, the nurse observes the patientfor systemic signs of infection, odors from the cast, and purulent drainagestaining the cast. It is important to notify the physician if any of theseoccurs.
MAINTAININGADEQUATE NEUROVASCULAR FUNCTION
Swelling and edema are natural responses of thetissue to trauma and surgery. The patient may complain that the cast is tootight. Vascular insufficiency and nerve compression due to unrelieved swellingcan result in compartment syndrome. The nurse monitors circulation, motion, andsensation of the affected extremity, assessing the fingers or toes of thecasted extremity and comparing them with those of the opposite extremity.Normal findings include minimal swelling, minimal discomfort, pink color, warmto touch, rapid capillary refill response, normal sen-sations, and ability toexercise fingers or toes. The nurse encour-ages the patient to move fingers ortoes hourly when awake to stimulate circulation.
It is important toperform frequent, regular assessments of neurovascular status. Earlyrecognition of diminished circulation and nerve function is essential toprevent loss of function. As-sessment data including progressive unrelievedpain, pain on passive stretch, paresthesia, motor loss, sensory loss, coolness,paleness, slow capillary refill, and sensation of tightness indicate potentialcompartment syndrome. The nurse adjusts the extrem-ity so that it is no higherthan heart level to enhance arterial per-fusion and control edema and notifiesthe physician at once.
MONITORINGAND MANAGING POTENTIAL COMPLICATIONS
CompartmentSyndrome
Compartment syndromeoccurs when there is increased tissue pressure within a limited space (eg,cast, muscle compartment) that compromises the circulation and the function ofthe tissue within the confined area. To relieve the pressure, the cast must bebivalved (cut in half longitudinally) while maintaining align-ment, and theextremity must be elevated no higher than heart level (Chart 67-2). If pressureis not relieved and circulation is not restored, a fasciotomy may be necessary to relieve the pressure within themuscle compartment. The nurse closely monitors the patient’s response toconservative and surgical management of compartment syndrome. The nurse recordsneurovascular re-sponses and promptly reports changes to the physician.
PressureUlcers
Pressure of the cast on soft tissues may cause tissueanoxia and pressure ulcers. Lower extremity sites most susceptible to pressureare the heel, malleoli, dorsum of the foot, head of thefibula, and anterior surface of the patella. The main pressure sites on theupper extremity are located at the medial epicondyle of the humerus and theulnar styloid (see Fig. 67-1).
Usually, the patientwith a pressure ulcer reports pain and tightness in the area. A warm area onthe cast suggests underly-ing tissue erythema. The area may break down. Thedrainage may stain the cast and emit an odor. Even if discomfort does not occurwith tissue breakdown and necrosis, there may still be extensive loss oftissue. The nurse must monitor the patient with a cast for pressure ulcerdevelopment and report findings to the physician.
To inspect the pressure area, the physician may bivalvethe cast or cut an opening (window) in the cast. If the physician elects tocreate a window to inspect the pressure site, a portion of the cast is cut out.The affected area is inspected and possibly treated. The portion of the cast isreplaced and held in place by an elastic com-pression dressing or tape. Thisprevents the underlying tissue from swelling through the window and creatingpressure areas around its margins.
DisuseSyndrome
While in a cast, the patient needs to learn to tense orcontract muscles (eg, isometric muscle contraction) without moving the part.This helps to reduce muscle atrophy and maintain muscle strength. The nurseteaches the patient with a leg cast to “push down” the knee and teaches thepatient in an arm cast to “make a fist.” Muscle-setting exercises (eg,quadriceps-setting and gluteal-setting exercises) are important in maintainingmuscles essential for walking (Chart 67-3). Isometric exercises should beperformed hourly while the patient is awake.
PROMOTINGHOME AND COMMUNITY-BASED CARE
Teachingthe Patient Self-Care
Self-care deficits occur when a portion of the body isimmobi-lized. The nurse encourages the patient to participate actively inpersonal care and to use assistive devices safely. The nurse must assist thepatient in identifying areas of self-care deficit and in developing strategiesto achieve independence in activities of daily living (ADLs) (Chart 67-4). Thepatient’s participation inplanning and accomplishing ADLs is an important aspect ofself-care, independence, maintaining control, and avoiding untowardpsychological reactions, such as depression.
When the cast is dry, the nurse instructs the patient asfollows:
·Move about as normally aspossible, but avoid excessive use of the injured extremity and avoid walking onwet, slippery floors or sidewalks.
·Perform prescribed exercisesregularly, as scheduled.
·Elevate the casted extremityto heart level frequently to pre-vent swelling.
·Do not attempt to scratch theskin under the cast. This may cause a break in the skin and result in theformation of a skin ulcer. Cool air from a hair dryer may alleviate an itch.
·Cushion rough edges of thecast with tape.
·Keep the cast dry but do notcover it with plastic or rubber, because this causes condensation, whichdampens the cast and skin. Moisture softens a plaster cast. (A wet fiberglasscast must be dried thoroughly with a hair dryer on a cool setting to avoid skinproblems.)
·Report any of the following tothe physician: persistent pain, swelling that does not respond to elevation,changes in sensation, decreased ability to move exposed fingers or toes, andchanges in skin color and temperature.
·Note odors around the cast,stained areas, warm spots, and pressure areas. Report them to the physician.
·Report a broken cast to thephysician; do not attempt to fix it yourself.
The nurse prepares the patient for cast removal or castchanges by explaining what to expect (Chart 67-5). The cast is cut with a castcutter, which vibrates. The patient can feel the vibration and pressure duringits use. The cutter does not penetrate deeply enough to hurt the patient’sskin. The cast padding is cut with scissors.
The casted body part is weak from disuse, is stiff, andmay ap-pear atrophied. There may be extreme stiffness even after only a fewweeks of immobilization. Therefore, support is needed when the cast is removed.The skin, which is usually dry and scaly from accumulated dead skin, isvulnerable to injury from scratching.
The skin needs to be washed gently and lubricated with anemol-lient lotion.
The nurse and physical therapist teach the patient toresume activities gradually within the prescribed therapeutic regimen.Exercises that are prescribed to help the patient regain joint motion areexplained and demonstrated. Because the muscles are weak from disuse, the bodypart that has been casted cannot withstand normal stresses immediately. Inaddition, the nurse teaches the patient who has noticeable swelling of the affectedextremity after the cast is removed to continue to elevate the ex-tremity tocontrol swelling until normal muscle tone and use are reestablished.
Evaluation
EXPECTEDPATIENT OUTCOMES
Expected patient outcomes may include:
1) Understandsthe therapeutic regimen
a) Elevatesaffected extremity
b) Exercisesaccording to instructions
c) Keepscast dry
d) Reportsany problems that develop
e) Keepsfollow-up clinic or physician appointments
2) Reportsless pain
a) Elevatesextremity that is in the cast
b) Repositionsself
c) Usesoccasional oral analgesic
3) Demonstratesincreased mobility
a) Usesassistive devices safely
b) Exercisesto increase strength
c) Changesposition frequently
d) Performsrange-of-motion exercises of joints not in the cast
4) Exhibitshealing of abrasions and lacerations
a) Demonstratesno local signs of infection (ie, local dis-comfort, purulent drainage, caststaining, or odor from cast)
b) Demonstratesno systemic signs or symptoms of infection
c) Demonstratesintact skin when cast is removed
5) Maintainsadequate neurovascular function of affected extremity
a) Exhibitsnormal skin color and temperature
b) Experiencesminimal swelling
c) Exhibitssatisfactory capillary refill on testing
d) Demonstratesactive movement of fingers or toes if they are not casted
e) Reportsnormal sensations in casted body part
f) Reportsthat pain is controllable
6) Exhibitsabsence of complications
a) Demonstratesnormal neurovascular status of casted extremity
b) Developsno pressure ulcers
c) Exhibitsminimal muscle wasting
7) Participatesin self-care activities
a) Performshygiene and grooming activities indepen-dently or with minimal assistance
b) PerformsADLs independently or with minimal assistance
c) Adheresto prescribed exercise regimen.
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Medical Surgical Nursing: Musculoskeletal Care Modalities : Nursing Process: The Patient in a Cast |
