Applying an Arm Sling

• Skill 25-1: Applying an Arm Sling

Assessment

• Check medical orders
• Evaluate skin color, temperature, capillary refill, edema, and peripheral pulses in the injured arm, using gloves if needed.
• Ask the client to describe how their fingers and arm feel and rate pain on a scale of 0-10
• Determine if the client has used an arm sling before

Planning

• Explain the sling's purpose to the patient
• Obtain a canvas or triangular sling as prescribed or available

Implementation

• Wash hands or use an alcohol-based rub
• Position the forearm across the chest with the thumb pointing upward
• Avoid flexing the elbow more than 90 degrees, especially if the elbow is injured
• For a canvas sling, slip the flexed arm into the sling so the elbow is flush with the corner, enclosing the forearm and wrist
• Bring the strap around the opposing shoulder and fasten it to the sling to provide support
• Pad and tighten the strap to reduce friction and pressure, preserving skin integrity
• Keep the elbow flexed and the wrist elevated to promote circulation
• For a triangular sling, position the longer side from the shoulder opposite the injured arm to the waist
• Position the apex/point under the elbow to create a hammock
• Bring the point at the waist up to the neck point and tie them to enclose the injured arm
• Position the knot to the side of the neck to avoid pressure on the vertebrae
• Fold in excess fabric at the elbow and secure to keep the elbow enclosed.
• Inspect the skin at the neck and the circulation, mobility, and sensation of the fingers at least once per shift, providing comparative data
• If the skin at the neck becomes irritated, use soft gauze or towel material to pad to reduce pressure and friction
• Instruct the client to report any sensation changes, especially pain with limited movement/pressure, which may indicate a developing complication

Evaluation

• Ensure the forearm is supported
• The wrist is elevated
• Pain and swelling are reduced
• Circulation, mobility, and sensation are maintained

Documentation

• Record baseline and comparative assessment data

• Note the type of sling used

• Record to whom abnormal assessments were reported

• Document the outcomes of the verbal report

• Skill 25-2: Assisting with a Cast Application

Assessment

• Verify medical orders
• Assess the skin to be covered by the cast for appearance, circulation, mobility, and sensation, which provides a baseline for comparison
• Inquire about the location, type, and intensity of any pain to determine whether the client needs analgesic medication
• Determine the clients understanding about the cast

Planning

• Obtain a signed treatment consent form if required to ensure legal protection
• Administer prescribed pain medication to relieve discomfort
• Remove clothing that may not stretch over the cast to avoid having to cut and destroy clothing
• Provide a gown or drape to preserve dignity and protect clothing
• Assemble necessary materials: stockinette, felt padding, cotton batting, cast material rolls, gloves, and apron.
• Anticipate the need for crutches and instructions if applying to a lower extremity, or an arm sling if applying to an upper extremity, showing awareness of discharge planning

Implementation

• Explain the cast application procedure to reduce anxiety and promote cooperation
• Tell the client the cast will feel warm while drying if using Plaster of Paris
• Wash hands or use an alcohol-based hand rub to prevent the risk of infection
• Wash the skin with soap and water and dry well to remove dirt, body oil, and microorganisms
• Apply a stockinette and protective padding to shield the skin from direct contact with the cast material and provide a fabric cushion
• If using a plaster cast, open rolls and strips of plaster gauze material
• Briefly dip them in water and wring out excess moisture to prepare the cast material
• If using fiberglass material, open the foil packets one at a time to reduce the risk of prematurely drying and becoming unfit to use
• Support the extremity while the physician wraps the cast material around the arm or leg to facilitate proper alignment
• Hold the extremity in position until a fiberglass cast dries (approx. 15 minutes) to maintain desired position
• Help fold back the edges of the stockinette at each end of the cast before the final layer to form a smooth edge to protect the skin

Evaluation

• Verify the skin has been cleaned and protected
• Ensure the cast is applied and drying or dried
• Circulation and sensation are within acceptable parameters
• Confirm the client can repeat discharge instructions

Documentation

• Record assessment data

• Note the type of cast and cast material

• Record the name of the physician who applied the cast

• Document discharge instructions

• Skill 25-3: Providing Basic Care of a Client with a Cast

Initial Assessment

• Note cast's type, location, and application date
• Verify presence of a trapeze on the bed

Planning

• Check cast condition, neurovascular status, and skin condition regularly
• Explain assessment purpose and methods to the client to promote understanding

Implementation

• Adjust the bed height for comfort to prevent back strain
• Wash hands or use an alcohol-based hand rub to prevent the risk of infection
• Check the cast's condition on all surfaces, positioning on pillows to prevent shape alteration and reduce direct force
• Handle a wet plaster cast with palms, not fingers, to prevent indentations
• Leave a fresh plaster cast uncovered to dry evenly. Avoid abduction bar use when turning a client with a hip spica cast
• Monitor and compare the color, temperature, and size of digits

Maintenance and Observation

• Assess capillary refill in exposed digits
• Elevate swollen extremities to promote venous return. Circle and note time on blood seepage areas
• Use ice packs at the injury/surgery level to reduce swelling. Monitor mobility
• Assess sensation.
• Ensure to report escalating, unrelieved pain promptly
• Monitor for foul odor or purulent drainage for suggestions of infection
• Encourage frequent finger/toe exercises to increase circulation, decrease swelling, and prevent stiffness
• Swab plaster remnants using a damp cloth, fiberglass resin with alcohol or acetone
• Dry a wet cast with a cool-setting blow dryer
• Ensure smooth, padded cast edges to reduce skin irritation. Caution against inserting objects within the cast

Client Education

• Report any itching which may be treated with medication or cool air; advise against painting a fiberglass cast
• Reinforce "windows" by taping down; encourage ambulation if possible

Evaluation

• Verify the cast is dry, intact, and without dents or cracks
• Check the exposed skin temperature and color without swelling
• Verify that the client can move fingers/toes and has normal sensation
• Confirm the exposed skin is intact with no evidence of purulent drainage.
• Note the absence of drainage

Documentation

• Document date and time of assessment

• Record swelling, itching and interventions taken.

• Describe pain level, pain-relieving techniques & outcomes

• Note skin care details

• Skill 25-4: Caring for Clients in Traction

Assessment

• Verify the type of traction and weight prescribed
• Note any trapeze
• Inspect equipment applying traction
• Verify that the ropes move freely and weights hang free
• Observe body position
• Inspect the skin and pin sites, looking for neurovascular and other complications
• Determine last bowel elimination date and note the frequency, volume, and color of urine, assessing lung sounds and monitoring the temperature
• Assess comfort and emotional state

Planning

• Explain traction purpose and expected care to understanding which fosters commitment

Implementation

• Unless contradicted by medical orders, maintain continuous traction by fostering desired outcomes
• Ensure proper bed height for weights to hang freely without obstruction which will provide musculoskeletal pull in traction
• Limit positions to avoid interfering with the pull and counterpull which can alter pull and counterpull. Encourage self-care
• Depress the mattress to reach while bathing and remove bottom bed linen from the foot of the bed which facilitates skin care
• Avoid tucking sheets, ensure no pillows, and use pressure-relieving devices
• Pad slings, cleanse pin insertion sites with antimicrobial agents
• Cover sharp device ends and use a fracture pan prevent accidental injury
• Encourage isometric, isotonic, and active range-of-motion exercises and provide diversional activities.

Evaluation

• Match traction type and amount of weight with the orders, check for free-hanging weights
• Observe traction rope integrity and movement, proper alignment
• Confirm trapeze availability and physical assessments.

Documentation

• Record all details of care like date, time, type and location of application, amount of weight applies, physical findings, and any reports given out.

• Skill 25-5: Providing Pin Site Care

Assessment

• Check medical orders for pin site care frequency and the preferred cleansing agent.
• Review the medical record for temperature trends, WBC count, and pain data.
• Inspect the pin insertion site for redness, swelling, tenderness, and drainage to provide data for future care
• Examine pins for bending or shifting, to avoid potential complications

Planning

• Explain pin site care to the client so they understand
• Assemble sterile cleansing agent, sterile cotton-tipped applicators, and gloves
• Put bed at comfortable height to prevent back strain

Implementation

• Wash hands or use an alcohol-based rub to remove microorganisms and reduce the transmission of pathogens.
• Wear gloves to prevent contact with blood or body fluids. Open sterile applicators carefully, and saturate with cleansing agent while holding over a basin
• Cleanse skin at the site in a circular motion to prevent microorganisms. Gently remove secretion buildup
• Use a new applicator per site or to get additional cleansing and don't apply ointment
• Check if physician orders, and teach not to touch pins

Evaluation

• Evaluation includes assessing the insertion sites for infection (redness, swelling, pain) and purulent drainage
• Temperature and white blood cell counts in normal ranges

Documentation

• Key documentation elements include date, time, pin site location, agent used, site appearance, client's comfort, cultures (if any), and caregiver communication