Arm Sling Application Nursing

• Applying an arm sling and assisting with cast application are essential nursing skills for clients with upper extremity injuries

Arm Sling Application (Skill 25-1)

• Assessment: Check the medical orders and assess the client's skin, circulation, and sensation in the affected arm
• Obtain baseline data by asking the client to describe their pain level and how their fingers and arm feel
• Determine if the client has a history of arm sling use
• Planning: Explain the purpose of the sling to the client and obtain the appropriate type of sling (canvas or triangular)
• Implementation: Wash hands before starting the procedure
• Position the forearm across the client's chest with the thumb pointing upward
• Avoid excessive flexion (more than 90 degrees), especially if the elbow is injured
• For a canvas sling, slip the flexed arm into the sling ensuring the elbow fits snugly into the corner of the sling
• Next, bring the strap around the opposing shoulder and fasten it to the sling
• For a triangular sling, place the longer side of the sling from the shoulder opposite the injured arm to the waist
• Position the apex (point) of the triangle under the elbow
• Secure the sling by bringing the point at the waist up to the point at the neck and tie them; position the knot to the side of the neck
• Fold in and secure any excess fabric at the elbow, using a safety pin if necessary
• Pad the strap around the neck area to prevent friction and pressure
• Keep the elbow flexed and the wrist elevated to promote circulation
• Evaluation: Ensure the forearm is supported and the wrist is elevated
• Assess for reduced pain and swelling
• Monitor circulation, mobility, and sensation in the fingers
• Documentation: Record baseline and comparative assessment data, the type of sling applied, any significant abnormal assessments reported, and the outcomes of the verbal report

Assisting with Cast Application (Skill 25-2)

• Assessment: Check medical orders and assess the client's skin, circulation, mobility, and sensation in the extremity to be casted
• Ask the client about their pain level and determine their understanding of the cast application procedure
• Planning: Obtain a signed treatment consent form if required and administer pain medication as prescribed
• Gather the necessary materials, including stockinette, felt padding, cotton batting, cast material (plaster of Paris or fiberglass), gloves, and an apron
• If applying a lower extremity cast, anticipate the need for crutches and provide instructions on their use
• Have an arm sling available for upper extremity casts
• Implementation: Explain the cast application process to the client, including the sensation of warmth experienced with plaster of Paris casts as they dry
• Wash hands before the procedure, then wash the client's skin with soap and water and dry thoroughly
• Cover the skin with a stockinette and protective padding as directed, ensuring it is smooth and wrinkle-free
• If using plaster of Paris, open rolls and strips of plaster gauze material
• Briefly dip them one at a time in water and wring out the excess moisture
• If using fiberglass material, open the foil packets one at a time
• Support the extremity while the physician wraps the cast material, ensuring proper alignment
• Hold a fiberglass cast in position until dry (about 15 minutes)
• Help fold back the edges of the stockinette at each end of the cast just before the final layer of cast material
• Elevate the cast on pillows or other support to reduce swelling and pain
• If a plaster cast was applied, dispose of plaster-contaminated water in a special sink with a plaster trap
• Provide the client with verbal and written cast care instructions
• Evaluation: Ensure the skin is cleaned and protected
• Check that the cast has been applied and is drying or dried, and circulation and sensation are within acceptable parameters
• Ensure the client can repeat discharge instructions
• Documentation: Document assessment data, type of cast, cast material, the name of the physician who applied the cast, and discharge instructions

Providing Basic Cast Care (Skill 25-3)

• Assessment: Determine the type and location of the cast, and when it was applied
• Check for a trapeze on the client's bed to aid in movement
• Planning: Plan to regularly check the cast condition, neurovascular status, and skin integrity
• Explain the assessment methods to the client
• Implementation: Place the bed at a comfortable height
• Wash hands before the procedure
• Observe and feel the cast for any dampness or irregularities
• A dry cast is white, shiny, and odorless; a damp cast is gray, dull, and musty
• Position a fresh plaster cast on pillows without plastic covers to aid drying
• Use palms of the hands (not fingers) to move or reposition the cast before it is dry
• Turn the client periodically to expose all cast surfaces to air
• Avoid using the abduction bar in a hip spica cast when turning a client
• Monitor the color, temperature, and size of the fingers or toes on the casted extremity
• Compare with those on the opposite extremity
• Assess capillary refill in exposed fingers or toes and compare with uncasted digits
• Elevate any swollen extremity
• Circle areas where blood has seeped through the cast and note the time
• Apply ice packs to the cast at the level of the injury or surgery if swelling is present
• Check mobility of the fingers or toes to measure patient motor function
• Assess sensation in exposed fingers or toes
• Assess pain in the casted area and note if pain is unrelieved by elevation, cold applications, and analgesics
• Always report escalating pain that is not responsive to interventions
• Check for any foul odor or purulent drainage coming from within the cast
• Encourage the client to regularly exercise fingers or toes
• Swab plaster remnants from the skin with a damp cloth; remove fiberglass resin with alcohol or acetone
• If the cast gets wet, dry it with a blow dryer on a cool setting
• Ensure the edges of the cast are smooth and padded to reduce skin irritation and breakdown
• Caution clients not to insert objects within the cast
• Report itching and manage with medication or a cool air dryer
• Advise clients not to paint a fiberglass cast
• Replace a window, a small cut from the cast for inspecting the skin or incision, by taping it back in place
• Promote ambulation or exercise in bed
• Evaluation: Confirm the cast is dry and intact, skin is warm and appropriately colored, and pain is managed
• Ensure sensation is intact and there is no evidence of drainage
• Documentation: Document assessments, measures taken for relief, level of pain, skin care provided, and any communicated findings

Caring for Clients in Traction (Skill 25-4)

• Assessment: Check medical orders for traction type and weight, and note if a trapeze is available
• Inspect the equipment, ensure ropes move freely, and weights hang freely
• Observe the client's body position
• Inspect the skin and pin sites
• Assess circulation and sensation
• Determine the last bowel movement date as well as urine frequency, volume, and color
• Auscultate lungs and review temperature trend
• Assess pain level and emotional state
• Planning: Explain the procedure and care to the client
• Implementation: Keep traction continuously applied unless ordered otherwise
• Raise bed height to keep weights hanging freely
• Limit client positions per medical standards
• Provide hygiene and encourage self-care
• Bathe backs of clients in supine position by depressing the mattress using a hand
• Avoid tucking in top sheets and limit pillow use if in neck traction
• Use pressure-relieving devices and frequent skin care
• Insert padding in slings if wrinkled
• Cleanse skin around skeletal pin insertions using an antimicrobial agent
• Cover any protruding metal pins with corks or covers
• Use a fracture pan to avoid altering traction line
• Encourage range-of-motion isotonic and isometric exercises
• Evaluation: Traction type and weight correlate with medical orders
• Weights hang freely, there are no rope knots, ropes are intact
• Client is aligned, there is a trapeze, and physical assessments are normal
• Hygiene is accomplished regularly
• Documentation: Date, time, traction type/location, weight applied, assessment results, and any communicated changes

Providing Pin Site Care (Skill 25-5)

• Assessment: Check orders for frequency, and preferred cleansing agent
• Review temperatures, white blood cell count, and pain reports
• Inspect the pin insertion, noting redness, swelling, drainage, or tenderness, and check pins for bending or shifting
• Explain purpose and technique to patient
• Implementation: Wash hands before the procedure
• Put on gloves
• Open and prepare supplies without touching applicator tips
• Cleanse the pin site, moving outward in a circular motion
• Gently remove crusted secretions
• Use separate applicators per pin site.
• Avoid ointments unless prescribed
• Check with physician/infection control if purulent drainage occurs
• Teach the client not to touch the pin sites
• Evaluation: Skin/tissue are free of inflammation, there is no drainage, and the patient's temperature/white blood cell counts are normal range
• Documentation: Date, time, location, cleansing agent, appearance of pin site, and client's subjective remarks noted and documented