Cast.pdf

College of Applied Medical Sciences ADULT HEALTH NURSING CLINICAL CAST CAST - A rigid external immobilizing device molded to contours of body part. PURPOSES OF CAST a. Immobilize the fractured part b. Correct deformity c. Apply uniform pressure to underlying soft tissue d. Support and st...

College of Applied Medical Sciences ADULT HEALTH NURSING CLINICAL CAST CAST - A rigid external immobilizing device molded to contours of body part. PURPOSES OF CAST a. Immobilize the fractured part b. Correct deformity c. Apply uniform pressure to underlying soft tissue d. Support and stabilize weakened joint Generally, cast permit mobilization of the patient while restricting movement of a body part.  Types of Cast 1. Short arm cast - It extends from below elbow to the palmar creases, secured around the base of the thumb. If thumb is included, it is known as a thumb spica or gauntle cast. 2. Long arm cast - It extends from the upper level of the axillary fold to the proximal palmar crease. The elbow usually is immobilized at a right angle.  3. Short- leg cast - It extends from below the knee to the base of the toes. The foot is at a right angle in a neutral position 4. Long- leg cast - It extends from the junction of the upper and middle third of the thigh to the base of the toes. The knee may be slightly flexed.  5. Walking cast - A short or long leg cast reinforced for strength 6. Body cast - It encircles the trunk 7. Shoulder spica cast - It is a body jacket that encloses the trunk and the shoulder and elbow 8. Hip spica cast - It encloses the trunk and a lower extremity. A double hip spica cast includes both legs  Casting Materials 1. Plaster - The traditional cast - Rolls of plaster bandage are wet in cool water and applied smoothly to the body. - A crystallizing reaction occurs, and heat is given off ( an exothermic reaction) which can be uncomfortable to the patient, and the nurse should inform him about this sensation. - The nurse explains that the cast must be exposed to allow maximum dissipation of the heat and that most casts cool after about 15 minutes. - After the plaster sets, the cast remains wet and soft. It does not have its full strength until dry. So the wet cast must be handled with palms of the hand and not allowed to rest on hard surfaces or sharp edges. - The cast requires 24 to 72 hours to dry completely, depending on its thickness and the environmental drying condition. - A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens. - A wet plaster cast appears dull and gray, sound dull on percussion, feels damp, and smell musty. - A dry plaster is white and shiny, resonant, odorless, and firm. 2. Nonplaster - Generally referred to as fiberglass cast, these water-activated polyurethane materials have the versatility of plaster but are lighter in weight, stronger, water resistant, and durable. - Nonplaster casts are porous and therefore diminish skin problems. - They do not soften when wet, which allows for hydrotherapy (use of water for treatment). When wet, they dried with a hair drier on a cool setting. ASSESSMENT 1. Assess factors that may affect wound healing, such as diabetes, poor nutritional status, or steroid medication use. - When there is risk of slower healing, additional nutritional supplement is required. 2- Assess client's ability to cooperate and level of understanding concerning the casting procedure. - Sudden movement during procedure could cause injury.  3. Inspect condition of skin that will be under the cast- specifically note any areas of skin breakdown, rashes present or incisional wound. - Provides baseline for skin condition. 4. Assess neurovascular status of the area to be casted. Specifically note presence or absence of motor and sensory function, skin color, temperature, and capillary refill (pain, paresthesia, pale, pulseless, paralysis) 5. Pay attention to tissue distal to cast. - Changes in neurovascular status may occur after casting, so it's important to take baseline neurovascular changes before cast application. 6. Assess client pain status using a scale of 0 to 10. 7. Consult the physician to determine the extent to which client will be able to use the casted body part. - Determine the extent to which self care will be required. EQUIPMENT Plaster cast: – Plaster rolls 2,3,4, or 6 inch. – Padding material. – Clean gloves, apron. – Plastic- lined bucket or basin. – Cart, chair and fracture table scissors. – Paper or plastic sheets. Synthetic cast: – Synthetic rolls. – Pail with water to damp in rolls. – Padding materials. – Cast cutter to trim edge of cast IMPLEMENTATION OF CARE DURING CAST APPLICATION 1. Prepare needed equipment. 2. Hand washing. 3. Explain the procedure. 4. Adjust the bed to appropriate level, lower side rails. 5. Provide adequate lightening. 6. Provide privacy. 7. Administer analgesics before cast application 20 to 30 minutes before cast application. - Reduces pain during cast application provide optimal analgesic effect. 8. Wear gloves. - Synthetic cast can leave glue like material on the hands which could cause allergy. 9. Assist physician in positioning client and injured extremity as desired, depending on type of cast to be used and area to be casted. - The part to be casted must be supported and in optimal alignment. 10. Prepare the skin that will be enclosed in the cast. Change any dressing if present and cleanse the skin with mild soap and water. - Assist in maintaining skin integrity. Note: Clients with skin damage may not be candidate for casting. 11. Assist with application of padding material around body part to be casted, avoid wrinkles or uneven thicknesses. - Decrease complication to the skin and prevents pressure points under the cast. 12. Hold body part or parts to be casted or assist with preparation of casting materials. - Support body part may require application of slight manual traction. a. Plaster cast: Mark the end of the roll by folding one corner of the material under it self. Hold plaster roll under water in a basin until bubbles stop then squeeze slightly and hand roll to person applying the cast. - Once the end dampened in water it may be difficult to find. b. Synthetic cast: Submerge cast roll in lukewarm water for 10 to 15 seconds, squeeze to remove excess water. - Submersion in water will initiate the chemical reaction which will result in the hardening of the cast. 13. Continue to hold the body part as necessary as the cast is applied, and supply necessary equipment and compress it gently with hands. - Positioning cast help maintain alignment. Thickness of plaster cast determine its strength, compression promote bonding and strength of cast layers. 14. Provide walking heel, brace to stabilize the cast as requested by physician - Braces incorporated into a cast assist in joint motion and mobility.  15. Assist with finishing the cast by folding the edge of the stockinette down over the cast to provide a smooth edge, unroll a dampened plaster roll over the stockinette to hold in place. - Smooth edges decrease the chance for skin irritation or tissue injury. 16. Using scissors, trim the cast around the fingers , toes, or the thump as necessary, remove and discard gloves and perform hand hygiene. - The cast should not restrict joint movement or restrict circulation. 17. Depending on the tissue to be casted, elevate the casted tissue to the level of the heart by pillows or sling, air dry the cast, if ice ordered apply it to the side of the cast not on the top. - Elevation enhance venous return and decrease edema, covering the cast delay drying. 18. Inform client to notify caregivers of any alteration in sensation, numbness, tingling, unusual pain, or inability to move fingers or toes in affected extremity. - Edema within a casted extremity causes pressure on nerves, blood vessels, and muscle tissues. This lead to neurovascular deficit, compartment syndrome and necrosis of tissue. 19. Using palm of hands to support casted areas, assist client with transfer to stretcher or wheelchair for return to unit. Or prepare for discharge. Use additional personnel to transfer client safely if needed. - To maintain principles of safe transport. 20. Review all home care instructions with the client and significant others. 21. Explain to the client the need to keep cast exposed until drying is complete, use elevation or ice. - Cast must dry from inside out, elevation and ice decrease edema. 22. Have client turn every 2-3 hours, do not rest heel over bed or pillow. - To prevent continuous pressure to one area. CAST CARE INSTRUCTIONS 1st- 24 hours: – Follow physician instructions. – Keep the cast and extremity elevated 1ST- 48 hours. – Put ice 1st- 24 hours beside cast not on the top. – Move body part above and below cast regularly or do massage to improve circulation. – Avoid handling cast in 1st- 24 hours. – Use fan placed 18 to 24 inches to help cast for drying and don’t cover the cast. – Never insert any object inside the cast for any purpose. For plaster cast: – Avoid wetting the cast. – Cover cast in plastic when bathing. – Do not trim cast edges. For synthetic cast: – It is water proof and can become wet if there is no incision under it. – You can clean the cast with mild soap and water. – You can rinse inside of your cast with warm water using a flexible shower head. – When wetting cast dry it with towel and hair dryer on low setting, don't cover the cast if wet. Skin care: – Inspect skin condition around the cast. – Do not insert any object inside the cast. – You can use lotion on areas outside the cast not inside. Activity: – Do not walk on a leg cast for the 1st- 48 hours. – Use a sling for casted arm to promote support and comfort. Contact the doctor if: – You have pain, burning or swelling. – Feel a blister or sore developing inside the cast. – Experience numbness or persistent tingling. – Your cast becomes badly soiled. – The cast break, cracks, develops soft spots. – The cast become too loose. – Develop skin problem at the cast edges. – Develop fever or foul odor under the cast. – If you have any questions regarding the treatment. Evaluation: 1. Inspect area distal to cast for capillary refill. 2. Palpate temperature around the cast assessing for hot spot which may indicate infection. 3. Palpate pulse distal to the cast. 4. Inspect condition of the cast. 5. Observe for edema. 6. Observe client for signs of anxiety. Recording and reporting: – Record cast application, condition of the skin, status of circulation and motion of distal parts. – Record instructions given to client and family. – Report abnormal findings from neurovascular checks, report signs and symptoms of compartment syndrome immediately.  CARE OF CLIENT DURING CAST REMOVAL Assessment: 1. Assess the clients understanding and ability to cooperate with cast removal - Cast removal may require a cast saw, client need to understand that saw is noisy but do not cut the skin. 2. Assess client readiness for cast removal (physician's order, X ray examination, physical findings). 3. Ask if client feel itching or burning below the cast - Skin dryness or irritation normally present. Equipment: – Cast saw. – Plastic sheet or paper. – Cold water enzyme wash – Skin lotion. – Basin, water, wash cloth, towels. – Scissors. – Eye protection (goggles) for client and nurse. Procedure 1. Prepare needed equipment. 2. Hand washing. 3. Explain the procedure. 4. Adjust the bed to appropriate level, lower side rails. 5. Provide adequate lightening. 6. Provide privacy. 7. Assist with positioning the client. - To prevent accidental injury to skin during cast removal. 8. Describe the sensation of vibration caused by cast saw during cast removal and the generation of heat. - To decrease client level of anxiety. 9. Describe that skin under the cast will be dry and scaly, and muscle atrophy from disuse. 10. Describe the loud noise caused by cast saw. 11. Apply gloves and goggles to prevent injury from cast saw. 12. Stay with the client and explain the progress of the procedure as cast and underlying padding removed. 13. Inspect tissues underlying the cast after removal. - Areas of irritation or breakdown may require treatment. 14. If skin intact apply water enzyme wash if available and leave it for 15-20 minutes, or mild soap and water could also be used but do not scrub the skin. - Enzyme wash assist in dissolving dead tissue. 15. Gently wash the extremity. - Vigorous scrubbing damage delicate tissues. 16. Pat extremity to dry, remove gloves, wash hands, and apply lotion to client skin. - Lotion moisturizes dry skin. 17. After cast removal, explain and write skin care procedure for the client. 18. Obtain physician order to perform active and passive ROM and clarify level of activity allowed. - After immobilization, the involved joints and muscles will be weak, and ROM may be limited. Activity is resumed slowly to avoid regarding injury. 19. Assist in transfer of client for return to unit or discharge. 20. Instruct client to observe for swelling and to continue to elevate the extremity to control swelling. 21. Return patient to comfortable position. 22. Dispose used supplies and equipment. 23. Wash hands. Report and record: – Record cast removal, condition of skin under the cast, skin care interventions; name of person removed the cast. – Record instructions given to client and family. Patient's instruction after cast removal include: – Elevate the extremity to decrease edema by pillows or chair. – Regular use of moisturizers for dry scaly skin. – Instruct client not to remove scaly skin by rubbing. – Teach client to ambulate slowly and carefully until muscle strength regained. Thank you…