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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

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)

NURSING ACTION3. DRAPE PATIENT.

RATIONALEAVOIDS UNDUE

EXPOSURE; PROTECTS OTHER BODY PARTS FROM CONTACT WITH CASTING MATERIALS.

NURSING ACTION4. WASH AND DRY

PART TO BE CASTED.

RATIONALEREDUCES INCIDENCE OF SKIN BREAKDOWN

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

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

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

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

NURSING ACTION9. REMOVE

PARTICLES OF CASTING MATERIALS FROM SKIN

RATIONALEPREVENTS

PARTICLES FROM LOOSENING AND SLIDING UNDERNEATH 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.

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

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

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.

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