Caring for a Patient with a Cast

Skill 9-16

Caring for a Patient With a Cast

A cast is a rigid external immobilizing device that is molded to the contours of the body and encases a body part (Hinkle et al., 2022). Casts are used to immobilize a body part in a specific position and to apply uniform pressure on the encased soft tissue. They may be used to treat injuries, correct a deformity, stabilize weakened joints, or promote healing after surgery. Casts generally allow the patient mobility while restricting movement of the affected body part (Hinkle et al., 2022). Nursing responsibilities after the cast is in place include maintaining the cast, preventing complications, and providing patient teaching related to cast care.

Delegation Considerations

Care of a cast may not be delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, care of a cast may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Disposable cleansing wipes or washcloth, towel, skin cleanser, and basin of warm water
Waterproof pads
Tape
Pillows
PPE, as indicated

Assessment

Review the patient's health record and prescribed interventions to determine the need for cast care and care of the affected area. Perform a pain assessment and administer the prescribed medication in sufficient time to allow for the full effect of the analgesic before starting care. Assess the neurovascular status of the affected extremity, including distal pulses, color, temperature, presence of edema, capillary refill to fingers or toes, and sensation and motion. Assess the skin distal to the cast. Note any indications of infection, including any foul odor from the cast, pain, fever, edema, and extreme warmth over an area of the cast. Assess for complications of immobility, including alterations in skin integrity, reduced joint movement, decreased peristalsis, constipation, alterations in respiratory function, and signs of thrombophlebitis . Inspect the condition of the cast. Be alert for cracks, dents, or the presence of drainage from the cast. Assess the patient's knowledge of cast care.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered skin integrity risk
Risk for impaired peripheral neurovascular function
ADL deficit

Outcome Identification and Planning

The expected outcomes to achieve when caring for a patient with a cast are that the cast remains intact, and the patient does not experience neurovascular compromise. Other outcomes include that the patient is free from infection, the patient experiences only mild pain and slight edema or soreness, the patient experiences only slight limitations of range-of-joint motion, the skin around the cast edges remains intact, the patient participates in activities of daily living (ADLs), and the patient verbalizes an understanding of and demonstrates appropriate cast-care techniques.

Implementation

Action	Rationale
1. Review the health record and the care plan to determine the need for cast care and care for the affected body part.	Reviewing the health record and care plan validates the correct patient and correct procedure.
2. Perform hand hygiene. Put on PPE, as indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain the procedure to the patient.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. Close the curtains around the bed and close the door to the room, if possible. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016).	Closing the door or curtains provides for privacy. Proper bed height helps reduce back strain while you are performing the procedure.
5. If a plaster cast was applied, handle the casted extremity or body area with the palms of your hands for the first 24 to 36 hours, until the cast is fully dry.	Proper handling of a plaster cast prevents dents in the cast, which may create pressure areas on the inside of the cast.
6. If the cast is on an extremity, elevate the affected area at heart level as prescribed, making sure pressure is evenly distributed under the cast. Maintain the normal curvatures and angles of the cast.	Elevation promotes venous return and reduces swelling. Maintaining curvatures and angles maintains proper joint alignment. Evenly distributed pressure prevents molding and denting of the cast and development of pressure areas.
7. Do not rest cast on pillows while drying. Keep cast (plaster) uncovered until fully dry.	Resting the cast on a pillow can increase the risk of thermal injury to the extremity as a result of the exothermic reactions during maturing and hardening of the cast materials (Sabeh et al., 2020). Keeping the cast uncovered allows heat and moisture to dissipate and air to circulate to speed drying.
8. Assess the condition of the cast. Be alert for cracks, dents, or the presence of drainage from the cast. Perform skin assessment, particularly around edges of the cast, and neurovascular assessment according to facility policy, as often as every 1 to 2 hours. Assess for pain, edema, inability to move body parts distal to the cast, pallor, pulses, and abnormal sensations. If the cast is on an extremity, compare it with the noncasted extremity (Figure 1).	Assessment helps detect abnormal neurovascular function or infection and allows for prompt intervention. Assessing the neurovascular status determines the circulation and oxygenation of tissues. Pressure within a cast may increase with edema and lead to compartment syndrome.
9. If breakthrough bleeding or drainage is noted on the cast, mark the area on the cast, according to facility policy (Figure 2). Indicate the date and time next to the area. Follow prescribed interventions or facility policy regarding the amount of drainage that needs to be reported to the health care team.	Marking the area provides a baseline for monitoring the amount of bleeding or drainage.
10. Assess for signs of infection. Monitor the patient's temperature. Assess for a foul odor from the cast, increased pain, or extreme warmth over an area of the cast.	Infection deters healing. Assessment allows for early detection and prompt intervention.
11. Reposition the patient every 2 hours. Provide back and skin care frequently. Encourage range-of-motion exercise for unaffected joints. Encourage the patient to cough and breathe deeply.	Repositioning promotes even drying of the cast and reduces the risk for the development of pressure areas under the cast. Frequent skin and back care prevents patient discomfort and skin breakdown. ROM exercises maintain joint function of unaffected areas. Coughing and deep breathing reduce the risk for respiratory complications associated with immobility.
12. Instruct the patient to report pain, odor, drainage, changes in sensation, abnormal sensation, or the inability to move fingers or toes of the affected extremity.	Pressure within a cast may increase with edema and lead to compartment syndrome. The patient's understanding of signs and symptoms allows for early detection and prompt intervention.
13. Place the bed in the lowest position, with the side rails up. Make sure the call bell and other essential items are within easy reach.	Having the bed at the proper height and leaving the call bell and other items within reach ensures patient safety.
14. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient has exhibited a cast that is intact without evidence of neurovascular compromise to the affected body part, the patient has remained free from infection, the patient has verbalized only mild pain and slight edema or soreness, the patient has maintained range-of-joint motion, the patient has demonstrated intact skin at cast edges, the patient is able to perform ADLs, and the patient has verbalized an understanding of and demonstrated appropriate cast-care techniques.

Documentation

Guidelines

Document all assessments and care provided. Document the patient's response to the cast, repositioning, and any teaching.

Sample Documentation

9/1/25

0845 Fiberglass cast in place on right lower extremity from just below knee to toes. Patient repositioned from right side to back. Cast clean and dry; edges padded. No signs of irritation noted. Patient able to move toes freely. Skin tone on right toes somewhat paler tone compared with left toes; toes warm and dry. Capillary refill less than 2 seconds. Patient denies any numbness, tingling, or pain. Right lower extremity elevated on two pillows. Patient verbalized an understanding of the need to report any complaints of pain, pressure, numbness, tingling, or decreased ability to move toes.

—P. Collins, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient, who has a cast on his hand and forearm, has been experiencing pain relief in the extremity with ice application and oral analgesics. He now reports pain unrelieved by the analgesic and a feeling of tightness in his arm. In addition, his fingers are cool, with sluggish capillary refill: Compartment syndrome may be developing. Adjust the arm so that it is no higher than heart level. This enhances arterial perfusion and controls edema. Notify the health care team of the situation immediately. Prepare for bivalving of the cast (cutting of the cast in half longitudinally) to relieve pressure.

Special Considerations

General Considerations

Explain that itching under the cast is normal, but the patient should not stick objects down or in the cast to scratch. Scratching the skin inside the cast could cause an injury or infection (MFMER, 2020; Sebeh et al., 2020). As suggested by the Mayo Clinic, to relieve itchy skin under a cast, turn a hair dryer on acool settingand aim it under the cast (MFMER, 2020).
Ice can be used to reduce swelling and edema. Loosely wrap an ice pack covered in a thin towel around the cast at the level of the injury. Wrapping the ice pack in a towel keeps the cast dry. Applying the ice over a larger surface area around the cast is more effective at reducing edema (MFMER, 2020).
Begin patient teaching immediately after the cast is applied and continue until the patient or a significant other can provide care.
If a cast is applied after surgery or trauma, monitor vital signs (the most accurate way to assess for bleeding).
Synthetic casts are lightweight, easy to clean, and somewhat water resistant. A fiberglass cast with a waterproof liner may be immersed in water without affecting the cast integrity (MFMER, 2020).

Infant and Child Considerations

Do not allow the child to put anything inside the cast. Avoid placing powder, lotion, or deodorant on or near the cast (MFMER, 2020).
Remove toys, hazardous floor rugs, pets, or other items that might cause the child to stumble.
Keep in mind that synthetic casts come in different colors and with designs, such as cartoons and stripes. These features may make the experience more pleasant for a child.
Cover cast with two layers of plastic sealed with duct tape for bathing and do not submerge or hold under running water (AAOS, 2020; MFMER, 2020).
Instruct the parents/guardians/caregivers of an infant/child with a cast not to alter standard car seats to accommodate a cast. Specially designed car seats and restraints are available for travel in a car (UNC Tar Heel Trauma, 2018).
Instruct the parents/guardians/caregivers of an infant/child with a cast to immediately report the following symptoms to their health care provider (MFMER, 2020). If your child:
- Feels increasing pain and tightness in the injured limb
- Feels numbness or tingling in the injured hand or foot
- Feels burning or stinging under the cast
- Develops excessive swelling below the cast
- Can't move the toes or fingers of the injured limb, or the toes or fingers turn blue or cold
- Tells you the cast feels too tight or too loose
- Develops red or raw skin around the cast
- Develops a crack, soft spots or a foul odor in the cast, or gets the cast soaking wet

Older Adult Considerations

Older adults may experience changes in circulation related to their age. They may have slow or poor capillary refill related to peripheral vascular disease. Obtain baseline information for comparison after the cast is applied. Use more than one neurovascular assessment to assess circulation. Compare extremities or sides of the body for symmetry.

Community-Based Care Considerations

Instruct patients to rest the extremity, apply ice to the extremity, and elevate the extremity for the first 24 to 72 hours to prevent pain and swelling after the application of the cast (AAOS, 2020; MFMER, 2020).
To control itching after the cast is dry, use a hair dryer oncool settingto blow cool air into the cast (Hinkle et al., 2022; MFMER, 2020). Instruct patients to never insert an object into the cast and report a wet cast to their health care provider (Hinkle & Cheever, 2018).
Instruct patients to immediately to report the following symptoms to their health care provider (AAOS, 2020; Hinkle et al., 2022):
- Increased pain and/or the feeling that the cast is too tight, which may indicate excessive swelling
- Numbness and tingling in the hand or foot, which may be caused by too much pressure on the nerves
- Burning and stinging, which may be caused by too much pressure on the skin
- Excessive swelling below the cast, indicating compromised circulation
- Loss of active movement of toes or fingers, indicating neurovascular compromise

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Skill 9-16