Assisting with Cast Application

Skill 9-15

Assisting With Cast Application

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). Casts may be made of plaster or synthetic materials, such as fiberglass. Each material has advantages and disadvantages. Nonplaster casts set in 15 minutes and can sustain weight bearing or pressure in 15 to 30 minutes. Plaster casts can take 24 to 72 hours to dry, and weight bearing or pressure is contraindicated during this period. Patient safety is of utmost importance during the application of a cast. Typically, a physician, advanced practice nurse, or other advanced practice professional applies the cast. Nursing responsibilities include preparing the patient and equipment, assisting during the application, and patient education. The nurse provides skin care to the affected area before, during, and after the cast is applied.

Delegation Considerations

Assisting with the application 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, assisting with the application 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

Casting materials, such as plaster rolls or fiberglass, depending on the type of cast being applied
Padding material, such as stockinette or sheet wadding, depending on the type of cast being applied
Plastic bucket or basin filled with warm water
Disposable, nonsterile gloves and aprons
Scissors
Waterproof, disposable pads
PPE, as indicated

Assessment

Assess the skin condition in the affected area, noting redness, contusions , edema, or open wounds. Assess the neurovascular status of the affected extremity, including distal pulses, color, temperature, presence of edema, capillary refill to fingers or toes, weakness, sensation, and motion. Perform a pain assessment. If the patient reports pain, administer the prescribed analgesic in sufficient time to allow for the full effect of the medication. Assess for muscle spasms and administer the prescribed muscle relaxant in sufficient time to allow for the full effect of the medication. Assess for the presence of disease processes that may interfere with wound healing, including skin diseases, peripheral vascular disease, diabetes, and open or draining wounds.

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 outcome to achieve when assisting with a cast application is that the cast is applied without interfering with neurovascular function. Other outcomes that may be appropriate include that the patient is free from complications, verbalizes an understanding of cast care, and experiences increased comfort.

Implementation

Action	Rationale
1. Review the health record and prescribed interventions to determine the need for the cast.	Reviewing the health record and prescribed interventions validates the correct patient and correct procedure.
2. Perform hand hygiene. Put on gloves and/or other 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 and verify area to be casted.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. Perform a pain assessment and assess for muscle spasm. Administer prescribed medications in sufficient time to allow for the full effect of the analgesic and/or muscle relaxant.	Assessment of pain and analgesic administration ensures patient comfort and enhances cooperation.
5. 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.
6. Position the patient, as needed, depending on the type of cast being applied and the location of the injury. Support the extremity or body part to be casted. Remove any rings or other jewelry from area to be casted.	Proper positioning minimizes movement, maintains alignment, and increases patient comfort. Rings or other jewelry could produce pressure points and contribute to alterations in circulation and perfusion.
7. Drape the patient with the waterproof pads.	Draping provides warmth and privacy and helps protect other body parts from contact with casting materials.
8. Cleanse and dry the affected body part.	Skin care before cast application helps prevent skin breakdown.
9. Position and maintain the affected body part in the position indicated by the physician or advanced practice professional as the stockinette (Figure 1), sheet wadding, and padding are applied. The stockinette should extend beyond the ends of the cast. As the wadding is applied, check for wrinkles.	Stockinette and other materials protect the skin from casting materials and create a smooth, padded edge, protecting the skin from abrasion. Padding protects the skin, tissues, and nerves from the pressure and raw edges of the cast.
10. Continue to position and maintain the affected body part in the position indicated by the physician or advanced practice professional as the casting material is applied (Figure 2). Assist with finishing by folding the stockinette or other padding down over the outer edge of the cast.	Smooth edges lessen the risk for skin irritation and abrasion.
11. Support the cast during hardening. Handle hardening plaster casts with the palms of hands, not fingers (Figure 3). Support the cast on a firm, smooth surface. Do not rest it on a hard surface or sharp edges. Avoid placing pressure on the cast. Do not rest cast on pillows while drying.	Proper handling avoids denting of the cast and development of pressure areas. 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).
12. Elevate the affected area at heart level as prescribed, making sure pressure is evenly distributed under the cast.	Elevation promotes venous return and reduces swelling. Evenly distributed pressure prevents molding and denting of the cast and development of pressure areas.
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 ensure patient safety.
14. Remove gloves and any other 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.
15. Obtain x-rays, as prescribed.	X-rays identify that the affected area is positioned properly.
16. 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. Patient complaints allow for early detection of, and prompt intervention for, complications such as skin irritation or impaired tissue perfusion.
17. Leave the cast uncovered and exposed to the air. Reposition the patient every 2 hours. Depending on facility policy, a fan may be used to dry the cast.	Keeping the cast uncovered promotes drying. Repositioning prevents development of pressure areas. Using a fan helps increase airflow and speeds drying.

Evaluation

The expected outcomes have been met when neurovascular function was maintained and healing occurred. In addition, the patient was free from complications, has verbalized an understanding of cast care, and has experienced increased comfort.

Documentation

Guidelines

Document the time, date, and site that the cast was applied. Include the skin assessment and care provided before application. Document the patient's response to the cast and the neurovascular status of the extremity.

Sample Documentation

6/1/25

1245 Fiberglass cast applied to right forearm from mid-upper arm to middle of hand. Cast clean and dry; edges padded. No signs of irritation noted. Patient able to move fingers freely. Fingers pale with consistent skin tone, warm, and dry. Capillary refill less than 2 seconds. Patient denies any numbness, tingling, or pain. Right forearm resting on two pillows. Patient verbalized an understanding of the need to report any complaints of pain, pressure, numbness, tingling, or decreased ability to move fingers.

—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 position of 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

Perform frequent, regular assessment of neurovascular status. Early recognition of diminished circulation and nerve function is essential to prevent loss of function. Be alert for the presence of compartment syndrome.
If a fiberglass cast was applied, remove any fiberglass resin residue on the skin with alcohol or acetone.
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

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.

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Skill 9-15