Nursing Procedure 9.5
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Consideration in Planning and Implementation
Compartment syndrome may be manifested by severe pain unrelieved by analgesics that is out of proportion to the injury, or a sudden decrease in capillary refill and loss of pulse during first 24 to 48 hr after the cast is in place. Watch for these signs and symptoms. Drying time for synthetic casts is extremely quick (15 min) compared to plaster casts (up to 48 hr).
Provide care based on developmental level. Demonstrate the casting procedure using a doll or a stuffed toy. Allow child to express concerns and understanding through play (e.g., have child teach a doll not to stick things under the cast or get the cast wet).
Watch client closely during initial gait retraining; additional weight of cast could cause lack of balance and result in stress and fracture of fragile bones.
Instruct the homebound client to prevent the cast from getting wet in order to maintain the integrity of the cast. If the cast does get wet, the client can dry it using a hair dryer on the LOW setting. To prevent skin breakdown, instruct client not to use lotions, oils, or powder under the cast and not to stick objects under the cast.
Instruct assistive personnel on transfer or moving of clients with casts. Routine monitoring of the client's neurovascular status, however, remains the responsibility of licensed personnel.
Action | Rationale | |
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1 | Perform hand hygiene. | Reduces microorganism transfer |
2 | Place draw sheet and linen savers on bed before client returns from casting area (place these items on bed with each linen change). | Promotes ease of positioning client; prevents pain when moving client |
3 | Explain procedure to client, emphasizing importance of keeping extremity elevated and not handling wet cast. Explain why frequent assessment is important. Instruct client not to insert anything between cast and extremity. Reassure client that the casting material will feel warm as it dries but will cool when drying is complete. | Reduces anxiety; promotes cooperation; prevents injury and infection |
4 | Provide privacy. | Decreases embarrassment |
5 | Don gloves. | Prevents contamination of hands; reduces risk of infection transmission |
6 | Handle casted extremity or body area with palms of hands for first 2448 hr or until cast is fully dry (Fig. 9.14). | Avoids dents, which could result in edema and pressure areas |
7 | If cast is slow to dry, place small fan directly facing the cast (about 24 in. away). DO NOT PLACE LINEN OVER CAST UNTIL CAST IS DRY. | Enhances speed of drying; allows air to circulate and assist in drying cast |
8 | If cast is on extremity, elevate extremity on pillows (cover pillow with linen savers or plastic bags) so normal curvatures created with casting are maintained. | Prevents edema; enhances venous return; prevents soiling pillows; prevents creation of flattened areas on cast as it dries; prevents pressure areas |
9 | Wash excess antimicrobial agents (e.g., povidone) from skin. Rinse and pat dry. | Allows for clear skin and vascular assessment |
10 | Perform skin and neurovascular assessments every 30 min to 1 hr for first 24 hr, every 2 hr for next 24 hr, and then every 4 hr thereafter. If cast is on one extremity, compare it with the opposite extremity. | Detects signs of abnormal neurovascular function, such as vascular or nerve compression; suggests possible nature of neurovascular deficit |
| Prevents nerve damage that would result in foot drop | |
11 | If breakthrough bleeding is noted on cast, circle area and write date and time on cast. If there is a moderate to large amount of bleeding, notify doctor; otherwise, follow orders as written for bleeding. | Provides baseline data for amount of bleeding; facilitates early intervention and prevention of complications |
12 | Assess for signs of infection (e.g., purulent drainage, foul odor, fever). | Detects infectious process at early stage |
13 | Reposition client every 2 hr. If client has body or spica cast, secure three assistants to help turn client. | Prevents client discomfort; makes turning quick, efficient, and safe |
14 | Provide back and skin care frequently. | Prevents skin breakdown |
15 | If flaking of cast around edges is noted, remove flakes and apply tape over cast edges: | Prevents accumulation of particles inside cast, which can cause skin breakdown |
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16 | Place client with leg or body cast on fracture pan for elimination. For clients with good bowel and bladder control, temporarily line edge of cast close to perineal area with plastic; if client has little or no elimination control (e.g., some pediatric and elderly clients), maintain plastic lining on cast edges and change once a shift. | Provides for elimination needs; prevents soiling of cast |
17 | Perform range-of-motion exercises on all joint areas every 4 hr (except where contraindicated). | Supports plan for maintaining mobility |
18 | Instruct client to cough and deep breathe and reposition client (within guidelines of orders) every 2 hr. | Prevents pneumonia, decubitus ulcers, and other complications of immobility |
19 | Instruct client to keep cast and skin under cast dry. Avoid putting lotion or powder under cast. | Preserves integrity of cast; prevents skin breakdown |
20 | Raise side rails, lock wheels, and place bed in low position. | Promotes safety |
21 | Place call light within reach. | Facilitates communication |
22 | Restore or discard all equipment properly. | Reduces transfer of microorganisms among clients; prepares equipment for future use |
23 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record: