Rama Report

7/30/2019 Rama Report

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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 moveduring healing.

>these are applied on clients who have relatively stable fractures.

Types of casts

Short-arm cast

Long-arm cast

Short-leg cast

Long-leg cast

Walking cast

Body cast

Shoulder spica cast

Hip spica cast

Double hip spica cast

Casting materials

Plaster

Nonplaster

Guidelines for applying a cast

Nursing action

1. Support extremity or body part to becasted.

Rationale

It minimizes movement; maintains reduction

and alignment; increases comfort


Nursing action

2. Position and maintain part to be casted

in position indicated by physician during casting

procedure.

Rationale

Facilitates casting; reduces incidence of

complications (eg, malunion, nonunion,

contracture)


Nursing action

3. Drape patient.

Rationale

Avoids undue exposure; protects other bodyparts from contact with casting materials.


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Nursing action

4. Wash and dry part to be casted.

Rationale

Reduces incidence of skin breakdown


Nursing action

5. Place knitted material (eg, stockinette)over part to be casted.

1. Apply in smooth andnonconstrictive manner

2. Allow additional material

Rationale

Protects 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 action

6. Wrap soft, nonwoven roll paddingsmoothly and evenly around part.

1. Use additional padding overbony prominences to protect

superficial nerves (eg, head of

fibula and olecranon process)

Rationale

Protects skin from pressure of cast

Protects skin at bony prominences

Protects superficial nerves


Nursing action

7. Apply plaster or nonplaster castingmaterial evenly on body part

1. Choose appropriate width ofbandage

2. Use continous motion,maintaining constant contact

with body part

3. Use additional casting materials(splints) at joints and at points

of anticipated cast stress

Rationale

Creates smooth, solid, well-contoured cast

Facilitates smooth application

Creates smooth, solid, immobilizing cast

Shapes cast properly for adequate support

Strengthens cast


Nursing action

8. Finish cast1. Smooth edges

>Trim and reshape with cast knife and/or cutter


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Rationale

Protects skin from abrasionAllows full range of

motion of adjacent joints


Nursing action

9. Remove particles of casting materials from

skin

Rationale

Prevents particles from loosening and sliding

underneath cast


Nursing action

10.Support cast during hardening1. Handle hardening cast with

palms of hands

2. Support cast on firm, smoothsurface

3. Do not rest cast on hardsurfaces or on sharp edges

4. Avoid pressure on cast

Rationale

Casting 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 action

11. Promote drying of cast.

1. Leave cast uncovered and exposed

to air

2. Turn patient every 2 hours

supporting major joints

3. Fans may be used to increase air flow and

speed drying.

Rationale

Facilitates drying.

Procedure for bivalving a cast

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.


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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).

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


Frequent turning

Encourage frequent coughing and deep breathing


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Integumentary Complication

Breakdown of skin integrity (abrasions, decubitus ulcer) caused by friction, pressure, or shearing force


Frequent turnig and repositioning

Regular inspection of skin for signs of pressure

Gentle massage of skin, especially over bony prominences

Gastrointestinal Complication

Constipation


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)


Exercises

Encourage participation in adl as much as possible

Proper positioning and repositioning of joints


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Urinary Complication

Increased calcium excretionfrom bone destruction (calculi formation)

Increased urine ph (alkaline)

Stasis of urine in kidney and bladder

Urinary infection


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


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


Active or passive rom exercises

The patient with splints or braces

The patient with an external fixator


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Managing the patient in traction

Traction

Is 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 traction2. Balanced suspension traction

Straight traction

The pulling force is applied in a straight line to the injured body part resting on the bed

Bucks traction

It is the most common type of straight traction. The lower portion of the injured extremity is placed in acradle-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 comfort

Disadvantage: the weight required to maintain normal body alignment or fracture alignment cannot

exceed the tolerance of the skin, about 6 lb per extremity.

Balanced suspension traction

It involves more than one force of pull. Several forces work in unison to raise and supportthe clients

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 continuity

Disadvantage: 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 kg

2. Skeletal traction

3. Balanced suspension traction7 -12 kg

4. Thomas splint and pearson attachment

5. Manual traction


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Types of skin traction

1. Bucks extension traction2. Russel traction3.

Cervical traction

4. Pelvic traction- 4.5-9 kgManual traction

The hand directly applies the pulling force

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

Skeletal traction

Advantage: more weight can be used to maintain the proper anatomic alignment if necessary

Disadvantage: increased anxiety, increased risk of infection, increased discomfort

Managing the patient in undergoing orthopedic surgery

Joint replacement

Total hip replacement

Orthopedic surgeries

Open reduction

Internal fixation

Arthroplasty

Hemiarthroplasty

Joint arthroplasty or replacement

Total joint arthroplasty or replacement

Meniscectomy

Amputation

Bone graft


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Tendon transfer

Fasciotomy

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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