(orthopaedic )Care of a Patient in a cast &Patients with an External Fixator/Ilizarov

Nursing Care Plans

***Timing of interventions may vary depending on the protocol of the individual institution.***

Care of a Patient in a cast

Nursing Diagnosis	Expected Outcome	Nursing Intervention
Potential: Neurovascular compromise and/or alteration in skin integrity R/T cast.	Patient will experience no change in movement/circulation of exposed parts (fingers/toes). Skin will remain intact without breakdown.	Check color, temp, capillary refill, movement & sensation of exposed part q2 hrs. x 24 hrs. then q4 hrs. Elevate cast above the heart (unless otherwise ordered) to minimize edema. Notify MD for any change in movement/sensation or increase in edema. Change patient's position q2 hrs. while awake (q4 hrs NOC) Use proper positioning to keep pressure off prominences in cast (i.e. heels). Check skin around cast edge q4 hrs. and at least q shift. Petal edge of cast with moleskin or waterproof tape when dry. Notify MD of any broken skin, foul odor or drainage noted under cast edges. Mobilize as ordered. Assess skin q shift. Turn as indicated by procedure and condition. Provide daily nursing care. Teach family care of cast while in hospital.
Potential knowledge deficit R/T home cast care.	Patient/parent will verbalize understanding of: a. skin checks b. proper positioning c. mobilization d. toileting e. care of cast f. reasons to call MD	Teach family care of cast while in hospital. Give cast care book prior to discharge. Document verbalization, demonstration of learned skill.

Care of Patients with an
External Fixator/Ilizarov

Nursing Diagnosis	Expected Outcome	Nursing Intervention
Potential impaired mobility R/T surgical procedure/pain.	ROM will remain within 80% of normal.	Assist & encourage change in position q2 hrs while awake/prn NOC Assist in AROM q2 hrs while awake or per schedule. Make sure medication is given prior to P.T. Encourage ambulation as much as possible. Have patient wear shoe with laces attached to frame while not active to encourage flexion.
Self care deficit R/T apparatus immobility.	Patient will maintain ADL's & hygiene needs.	Assist patient in toileting & bath. O.T. to assist in safe means to accomplish ADL's. Nurses to reinforce and assist prn. May shower when ordered. Dry apparatus well after shower. Suggest velcro closing shorts or underwear that opens on one side.
Knowledge deficit R/T new technique & home care.	Patient/parent/significant other will state and demonstrate confidence in care of Ilizarov or external fixator.	Paint nuts and adjacent rings that are to be turned with nail polish. Place tape with arrows in the direction the nuts are to be turned. Turning schedule to be implemented as ordered.
Potential alteration in tissue perfusion R/T Ilizarov/external fixator.	Neurovascular & circulatory status will be as preop without numbness, tingling or loss of sensation or function.	Check neurovascular status for color, temp, capillary refill, movement, numbness of affected extremity q2 hrs x 48 hrs. then q4 hrs. Notify MD of any changes in neurovascular status. Elevate extremity.
Potential infection R/T Ilizarov/external fixator.	Pin sites will heal without any signs of infection & edema will be minimal.	Use clean technique when doing dressing changes. Observe pin sites & notify MD of any purulent drainage, foul odor, redness, edema or increase in temp. (101 degrees F or greater) q shift. Apply ABD's next to large pins to prevent soft tissue movement.
Alteration in comfort R/T surgical procedure.	Patient will obtain adequate pain relief and experience minimal discomfort.	Assess for pain & medicate per protocol. Reposition for comfort. Elevate affected extremity. Check for pressure areas around rings, apply gauze or ABD pad if pressure present. Use distraction techniques, bio-feedback (games, T.V., hobbies, etc.). Implement teaching program. Teach patient/parent how to turn nuts. Report any excessive pain, nerve problem R/T turning to MD. Teach patient/parent how to do pin care while in hospital. Give pin care handout sheet prior to discharge. Document verbalization/ demonstration of learned skills.