(orthopaedic) cast

Assessing neurovascular status in a casted limb

* Evaluate neurovascular status every 1 to 2 hours for the first 24 hours after a cast is applied
* Note the size of the fingers or toes to detect edema. Rule out concurrent dependent edema due to a health problem.
* Make sure that the cast isn't too tight because of edema. You should be able to insert one or two fingertips into the proximal and distal ends.
* If possible, palpate the distal pulse of the casted limb and note the strength.
* Observe the color of the nail beds. Pink indicates normal arterial pressure; white, decreased arterial supply; and bluish, venous stasis. Bluish color may be normal in an older adult, but he shouldn't have other signs of circulatory compromise.
* Ask the patient to describe any sensations in the limb with the cast. Be alert for reports of such sensations as numbness, burning, pins and needles, throbbing, and achiness.
* Ask him to wiggle his fingers or toes. Then move one finger or toe while he has his eyes closed and ask him what position it's in.
* Compare temperature by simultaneously feeling the affected and unaffected fingers or toes.
* To assess capillary refill, press on the distal tip of an affected finger or toe until it's white, then release pressure. Normal color should return within 3 seconds.
DON'T
* Don't forget to compare bilateral findings when judging neurovascular status.
* Don't coach the patient when assessing pain. Let him describe it in his own words.
* Don't rely on just one neurovascular assessment to evaluate an older adult's circulation because certain age-related changes may be normal for him.




General Nursing Management of the Patient with a Cast
1)
Make a shallow groove to indicate the cutting lines on both sides of the

cast.

(2) Apply water or peroxide along the cutting lines to soften the plaster. Use

a syringe to apply.

(3) With the knife, cut through the layers of plaster along the cutting line. Do

not attempt to slice through all layers at once and do not use the knife to cut through the

base material.

(4) With the bandage scissors, cut through the base material down to the

skin. Cut every thread of the lining material completely through since the lining is

sometimes the source of the trouble.

(5) Use tape or an elastic bandage to loosely hold the bivalve cast together

in order to maintain support of the casted part until further instructions are obtained.

b. Windowing the Cast. This procedure is done on specific order of the

physician. It is a potentially dangerous procedure because the underlying tissue may

bulge through the window opening, causing "window edema." If a window is cut, the

piece of plaster removed should be saved.

(1)

The physician indicates the area to be windowed.

(2) The physician or orthopedic technician cuts the window, usually a

square or rectangular area, out of the cast. Once the plaster has been cut out, the

lining material is carefully cut away from the skin.

(3) After the physician examines and treats the underlying area, a dressing

may be applied over the exposed skin area and the cutout piece of plaster bound in

place again. Replacing the cutout plaster section will prevent window edema.

1-20. GENERAL NURSING MANAGEMENT OF THE PATIENT WITH A CAST

a. Although a patient with an arm or leg cast is much more self-reliant than a

patient in a body or spice cast, it is a nursing responsibility to monitor all patients and

assist as needed. Nursing management includes the following actions to assess the

effectiveness of the cast.

(1) Check the edges of the cast and all skin areas where the cast edges

may cause pressure. If there are signs of edema or circulatory impairment, notify the

charge nurse or physician immediately.

(2) Slip your fingers under the cast edges to detect any plaster crumbs or


other foreign material. Move the skin back and forth gently to stimulate circulation







Patient Care After Cast Removalc. One person should remain at the patient's affected side, while the others
move to the opposite side of the bed to straighten the bed linen and position another set
of pillows along side the patient. The pillows should be arranged so that they will
support the cast and the patient's head and shoulders when you turn the patient.
d. The patient should be instructed to raise the arm on his unaffected side above
his head.
e. The person on the patient's affected side should place his hands, with palms
up, under the patient's torso.
f. The assistants on the patient's unaffected side should reach across the bed
and place their hands, with palms down, on the patient's affected side. The person
nearest the patient's head should place his hands on the patient's shoulder while the
person nearest the patient's feet should place his hands on the patient's hip and leg.
g. Moving simultaneously, the person on the patient's affected side should
gently draw the patient toward himself while the assistants on the opposite side ease
the patient over toward themselves. Care should be taken to support the leg and arm
on the affected side of the body.
h. After the patient has been turned, check the placement of the supporting
pillows. Be sure that there are no gaps between pillows. When the patient is turned to
the prone position, place a pillow under the lower legs to allow the feet to rest in the
position of function and avoid having the toes pushed against the mattress.
i. Position a pillow under the patient's head and shoulders and be sure to place
the call bell within his reach.
1-24. PATIENT CARE AFTER CAST REMOVAL
a. After a cast has been removed, continue to provide support to joints and
normal body curves. The muscles will have become weakened from disuse and,
although movement is encouraged, support is necessary. Use firm pillows to support
the patient while in bed and use elastic bandages or an arm sling, if necessary, when
the patient is up and about.
b. Avoid vigorous attempts to remove skin exudate and crusts of dead skin cells,
which are present when a cast has been in place for several weeks. Gentle soaking
and applications of oil to soften the skin and loosen crusts may be recommended.
c. After the cast is removed, the physician or physical therapist may prescribe
exercises to increase strength. If the patient has been doing isometric muscle
contractions, he will not have to "relearn" to contract his muscles and will progress more
rapidly through rehabilitation. Atrophy of the part may be noticed, but this should
gradually disappear with the return of muscle function. Swelling may develop for a
while, but decreases with improved muscle tone and circulation as the patient becomes
more active.

.