Casts are essential orthopedic devices used to immobilize and protect bones and soft tissues following fractures, surgeries, or injuries. As a healthcare professional, particularly in orthopedic nursing, understanding cast care and related nursing diagnoses is paramount for ensuring patient comfort, promoting healing, and preventing complications. This guide provides a comprehensive overview of cast care nursing diagnoses, expanding upon basic notes to offer in-depth insights and practical applications.
Understanding Casts: Types, Purposes, and Materials
Casts are rigid external fixators that play a crucial role in orthopedic treatment. They serve multiple purposes, including:
- Immobilization: Restricting movement of a fractured bone or injured joint to facilitate proper healing.
- Support: Providing structural support to weakened or unstable limbs.
- Pain Management: Reducing pain by limiting movement and muscle spasms.
- Deformity Correction: Gradually correcting bone or joint deformities.
- Early Mobilization of Unaffected Parts: Allowing patients to maintain mobility in uncasted areas, promoting overall well-being.
Casts are categorized by their location and extent:
- Arm Casts:
- Short Arm Casts: Extending from below the elbow to the palm crease, typically used for wrist fractures.
- Long Arm Casts: Extending from the axillary fold to the palm crease, used for forearm or elbow fractures.
- Leg Casts:
- Short Leg Casts: Extending from below the knee to the toes, used for ankle or foot fractures.
- Long Leg Casts: Extending from the upper thigh to the toes, used for tibia or femur fractures.
Types of arm and leg casts, including short arm, long arm, short leg, and long leg casts.
- Spica Casts: Large casts encasing part of the trunk and one or both extremities, commonly used for hip or femur fractures in children.
- Body Casts: Enclosing the trunk, used for spinal injuries or deformities.
- Splints: Not fully circumferential casts; often adjustable and used in the acute phase to accommodate swelling. They provide support and immobilization while allowing for some movement and edema management.
The materials used in cast construction have evolved:
- Plaster Casts: Traditional casts made of plaster of Paris bandages. They offer excellent molding and are cost-effective but are heavy, take longer to dry (24-72 hours), and are not water-resistant. During drying, plaster casts generate heat.
- Fiberglass Casts: Made of synthetic fiberglass materials. They are lightweight, dry quickly (10-15 minutes), become weight-bearing sooner (30 minutes), are more breathable, and water-resistant. However, they are more expensive than plaster casts and mold less smoothly.
- Polyester-Cotton Knit Casts: A hybrid option, drying in 7-10 minutes and allowing almost immediate weight-bearing. They offer a balance of properties but may not be as widely used as plaster or fiberglass.
Nursing Assessment Before and After Cast Application
A thorough nursing assessment is crucial before and after cast application to ensure optimal patient outcomes. This includes:
- Pain Assessment: Evaluate pain characteristics – severity (using pain scales), location, nature (sharp, dull, throbbing), and factors that aggravate or alleviate the pain. Differentiate between pain related to the injury and potential cast-related pain.
- Neurovascular Assessment (Crucial for Cast Care Nursing Diagnosis): Assess circulation, sensation, and movement in the extremity distal to the cast. This includes:
- Pulse: Palpate peripheral pulses (dorsalis pedis, posterior tibial for leg casts; radial, ulnar for arm casts) distal to the cast and compare to the unaffected limb. Note rate, rhythm, and strength.
- Capillary Refill: Assess capillary refill time in nail beds distal to the cast. Normal refill is less than 3 seconds.
- Sensation: Evaluate sensation to light touch and pinprick in the fingers or toes. Assess for numbness, tingling (paresthesia), or increased sensitivity (hyperesthesia).
- Movement: Assess the patient’s ability to move fingers or toes actively. Note any weakness or paralysis.
- Color and Temperature: Observe skin color distal to the cast. It should be pink and warm. Pallor (paleness), cyanosis (bluish discoloration), or coolness indicate potential circulatory compromise.
- Edema: Monitor for swelling distal to the cast, which can indicate impaired venous return.
- Skin Assessment: Inspect the skin for any pre-existing lesions, wounds, bruises, or discoloration before cast application. Document any non-removable foreign materials under the intended cast area. This baseline is essential for identifying cast-related skin issues later.
- Learning Needs Assessment: Evaluate the patient’s understanding of the cast care regimen, including sling application, crutch walking (if applicable), and using assistive devices. Assess their readiness and ability to learn essential self-care procedures.
Key Nursing Diagnoses Related to Cast Care
Based on assessments, several nursing diagnoses are commonly associated with patients in casts. Addressing these diagnoses through targeted interventions is central to cast care nursing.
- Deficient Knowledge Related to Treatment Regimen: Many patients lack understanding about cast care, complications, and activity restrictions. This is a primary nursing diagnosis to address through patient education.
- Acute Pain Related to Musculoskeletal Disorder and/or Cast Application: Pain is a significant concern. It can be due to the initial injury, surgical procedure, or pressure from the cast itself. Effective pain management is crucial.
- Impaired Physical Mobility Related to Cast Immobilization: Casts inherently limit mobility. This diagnosis focuses on the functional limitations imposed by the cast and strategies to maintain mobility within restrictions.
- Self-Care Deficit (Bathing/Hygiene, Feeding, Dressing/Grooming) Related to Restricted Mobility: Cast immobilization can significantly impact a patient’s ability to perform daily self-care activities.
- Impaired Skin Integrity Related to Pressure, Lacerations, and Abrasions: Pressure from the cast, especially at bony prominences, and friction can lead to skin breakdown. Pre-existing skin conditions increase risk.
- Risk for Peripheral Neurovascular Dysfunction Related to Physiological Responses to Injury and Cast Compression: This is a critical diagnosis. Casts can potentially compromise circulation and nerve function, leading to serious complications like compartment syndrome.
Nursing Management and Interventions for Cast Care
Effective nursing management is vital for preventing complications and promoting healing in patients with casts.
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Preparation for Cast Application:
- Explain the Procedure: Thoroughly explain the cast application process to the patient, including sensations they may experience (warmth from plaster, pressure). Address anxieties and answer questions.
- Informed Consent: Obtain informed consent, especially if the cast application is part of a surgical procedure.
- Skin Preparation: Ensure the skin is clean and dry before application. Cleanse the affected area gently.
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Assisting During Cast Application:
- Assist the healthcare provider as needed during cast application. This may involve positioning the patient, holding the limb, and preparing casting materials.
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Post-Cast Application Care (Core of Cast Care Nursing Diagnosis Management):
- Cast Support: Support the newly applied cast with the palms of your hands (not fingertips) to prevent indentations while it dries. Use pillows to support the casted extremity.
- Stockinette Management: Ensure the stockinette is pulled over the cast edges to protect skin from rough edges.
- Elevation: Elevate the casted extremity above heart level, especially for the first 24-48 hours, to minimize swelling.
- Warmth and Coverage: Provide blankets or coverings to uncasted areas to maintain patient warmth and comfort.
- Drying the Cast:
- Plaster Casts: Expose plaster casts to room air for 24-72 hours to dry thoroughly. Avoid covering with plastic, which can trap moisture.
- Synthetic Casts: Synthetic casts set relatively quickly (around 20 minutes). Air dry to ensure complete hardening. For synthetic casts that get wet, a cool setting hairdryer can be used to dry them.
- Cast Hygiene: Instruct the patient to keep the cast dry. For synthetic casts, advise using a hairdryer on a cool setting if it gets slightly wet. Avoid immersing any type of cast in water.
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Pain Relief Measures:
- Positioning: Encourage frequent position changes to enhance comfort.
- Elevation: Maintain elevation of the casted limb to reduce edema and pain.
- Analgesics: Administer prescribed analgesics (oral or parenteral) as needed and ordered.
- Non-Pharmacological Pain Relief: Promote non-pharmacological methods such as:
- Guided Imagery: Help the patient visualize peaceful and pain-free scenarios.
- Relaxation Techniques: Teach deep breathing exercises and muscle relaxation techniques.
- Distraction: Encourage activities that divert attention from pain, such as reading, watching movies, or listening to music.
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Monitoring for Cast Syndrome (Especially with Large Casts):
- Cast Syndrome: Be vigilant for cast syndrome, particularly in patients with large casts like body or spica casts.
- Physiological Cast Syndrome: Observe for:
- Abdominal pain and distention
- Nausea and vomiting
- Elevated blood pressure and heart rate (tachycardia)
- Rapid breathing (tachypnea)
These symptoms can be due to bowel obstruction or superior mesenteric artery syndrome. Report these signs immediately.
- Psychological Cast Syndrome: Patients with claustrophobia are at risk for anxiety and panic. Assess for acute anxiety, irrational behavior, and provide psychological support.
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Compartment Syndrome Management (Emergency Intervention):
- Compartment Syndrome: Be acutely aware of compartment syndrome, a serious complication where increased pressure within a muscle compartment compromises circulation and nerve function.
- Signs and Symptoms (The 5 P’s):
- Pain: Severe pain out of proportion to the injury, unrelieved by analgesics, and increasing with passive stretching of fingers or toes.
- Pallor: Pale skin.
- Paresthesia: Numbness or tingling.
- Paralysis: Weakness or inability to move fingers or toes. (Late sign)
- Pulselessness: Diminished or absent peripheral pulses. (Late sign)
- Immediate Action: If compartment syndrome is suspected, immediately notify the healthcare provider. Elevate the limb to heart level (not above), and prepare for possible fasciotomy (surgical decompression). Do not elevate above heart level in suspected compartment syndrome as it can worsen arterial flow.
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Neurovascular Complication Monitoring:
- Promptly report any signs of neurovascular compromise to the healthcare provider.
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Infection Monitoring:
- Hot Spots: Investigate and report any “hot spots” on the cast, which may indicate underlying infection. Also note any foul odor or drainage from the cast.
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Patient and Family Education (Crucial for Deficient Knowledge Nursing Diagnosis):
- Isometric Exercises: Teach isometric exercises to maintain muscle strength in the casted limb.
- Upper Body Strengthening: If crutches will be used, instruct on upper body strengthening exercises.
- Complication Recognition: Educate the patient and family about signs and symptoms of complications (circulatory problems, cast syndrome, compartment syndrome, infection). Emphasize the importance of prompt reporting.
- Avoid Inserting Objects: Warn against inserting objects into the cast to scratch itching skin. Recommend using cool air from a hairdryer to relieve itching.
- Cast Care Education: Provide detailed instructions on cast care, including keeping it dry, cleaning (if applicable for synthetic casts), and protecting it during activities.
- Safety Precautions: Advise on safety measures, such as avoiding slippery surfaces, using assistive devices properly, and being cautious on stairs.
- Post-Cast Removal Care: Teach skin care and muscle-strengthening exercises to be performed after cast removal.
- Mobility and Self-Care: Encourage mobility within limitations and active participation in self-care activities.
- Weight-Bearing Instructions: Reinforce the healthcare provider’s instructions regarding weight-bearing restrictions.
Nursing Care Plan Examples: Addressing Key Nursing Diagnoses
Nursing Care Plan 1: Deficient Knowledge [Learning Need] Regarding Cast Care
Nursing Diagnosis: Deficient Knowledge [Learning Need] regarding cast care, prognosis, treatment, self-care, and discharge needs.
May be related to: Lack of exposure to information, misinterpretation of information, unfamiliarity with resources.
Possibly evidenced by: Questions about cast care, statements of misconception, inaccurate follow-through of instructions, preventable complications.
Desired Outcomes: Patient will verbalize understanding of cast care, prognosis, and potential complications. Patient will correctly demonstrate cast care procedures and explain rationale.
Nursing Interventions:
- Review Condition and Prognosis: Explain the injury, healing process, and expected outcomes using clear and simple language.
- Discuss Cast Care: Provide step-by-step instructions on keeping the cast dry, cleaning (if appropriate), skin care around cast edges, and recognizing danger signs.
- Medication Education: Explain any prescribed medications, including pain relievers, their purpose, dosage, and potential side effects.
- Mobility and Ambulation: Reinforce instructions from physical therapy regarding safe mobility, use of crutches or walkers, and weight-bearing limitations.
- Community Resources: Provide information on available community resources like home health services or support groups, if needed.
- Exercise Regimen: Teach exercises for joints above and below the cast to maintain strength and range of motion.
- Follow-up Appointments: Emphasize the importance of attending all scheduled follow-up appointments with the healthcare provider and physical therapy.
- Danger Signs Education: Clearly outline signs and symptoms that require immediate medical attention (increased pain, swelling, numbness, changes in skin color, fever, drainage, cast damage).
- Demonstration and Return Demonstration: Demonstrate cast care techniques and have the patient or family member perform return demonstrations to ensure understanding.
- Written Materials: Provide written cast care instructions for the patient to take home.
Nursing Care Plan 2: Acute Pain Related to Cast and Injury
Nursing Diagnosis: Acute Pain related to musculoskeletal injury, edema, and potential cast pressure.
May be related to: Muscle spasms, bone fragment movement, soft tissue injury, traction/immobilization device, anxiety.
Possibly evidenced by: Reports of pain, facial grimacing, guarding behavior, restlessness, changes in vital signs (increased heart rate, blood pressure).
Desired Outcomes: Patient will report pain is managed to a tolerable level (using pain scale). Patient will demonstrate relaxed manner, participate in activities, and rest adequately.
Nursing Interventions:
- Pain Assessment: Regularly assess pain characteristics (location, intensity, quality, aggravating/relieving factors). Use a pain scale (0-10).
- Immobilization: Ensure proper immobilization of the affected part with the cast.
- Elevation and Support: Elevate and support the casted extremity with pillows.
- Avoid Heat-Retaining Materials: Avoid plastic sheets or pillows directly under the cast, which can increase heat and discomfort.
- Cool Environment: Maintain a comfortable room temperature to prevent overheating under the cast.
- Medication Administration: Administer prescribed analgesics promptly and as needed. Educate patient on requesting pain medication before pain becomes severe. Consider around-the-clock pain medication for the first few days post-application.
- Comfort Measures: Provide alternative comfort measures:
- Gentle massage to uncasted areas (back rub, shoulder rub).
- Repositioning frequently.
- Cool compresses to uncasted areas near the cast edge (avoid getting cast wet).
- Relaxation Techniques: Teach and encourage relaxation techniques (deep breathing, guided imagery, progressive muscle relaxation).
- Distraction Activities: Encourage diversional activities to shift focus away from pain.
- Emotional Support: Provide emotional support and listen to patient concerns about pain and immobility.
- Monitor for Complications: Be vigilant for signs of compartment syndrome or infection, which can cause increased pain. Investigate any reports of sudden or unusual pain.
- Cold Therapy: Apply ice packs (covered in cloth) to the casted area for 20-30 minutes at a time, as ordered, especially in the first 24-72 hours to reduce swelling and pain.
Nursing Care Plan 3: Risk for Peripheral Neurovascular Dysfunction
Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction related to cast compression, edema, and potential injury.
Risk factors may include: Cast application, tissue trauma, edema, pressure on nerves and blood vessels.
Desired Outcomes: Patient will maintain adequate peripheral neurovascular function as evidenced by palpable pulses, warm and dry skin, normal sensation and movement, and timely capillary refill.
Nursing Interventions:
- Baseline Neurovascular Assessment: Perform and document a thorough baseline neurovascular assessment before and after cast application.
- Frequent Neurovascular Checks: Perform neurovascular assessments at least every 2-4 hours for the first 24-48 hours and then as needed. Document findings clearly.
- Pulse Assessment: Palpate and compare peripheral pulses in both extremities. Use Doppler if pulses are weak or difficult to palpate.
- Capillary Refill Check: Assess capillary refill time in nail beds.
- Sensation and Movement Assessment: Assess sensation to light touch and movement of fingers/toes.
- Color and Temperature Monitoring: Observe skin color and temperature distal to the cast.
- Edema Monitoring: Assess for increased swelling distal to the cast.
- Pain Monitoring (as related to neurovascular compromise): Assess pain characteristics, especially pain that is disproportionate to injury and increases with passive motion.
- Elevation (with caution): Elevate the casted extremity to promote venous return and reduce edema unless compartment syndrome is suspected. In suspected compartment syndrome, elevate to heart level.
- Loosen Restrictive Dressings: If neurovascular compromise is suspected, loosen any constricting bandages or dressings around the cast and notify the healthcare provider immediately.
- Cast Bivalving/Splitting: Be prepared to assist with cast bivalving or splitting if ordered by the healthcare provider to relieve pressure.
- Patient Education (Report Symptoms): Educate the patient and family to immediately report any changes in sensation, movement, pain, color, or temperature in the casted extremity.
- Avoid Prolonged Pressure: Ensure the cast is not causing prolonged pressure on any nerve or blood vessel. Reposition patient frequently.
- Maintain Hydration: Encourage adequate fluid intake to maintain blood volume and circulation.
- Monitor for Compartment Syndrome: Be vigilant for early signs of compartment syndrome (severe pain, pallor, paresthesia, paralysis, pulselessness).
- Prepare for Potential Surgical Intervention: In cases of compartment syndrome, prepare the patient for potential fasciotomy as an emergency procedure to relieve pressure.
By understanding these cast care nursing diagnoses and implementing comprehensive nursing management strategies, healthcare professionals can significantly improve patient outcomes, minimize complications, and ensure a smoother recovery process for individuals requiring cast immobilization. This in-depth guide aims to empower nurses with the knowledge and skills necessary to provide exceptional cast care.
