Home
Nursing Notes
Medical & Surgical Nursing (Notes)
Cast Application Nursing Care Plan & Management
Medical & Surgical Nursing (Notes)

Cast Application Nursing Care Plan & Management

Notes

Definition
  • Casts are solid dressings applied to a limb or other body part.

TYPES:

  • Short arm casts – extend from below the elbow to the proximal palmer crease.
  • Long arm casts – extend from the axillary fold to the proximal palmer crease.

arm casts

  • Short leg casts – extend from below the knee to the base of the toes.
  • Long leg casts – extend from the upper third of the thigh to the base of the toes.

types of cast

  • Spica casts – extend from the midtrunk to cover one or both extremities.
  • Body casts – encase the trunk of the body.
  • Splints – are bivalve casts that provide immobilization and allow for edema.

hip cast

Casts are applied to:

  • Immobilize a body part in a specific position
  • Exert uniform compression to soft tissue
  • Provide for early mobilization of unaffected body parts
  • Correct or prevent deformities
  • Stabilize and support unstable joints.

Several types of materials are used to make casts.

  • Plaster casts – mold very smoothly to the body’s contours. The cast initially emits heat and takes about 15 minutes to cool and 24 to 72 hours to dry. It must be handled carefully until dry.
  • Fiberglass casts – are dry in 10 to 15 minutes and can bear weight 30 minutes after application.
  • Polyester-cotton knit casts – take about 7 to 10 minutes to dry and can withstand weight bearing almost immediately.
Assessment. Assess the following before and after cast application:
  • Evaluate the client’s pain, noting severity, nature, exact location, source and alleviating and exacerbating factors.
  • Access neurovascular status.
  • Inspect for and document any skin lesions, discoloration, or no removable foreign material.
  • Evaluate the client’s ability to learn essential procedures, such as applying slings correctly, crutch walking, or using a walker.
Nursing Diagnosis
  • Deficient knowledge related to the treatment regimen
  • Acute pain related to the musculoskeletal disorder
  • Impaired physical mobility related to the cast
  • Self-care deficit: bathing/hygiene, feeding, dressing/grooming due to restricted mobility
  • Impaired skin integrity related to lacerations and abrasions
  • Risk for peripheral neurovascular dysfunction and related to physiologic responses to injury and compression effect of cast
Nursing Management
  1. Prepare the client for cast application.
    • Explain the procedure and what to expect.
    • Obtain informed consent if surgery is required.
    • Clean the skin of the affected part thoroughly.
  2. Assist the health care provider during application of the cast as needed.
  3. After the cast application, provide cast care.
    • Support an exposed cast, with the palms of your hands to prevent indentations.
    • Ensure that the stockinet is pulled over rough edges of the cast.
    • Elevate the casted extremity above the level of the heart.
    • Provide covering and warmth to uncasted areas.
    • Expose the fresh plaster cast to circulating air, uncovered, until dry (24 to 72 hours). Expose the fresh synthetic cast until it is completely set (about 20 minutes).
    • Instruct the client to avoid wetting the cast. Instruct him to dry a synthetic cast with a hair dryer on cool setting if it gets wet.
  4. Initiate pain relief measure if indicated.
    • Encourage position changes.
    • Elevate the affected body part.
    • Provide analgesics as appropriate.
    • Promote nonpharmacologic pain relief measures, such as guided imagery, relaxation and distraction.
  5. Observe for signs and symptoms of cast syndrome with clients who are immobilized in large casts, such as a body or hip spica cast.
    • Report abdominal pain and distention, nausea and vomiting, elevated blood pressure, tachycardia, and tachypnea which are physiologic effects of cast syndrome.
    • Any client who is claustrophobic is at risk for psychological cast syndrome, which includes acute anxiety and possible irrational behavior.
  6. Provide nursing care for compartment syndrome, if indicated. Observe for signs and symptoms and discuss and assist with treatments.
  7. Notify the health care provider immediately if signs or symptoms of other neurovascular complications occur.
  8. Notify the health care provider if “hot spots” occur along the cast; they may indicate infection under cast.
  9. Provide client and family teaching.
    • Encourage isometric exercises to strengthen muscles covered by the cast. Promote muscle-strengthening exercises for the upper body if crutches are to be used.
    • Advise the client to promptly report cast breaks and signs and symptoms of complications (i.e. circulatory compromise, cast syndrome, and hot spots).
    • Warn the client against inserting sharp objects (e.g. coat hanger to scratch itchy skin under the cast). Instruct him to use a cool air from a dryer to help alleviate the itch.
    • Teach the client appropriate cast care, depending on the type of cast.
    • Encourage safety precautions (e.g. avoid walking on wet floors, watch throw rugs, be careful with stairs).
    • Teach the client skin care and muscle-strengthening exercises for the affected body part after cast removal.
    • Encourage mobility and active participation in self-care.
    • Reinforce health care provider instructions on the amount of eight bearing allowed.

 

Nursing Care Plan

Nursing Diagnosis
  • Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May be related to
  • Lack of exposure/recall
  • Information misinterpretation/unfamiliarity with information resources
Possibly evidenced by
  • Questions/request for information, statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications
Desired Outcomes
  • Verbalize understanding of condition, prognosis, and potential complications.
  • Correctly perform necessary procedures and explain reasons for actions.
Nursing Interventions
  • Review pathology, prognosis, and future expectations.
    • Rationale: Provides knowledge base from which patient can make informed choices. Note: Internal fixation devices can ultimately compromise the bone’s strength, and intramedullary nails and rods or plates may be removed at a future date.
  • Discuss dietary needs.
    • Rationale: A low-fat diet with adequate quality protein and rich in calcium promotes healing and general well-being.
  • Discuss individual drug regimen as appropriate.
    • Rationale: Proper use of pain medication and antiplatelet agents can reduce risk of complications. Long-term use of alendronate (Fosamax) may reduce risk of stress fractures. Note: Fosamax should be taken on an empty stomach with plain water because absorption of drug may be altered by food and some medications (antacids, calcium supplements).
  • Reinforce methods of mobility and ambulation as instructed by physical therapist when indicated.
    • Rationale: Most fractures require casts, splints, or braces during the healing process. Further damage and delay in healing could occur secondary to improper use of ambulatory devices.
  • Suggest use of a backpack.
    • Rationale: Provides place to carry necessary articles and leaves hands free to manipulate crutches; may prevent undue muscle fatigue when one arm is casted.
  • List activities patient can perform independently and those that require assistance.
    • Rationale: Organizes activities around need and who is available to provide help.
  • Identify available community services (rehabilitation teams, home nursing or homemaker services).
    • Rationale: Provides assistance to facilitate self-care and support independence. Promotes optimal self-care and recovery.
  • Encourage patient to continue active exercises for the joints above and below the fracture.
    • Rationale: Prevents joint stiffness, contractures, and muscle wasting, promoting earlier return to independence in activities of daily living (ADLs).
  • Discuss importance of clinical and therapy follow-up appointments.
    • Rationale: Fracture healing may take as long as a year for completion, and patient cooperation with the medical regimen facilitates proper union of bone. Physical therapy (PT) or occupational therapy (OT) may be indicated for exercises to maintain and strengthen muscles and improve function. Additional modalities such as low-intensity ultrasound may be used to stimulate healing of lower-forearm or lower-leg fractures.
  • Review proper pin and wound care.
    • Rationale: Reduces risk of bone or tissue trauma and infection, which can progress to osteomyelitis.
  • Recommend cleaning external fixator regularly.
    • Rationale: Keeping device free of dust and contaminants reduces risk of infection.
  • Identify signs and symptoms requiring medical evaluation (severe pain, fever, chills, foul odors; changes in sensation, swelling, burning, numbness, tingling, skin discoloration, paralysis, white or cool toes or fingertips; warm spots, soft areas, cracks in cast).
    • Rationale: Prompt intervention may reduce severity of complications such as infection or impaired circulation. Note: Some darkening of the skin (vascular congestion) may occur normally when walking on the casted extremity or using casted arm; however, this should resolve with rest and elevation.
  • Discuss care of “green” or wet cast.
    • Rationale: Promotes proper curing to prevent cast deformities and associated misalignment and skin irritation. Note: Placing a “cooling” cast directly on rubber or plastic pillows traps heat and increases drying time.
  • Suggest the use of a blow-dryer to dry small areas of dampened casts.
    • Rationale: Cautious use can hasten drying.
  • Demonstrate use of plastic bags to cover plaster cast during wet weather or while bathing. Clean soiled cast with a slightly dampened cloth and some scouring powder.
    • Rationale: Protects from moisture, which softens the plaster and weakens the cast. Note: Fiberglass casts are being used more frequently because they are not affected by moisture. In addition, their light weight may enhance patient participation in desired activities.
  • Emphasize importance of not adjusting clamps and nuts of external fixator.
    • Rationale: Tampering may alter compression and misalign fracture.
  • Recommend use of adaptive clothing.
    • Rationale: Facilitates dressing and grooming activities.
  • Suggest ways to cover toes, if appropriate (stockinette or soft socks).
    • Rationale: Helps maintain warmth and protect from injury.
  • Instruct patient to continue exercises as permitted;
    • Rationale: Reduces stiffness and improves strength and function of affected extremity.
  • Inform patient that the skin under the cast is commonly mottled and covered with scales or crusts of dead skin;
    • Rationale: It will be several weeks before normal appearance returns.
  • Wash the skin gently with soap, povidone-iodine (Betadine), or pHisoDerm, and water. Lubricate with a protective emollient;
    • Rationale: New skin is extremely tender because it has been protected beneath a cast.
  • Inform patient that muscles may appear flabby and atrophied (less muscle mass). Recommend supporting the joint above and below the affected part and the use of mobility aids (elastic bandages, splints, braces, crutches, walkers, or canes).
    • Rationale: Muscle strength will be reduced and new or different aches and pains may occur for awhile secondary to loss of support.
  • Elevate the extremity as needed.
    • Rationale: Swelling and edema tend to occur after cast removal.
Nursing Diagnosis
  • Acute Pain

May be related to

  • Muscle spasms
  • Movement of bone fragments, edema, and injury to the soft tissue
  • Traction/immobility device
  • Stress, anxiety

Possibly evidenced by

  • Reports of pain
  • Distraction; self-focusing/narrowed focus; facial mask of pain
  • Guarding, protective behavior; alteration in muscle tone; autonomic responses

Desired Outcomes

  • Verbalize relief of pain.
  • Display relaxed manner; able to participate in activities, sleep/rest appropriately.
  • Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing Interventions
  • Maintain immobilization of affected part by means of bed rest, cast, splint, traction.
    • Rationale: Relieves pain and prevents bone displacement and extension of tissue injury.
  • Elevate and support injured extremity.
    • Rationale: Promotes venous return, decreases edema, and may reduce pain.
  • Avoid use of plastic sheets and pillows under limbs in cast.
    • Rationale: Can increase discomfort by enhancing heat production in the drying cast.
  • Elevate bed covers; keep linens off toes.
    • Rationale: Maintains body warmth without discomfort due to pressure of bedclothes on affected parts.
  • Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (0–10 scale), relieving and aggravating factors. Note nonverbal pain cues (changes in vital signs, emotions and behavior). Listen to reports of family members or SO regarding patient’s pain.
    • Rationale: Influences effectiveness of interventions. Many factors, including level of anxiety, may affect perception of pain. Note: Absence of pain expression does not necessarily mean lack of pain.
  • Encourage patient to discuss problems related to injury.
    • Rationale: Helps alleviate anxiety. Patient may feel need to relive the accident experience.
  • Explain procedures before beginning them.
    • Rationale: Allows patient to prepare mentally for activity and to participate in controlling level of discomfort.
  • Medicate before care activities. Let patient know it is important to request medication before pain becomes severe.
    • Rationale: Promotes muscle relaxation and enhances participation.
  • Perform and supervise active and passive ROM exercises.
    • Rationale: Maintains strength and mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues.
  • Provide alternative comfort measures (massage, backrub, position changes).
    • Rationale: Improves general circulation; reduces areas of local pressure and muscle fatigue.
  • Provide emotional support and encourage use of stress management techniques (progressive relaxation, deep-breathing exercises, visualization or guided imagery); provide Therapeutic Touch.
    • Rationale: Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of the stress of traumatic injury and pain, which is likely to persist for an extended period.
  • Identify diversional activities appropriate for patient age, physical abilities, and personal preferences.
    • Rationale: Prevents boredom, reduces muscle tension, and can increase muscle strength; may enhance coping abilities.
  • Investigate any reports of unusual or sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics.
    • Rationale: May signal developing complications (infection, tissue ischemia, compartmental syndrome).
  • Apply cold or ice pack first 24–72 hr and as necessary.
    • Rationale: Reduces edema and hematoma formation, decreases pain sensation. Note: Length of application depends on degree of patient comfort and as long as the skin is carefully protected.

Administer medications as indicated:

  • Narcotic and nonnarcotic analgesics: morphine, meperidine (Demerol),hydrocodone (Vicodin); injectable and oral nonsteroidal anti-inflammatory drugs (NSAIDs): ketorolac (Toradol), ibuprofen (Motrin); muscle relaxants: cyclobenzaprine(Flexeril), carisoprodol (Soma), diazepam (Valium). Administer analgesics around the clock for 3–5 days.
    • Rationale: Given to reduce pain or muscle spasms. Studies of ketorolac (Toradol) have proved it to be effective in alleviating bone pain, with longer action and fewer side effects than narcotic agents.
  • Maintain and monitor IV patient-controlled analgesia (PCA) using peripheral, epidural, or intrathecal routes of administration. Maintain safe and effective infusions and equipment.
    • Rationale: Routinely administered or PCA maintains adequate blood level of analgesia, preventing fluctuations in pain relief with associated muscle tension and spasms.
Nursing Diagnosis
  • Impaired Physical Mobility
May be related to
  • Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization)
  • Psychological immobility
Possibly evidenced by
  • Inability to move purposefully within the physical environment, imposed restrictions
  • Reluctance to attempt movement; limited ROM
  • Decreased muscle strength/control
Desired Outcomes
  • Regain/maintain mobility at the highest possible level.
  • Maintain position of function.
  • Increase strength/function of affected and compensatory body parts.
  • Demonstrate techniques that enable resumption of activities.
Nursing Interventions
  • Assess degree of immobility produced by injury or treatment and note patient’s perception of immobility.
    • Rationale: Patient may be restricted by self-view or self-perception out of proportion with actual physical limitations, requiring information or interventions to promote progress toward wellness.
  • Encourage participation in diversional or recreational activities. Maintain stimulating environment (radio, TV, newspapers, personal possessions, pictures, clock, calendar, visits from family and friends).
    • Rationale: Provides opportunity for release of energy, refocuses attention, enhances patient’s sense of self-control and self-worth, and aids in reducing social isolation.
  • Instruct patient or assist with active and passive ROM exercises of affected and unaffected extremities.
    • Rationale: Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures or atrophy and calcium resorption from disuse
  • Encourage use of isometric exercises starting with the unaffected limb.
    • Rationale: Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema is present.
  • Provide footboard, wrist splints, trochanter or hand rolls as appropriate.
    • Rationale: Useful in maintaining functional position of extremities, hands and feet, and preventing complications (contractures, footdrop).
  • Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures.
    • Rationale: Reduces risk of flexion contracture of hip.
  • Instruct and encourage use of trapeze and “post position” for lower limb fractures.
    • Rationale: Facilitates movement during hygiene or skin care and linen changes; reduces discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed.
  • Assist with self-care activities (bathing, shaving).
    • Rationale: Improves muscle strength and circulation, enhances patient control in situation, and promotes self-directed wellness.
  • Provide and assist with mobility by means of wheelchair, walker, crutches, canes as soon as possible. Instruct in safe use of mobility aids.
    • Rationale: Early mobility reduces complications of bed rest (phlebitis) and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety.
  • Monitor blood pressure (BP) with resumption of activity. Note reports of dizziness.
    • Rationale: Postural hypotension is a common problem following prolonged bed rest and may require specific interventions (tilt table with gradual elevation to upright position).
  • Reposition periodically and encourage coughing and deep-breathing exercises.
    • Rationale: Prevents or reduces incidence of skin and respiratory complications (decubitus, atelectasis, pneumonia).
  • Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy.
    • Rationale: Bed rest, use of analgesics, and changes in dietary habits can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent or limit complications. Fracture pan limits flexion of hips and lessens pressure on lumbar region and lower extremity cast.
  • Encourage increased fluid intake to 2000–3000 mL per day (within cardiac tolerance), including acid or ash juices.
    • Rationale: Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation
  • Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement.
    • Rationale: In the presence of musculoskeletal injuries, nutrients required for healing are rapidly depleted, often resulting in a weight loss of as much as 20 to 30 lb during skeletal traction. This can have a profound effect on muscle mass, tone, and strength. Note: Protein foods increase contents in small bowel, resulting in gas formation and constipation. Therefore, gastrointestinal (GI) function should be fully restored before protein foods are increased.
  • Increase the amount of roughage or fiber in the diet. Limit gas-forming foods.
    • Rationale: Adding bulk to stool helps prevent constipation. Gas-forming foods may cause abdominal distension, especially in presence of decreased intestinal motility.
  • Consult with physical, occupational therapist or rehabilitation specialist.
    • Rationale: Useful in creating individualized activity and exercise program. Patient may require long-term assistance with movement, strengthening, and weight-bearing activities, as well as use of adjuncts (walkers, crutches, canes); elevated toilet seats; pickup sticks or reachers; special eating utensils.
  • Initiate bowel program (stool softeners, enemas, laxatives) as indicated.
    • Rationale: Done to promote regular bowel evacuation.
  • Refer to psychiatric clinical nurse specialist or therapist as indicated.
    • Rationale: Patient or SO may require more intensive treatment to deal with reality of current condition, prognosis, prolonged immobility, perceived loss of control.
Nursing Diagnosis
  • Skin/Tissue Integrity, impaired: actual/risk for
May be related to
  • Puncture injury; compound fracture; surgical repair; insertion of traction pins, wires, screws
  • Altered sensation, circulation; accumulation of excretions/secretions
  • Physical immobilization
Possibly evidenced by (actual)
  • Reports of itching, pain, numbness, pressure in affected/surrounding area
  • Disruption of skin surface; invasion of body structures; destruction of skin layers/tissues
Desired Outcomes
  • Verbalize relief of discomfort.
  • Demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing as indicated.
  • Achieve timely wound/lesion healing if present.
Nursing Interventions
  • Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration, duskiness, blanching.
    • Rationale: Provides information regarding skin circulation and problems that may be caused by application or restriction of cast, splint or traction apparatus, or edema formation that may require further medical intervention.
  • Massage skin and bony prominences. Keep the bed linens dry and free of wrinkles. Place water pads, other padding under elbows or heels as indicated.
    • Rationale: Reduces pressure on susceptible areas and risk of abrasions and skin breakdown.
  • Reposition frequently. Encourage use of trapeze if possible.
    • Rationale: Lessens constant pressure on same areas and minimizes risk of skin breakdown. Use of trapeze may reduce risk of abrasions to elbows and heels.
  • Assess position of splint ring of traction device.
    • Rationale: Improper positioning may cause skin injury or breakdown.
Plaster cast application and skin care:
  • Cleanse skin with soap and water.
    • Rationale: Provides a dry, clean area for cast application. Note: Excess powder may cake when it comes in contact with water and perspiration.
  • Rub gently with alcohol or dust with small amount of a zinc or stearate powder;
    • Rationale: Useful for padding bony prominences, finishing cast edges, and protecting the skin.
  • Cut a length of stockinette to cover the area and extend several inches beyond the cast;
    • Rationale: Prevents indentations or flattening over bony prominences and weight-bearing areas (back of heels), which would cause abrasion or tissue trauma. An improperly shaped or dried cast is irritating to the underlying skin and may lead to circulatory impairment.
  • Use palm of hand to apply, hold, or move cast and support on pillows after application;
    • Rationale: Uneven plaster is irritating to the skin and may result in abrasions.
  • Trim excess plaster from edges of cast as soon as casting is completed;
    • Rationale: Prevents skin breakdown caused by prolonged moisture trapped under cast.
  • Promote cast drying by removing bed linen, exposing to circulating air;
    • Rationale: Pressure can cause ulcerations, necrosis, or nerve palsies.
  • Observe for potential pressure areas, especially at the edges of and under the splint or cast;
    • Rationale: These problems may be painless when nerve damage is present.
  • Pad (petal) the edges of the cast with waterproof tape;
    • Rationale: Provides an effective barrier to cast flaking and moisture. Helps prevent breakdown of cast material at edges and reduces skin irritation and excoriation.
  • Cleanse excess plaster from skin while still wet, if possible;
    • Rationale: Dry plaster may flake into completed cast and cause skin damage.
Protect cast and skin in perineal area:
  • Provide frequent perineal care
    • Rationale: Prevents tissue breakdown and infection by fecal contamination.
  • Instruct patient and SO to avoid inserting objects inside casts;
    • Rationale: “Scratching an itch” may cause tissue injury.
  • Massage the skin around the cast edges with alcohol;
    • Rationale: Has a drying effect, which toughens the skin. Creams and lotions are not recommended because excessive oils can seal cast perimeter, not allowing the cast to “breathe.” Powders are not recommended because of potential for excessive accumulation inside the cast.
  • Turn frequently to include the uninvolved side, back, and prone positions (as tolerated) with patient’s feet over the end of the mattress.
    • Rationale: Minimizes pressure on feet and around cast edges.
Skin traction application and skin care:
  • Cleanse the skin with warm, soapy water;
    • Rationale: Reduces level of contaminants on skin.
  • Apply tincture of benzoin;
    • Rationale: “Toughens” the skin for application of skin traction.
  • Apply commercial skin traction tapes (or make some with strips of moleskin or adhesive tape) lengthwise on opposite sides of the affected limb;
    • Rationale: Traction tapes encircling a limb may compromise circulation.
  • Extend the tapes beyond the length of the limb;
    • Rationale: Traction is inserted in line with the free ends of the tape.
  • Mark the line where the tapes extend beyond the extremity;
    • Rationale: Allows for quick assessment of slippage.
  • Place protective padding under the leg and over bony prominences;
    • Rationale: Minimizes pressure on these areas.
  • Wrap the limb circumference, including tapes and padding, with elastic bandages, being careful to wrap snugly but not too tightly;
    • Rationale: Provides for appropriate traction pull without compromising circulation.
  • Palpate taped tissues daily and document any tenderness or pain;
    • Rationale: If area under tapes is tender, suspect skin irritation, and prepare to remove the bandage system.
  • Remove skin traction every 24 hr, per protocol; inspect and give skin care.
    • Rationale: Maintains skin integrity
Skeletal traction and fixation application and skin care:
  • Bend wire ends or cover ends of wires or pins with rubber or cork protectors or needle caps;
    • Rationale: Prevents injury to other body parts.
  • Pad slings or frame with sheepskin, foam.
    • Rationale: Prevents excessive pressure on skin and promotes moisture evaporation that reduces risk of excoriation.
  • Provide foam mattress, sheepskins, flotation pads, or air mattress as indicated.
    • Rationale: Because of immobilization of body parts, bony prominences other than those affected by the casting may suffer from decreased circulation.
  • Monovalve, bivalve, or cut a window in the cast, per protocol.
    • Rationale: Allows the release of pressure and provides access for wound and skin care.
Nursing Diagnosis
  • Risk for Peripheral Neurovascular Dysfunction
Risk factors may include
  • Reduction/interruption of blood flow
  • Direct vascular injury, tissue trauma, excessive edema, thrombus formation
  • Hypovolemia
Desired Outcomes
  • Maintain tissue perfusion as evidenced by palpable pulses, skin warm/dry, normal sensation, usual sensorium, stable vital signs, and adequate urinary output for individual situation.
Nursing Interventions
  • Remove jewelry from affected limb.
    • Rationale: May restrict circulation when edema occurs.
  • Evaluate presence and quality of peripheral pulse distal to injury via palpation or Doppler. Compare with uninjured limb.
    • Rationale: Decreased or absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Be aware that occasionally a pulse may be palpated even though circulation is blocked by a soft clot through which pulsations may be felt. In addition, perfusion through larger arteries may continue after increased compartment pressure has collapsed the arteriole or venule circulation in the muscle.
  • Assess capillary return, skin color, and warmth distal to the fracture.
    • Rationale: Return of color should be rapid (3–5 sec). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. Note:Peripheral pulses, capillary refill, skin color, and sensation may be normal even in presence of compartmental syndrome because superficial circulation is usually not compromised
  • Maintain elevation of injured extremity(ies) unless contraindicated by confirmed presence of compartmental syndrome.
    • Rationale: Promotes venous drainage and decreases edema. Note: In presence of increased compartment pressure, elevation of the extremity actually impedes arterial flow, decreasing perfusion.
  • Assess entire length of injured extremity for swelling or edema formation. Measure injured extremity and compare with uninjured extremity. Note appearance and spread of hematoma.
    • Rationale: Increasing circumference of injured extremity may suggest general tissue swelling or edema but may reflect hemorrhage. Note: A 1-in increase in an adult thigh can equal approximately 1 unit of sequestered blood.
  • Note reports of pain extreme for type of injury or increasing pain on passive movement of extremity, development of paresthesia, muscle tension or tenderness with erythema, and change in pulse quality distal to injury. Do not elevate extremity. Report symptoms to physician at once.
    • Rationale: Continued bleeding and edema formation within a muscle enclosed by tight fascia can result in impaired blood flow and ischemic myositis or compartmental syndrome, necessitating emergency interventions to relieve pressure and restore circulation. Note: This condition constitutes a medical emergency and requires immediate intervention.
  • Investigate sudden signs of limb ischemia (decreased skin temperature, pallor, and increased pain).
    • Rationale: Fracture dislocations of joints (especially the knee) may cause damage to adjacent arteries, with resulting loss of distal blood flow.
  • Encourage patient to routinely exercise digits and joints distal to injury. Ambulate as soon as possible.
    • Rationale: Enhances circulation and reduces pooling of blood, especially in the lower extremities.
  • Investigate tenderness, swelling, pain on dorsiflexion of foot (positive Homans’ sign).
    • Rationale: There is an increased potential for thrombophlebitis and pulmonary emboli in patients immobile for several days. Note: The absence of a positive Homans’ sign is not a reliable indicator in many people, especially the elderly because they often have reduced pain sensation.
  • Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation.
    • Rationale: Inadequate circulating volume compromises systemic tissue perfusion.
  • Test stools or gastric aspirant for occult blood. Note continued bleeding at trauma or injection site(s) and oozing from mucous membranes.
    • Rationale: Increased incidence of gastric bleeding accompanies fractures and trauma and may be related to stress or occasionally reflects a clotting disorder requiring further evaluation.
  • Perform neurovascular assessments, noting changes in motor and sensory function. Ask patient to localize pain and discomfort.
    • Rationale: Impaired feeling, numbness, tingling, increased or diffuse pain occur when circulation to nerves is inadequate or nerves are damaged.
  • Test sensation of peroneal nerve by pinch or pinprick in the dorsal web between the first and second toe, and assess ability to dorsiflex toes if indicated.
    • Rationale: Length and position of peroneal nerve increase risk of its injury in the presence of leg fracture, edema or compartmental syndrome, or malposition of traction apparatus.
  • Assess tissues around cast edges for rough places and pressure points. Investigate reports of “burning sensation” under cast.
    • Rationale: These factors may be the cause of or be indicative of tissue pressure, ischemia, leading to breakdown and necrosis.
  • Monitor location of supporting ring of splints or sling.
    • Rationale: Traction apparatus can cause pressure on vessels and nerves, particularly in the axilla and groin, resulting in ischemia and possible permanent nerve damage.
  • Apply ice bags around fracture site for short periods of time on an intermittent basis for 24–72 hr.
    • Rationale: Reduces edema and hematoma formation, which could impair circulation. Note: Length of application of cold therapy is usually 20–30 min at a time.
  • Monitor hemoglobin (Hb), hematocrit (Hct), coagulation studies such as prothrombin time (PT) levels.
    • Rationale: Assists in calculation of blood loss and effectiveness of replacement therapy. Coagulation deficits may occur secondary to major trauma, presence of fat emboli, or anticoagulant therapy.
  • Administer IV fluids and blood products as needed.
    • Rationale: Maintains circulating volume, enhancing tissue perfusion.
  • Split or bivalve cast as needed.
    • Rationale: May be done on an emergency basis to relieve restriction and improve impaired circulation resulting from compression and edema formation in injured extremity.
  • Assist with intracompartmental pressures as appropriate.
    • Rationale: Elevation of pressure (usually to 30 mm Hg or more) indicates need for prompt evaluation and intervention. Note: This is not a widespread diagnostic tool, so special interventions and training may be required.
  • Review electromyography (EMG) and nerve conduction velocity (NCV) studies.
    • Rationale: May be performed to differentiate between true nerve dysfunction, muscle weakness and reduced use due to secondary gain.
  • Prepare for surgical intervention (fibulectomy, fasciotomy) as indicated.
    • Rationale: Failure to relieve pressure or correct compartmental syndrome within 4–6 hr of onset can result in severe contractures or loss of function and disfigurement of extremity distal to injury or even necessitate amputation.

Related Posts