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Care of Clients with Cast

Jan 01, 20247 min read1359 words

A method of temporary immobilization for a variety of musculoskeletal disorders involving bones, tendons, muscles, and other tissues. It is a hard-covering that is used to support fractured arms, legs, or other body parts. Casts are made of two types of materials:

  1. Plaster of Paris: gypsum (calcium sulfate dihydrate) is the precursor.
    • White in color
    • Dries in 1 to 3 days. When dried, it becomes shiny and white
    • Not water resistant.
  2. Synthetic Fiberglass: a resin cast; the cast is filled with a polymer fluid which then hardens. It is a type of “moldable plastic” which may come with various colors, patterns, or designs.
    • Dries in 20 to 30 minutes, but may require up to 24 hours to fully harden.
    • Water resistant
    • Lighter, cooler, and waterproof compared to plaster of paris.

Characteristics of a Good (POP) Casting

  • White and Shiny
  • Odorless
  • Light in weight
  • Not too tight nor too loose
  • Resonant upon percussion

Purposes of Casting

  1. Correct deformity
  2. Immobilize a bone during healing
  3. Immobilize a bone after surgery
  4. Support, maintain, and realign a bone
  5. Prevent or decrease muscle contractions
  6. Serve as a mold of a limb in making an artificial limb

Types of Casts

  1. Unilateral Hip Spica Cast
  2. One-and-One-Half Hip Spica Cast with an abduction bar
  3. Bilateral Long-leg Hip Spica Cast with an abduction bar
  4. Short-Legged Hip Spica Cast from the chest to the thigh or knees
  5. Walking Cast: affectation of tarsals and metatarsals with callus formation
  6. Basket Cast used for massive bone injury of the patella to facilitate wound dressing.
  7. Patellar Tendon Bearing Cast affectation of tibia-fibula with callus formation
  8. Quadrilateral/Ischial Weight Bearing Cast: affectation of the shaft of femur with callus formation
  9. Pantalon Cast: affectation of the pelvis.
  10. Delvit cast: affectation of the 1/3rd of the tibia-fibula with callus formation.
  11. Cast brace: fracture of the distal 1/3rd of the femur and proximal 1/3rd of the tibia with callus formation.
  12. Body Cast: encircles the trunk, stabilizing the spine. Used for affectation of the lower dorsolumbar spine.
  13. Minerva Cast: applied around the neck and trunk of the body. Used for affectation of the cervical and upper dorsolumbar spine.
  14. Rizzer’s Jacket Cast: used in the affectation of the thoracolumbar spine and scoliosis (esp. S-shaped variations)
  15. Shoulder Spica Cast: applied around the trunk of the body then the shoulder, arm, and hand. Used for the affectation of the humerus and shoulder joint.

Cast Techniques

  1. Bivalving: cutting the cast into two halves from the upper to bottom portion to relieve tightness of the casted extremity.
  2. Windowing: creating a “window” on a cast on the site of a wound or such for the purpose of visualization, care, medication, etc.
  3. Reinforcing: reapplication of POP to regain strength when instabilities (getting POP wet, cracks, breaks) are found.
  4. Petalling: pulling the stockinet over the cast, wrapping it around the rough edges of the cast, providing protection for the skin. A 4” piece of tape is wrapped half inside and half outside the cast.

Guidelines of Casting

  1. Required Materials for Casting
    • Pail of water (room temp), where POP is submerged
    • Stockinet: used to protect the skin
    • Wadding/Padding Sheet: used as padding
    • Bandage Scissors: used to cut the sheets/stockinet
    • Trimming Knife: used to smoothen the edges of the cast
    • Newspaper: used to protect the floor or area
    • Disposable Gloves
    • Plaster of Paris or Fiberglass: casting materials
  2. Required Materials for Removal of Casting:
    • Stryker Cast Cutter: used for bivalving, windowing, and removal of cast.
    • Cast Spreader: used to spread a bivalved cast.
  3. General Procedure:
    • Apply Stockinet for skin protection
    • Apply Wadding/Padding Sheet: gives room for the arm to move very slightly.
    • Apply the Fiberglass or the Plaster Cast
  4. Principles of Casting:
    • Apply stockinet and padding first before applying a cast
    • Apply cast by including the joint above and the joint below the affected part
    • Apply cast in circular motion and smoothen with the palm (not with fingertips to avoid uneven indentation)
    • Support with the palm and not the fingertips
    • 8” (thigh), 6” (leg), 4” (forearm)
  5. Considerations During Drying:
    • Keep the cast uncovered to dry.
    • Check for cracks or breaks in the cast.
    • Keep the cast always clean.
    • Turn the patient every 2 hours while the cast dries
    • Prevent any indentation in the cast due to pressure
    • Avoid resting the cast on hard surfaces or sharp edges
    • Do not use the abduction bar in lifting or carrying the patient. (Abduction bars are used to hold muscles, tendons, bones in place)
    • Place a plastic lining at the edge of the cast if the cast is near the groin to avoid soiling and wetting the cast.

Cast Care Instructions and Health Education

  • Nursing Interventions:
    • Assess the alarming signs and complications of casting body and extremities.
    • Assess neurovascular status hourly during the first 24 hours.
    • The patient may ambulate with the use of assistive devices.
  • Maintain cast hygiene and dryness. Do not allow patients or nurses to write on casts while in admission.
  • Report presence of cracks or breaks in the cast
  • Rough edges should always be padded to protect the skin from irritation
    • Padding is added and taped on.
  • Avoid using any objects in scratching the skin under the cast.
    • A hairdryer set to cool air may relieve itchiness. Do not blow hot or warm air into the cast as this may cause sweating.
  • Avoid putting powders or lotions inside the cast.
  • Cover the cast while eating to avoid any spills or crumbs to enter the cast.
  • Elevate the cast on a cloth-covered pillow above the level of the heart to decrease swelling
    • If for legs, 6” to 10” or on a 45 degree elevation.
  • Encourage the client to move digits to promote circulation.
  • Do not use the abduction bar in turning, lifting, or carrying the patient.
  • Report any alarming signs:
    • Fever: 36.5°C to 37.5°C is normal. Drink fluids, regular IVF, wear light clothing.
    • Pain: always the first sign to be assessed during cast care using a pain scale (don’t use 1 to 10??)
    • Swelling
    • Drainage
    • Discolorations on the distal limb (cyanotic, pallor)
    • Numbness or tingling sensation (paresthesia)
    • Cold fingers or toes: skin should be warm to touch.

Complications of Casting

  1. Necrosis, Pressure Sores, and Nerve Paralysis as a result of inappropriate pressure of the cast on the neurovascular components and bony prominences.
  2. Compartment Syndrome is a resultant vascular insufficiency and nerve and muscle compression due to unrelieved swelling and can cause irreversible damage to the extremity.
    • Pain
    • Puffiness in the limb or swelling
    • Pallor (or discoloration)
    • Pulselessness or persisting cold feel
    • Paresthesia
    • Paralysis of nerves or absent/diminished sensation
  3. Multisystem Problems as a result of Immobility:
    • Digestive: anorexia, constipation, nausea, vomiting, abdominal distention
    • Respiratory: pneumonia, respiratory atelectasis
    • Urinary: UTI, renal and bladder calculi may also form
    • Circulatory: thrombophlebitis and pulmonary embolus
    • Psychological: depression, anxiety
  4. Delayed Complications:
    • Malunion, where bone heals in a disfigured manner.
    • Nonunion, where bones do not reattach.
    • Delayed Union, where bone healing takes longer than normal.

Procedure

  1. Identify the patient
  2. Explain the procedure
  3. Perform hand washing
  4. Assess for Pain
    • Is there pain? Is it progressive?
    • Is pain present during passive extension?
    • Where is the pain? Describe its character (local, generalized, soreness, stabbing, throbbing) and intensity (mild; 1-3, moderate; 4-7, severe; 8-10).
    • How long has pain been present? When did it start?
    • What causes or exacerbates pain? What relieves pain?
    • Pain Management:
      • Elevate the involved part (decrease swelling and promote venous return)
      • Apply cold packs.
      • Administer analgesic agents as prescribed.
  5. Assess for Circulation
    • Capillary Refill: apply pressure on digit nail. Color should return within <2 seconds.
    • Temperature of the Skin: should be warm to touch
  6. Assess for Neurovascular Function
    • Numbness or Tinging Sensation (Paresthesia)
    • Absent or Diminished Sensation
    • Ask the patient if they are able to move the digits of the extremity.
    • Ask the patient for presence of paresthesia
    • Ask the patient if they are able to feel the nurse touching their digits (with a pen). Inability to do so may indicate nerve paralysis.
  7. Assess for Infection
    • Check for swelling above and below the cast.
    • Check for presence of a foul odor in the casted extremity.
    • Check for drainage and note for color, amount, and odor. Mark the perimeter of the stains on the cast to gauge any increases in drainage.
    • Fever
  8. Provide the client with findings and document the findings.

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