chapter 40 Musculoskeletal Care modalities

The patient undergoing surgery

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Nursing management of a patient with a cast, splint or brace

-before the cast, splint or brace is applied the nurse completes the assessment of general health, presenting signs and symptoms, emotional status, understanding of the need for the device, and the condition of the body part that needs to be immobilized. -physical assessment of the part to be immobilized must include a thorough assessment of the skin and neuromuscular status (neurologic and circulatory function), including degree and location of swelling, bruising and skin abrasion. -the promote healing, any lesion, lacerations and abrasions that may occurred as a result of trauma that caused the fracture must be treated before the cast, brace, or splint is applied. -the nurse cleanses the skin and treats it as prescribed. -the patient may require tetanus booster if the wound is dirty and the last known shot was given over 5 years ago. -sterile dressing are used to cover the injured skin -if skin wounds are extensive then an external fixator may be chosen to immobilize the body part -the nurse gives the patient or family information about the underlying pathologic condition and the purpose and expectations of the prescribed treatment regimen. -this knowledge promote active participation in and adherence to the treatment program -the nurse prepares the patient for application of cast, splint or brace by describing anticipated sights, sounds and sensations (heat from the hardening fiberglass or plaster) -ask the patient and family what they know about the application and care of the cast can help determine teaching opportunities - the patient needs to know what to expect and the reason for immobilization -the main concern following the application of the immobilization device is assessment and prevention of the neuromuscular dysfunction or compromise of the extremity. -assessments are performed eery 1-4 hours to prevent neuromuscular compromise and related to edema and the device -neurovascular assessment includes assessing the peripheral circulation, motion, and sensation of the affected extremity, assessing fibers and toes and comparing them with the opposite side. -when assessing peripheral circulation nurse needs to check the peripheral pulses, capillary refill time (within 3 seconds), edema, and the color and temperature of the skin. - while assessing motion the nurse notes weakness, or paralysis -for sensation monitor for parasthesia (numbness or tingling) or absence of feeling which may be nerve damage -the 6 p's indicate neuromuscular damage: Pain, poikilothermia (temperature), pallor, pulselessness, paresthesia, and paralysis. -early recognition of damage is essential to prevent loss of function -swelling is a concern and can create excessive pressure under the cast. to help with the flow elevated the extremity above heart level during the first 24-48 hours after cast is applied to enhance arterial perfusion and minimize edema -evaluate pain with musculoskeletal condtion, asking the patient to indicate the exact site and describe the character and intensity of pain using the pain rating scale. -pain associated with fracture is usually controlled by immobilizing. -pain that is associated with edema from trauma, surgery, or bleeding into tissues can be controlled by elevating and or application of heat or ice packs. - ice bags are placed at each side of the cast, making sure not wet or indent the cast. -out of control pain following the cast application may indicate complications. -pain associated with compartment syndrome is relentless and not controlled by modalities like elevation application het or cold and analgesic agents. -severe burning pain over bony prominences, especially heels and ankles, and elbows warns of an impending pressure ulcer. this may also occur from too tight elastic wraps used to hold splints in place. - while the cast is on the nurse observe the patient for signs of infection which include unpleasant odor from the cast, splint or brace and purulent drainange staining the cast. -infection is common in open wounds -but warm, moist environment of a splint can cause infection -foul smelling casts should be removed to precent skin and wound infections -if infection progresses fever may develop notify HCP is these signs occur. -some degree of joint stiffness is inevitable with immobilization (complication) -every joint that is not immobilized should be moved and exercised through its range of motion to maintain function - encourage patient to move all fingers or toes hourly when awake to stimulate circulation

Nursing management for external fixator

-patients need to be mentally prepared for application of external fixator they may be at risk for altered body image because of size and bulk of the device. -to promote acceptance patient should be given comprehensive information about the frame, reassurance about the discomfort associated with the device is minimal, and that early mobility is anticipated. -those who have had significant trauma there may not be enough time to prepare them clothing and other materials may need to be altered or used to cover the device -after the external fixator is applied the extremity is elevated to the level of the heart to reduce swelling -any sharp points or pins on the fixator are covered with caps to prevent device induced injury -nurse needs to be aware of the potential problems caused by pressure from the device on the skin, nerves, or blood vessels and for the development of compartment syndrome -monitor neuromuscular status every 2-4 hours because pins are located externally particular attention is focused on pin sights fro signs of inflammation and infection -the end goal is to avoid osteomyelitis (infection of the bone) -the nurse assesses each pin site at least every 8-12 hours for redness, swelling, pain around the pin, warmth and purulent drainage= infection -in the first 48-72 hours postinsertion some serious drainage, skin warmth and mild redness at the pin site are expected they should subside after 72 hours -use aseptic technique during pin insertion along with cleaning each pin separately to avoid cross contamination with non shedding material (gauze, cotton tip, swab) and using chlorhexidine 2 mg/mL once a week -pin sites should be cleaned and dressed as prescribed unless their in copious drainage, the dressing becomes wet, or infection is suspected which means cleaning and dressing changes should be done more. -if signs of infection are present or the pins or clamps seem loose notify the prescriber. -if an activity is restricted the nurse encourages isometric exercises as tolerated to prevent thrombus events. -when the swelling subsides the nurse helps the patient mobilize within the prescribed weight bearing limits (non weight bearing to full weight bearing) -adherence to the weight bearing prescription lowers the chance of a pin loosening when stress is applied to the bone pin interface -the external fixator may be removed once the soft tissue has healed and there are no infections -the fracture may require additional stabilization by a cast, molded orthosis, or internal fixation while healing -Ilizaro fixation is a specialized type of external fixator that has numerous wires and penetrate the limb and are attached to circular metal frame. used to correct angulation and rotational defects, to treat nonunion (failure of bone fragments to heal), and to lengthen limbs -the device gently pulls apart the cortex of the bone and stimulates new growth through daily adjustment of the telescoping rods -the nurse must educate the patient on the telescoping rods and caring for the pin sites and apparatus, because fixator can be in place for many months -when discharged the nurse educates patient and caregiver about pin site care protocol (clean technique at home) and to report pin infection signs. -the nurse at discharge also instructs family to report/ monitor neurovascular signs. the patient and family is instructed to check the integrity of the fixator frame daily and report loose pins or clamps. -PT helps educate on how to transfer, use ambulatory aids safely, and adjust weight bearing limits and altered fait pattern

Skin traction; bucks extension traction

- (unilateral or bilateral) is the skin traction to the lower leg -the pull is exerted in one plane when partial or temporary immobilization is desired - it is used for temporary measure to overcome muscle spasm and promote immobilization hip fractures in adult patients waiting for definitive treatment such as surgery. -no evidence supports using skin fractures for hip fractures -before applied nurse inspects the skin for abrasion and circulatory disturbances -the skin and circulation must be healthy to tolerate the traction. -the extremity should be cleaned and dried before the foam boot or traction tape is applied -to apply Buck's traction the extremity is elevated and supported under the patients heel and knee while the foam boot is placed under the leg, with the patients heel in the heel of the boot. -next the velcro straps are secured -traction tape that is overwrapped with an elastic bandage in a spiral fashion may be used instead of the boot -excessive pressure is avoided over the malleolus, and proximal fibula during application to prevent pressure ulcers and nerve damage. -the rope is than affixed to the spreader or footplate over a pulley fastened to the end of the bed and attached the prescribed weight usually 5-8 pounds to the rope. -the weight should hang freely, not touching the bed or the floor this compromises the effect of the traction

Nursing management of the patient with a body or spica cast

-casts that encase the trunk of the body (body cast) and protons of one or two extremities (spica cast) require special nursing strategies -body cast are used to immobilize the spine. -hip spica are used to immobilize various fractures of the hip or fear or to correct and maintain the corrections of a hip deformity after surgery. these cast typically remain in place for 4-6 weeks -nursing: include preparation and positioning the patient, assisting with skin care and hygiene, and monitoring for cast syndrome -explaining the cast procedures helps reduce the patient's apprehension about being encased in a large cast. -the nurse reassures the patient that several people will be there for the application, support for the injured area will be adequate, and care providers will be as gentle as possible -patients immobilized in large casts ay develop cast syndrome ( psychological pr physiologic manifestations and can occur weeks or months after the cast has been applied) the psychological reaction is similar to a claustrophobic response. the patient exhibits an acute anxiety reaction characterized by behavioral changes and autonomic responses (increased RR, diaphoresis, dilated pupils, increased HR, elevated BP) the nurse needs to recognize the anxiety reaction and provide an environment in which the patient feel secure. -superior mesenteric artery syndrome is the physiologic manifestation associated with immobilization from a body cast, with decreased physical activity, gastrointestinal motility decreases, and intestinal gases accumulate. the patient exhibits abdominal destination and discomfort, nausea, vomiting, leading to food aversion, and weight loss. this may eventually leads to increased abdominal pressure and ileus. as with other instances of adtnamic isles the patient is treated conservatively with decompression ( nasogastric intubation connected to suction) and IV fluid therapy until gastrointestinal motility is restored -superior mesenteric artery syndrome: rally abdominal distention can place added pressure on the superior mesenteric artery, reducing the blood supply to the bowel, which can result in gangrenous bowel. the descending aorta may also sustain pressure as it may be compressed between the spine and pressure of abdominal distention which results in ischemia. -cutting a window in the abdominal portion off the cast or bivalving the cast may be sufficient to prevent or relieve pressure on the duodenum -caring for a patient with a body or spica cast at home can be stressful for the caregiver it is essential the nurses provide appropriate support and discharge education to minimize complications after the cast is applied -the nurse should give the patient comprehensive discharge package that supplements home care instructions with visual training instructions, as well as provide telephone counseling after discharge -specifically the nurse educates the family about how to care for the patient which includes providing hygienic, cast and skin care, ensuring proper positioning, preventing complications, and recognizing symptoms that should be reported

Nursing interventions for skeletal tractions

-check the traction to see that the ropes are in the wheel grooves of the pulleys, the ropes are not frayed, weights hang freely, and knots in rope are tied securely -evaluate the patients portion slipping down in bed is ineffective traction -postion patients foot in plantar flexion to avoid foot drop, inward rotation (inversion), and outward rotation (extraversion0 -foot may be supported in natural position by foot supporter -if patient reports severe pain from muscle spasm the weights may be too heavy or the patient may need realignment - pain needs to be reported if alignment fails to reduce pain -opioids or nonopioids can be used for pain -muscle relaxants may be prescribed to relieve muscle spasms -elbows become frequently sore, and nerve injury may occur if patient repositions by pushing on elbows -patient also pushes on their heels of the unaffected leg when they raise themselves -the digging of the heel into the mattress may injure the tissue. -instruct patients not to use heels or elbows to push themselves up -a trapeze can be used to move about in the bed or on and off a bedpan -transparent films, hydrocolloid dressings and skin sealantsmay be applied to bony prominences to reduce the shearing and friction force (elbows) -specific pressure points are assessed for irritation and inflammation at least every 8 hours -patients at high risk (older adults, malnurished patients) need to be assessed more frequently -pressure areas vulnarible with lower extremity traction: ischial tuberosity, popliteal space, achilles tendon and heel. -if patient can't turn on any sides perform special back care and keep the bed dry and free of crumbs and wrinkles. patient can assist by using the trapeze and raising the hips off the bed. if patient can't do this the nurse can push on the mattress with one hand to relieve pressure on the back and bony prominences and to provide some shiftignof weight -advanced static mattress or overlays should be used rather than foam or altering air/low airloss mattresses to reduce ulcer formation -heels should be placed on a pillow or heel suspension device keeping the patients heel off the bed -to change the bed linens the patient raises the torso while caregivers on both sides of the bed roll down and replace the upper mattress sheet then the patient raises the buttocks off the mattress the sheets are slid the under the buttocks and then the lower sections of the sheets are replaced while the patient rests on the back. sheets and blankets are placed over the patient in such a way that traction is affected - neurovascular status (color, temp, capillary refill, edema, pulses, ability to move, and sensation) the th unaffected extremity every hour for the first 24 hours after traction is applied then every 4 hours after the 24 hour mark. -patient is told to report changes in sensation or movement -VTE formation is a big risk for immobilized patents -encourage patient to do active flexion-extension ankle exercises and isometric contraction of the calf (calf pumping exercises) 10 times an hour while awake to decrease venous stasis -antiembolism stocking, compression devices and anticoagulant therapy may be prescribed to prevent thrombus formation -wound at pin insertion site require attention -goal is to avoid infection and development of osteomyelitis -for the first 48 hours after insertion the site is covered in a sterile absorbent, nonstick dressing and rolled gauze or ace type bandage -pin site care: 1) pins located in soft tissue area are at greatest risk for infection 2) after first 48-72 hours following skeletal pin placement pin site care is needed daily or weekly 3) chlorhexidine 2mg is most effective cleansing solution if reaction to this use NS 4) strict hand washing before and after skeletal pin site care - inspect pin site every 8 hours for reaction normal changes and infection -reaction may include warmth, redness, serisanguineous drainage at the site which tends to subside after 72 hours -signs of infection may include those of reaction but purulent drainage, pin loosening, testing of the skin at pin site. odor and fever -IV antibiotic may be given the first 24-48 hours to prevent infection. minor infections can be treated with antibiotics severe require pin removal -crusting at the pin site should be retained as long as the pin remains uninfected as the crust provides a natural barrier from bacterial contamination -patient and fam are taught pin site care before discharge, written follow up instructions and S/S of infection -exercise for muscle strength and tone and in promoting circulation -active exercises include pulling up on the trapeze, flexing and extending the feet, ROM and resistance weight training for noninvolved joints -isometric exercises of immobilized extremity (gluteal and quadrceps setting exercises) important for ambulatory muscles -without exercise the patient will loos muscle mass and strength and rehab will be prolonged

managing complications; tissue disuse

-immobilization in a cast, splint, or brace can case muscle atrophy and loss of strength, and can place patients at risk for disuse syndrome, which is the deterioration of body systems as a result of prescribed r unavoidable musculoskeletal inactivity -to prevent this nurses instruct patients to tense and contract muscles (isometric muscle contractions) without moving the underlying bone. -isometrci exercises; instruct patient with a log or arm cast to splint or brave to "push down" on the knee of to make a fist respectively helps reduce muscle atrophy and maintain strength -muscle setting exercises ( quadriceps. and gluteal setting exercises) are important in maintaining muscles essential for walking -isometric exercises should be performed hourly while the patient is awake

Nursing interventions skin traction nerve damage

-skin traction can place pressure on peripheral nerves -care must be taken to avoid perioneal nerve pressure at the point which it passes around the neck of the fibula or just below the knee when traction is applied to lower extremity pressure at this point can cause foot droop -nurse regularly questions patient about sensation and asks the patient to move the toes and foot -immediately investigate any complaint of burning under the traction bandage or boot -dorsiflexion of the foot demonstrates functional the tibial nerve. -report altered sensation or impaired motor function Circulatory impairment -after applied assess circulation within 15-30 minutes than every 1-2 hours assessment consists of 1)peripheral pulses, color, capillary refill, and temperature of the fingers and toes 2) manifestations of DVT; unilateral calf tenderness, warmth, redness, and swelling -encourage patient to perform active foot exercises every hour when awake

Skin traction

-use less frequently -reported that there is no reduction of pain or complications -may be used for short term use to stabilize a fractured leg, control muscle spasms, and immobilize the area before surgery. -the pulling force is applied by weights that are attached to the client with velcro, tape, straps, boots, or cuffs. no more than 2-3.5 kg can be used on an extremity -pelvic traction is usually limited to 4.5-9 kg depending the weight of the patient -

Splints and braces

- many injuries treated with casts may not be treated with splints and braces. -splinting is common and preferred for acute care setting and the initial treatment of fractures that eventually require casts -splints are often used for simple and stable fractures, sprains, tendon injuries, and other soft tissue injuries. -they offer many many advantages over casts in that they are faster and easier to apply. -they are noncircumferential and allow for natural swelling during inflammatory phase of injury. -pressure related complications ( skin breakdown, necrosis, compartment syndrome, are more prevalent when soft tissue swelling occurs within a contained space (circumferential cast) -splints are easily removed facilitating inspection for injury site. -splints can be indicated for initial stability for fractures that are unstable while awaiting defensive care. -Contoured splints of plaster or pliable thermoplastic materials may be used for conditions that do not require rigid immobilization for those who are swelling may be anticipated, and for this that require special skin care. -splints made of thermoplastics are warm and molded to custom fit the affected body part (hand and thoracolumbosacral orthotics, clamshell type back brace) -the splint needs to immobilize and support the functional body part in a functional position, and must be well padded to prevent pressure, skin abrasion, and skin breakdown. -the splint is over wrapped with an elastic bandage applied in a spiral fashion and with pressure uniformly distributed so the circulation os not restricted. -Braces: or orthoses are used to provide support, control movement and prevent additional injury. -braces are customfitted to various parts of the body thus they tend to be indicated for long term use than splints -the orthotist adjust the brace for fit, positioning and motion so the movement is enhanced any deformities are corrected and discomfort is minimized. -many splints and braces are prefabricated and fastened with velcro straps. they may be made out of plastic and other materials like cloth, leather, metal, and elastic. -knee immobilizers, ankle straps and cock up wrist splints are types of prefabricated splints and braces. -both splints and braces may either be custom made or standard -splints and braces are usually less compliant and permit more motion at the injury site than casts, which can be a serious disadvantage in that underlying injuries are not as well stabilized

Managing complications; pressure ulcers (nursing)

-cast or splints put pressure on soft tissue, particularly if they are inappropriately applied, causing tissue anoxia and pressure ulcers. -lower extremities most susceptible; heels, malleoli, dorm of the foot, head of the fibula, and anterior surface of the patella. -the main pressure sites on the upper extremities are located at the medial epicondyle od the humerus and the ulnar styloid -if the pressure necrosis occurs, the patient typically reports a very painful "hot spot: and tightness under their cast. -the cast may feel warmer in the affected area, suggesting underlying tissue erythema - drainage may stain the cast or splint and emit an unpleasant odor. -even if discomfort does not occur there still may be extensive loss of tissue with skin breakdown and tissue necrosis. -to asses for pressure ulcer development the primary provider may univalve, bivalve, or cut an opening in the cast to allow for inspection, access and possible treatment -a dressing may be applied over the exposed skin and the cutout portion of the cast is replaced and held in place bu an elastic compression dressing or tape. this prevents window edema from occurring, which is swelling or budging or the underlying soft tissue through the window opening.

The patient in a cast

-cast: rigid external immobilizing device that is molded to the contours of the body. -the cast must fit the shape of the injured limb correctly to provide the best support possible -cast is used to reduce and immobilize fractures to prevent a deformity (clubfoot, hip diplacemant), apply uniform pressure to underlying soft tissue, or support or stabilize weakened joints -casts permit mobilization while restricting the movement of the affected body part -because they allow more complete immobilization they are the main treatment for many fractures (which are breaks in the continuity of the bone) -common casting material: fiberglass, or plaster of Paris, these are materials that can be molded. -choice of material depends on several factors: the condition being treated, availability, and costs -generally the joints proximal and distal to the area immobilized are included in the cast. but some fractures, cast construction and molding may allow movement of a joint while immobilizing a fracture ( three point fixation, patellar tendon weight bearing cast.) -generally casts can be divided into three main groups; arm casts, leg cast or spica cast: -short arm casts: extends from below the elbow to the palmar crease, secured around the base of the thumb. if the thumb is included it is known as a thumb spica pr gauntlet cast - long arm cast: extends from the axillary fold to the proximal palmar crease. the elbow is usually immobilized at a right angle. -short leg cast: extends from below the knee to the base of the toes. the foot is flexed at a right angle in a neutral position. -long leg cast: extends from the junction of the upper and middle third of the thigh to the base of the toes. the knee is slightly flexed. -Walking cast: a short- or long leg cast reinforced for strength -Body cast: encircles the trunk -Shoulder spica cast: a body jacket that encloses the trunk, shoulder, and elbow -Hip spica cast: encloses the trunk and a lower extremity, a double hip spica cast includes both legs -applying a cast is a special skill performed by orthopedic technology -skillset needed to apply and remove casts involves education, training, practice, and constant review of provider competence to ensure patients receive safe, high quality care.

Fiberglass casts

-composed of polyurethane resins that have the versatility of plaster but are lighter in weight, stronger, water resistant, and more durable than plaster. -fiberglass cast can facilitate radiographic imaging better than plaster. and can reach full rigidity in 30 minutes of application -because they're difficult to mold and contour fiberglass cast are used for simple fractures of the upper and lower extremities. -they consist of open weave, nonabsorbent fabric, that requires tepid water for activation, heat is given off during this reaction (exothermic reaction) while the cast is applied -the heat can be uncomfortable, and the nurse should prepare the patient for this sensation so the patient isn't alarmed. -can cause thermal injury like plaster cast but the risk is lower. -some fiberglass cast have waterproof lining which allows the patient to shower, swim, or engage in hydrotherapy (the use of water for treatment) -when the cast is wet the patient is instructed to shake or drain the water coming out of it.;thorough drying is important to prevent skin breakdown, infection or irritation. -the best results are achieved when cast can easily drain such as short arm casts -heels and elbows encased in wet casts may become macerated from the trapped water and therefore associated with more skin breakdown

The patient with the external fixator

-external fixators are used to manage fractures with soft tissue damage. -complicated fractures of the humerus, forearm, femur, tibia, and pelvis are managed with external skeletal fixators -they are used to correct deficits, that nonunion, and lengthen limbs -the fixator provides skeletal stability for severe comminuted (crushed or splintered) fractures while permitting active treatment of extensive soft tissue damage. -external fixation involves the surgical insertion of pins through the skin and soft tissues into the through the bone. a metal external frame is attached to these pins and is designed to hold the fracture in proper alignment to enable healing to occur. -advantages to having external fixator compared to other modes of treatment include: immediate fracture stabilization, minimization of blood loss (compared to internal fixation),increased patient comfort, improved wound care, promotion of early mobilization and weight bearing on the affected limb, and active exercise of adjacent uninvolved joints. -the disadvantages: increased risk for pin site loosening and infection, which can lead to osteomyelitis

Nursing interventions for skin traction

-its important to avoid wrinkling and slipping of the traction bandage and to maintain counteraction -keep leg in neutral position -to prevent bony fragments from moving against one another patient should not turn side to side but patient may shift position slightly with assistance -initial assessment identify fragile sensitive skin -inspect skin area in contact with tape, foam, or shearing forces every 8 hours for signs of irritation, or inflammation -the nurse performs the following procedures 1) removes the foam boots to inspect the skin, the ankle, and the achilles tendon three times a day. a second person is needed to support the extremity. 2) palpates the area of the traction tapes daily to detect underlying tenderness 3)provides frequent repositioning to alleviate pressure and discomfort, because the patient who mist remain in supine position is at increased risk for ulcer 4) uses advanced static mattresses for overlays rather than standard hospital foam or pressure ulcer formation

Managing patients with immobilized lower extremity

-leg cast, splint or brace imposes a degree of immobility on the patient -casts may include short leg casts, extending to the knees, or long leg casts extending tot he groin. -hinged knee immobilizers and braces extend from the ankle to the groin -the patients leg must be supported with pillows to the level of the heart to control swelling -cold therapy or ice packs should be applied as prescribed over the fracture site for 1-2 days. -patient is taught to elevate the immobilized leg when seated. -patient should resume a recumbent position several times a day with the immobilized leg elevated to promote venous return and control swelling. -gentle toe and ankle exercises that allow for isometric contraction of muscles beneath the cast increase venous return and diminish edema - nurse assesses the patients circulation by observing the color, temperature, and capillary refill of the exposed toes. -nerve function is assessed bu observing patients ability to move the toes and by asking the patient about sensation int he foot. -numbness, tingling, burning may indicate peroneal nerve injury from pressure at the head of the fibula -nurse and PT instruct the patient ho to transfer and ambulate safely with assistive devices (crutches, walker) - the gait to be used is dependent upon if the patient is permitted to bear weight -if weight bearing is allowed, the cast, splint or brace is reinforced to withstand the body weight. -a cast boot or shoe which is worn over the casted foot provides a broad, nonskid, walking surface

Plaster cast

-made of plaster of Paris, are less expensive and retain a better mold than fiberglass -plaster of Paris are heavy and not water resistant and can take up to 24-72 hours to dry post application -the exothermic reaction during application can cause serious burns -extra care needs to be taken when these types of casts are applied to the older adult because their skin is more temperature sensitive than the average adult skin.. -during the application process, clean,, room temperature water should be used. minimal layers of padding should be used, the cast should not be covered while it is drying because the heat generated by the chemicals cannot escape -the time that it takes for plaster cast to dry completely depends on the size, thickness, and location as well as environmental drying condition. - a freshly applied cast should be handled as little as possible to prevent denting and crackle -the wet plaster cast should be handled by only the palms so the indentations in the cast may be prevented; indentations can result in the area of pressure on the skin. -the cast should exposed to circulating air to dry and supported on a firm and smooth surface; it should not be placed on a metallic surface or one with sharp edges. and supported on a firm smooth surface. -if elevation is requested to reduce swelling, a cloth covered pillow is preferred to once covered in plastic, which could retain heat and prevent drying. -a wet plaster cast appears damp, appears dull and gray, sounds dull on percussion, and smells musty. the cast is dry when it feels hard and firm, has a white and shiny appearance, is resonant to percussion and odorless. -an occasion, the plaster cast may have rough edges, which can crumble and cause skin irritation. petaling or smoothing the rough edges of the cast can resolve the problem if the underlying stockinette does does not cover the edges of the cast. -to prevent breakdown the moleskin can be used over any rough area of the cast that may rub against the patients skin.

Monitoring and managing potential complications; compartment syndrome

-monitor for compartment syndrome, pressure ulcer formation, and disuse syndrome Compartment syndrome -the most serious complication of casting and splitting occurs when increased pressure within a confined space (cast, muscle compartment) -compromises blood flow, and tissue perfusion. -ischemia is potentially irresponsible to soft tissue that occurs within space and can occur within a few hours if action is not taken -a tight or rigid cast/splint that constricts a swollen limb is associated with this complication -diagnosis is based on the 6 P's: pulselessness, pain, paresthesia, paralysis, pallor, poikilithermia) and intracompartmental pressure -the earliest indicator is pain that seems out of proportion to the injury and pain on passive stretch of other muscles in the immobilized limb -the patient may complain that the cast, splint or brace is too tight. -notify provider immediately because delay can cause poor outcomes, failed treatment, additional operations, and the possibility of amputation -pulselessness, paralysis and paresthesia are found in the later stages. -if the complication if from a tight cast or splint it may be loosened or removed nd the cast univalved and bivalved (cut in half longitudinally, on one side or two parallel sides of the cast) to release constriction and allow for inspection -the extremity must be elevated no higher than heart level to maintain arterial perfusion. -if circulation and pressure is not relieved and emergency fasciotomy may be performed to releve pressure in the compartments -nurse monitors response to conservative and surgical management -the nurse record neuromuscular responses and prompts report changes to provider

Types of traction

-several types straight or running traction applies the pulling force in a straight line with the body part resting on the bed. the counteraction is provided by the patients body and movements can alter the traction -back extension traction is an example of straight traction -balanced suspension traction: supports the affected extremity off the bed and allows for some patient movement without disrupting the line of pull. counteraction is produced from slings or splints -traction may be applied to the skin (skin traction) or directly to the bony skeleton (skeletal traction) -traction can be applied with the hands (manual traction) this is temporary traction and may be used when applying a cast, giving skin care under a bucks extension foam boot or adjusting the traction apparatus

Education patient about self care

-the nurse encourages the patient to participate actively in personal care and to use assistive devices safely -the nurse just assist the patient in identifying areas of self care deficits and in developing strategies to achieve them independently (ADL's) -patients with casts ready for removal the nurse should prepare and explain what to expect -instruct patient to never remove the cast and that a saw will be used to remove the cast. -the saw uses an oscillating blade that vibrates but does not spin; thus it cuts through the outer layer of the cast but does not penetrate deeply enough to injure the patient -the cast will be cut in several places usually along both sides of the cast -the cast is then spread and opened and a special tool is used to lift it off. -scissors are used to cut the protective padding and stockinette laters to ensure that the patients skin will not be cut. -the formally immobilized body part will be weak from disuse and stiff and may appear atrophied. -as the cast or splint is removed the body part should be supported to prevent injury -the skin that is dry and scaly from accumulated dead skin is vulnerable to injury from scratching. the skin needs to be washed gently and lubricated with an emollient lotion - the patient should be instructed to avoid rubbing and scratching the skin because it can damage newly exposed skin -the nurse and PT educate the patient to resume activities gradually within he prescribed therapeutic regimen - exercises prescribed help the patient restore muscle, strength, joint motion, and flexibility are explained and demonstrated. -becasue the body part that was immobilized is weak from disuse it cannot withstand normal stresses immediately -patient needs to control swelling by elevating the formerly immobilized body part no higher than the heart until normal muscle tone and use are restored.

Nursing management of the patient with an immobilized upper extremity

-the patient whose arm is immobilized must readjust to many routine tasks. - the unaffected arm will assume all upper extremity acitivities -the occupational therapist helps the nurse figure out which devices should be used for one handed activities -patietn may experience fatigue modified activities and the weight of the cast, splint, or brace. frequent rest periods are necessary -to control swelling the immobilized extremity elevated above heart level with a pillow. -when lying the down the arm is elevated so that the joint is positioned higher than the proceeded proximal joint (elbow higher than the shoulder, hand higher than the elbow) -sling may be used when the patient ambulates to prevent pressure on the cervical spinal nerves the sling should distribute normal weight over a large area of the shoulders and trunk not just the back of the neck -the nurse encourages the patient to remove the arm from the sling and elevate it frequently -circulatory disturbances in the hand may become apparent with signs of cyanosis, swelling, and inability to move the fingers -a missed compartment syndrome in the arm can cause Volkmann's ischemic contracture which may lead to impairment of motor function and sensibility -contractures of the fingers and wrists appear from obstructed arterial blood flow to the forearm and hand. the patient unable to extend the fingers describes abnormal sensation (unrelenting pain , pain on passive stretch) and shows signs of diminished circulation to the hand irreversible damage develops within a few hours if action is not taken. can be prevented with proper nursing survallience and proper care.

Patient in traction

-traction: ises a pulling force to promote and maintain alignment to an injured part of the body -goals of tractionL decreasing muscle spasm and pain, realignment of the bone fracture, correcting or preventing previous bone deformities. -traction needs to be applied in more than one direction at times to achieve desired line of pull. when this is done, one of the lines of pull counteracts the other. these line pull are known as the vectors of force -the actual resultant pulling force is somewhere between the two lines of pull -the effects of traction are evaluated with A-ray, and adjustments are made if needed -traction is primarily for short term intervention until other modalities like external or internal fixation are possible. these modalities reduce the risk of disuse syndrome and minimize hospital length stay Principles in effective traction -counteraction is the forces acting in the opposite direction. -usually the patients body weight and bed position supply the needed counteraction -when caring for a patient in traction the nurse should: 1)traction must be continuous to be effective in reducing immobilizing fractures 2) skeletal traction is NEVER interrupted 3) weights are not removed unless intermittent traction is prescribed 4) any factor that might reduce the effective pull, or alter its resultant line of pull must eb eliminated 5) the patient must be in good body alignment in the center of the bed when traction is applied 6) ropes must not be unobstructed 7) weights must hang freely and not rest on the bed or floor 8) knots in the rope or footplate must bot touch the pulley or the foot of the bed

Skeletal traction

-used when continuous traction is desired to immobilize, position and align a fracture of the femur, tibia, and cervical spine. -used when traction is to be maintained for a significant amount of time, when skin traction isn't possible, and when greater weight is need (25-40 pounds) - involves passing metal pin or wire (stienmann pin, Kirschner wire) through the bone (proximal tibia or distal femur) under local anesthesia, avoiding nerves, blood vessels, muscles, tendons, and joints. -traction uses ropes weights attached to ends of pins -can use tongs to the head that are fixed to the skull. and immobilize cervical fractures -surgical asepsis is used -prepared with surgical scrub agent chlorhexidine. local anesthetic is given at the site -surgeon makes small incisions and drills sterile pin or wire through the bone. patient feels pressure during this procedure and possible pain when periosteum is penetrated - after insertion pin or wire is attached to bow or caliper traction -the ends of the pin wire are covered with caps . the weights are attached to the pins or wire bow bt a rope and pulley that exerts the amount and direction of pull the weight initialy applied must overcome the shortening spasms of the affected muscles. -as the muscles relax the the traction weight is reduced to prevent fracture dislocation and promote healing - it is often balanced traction which supports the affected extremity, allows for some patient patient movement and facilities patient independence and nursing care while having effective traction -the Thomas splint with a Pearson attachment is frequently used with skeletal traction for fractures of the femur. because upward traction's required an overbid frame is used.

Nursing management

assessing anxiety -the nurse must consider the psychological and physiological impact of musculoskeletal problem, traction device and immobility -traction restricts mobility and independence -the equipment can look threatening application can be frightening -confusion, disorientation, and behavioral changes may develop in patients who are confined in a limited space for a long time -the nurse must monitor the patients anxiety and response to traction assisting with self care -may require assistance the nurse helps the patient, eat, bathe, dress. and toilet -convienent arrangement of items like tissues, telephone, water, and assistive devices ( reaches, overbid trapeze) may facilitate self care -the patient will feel less dependent when they resume self care and less frustrated and will have improved self esteem -because help is required throughout care patient and nurse develop plan to maximize independence and routine monitoring for potential complications -pressure ulcers, atelectasis, pneumonia, constipation, loss of appetite, urinary stasis, UTI, and VTE Atelectasis and pneumonia -auscultates lung every 4 hours to 8 hours -educates patients about deep breathing and coughing exercises to expand lungs and clear secretions 0if at risk use incentive spirometer Constipation and anorexia -reduced GI motility= constipation and anorexia -foods high in fiber help stimulate motility 0if constipation, stool softeners,, laxatives, suppositories, and enemas -to help appetiete food preferences - Urinary stasis and infection -incomplete emptying r/t position in bed can = urinary stasis and infection -bedpan may be uncomfortable and may limit fluids to avoid using it -monitor fluid intake and character of urine -adequate hydration encourage patient to drink and void every 3-4 hours -if signs of UTI burning, pain or urination, hematuria report VTE -venous stasis= risk for VTE -educate patient about ankle and foot exercises every 1-2 hours when awake to prevent DVT -involving family members to perform exercises increases adherence and helps with involvement -encouraged to drink fluids preventing dehydration and associated hematoconcentration which contributes to hemostasis -monitor for unilateral calf tenderness, warmth, redness, swelling (increased calf circumference) -durign traction encourage patient to exercise joints and muscles that are not interaction to prevent deterioration, deconditioning, and venous stasis -during exercise the nurse makes sure traction devices is maintained and the patient is properly positioned