Mechanical Immobilization Chapter 25
Nursing Care Plans for Risk of Peripheral Neurovascular Assessment
- BILATERALLY - monitor peripheral circulation - check for presence and quality of pulses - check temperature, skin color - capillary refill - observe for swelling - neruologic status - move toes/fingers - sensation; touch sharp, dull - level of pain
The nurse is caring for a client in skeletal traction. What should the nurse tell the client not do in order to prevent bony fragments from moving against one another?
Turning from side to side, however, the client may shift position slightly with assistance.
The nurse is caring for a 19-year-old client who sustained a knee sprain while playing college sports. Which type of splint does the nurse anticipate will be ordered to support the knee while it heals?
immobilizer
The nurse is caring for a client with carpal tunnel syndrome. Which type of splint does the nurse anticipate will be ordered?
molded.
Circulation Assessment
Pain Pulse Pallor Paresthesia Paralysis
A nurse is providing care for a client in skin traction. What is a recommended guideline?
Place the client in a supine position with the foot of the bed elevated slightly and ensure the traction apparatus is attached securely to the bed.
A client with severe arthritis needs temporary immobilization of the wrist and hand. Which type of cast does the nurse anticipate will be ordered?
cylinder bivalve
Cylinder Cast
- encircles an arm/leg leaves fingers/exposed toes - extends from the joint above injury to joint below injury - maintains correct alignment during healing - cast may be trimmed/shorten as it heals
The nurse is caring for a client with a dislocated fracture who will undergo reduction and casting. When will the nurse plan to administer an opioid pain medication.
15 minutes before reduction
Types of Splints
ER Commercial - inflatable, traction, immobilizers, molded, cervical collar
A nurse is assessing the neuromuscular status of a client who is recovering from severe neck pain. What should the nurse ask the client to do in assess this? drop down both shoulders flex and extend the elbows and wrists generate a loose had grip contract the fingers
Flex and extend the elbows and wrist. Elevate both shoulders generate a strong grip spread the fingers
A nurse is caring for a client with a cervical halter applied. Which intervention should the nurse perform when caring for this client?
Provide a trapeze or an overbed frame to the client.to facilitate mobility and self-care.
A 45yo female is admitted after undergoing a hysterectomy. She has been immobile for 2 days. She has a 20y history of smoking, takes an oral estrogen to manage hot flashes. The nurse notices that the client's left leg is dark purple and measures 2 inches larger than her right leg. What is the client MOST at risk for?
Pulmonary Embolism
Principles applied to the client in traction.
Skeletal traction is never interrupted. it is applied directly tot he bone and is never interrupted. To be effective, the weights must hang freely and not rest on the bed or floor. Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Traction must be continuous to be effective in reducing and immobilizing fractures.
Which would the nurse expect a MD to use on a short-term basis for a client with an injured body part that does not require rigid immobilization?
Splint it immobilizes and supports an injured body par in a functional position and is used when the condition does not require rigid immobilization, causes a large degree of swelling, requires special skin treatment.
Splints
a device that immobilizes, and protects an injured body part. - use before or instead of cast/traction
A nurse is fitting prophylactic braces to a client. What is the major function of this type of brace?
to prevent or reduce the severity of a joint injury
orthoses
are orthopedic devices that support or align a body part and prevent or correct deformities. (i.e. splints, immobilizers, braces)
A nurse is helping to position a triangular sling. Why does the nurse position the sling to the side of the neck?
avoids pressure on the vertebrae
Compartment syndrome
caused by pressure due to swelling within the inelastic fascia that surrounds muscles. If the pressure is unrelieved, disrupts circulation and damages nerves, which may cause permanent disability
A client reports pain in the casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. This may be a sign of
compartment syndrome
The client was placed in a long arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the client's arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action.
preparing to client for cast removal or bivalving of the cast
The nurse is caring for a client who has a hip spica. What intervention is appropriate? provide fracture pain prn delegate ambulation to bathroom to UAP order bedside commode prepare foley catheterization
provide fracture pan
The client is about to have a plaster cast applied to his left arm. The nurse would alert the client to what as the cast is applied?
sensation of warmth or heat with application
Applying an Arm Sling Implementation
- wash your hands - position forearm across the client's chest with the thumb pointing upward - avoid more than 90 degrees of flexion, especially if the elbow has been injured - slip the flexed arm into the canvas sling so that the elbow fits flush with the corner of the sling - pad and tighten the strap sufficiently - keep the elbow flexed and the wrist elevated - place the longer side of the sling from the shoulder opposite the injured arm to the waist - position the apex or point of the triangle under the elbow - bring the point at the waist up to join the point at the neck and tie them. - position the know to the side of the neck - fold in and secure excess fabric at the elbow, a safety pin may be necessary - inspect the condition of the skin at the neck and the circulation, mobility, and sensation of the fingers at least once per shift - pad the skin at the neck with soft gauze or towel material if the skin becomes irritated - Instruct Pt to report changes in sensation, pain with limited movement or pressure
Braces and 3 categories
- Custom made to support weaken structure - leg braces into shoes - ill fitting braces can cause discomfort, deformity, and skin ulcerations from friction or prolonged pressure. - (1) Prophylactic Brace = prevent/reduce the severity of the joint injury - (2) Rehabilitative Braces = those that allow protect motion of an injured joint that has been treated operatively - (3) Functional Braces = those that provide stability for an unstable joint
Traction care and principles
- Regardless of the type of traction used, its effectiveness depends on the application of certain principles during the clients care - must produce a pulling effect on the body - counter traction (counterpull) must be maintained - pull and counter pull must be exactly opposite directions - splints and slings must be suspended without interference - ropes must move freely through pulley - prescribed amount of weight must be applied - weight must hang free
Slings
- a cloth device used to elevate, cradle and support parts of the body - commonly applied to arm, leg, or pelvis
External Fixator
- a metal device inserted into and through one or more broken bones to stabilize fragments during healing - encourage to be active and mobile
Traction Implementation
- keep traction applied continuously - ensure weights are off the floor - limit positions to those indicated in order - provide hygiene - depress mattress enough to insert hand under back side of Pt's who are supine or on back - avoid tucking top sheets, blankets, or bedspread beneath mattress - do not use a pillow if the Pt's head or neck is in traction (unless order states otherwise) - use pressure-relieving devices - insert padding with slings if they tend to wrinkle - cleanse around pin insertion with antimicrobial agent - cover tips of protruding metal pins or other sharp traction devices with corks or other protective material - use "fracture pan" if elevating the hips alters the line of pull - encourage isometric, isotonic, and AROM exercises
Manual traction
- pulling on body using a person's hands and muscular strength - realign bones - replace dislocated bones
The nurse is caring for a client with bilateral leg fractures who will be in skeletal traction for an extended period of time. Which nursing intervention will best address the client's self-care deficit? delegate bathing to UAP assess skin integrity q shift provide client with washcloth to clean face preform ROM for joint
Provide client with washcloth to clean face
Immobilizers
- are commercial splints made from the cloth and foam and held in places by adjustable hook and loop tape (Velcro) - limit motion in the area of a painful but healing injury such as the neck and the knee - removed for brief periods for hygiene
Traction
- a pulling effect exerted on a part of the skeletal system - used to accomplish - reduce muscle spasms - realign bones - relieve pain - prevent deformities - the pull of the traction generally is offset by the counterpull from the client's own body weight. - 3 types: manunal, skin, skeletal
Nursing Diagnoses
- acute pain (Rx cause constipation, also lack of mobility impacts BM) - impaired physical mobility - risk for disuse syndrome - risk for peripheral neurovascular dysfunction - impaired bed mobility - risk for impaired skin integrity (pressure from traction) - risk ineffective tissue perfusion - bathing self-care deficit - evaluate emotional state= risk for boredom, depression and loneliness
Traction splint
- also called, "Thomas splint" - metal devices that immobilize and pull on contracted muscles. - requires special training to put on - not easy to apply, used on lower extremities
Inflatable splint
- also called, "pneumatic splints" - becomes rigid when filled with air - controls bleeding and swelling - limits motion - filled with air to the point at which it can be indented 0.5in (1.3cm) with the finger tips. - short term use, usually applied just after the injury and are removed shortly after a more thorough assessment of the injury within 30 - 45 minutes otherwise, circulation may be affected
ER Splint
- avoid changing the position of the injured part even if it appears grossly deformed. - leave a high-top shoe or a ski boot in place if the injury involves an ankle. - cover any open wounds - rigid splinting material such as a flat board, broom handle, or rolled-up newspaper - pad bony prominences - apply the splinting device so that it spans the injured area from the joint above to the joint below the injury - use an uninjured area of the body adjacent to the injured part as a splint - use wide tape or wide strips of fabric to confine the injured part to the splint - loosen the splint of the material used to attach it if the fingers or toes are pale, blue, or cold - elevate the immobilized part, so that the lowest point is higher than the heart - keep the client warm and safe - seek assistance in transporting the client to a health care agency.
Providing Basic Care of a Client with a Cast
- check neurovascular status q 30 minutes initially and twice per shift once it has dried - use palms of the hands, not the fingers, to move or reposition the cast before it is thoroughly dry - leave a freshly applied plaster cast uncovered until it is dry, turn the client periodically to expose all the surfaces of the cast to air - avoid using the abduction bar in a hip spica cast when turning a client, pulling on it is likely to break it free from its attachment to the cast - observe the color, temperature, and size of the fingers/toes on the extremity with cast, compare with those opposite. - assess capillary refill - circle areas where blood has seeped through the cast, note the time on the cast. Re-circle any expanding blood seepage and identify the time. - apply ice packs to the cast if swelling is evident - monitor the mobility - assess sensation and presence and quality of pain - be aware of any foul odor or purulent drainage (infection) - avoid getting wet (use dryer on low setting) - caution do not insert objects - report itching = Tx with oral medication or blowing cool air into the cast - replace a window, a small square cut from a cast for the purpose of inspecting the skin or incision beneath the cast, tape it back up.
Traction Assessment
- check the order - note whether there is a trapeze attached to the overbed frame - inspect the equipment - determine whether the weights are hanging free of the bed or floor - observe the client's body postion - hygiene - inspect skin and pin sites - assess circulation and sensation - determine last BM (immobility leads to constipation) - observe urine ( urinary stasis predisposes to stone formation and bladder infection) - lungs (tends to breath shallowly, risk for pneumonia) - temperature (infection) - level of pain - emotional state (boredom, depression, loneliness)
Making and applying petals
- cut multiple strips of adhesive tape approximately 2 in, wide by 2 to 3 in in length or use precut ovals from moleskin - round the end of each adhesive strip like a flower petal or trim to create chevrons that resemble arrows, moleskins may already be oval - tuck one end of the tape or moleskin inside the cast edges, talking care to avoid wrinkles - overlap the strips of tape or moleskin around the rough cast edge - continue to monitor the skin for signs of impairment
Body Cast
- cylinder cast and encircles the trunk of the body instead of an extremity - generally nipple line to the hip - spinal problems, the cast extends from the back of the head and chin areas to the hips, with modifications for exposing the arms.
Nursing Care Plans for Risk of Peripheral Neurovascular dysfunction interventions
- elevate the cast higher that heart - exercise toes/fingers q 15 minutes while awake - apply ice over injury, empty and refill ice bag q 20 minutes - monitor circulatory status, sensation including tactile and pain and mobility of toes/fingers in affected extremity q 30 minutes - report worsening symptoms
Spica Cast
- encircles one or both the arms or legs and the chest or trunk - especially lower extremities, are heavy, hot and frustrating because restrict ROM and activity - with lower extremity, the cast is trimmed in the anal and genital ares to allow for the elimination of urine and stool - avoid using abduction bar
Assisting with a Cast Application Implementation
- explain how the cast will be applied - hygiene - wash the Client skin with soap and water and dry well - cover the skin with a stockinette and protective padding as directed - if applying PLASTER, open the rolls and strips of plaster gauze material. Dip them, one at a time, briefly in water and wring out the excess moisture. (use special sink to clean up mess) - if applying FIBERGLASS, open the foil packets one at a time - support the extremity while the MD wraps the cast - help to fold back the edges of the stockinette at each end of the cast just before the final layer of cast material is applied - elevate the cast - provide verbal and written instruction on cast care
Plaster of Paris
- feels warm as it drys - remove remnants with a damp cloth ADVANTAGES; - inexpensive - easy to apply - low incidence of allergic reactions DISADVANTAGES; - takes 24-48 hours to dry, large cast may take up to 72 hours - weight bearing must be delayed until thoroughly dried - heavy - prone to cracking or crumbling, especially at the edges - softens when wet
Cervical Collars
- foam or rigid splint placed around the neck - use for neck injuries, "whiplash" (pain is normally increased on teh second day) - mild to moderate = foam collar - serious = rigid splint made from polyurethane used to control neck motion and support the head (determine size by measuring the neck circumference and distance between the shoulders and chin; the open is centered at the back of the neck) - continuously wear the collar even in sleep, for 10 days to 2 weeks - remove to complete gentle ROM exercises - check neuromuscular function: - elevate both shoulders - flex and extend the elbows and the wrist - generate a strong hand grip - spread the fingers - touch the thumb to the little fingers on each hand
Gerontologic Considerations
- longer healing time due to brittle bones - stiffer joints due to decreased synovial joint fluid - due to diminished cutaneous/tactile sensation, older adults may be unaware of skin pressure from cast, brace, etc - caution with narcotics (i.e. risk for falls, constipation, confusion, urinary retention) - nonsurgical treatment of fractures of the upper extremities - immobilization - occupational and physical therapy to regain function and ROM - hip fractures are common in older adults, especially postmenopausal women not treated for osteoporosis. The fracture may result from weakness of the bone and lead to fall, or fall may cause the fracture.
Skin Traction
- means a pulling effect on the skeletal system by applying devices to the skin (i.e. pelvic belt) - Buck's traction - Russell's traction - these are two types however the book does not describe them
Bivalved Cast
- one that is cut into two pieces lengthwise - facilitates bathing - created when; - swelling interferes with circulation - client is being weaned from the cast - a sharper X-ray is needed - painful joint need to be immobilized temp for a client with arthritis
Molded splints
- orthotic devices made of rigid materials and are used for chronic injures or disease. - appropriate for repetitive motions disorders (i.e. carpal tunnel syndrome) - prevent contractures and muscle atrophy during immobility
Skeletal Traction
- pulls exerted directly on the skeletal system by attaching wires, pins, or tongs into or through a bone - applied continuously for an extended period
Mechanical immobilization of a body part accomplishes the following:
- relieves pain and muscle spasm - supports and aligns skeletal injuries - restricts movements while injuries heal - maintains a functional position until healing is complete - allows activity while restricting movement of an injured area - prevents further structural damage and deformity
Cast Removal
- removed to be change and reapplied or removed completely - with a noisy electric cast cutter (circular saw) - unexercised muscle is smaller and weaker, appears pale and waxy and may contain scales or patches of dead skin. (wash with soapy water and do not forcibly removed patches) - apply lotion
Fiberglass
- requires UV light to harden - remove with alcohol or acetone - do not paint (may write on) - removed fiberglass resin from the skin with alcohol or acetone ADVANTAGES; - light weight - porous - dies in 5 - 15 minutes - allows immediate weight bearing - durable - unaffected by water DISADVANTAGES; - expensive - not recommended for severe injuries or those accompanied by excessive swelling - macerated skin if padding becomes wet - cast edges may be sharp and may cause skin abrasions.
Cast
- rigid mold placed around an injured body part after it has been restored to correct the anatomic alignment - purpose of the cast is to immobilize the injured structure - usually are applied to fractured bones - materials [plaster of Paris and fiberglass] - types: cylinder, body, bivalved, spica cast
Pin Site
- the location where pins, wires, tongs enter or exit the skin - prevent infection
An older adult is undergoing mechanical immobilization. What factor is the nurse aware of contributing to the client's increased risk for pressure sores?
diminished tactile sensation they maybe unaware of skin pressure from a splint, cast, traction or other mechanical device.
The nurse is assessing a client who had a plaster cast applied after surgery to the right ankle 3 hours ago. What finding requires immediate nursing intervention?
cool and dry toes/fingers complications are most likely to occur in the early hours after initial casting.
