Immobilization & Use of Orthopedics Device – An orthopedic nurse is a nurse who specializes in treating patients with bone, limb, or musculoskeletal disorders. Nonetheless, because orthopedics and trauma typically follow one another, head injuries and infected wounds are frequently treated by orthopedic nurses.
Ensuring that patients receive the proper pre-and post-operative care following surgery is the responsibility of an orthopedic nurse. They play a critical role in the effort to return patients to baseline before admission. Early detection of complications following surgery, including sepsis, compartment syndrome, and site infections, falls under the purview of orthopedic nurses.
Immobilization & Use of Orthopedics Device
Concepts of immobilization:
In the care of orthopaedic clients, immobilization frequently employs to the clients when musculoskeletal trauma or surgery is mentioned. Modalities for immobilization include casts, splints, external fixation and tractions. Nursing concerns and interventions are prevention of complications, keep bone alignment as normal anatomy or as order and promote exercise and nutrition. Immobilization is caused by either client’s pathology or modalities. Although immobilization produces beneficial, effects if used as modalities, it also causes adverse effects either systemic or locally depending on several factors. It is important to implement effective nursing management/intervention to prevent or reduce adverse effects of those adverse effects.
Definition of Immobilization:
Immobilization is a method or technique in which the part of the body remains in rest to hold the fragments of bone in correct position and promote healing.
[Ref- Lippincott, Adult ortopaedics nursing.P-92]
Or
Impaired mobility which is temporary or permanent is called immobilization. Level of impairment depends on the client’s health status. Client could be partially or completely unable to move. Immobilization involves both physical and psychological aspects.
Methods of immobilization:
There are four methods of immobilization. These are given bellow:
1) By external splint:
a) Plaster of Paris cast
b) Other external fixator.
2) By continuous traction:
a) Gravity-hanging cast’,
b) Fixed,
e) Sliding.
3) By external fixation:
a) Pin in plaster,
b) One-bar fixator.
c) Rings.
4) By internal fixation:
a) Plate and screws,
b) Intramedullary nails,
c) Compression screw plate,
d) Combined nail and plate.
e) Transfixion screws,
f) Circumferential wires or bands,
g) Sutures through soft tissue.
[Ref-Adams/11/43 Baily & Loves/25/361-365]
Purpose of immobilization:
1) To prevent displacement or angulation of the fragments.
2) To relieve pain.
3) To reduce risk of complication.
4) To helps the healing of bone quickly.
5) To prevent the risk of nerve damage in case of open fracture.
[Ref-Adams/11/32 + Lippincott, Adult orthpaedic Nursing,P-92]
Cast
Definition of Cast:
A cast is a rigid dressing that circumferentially encircles an extremity It is used to immobilize an extremity to keep the fractured bones ends in apposition and correct alignment until calcifications occur.
[Ref-Lippincott.Adult Orthopaedic Nursing,P-113]
Or
A cast is a rigid external immobilizing device that is moulded to the part of the body in which it is applied. Cast application is a process of applying plaster of Paris to a body part for immobilization, or to align malpositioned tissues such as club foot, congenital hip dislocation, etc.
[Ref-SN Nanjunde Gowda’s “Foundations of Nursing” f” edition, page- 249]
Or
Cast is a rigid dressing that is immobilized the part of the body which is severly injured like fracture, dislocation, sprain to obtain bones ends in apposition.
Or
Casts is a solid mould of a part, usually applied in situ for immobilization as in fracture, dislocations and other serve injuries. Most often made of plaster of Pans. sodium silicate, starch or dextrin, which is rubbed into crinoline, then soaked in water, carefully applied to the immobilized part and allowed to harden.
Purposes of casts:
1) To immobilize the injured extremity for comfort.
2) To maintain adequate alignment of fracture.
3) To hold bone fragments in reduction and alignment.
4) To permit early ambulation and weight bearing.
5) To improve function of the joint.
6) To correct and prevent deformity.
7) To reduce and pain and swelling and muscle spasms following injury.
8) To promote healing by protection of the injured part.
9) To immobilize a body part in a specific position.
10) To provide support and stability for weakened joints.
11) To support and rest a part after surgical intervention until healing occurs.
[Ref- Lippincott.Adult Orthopaedic Nursing, P-113+SN Nanjunde Gowda’s “Foundations of Nursing” 1″ edition,P-249]
Types of casts:
A) Upper-extremity casts:
1. Thumb spica cast,
2. Short arm cast (SAC).
3. Long arm cast (LAC).
4. Hanging arm cast.
5. Shoulder spica cast.
B) Lower extremity cast:
1. Short.leg cast (SLC).
2. Long leg cast (LLC).
3. Walking cast.
4. Patellar-tendon-weight- bearing cast.
5. Long Leg cylinder cast (LLCC).
6. Cast brace,
7. Hip spica cast.
C) Body cast:
1. Hyper extension body cast.
2. Body jacket.
3. Minerva Jacket.
4. Halo cast.
Upper Extremity Casts
Lower extremity cast
Body cast
Complications of casts:
1) Impaired circulation produce soft tissue ischaemia.
a) Pulse lessness in extremity.
b) In adequate capillary refill in nail beds.
e) Peripheral cyanosis.
d) Coldness of skin.
2) Plaster sores.
3) Nerve damage: Pain Numbness of limbs.
4) Cast syndrome.
5) Tight cast.
6) Itching and burning sensation.
7) Volkmann ischaemic contracture.
8) Cast claustrophobia
9) Stiffness of the joint.
10) Skin blister and ulceration.
11) Infection tissue necrosis.
12) Lack of fracture immobilization.
[Ref-Lippincott, Adult orthopaedic Nursing p-122+Luckmann Medical Surgical nursing,2,P-1657]
Cast Syndrome:
Cast syndrome is caused by an obstruction of the 3 part of the duodenum resulting from the constriction by the superior mesenteric vessels. Patients with hyperextended body jackets develop
1) Repeated vomiting.
2) Prolonged nausea.
3) Abdominal distension.
4) Electrolyte loss.
These symptoms are known as cast syndrome.
(Ref-Lippincott. Adult Orthopaedic Nursing,P-122)
Cast claustrophobia:
Cast claustrophobia is a condition that affects a very small number of people when a cast is applied. The patients feeling fear that cast is constricting readily. The patients vomit or have many psychosomatic complaints leading to remove cast.
(Ref-Lippincott. Adult Orthopaedic Nursing, P-122)
Nursing interventions in patients who need cast:
Nursing care of plaster or cast are depends on according to side of plastering or general condition of the patient. However general care of those types of patients is following:
Care before plaster or cast:
A) Preparation of the patients:
1) Explain the procedure of application of cast.
2) Explain the benefits of cast to patients.
3) Take written consent, if necessary.
4) Ready to X-ray of the injure part for correct visualization of fracture.
5) Clean the limb with soap and water or antiseptic solution.
6) Shave the cast area, If more hair is present.
7) Remove all tight clothing around the neck, chest and waist. Because patients may sweating during plastering.
8) If any wounds are present dressing must be done.
9) Remove all kinds of ornaments such as bangles, rings before application of plaster.
B) Stress reduction/Mental preparation of patients:
1) Explain to the patients clearly what is going to be done so that he/she will take mental preparation.
2) Encourage the patients to ask his problem.
3) Take near relatives during plastering.
4) Assure that this plaster may not harm or painful.
C) Pain reduction technique:
1) Assess the fracture related pain.
2) Note down any bony crepitus.
3) Advise the patients to immobilize the injured part until cast is applied.
4) Elevate the limb which reduce the pain and swellings
5) Give analgesics to reduce the pain before application of cast.
D) Assess and manage:
1) If any open fracture assess bleeding points.
2) Check vital signs.
E) Patients teaching about plaster:
1) Advise the method of finger exercise after cast application.
2) Teach the patients about if any complication are seen such as Pain, burning sensation, itching,tight cast. Etc.
3) If plaster soaked with blood informed doctor.
4) Pts teaching about positioning of the limbs.
5) Avoid weight bearing activity on the affected limbs.
6) Taking calcium containing food.
F) Prepration of patients bed:
Bed must be prepared according to patients need such as traction facilities,tyrning facilities.
G) Prepration of a cast for application:
1) Keep appropriate sized plaster rolls, cotton,roller bandage and stockinettes.
2) Take a half bucket full of luke warm water.
3) Provide adequate light in the room.
4) Keep the patients in comfortable position in a stool or table.
5) Put rubber sheet under the limb.
(Ref-Lippincott, Adult orthopaedic Nursing p-122+Luckmann Medical- Surgical nursing, 2P-1652-1654)
Nursing care after application of cast:
A) Care immediately after plastering/Warning signs for a client AFTER cast applications:
1) Handling:
a) Wet plaster must be handled with the greatest care.
b) Never lift a hip spica by the leg (it cause certain cracks on the hips)
c) Do not dig the fingers into a wet plaster.
d) Do not move the patients until it become dry.
e) Avoid weight bearing activity on the limb.
f) Excess plaster is cleaned from the skin using warm water.
2) Care for plaster sore:
a) Ask patients about itching, burning pain,
b) Do a passive finger stretch, if patients complaints pain it indicates tight plaster.
c) Split open the plaster immediately.
d) Check capillary refilling.
e) Check neurovascular status of the extremity.
f) Discoloration of toes-pales or blue.
3) Immediate inspection of extremity:
a) Note the temperature, color of the fingers and toes- for cyanosis.
b) Arrange a check X-ray to determine the correct positioning of fracture part.
B) Symptomatic care:
1) Alleviation of pain:
a) Keep the patients in comfortable position.
b) Elevate the affected limb:
- Sling used in arm fracture.
- Pillows under the leg.
c) Apply ice bags at the fracture site (along the side of the thumb but not on the top of the thumb)..
d) Give analgesics according to doctors order.
2) Increase mobility:
a) Positioning:
i.. Keep the arm elevated while in bed, sitting, walking.( Arm east)
ii. Keep the foot end elevated by placing pillows under the legs (Leg cast)
iii. Hanging arm-Increase of injury to shoulder, humerus.
b) Exercise: Explain the benefit of exercise of a cast.
i.. Taught to exercise in the joints above and below cast.
ii. Teach the patients isometric exercise first on the unaffected limb.
iii. Teach the patients to frequent movement of finger exercise.
iv. Opening and closing the hand in casted arm.
v. Encourage to finger exercise that increased blood flow to area and reduce pain.
c) Ambulation:
i) Patients assistance in getting out of bed.
ii) Some support is need in early ambulation.
iii) Encourage to crutch walking in leg cast. iv . iv) Teach the patients raise the leg during crutch walking.
v) Explain that there will be pain in the affected foot when it is lowered.
vi) Raise slowly from lying to prevent orthostatic hypotension.
vii) Encourage to do-deep breathing, abdominal, gluteal.
3) Maintain skin integrity:
a) Frequent inspect the skin around the edge of the cast.
b) Check any sharp cast edge, if cast it smoothly.
e) Make sure that there are no pressure areas in the cast.
d) Alcohol swab may be used to cleanse between fingers.
e) Apply lotion when skin become dry.
f)Avoit wetting cast.
g) Never dragging the patients.
4) Preventing bed sores:
In hip spica, LLC(Long Leg Cast)
a) Change the position two hourly.
b) Apply powder on body prominence.
c) Assess the skin condition.
d) Apply soft pad under heal, sacrum.
e) Change wet linen.
5) Adequate nutrition:
a) Calcium in diet.
b) Vitamin D, Vitamin C.
6) Self care:
a) Assist the patients in daily activities.
b) For bathing patients cast is covered by plastic bag.
c) Assisting with buttoning shirt.
d) Assist in bowel and bladder care.
(Ref-Lippincott, Adult orthopaedic Nursing,p-124+Luckmann, Medical- Surgical nursing,2,P-1657-1660)
Removing the cast:
1. Position the patient and explain the procedure before starting to remove the cast.
2. Allow the patient times to ask questions.
3. A cast saw (cutter) produce sounds and looks dangerous, even though it is quiet safe because it cuts by vibration.
4. Demonstrate the safety of the cutter.
5. Reassure the patients he or she will not be cut by blade.
6. The patients should be told that patients only feel heat and some pressure during cutting process.
7. Start cast removal by first getting a grip on the cast saw and then applying it to the cast with an even amount of pressure.
8. Placing your thumb on the cast and holding the cast saw with your fingers give your better control over the saw and the amount of pressure you apply.
9. Gentle pressure and the vibrating blade allow the blade to penetrate the hard cast.
10. Release the pressure once you feel the blade penetrate the cast.
11. Try not to cut directly over the bony prominence.
12. Bivalve the cast, usually by cutting along the medial and lateral sides.
13. Once the cast is bivalve, you can separate the cast with cast spreader. And cut through the stockinette and padding below with large scissors.
14. Once you have completed cutting through the stockinette, padding, gently remove the anterior portion of the cast.
15. Expect to see old, loose semi attached skin, what appears to be a large amount of long hair on the extremity.
16. Hold the joint of patients and gently remove posterior portion of the cast.
17. The casted extremity may appear slightly smaller than the other extremity.
18. Do not wash the casted extremity as early as cast removal. 19. Do not try to remove all of the dead skin.
20. You can apply a little amount of oil for smoothness of the casted area.
(Ref-Lippincott, Adult orthopaedic Nursing,P-120)
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