12. Mobility and Immobility

MOBILITY AND IMMOBILITY

APPLYING AN ELASTIC BANDAGE

OVERVIEW OF THE SKILL

Elastic bandages or wraps are used to secure dressings in place, immobilize joints, decrease swelling, maintain circulation, support or immobilize a body part, stabilize an extremity, or secure equipment, such as traction, to a body part. Elastic bandages can be used on any body part and to apply compression to any area, with the exception of the neck. The type and size will vary with the body part or area to be covered. Elastic bandages are often used on the lower extremities to prevent edema and to support varicose veins. Elastic bandages can also be used to support the knee, ankle, elbow, and wrist for conditions such as strains and sprains. They can also be used to support fractured ribs.

ASSESSMENT

1. Check the client’s skin integrity to establish a baseline. Inspect the site to be bandaged. Indications of edema, abrasions, discoloration, or bony prominences need to be noted prior to bandaging. These assessments will affect the type of bandage used, and how the bandage is placed (see Figure 10-1-2).

2. Assess circulation. Inspect skin temperature, color, pulses, and sensation of body parts to be covered to determine a baseline neurovascular status.

3. Assess for the presence of a wound. If a dressing is to be applied under an elastic bandage, assess that wound prior to application of elastic bandage.

Determines if the bandage will put pressure on the wound, or compromise the sterile wound dressing. Make sure there is a sterile bandage between the elastic bandage and an open wound.

DIAGNOSIS

Altered Tissue Perfusion

Impaired Physical Mobility

Pain

PLANNING

Expected Outcomes:

1. The client will have decreased edema.

2. The client will have decreased pain.

3. The client’s body will be supported and in good alignment.

4. The client will not experience tingling or numbness distal to the elastic bandage.

5. The client will have good perfusion in parts distal to the elastic bandage.

6. The bandage will be properly anchored and the ends secured with no looseness or stricture.

Equipment Needed

(see Figure 10-1-3):

• Elastic bandage

• Gloves, if body fluids or wounds are involved

• Dressings, as appropriate, if covering open wounds

• Clips or tape to secure bandage in place

CLIENT EDUCATION NEEDED:

1. Client understands the purpose of the elastic bandage, e.g., for support, to decrease edema, or to secure dressing in place.

2. Client understands the need to keep bandage smooth, wrinkle free, and avoid constriction.

3. Client understands the need to report any tingling, numbness, discoloration, or any increased pain.

4. Client understands the need to report any oozing of blood through the elastic bandage.

5. Client understands the need to report cool extremity, blanching, or mottling.

EVALUATION

• The client has decreased edema.

• The client has decreased pain.

• The client’s body is supported and in good alignment.

• The client does not experience tingling or numbness distal to the elastic bandage.

• The client has good perfusion in parts distal to the elastic bandage.

• The bandage is properly anchored and the ends secured with no looseness or stricture.

DOCUMENTATION

Nurses’Notes

• Document procedure, type of wrap, and reason for wrapping.

• Document assessment of colour, movement, warmth, and sensation initially, and 20 minutes later.

• Document distal pulses, if applicable.

• Document vital signs, if needed, in acute injury situation.

CRITICAL THINKING SKILL

Introduction Assessment after the bandage is applied must consider all possible complications of the injury.

Possible Scenario A client is admitted to the unit after a motor vehicle accident. He fractured his leg. His leg is wrapped in an elastic bandage.He rings his call light, and complains of deep throbbing pain in his calf.

Possible Outcome The nurse rewraps the leg, and explains to the client that fractures are painful. She offers medications. The client continues to develop a deep venous thrombosis as a result of the injury.

Prevention The nurse needed to listen to the client’s complaints of pain. She should have done a thorough assessment, including assessing the leg for deep venous thrombosis by checking for pain, warmth, redness, discoloration, or a positive Homans’ sign.

NURSING TIPS

• Gently stretch the bandage as you apply it to make sure it is secure.

• If wounds are involved, check under bandages periodically.

Applying a Splint

OVERVIEW OF THE SKILL

Splinting is the process of applying a rigid device to a limb, joint, or wound to prevent movement of displaced or injured areas (see Figure 10-2-2).

Splinting is used primarily for immobilization of broken bones or dislocated joints in emergent situations and to prevent movement in the injured area after the extent of the injury is known in nonemergent situations. When a fractured or dislocated area has been correctly immobilized, the splint allows complete rest of the injured area in the anatomically correct position (see Figure 10-2-3).

This facilitates proper and complete healing. A properly applied splint is also important in controlling blood loss and pain. If a fracture with sharp bone ends is not immobilized, further tissue trauma, blood loss, and pain will occur. A splint can be made from any rigid material, from a stick to plaster or fiberglass, or a premade aluminum padded splint can be used. Ideally the material should be light, straight, and rigid enough not to change shape if the client moves. It is very important that the splint be long enough to extend beyond the joint distal to the involved area. If the injury is close to the proximal joint, that joint should also be immobilized to avoid movement in the injured area. The splint should be as wide as the area being immobi- lized. For client comfort, and to avoid further trauma, padding is recommended on the side next to the client’s skin. This is also of benefit if the area swells, as the padding will reduce interference with circulation. Splints are held in place with bandages (see Skill 10-1, Applying an Elastic Bandage), velcro straps, or tape.

ASSESSMENT

1. Assess the area that the splint is to be applied to. Check for bleeding, raw bone ends, or debris. Note if the site is in correct alignment. Do not attempt to align a suspected fracture when splinting. Affects how the splint will be applied, or if the procedure is contraindicated.

2. Assess the client’s skin integrity, paying special attention to the presence of an open fracture, edema, ecchymosis, lacerations, abrasions, and the condition of the skin (dry, cracked, infected, thin). Alerts to possible complications such as skin breakdown and infection.

3. Assess the neurovascular status. Circulation can be assessed by checking capillary refill in the distal area, and by checking the skin temperature and colour. The neurovascular status can be assessed by asking the client, if he is conscious, if there is any numbness or tingling in the involved area or distal to it, and by actually checking sensation. Provides baseline for future assessments.

4. Assess the client’s level of pain and how he is dealing with it. Pain can cause the client to thrash around, which could cause increased tissue trauma and bleeding.

DIAGNOSIS

Risk for Trauma

Risk for Disuse Syndrome

Impaired Physical Mobility

Pain

PLANNING

Expected Outcomes:

1. The client will not experience unnecessary pain.

2. The client will not sustain further tissue damage and blood loss.

3. The injury will be well supported and immobilized in correct anatomic alignment.

4. There will be adequate circulation to the wound and distal body part.

5. The client will not experience any skin breakdown as a result of the splinting.

6. The client will verbalize an understanding regarding care of the injured area and use of the splint.

Equipment Needed:

• Dressing for wound, if present

• Gloves

• Padding for under splint (febrile or gauze)

• Appropriate splint (see Figure 10-2-4)

• Elastic bandage,

Ace wrap,

Velcro straps, or tape to hold splint in place

CLIENT EDUCATION NEEDED:

1. Explain to the client that the splint will impair his mobility.

2. Reinforce the need to report any numbness, tingling, or cool skin distal to the splint.

3. Explain to the client that the splint needs to remain dry and in place until a health care provider has removed it.

EVALUATION

• The client did not experience unnecessary pain.

• The client did not sustain further tissue damage and blood loss.

• The injury is well-supported and immobilized in correct anatomic alignment.

• There is adequate circulation to the wound and distal body part.

• The client did not experience any skin breakdown as a result of the splinting.

• The client has verbalized understanding regarding care of the injured area and use of the splint.

DOCUMENTATION

Nurses’Notes

• Record the reason the splint was applied and the area the splint was applied to as well as the type of splint that was placed.

• Be sure to note if it was right or left, if indicated.

• Note the condition of the client’s skin prior to placing the splint.

• Note the neurovascular status of the area distal to the splint both before and after placement.

• Check and note the neurovascular status prior to discharging the client. • Record any client teaching that was done.

CRITICAL THINKING SKILL

Introduction Client education is an essential part of nursing care.

Possible Scenario Betty is a 34-year-old lab technician who fell and hurt her left ankle while jogging. She presents to the emergency room for evaluation. There are no obvious fractures or dislocations and she is stable so she is sent in a wheelchair for an x-ray. The x-ray reveals that she has a distal fibular fracture with no misalignment. She needs a posterior splint and to follow up with orthopedics for further evaluation. During the application of the splint, Betty becomes very agitated and moves around a great deal, making it difficult to size and properly apply the splint. After the posterior leg splint is put on and she is being discharged, she complains of numbness and tingling of her toes below the splint that you just applied.

Possible Outcome You reassure Betty that she should put her leg up and ice it when she gets home. This will reduce the swelling and the splint will feel much better. Betty stays home for two days, with her leg elevated and iced, taking her prescribed pain pills. Her foot is still numb and her toes are white, but she assumes that is the way it should be. When she sees her orthopedic doctor two days after the incident he notes that Betty seems to have nerve damage in her left foot.

Prevention Betty needed to be educated and included in the process of the splint application to ensure that she would remain cooperative. Her pain status and how she was managing the pain needed to be assessed prior to and during the process. The importance of a good fit to avoid interference with blood flow to the area and the neurovascular status cannot be overstressed. The neurovascular status needs to be evaluated before, during, and after the process.

NURSING TIPS

• Be sure the distal portion of the extremity is exposed for neurovascular assessment.

• Check and document the client’s neurovascular status before, during, and after applying the splint.

• Familiarize yourself with the splints and appliances available in your facility. Know what they are supposed to look like and how they work both on and off the client.

APPLYING AN ARM SLING

OVERVIEW OF THE SKILL

A sling is used to support an injured upper extremity. Slings are used to immobilize an injured arm or shoulder due to sprain, strain, dislocation, or fracture. Slings are used to prevent dependent edema, control pain, promote rest to aide healing, and, if a fracture is present, to hold the upper extremity in the correct anatomical position. Slings are often used after an arm has been casted, to avoid unnecessary pull on the neck and shoulders from the weight of the cast. In an emergent situation slings are used as first aid to prevent further tissue damage, bleeding, and to control pain. Slings are also used to hold dressings in place. Slings can be made of various materials. In the emergent situation any large triangular piece of fabric can be used. In the nonemergent situation commercially made slings are generally used. These are usually made from sturdy canvas, which forms a sleeve that fits around the client’s injured limb, with a supporting strap that is padded and fits around the neck. Some slings also have a strap that fits around the client’s waist to further immobilize the upper arm, in particular the shoulder.

ASSESSMENT

1. Assess the arm, shoulder, and clavicle that is to have the sling applied. In an emergent situation, any possibility of a neck injury would preclude the use of a sling. In a nonemergent situation assess for any other deformities or injuries that might preclude the use of an arm sling.

2. Assess the client’s skin integrity on the entire upper extremity and the neck, the sling is supported by the neck strap. If a triangular bandage is used as the sling, extra padding in the neck area will make the sling more comfortable, and may prevent skin breakdown. Extra padding on a manufactured sling may be used as well for client comfort (see Figure 10-3-2).

3. Assess the client’s level of consciousness to determine how he will tolerate the process of applying the sling and how he will deal with it after it is applied. If the client is noncompliant, the waist strap may be necessary to establish the needed immobilization.

4. Assess the client’s level of pain. If the client is having a great deal of pain, he may move around more, which could cause further tissue damage, bleeding, and improper immobilization.

DIAGNOSIS

Risk for Impaired Skin Integrity

Risk for Disuse Syndrome

Impaired Physical Mobility

Ineffective Management of Therapeutic Regimen

Pain

PLANNING

Expected Outcomes:

1. The client will not experience any unnecessary pain.

2. The procedure will be performed with a minimum of trauma to the client.

3. The injured area is adequately supported to allow healing in proper alignment.

4. The client will not experience any skin breakdown or neurovascular damage as a result of the arm sling.

Equipment Needed:

• Dressing for wound(s) if needed

• Sling: either large triangular piece of cloth or premade sling

• Padding, if needed

CLIENT EDUCATION NEEDED:

1. Teach the client how to put on and remove the sling if he will be wearing it at home.

2. Be sure the client understands not to let his hand droop down below the level of the elbow to prevent swelling and edema in the hand.

3. Unless otherwise ordered by the physician or qualified practitioner, teach the client to remove the sling once or twice a day to perform range of motion exercises.

4. Have the client or the caregiver perform a return demonstration of placing and removing the sling.

5. Teach the client how to check the neurovascular status of his fingers and hand. Instruct him to notify his physician or qualified practitioner if he notes any impairment.

EVALUATION

• The client did not experience any unnecessary pain.

• The procedure was performed with a minimum of trauma to the client.

• The affected arm is adequately supported to allow healing in proper alignment.

• The client is not experiencing any skin breakdown or neurovascular damage as a result of the arm sling.

DOCUMENTATION

Nurses’Notes

• Record the reason a sling was required and the type of sling applied. Note the condition of the client’s arm, including neurovascular status, prior to placement of the sling.

• Note the neurovascular status of the client’s arm after placement of the sling. • Record the client’s comfort level and understanding of the instructions received regarding care of the arm and placement of the sling.

CRITICAL THINKING SKILL

Introduction The proper equipment in the correct size is essential to good care.

Possible Scenario You are working in the infirmary at a summer camp. During the initial check-in you notice one of the campers is wearing an arm sling. His left forearm is in a cast and the cast is in the sling. Upon questioning the child he gives you a note from his doctor. The note indicates that the boy had recently sustained a hairline fracture of the wrist but that he would be able to participate in most camp activities as long as he wears his sling. Upon closer examination you note that the boy’s fingers have good capillary return but they are a little cool. You also note that the sling the boy is wearing extends well past the end of his fingers. When you ask about the sling, you are told that the clinic did not have a small sling so they used a larger one instead. You can see that the sling is so large it is not holding the boy’s hand above his elbow. Additionally his fingers are hidden from view for neurovascular assessment. Because the boy had not been wearing the cast very long and the possibility of bumping and injuring his arm is increased at camp, you are concerned that you cannot tell at a glance if the boy’s fingers are pale or swollen.You are reluctant to allow the boy to stay at camp with the oversized sling, but his parents have already left and he is obviously looking forward to camping.

Potential Outcome You resolve the dilemma by replacing the oversized sling with a triangle bandage sling. You carefully adjust the size of the triangle bandage so it will support the boy’s arm in proper alignment and will allow the boy’s fingers to be visible for inspection. When the boy’s fingers started to swell after a particularly vigorous day, you had the boy elevate his hand and arm and put ice on it. The swelling went down in his fingers and the boy was able to finish out the week at camp.

Prevention In areas that serve a specialized population, equipment of the proper size and variety should be on hand.

NURSING TIPS

• Have the client demonstrate applying and removing the sling if he will be doing it at home.

• Assess the client’s ability to perform the skill prior to discharge.

• Check neurovascular status before and after applying the sling.

APPLYING ANTIEMBOLIC STOCKINGS

OVERVIEW OF THE SKILL Antiembolic hose, also called TED hose or elasticized stockings, are used to promote circulation by compression and are useful to prevent thrombophlebitis. They are used on the legs of a client after surgery, in clients who are immobile and, in clients who have vascular disorders such as thrombophlebitis, varicose veins, and other conditions of impaired circulation of the lower extremities.

ASSESSMENT

1. Assess the condition of the client’s lower extremities, noting edema, color, temperature, intact skin, ulcers, or infections. Establishes a baseline for comparison (see Figure 10-4-2).

2. Assess the quality and equality of peripheral pulses in the legs (either dorsalis pedis or posterior tibial pulses) to determine circulatory status.

3. Assess the client’s understanding of the reasons for, and the use of, the antiembolic stockings to determine the amount of client teaching required.

4. Assess the client for signs and symptoms of deep vein thrombosis such as a positive Homans’ sign and increased calf size to determine the appropriateness of the TED hose placement.

DIAGNOSIS

Skin Integrity

Alteration in Circulation and Perfusion

Pain

PLANNING

Expected Outcomes:

1. The client will not experience any signs or symptoms of deep venous thrombosis or thrombophlebitis.

2. The client’s venous return will be improved.

3. The client’s popliteal, posterior tibial, and dorsalis pedis pulses will remain intact while stockings are in place.

4. The client will have good circulation while stockings are in place, as evidenced by warm skin temperature, capillary return is within normal limits, sensation is present, and no edema is present in both extremities.

Equipment Needed (see Figure 10-4-3):

• Antiembolic stockings and package directions

• Powder or cornstarch (if client is not allergic)

• Tape measure

CLIENT EDUCATION NEEDED:

1. Client understands the purpose of antiembolic stockings.

2. Client understands that stockings must be in place and free of wrinkles to avoid skin breakdown and constraints of circulation.

EVALUATION

• The client has not experienced any signs or symptoms of deep venous thrombosis or thrombophlebitis.

• The client’s venous return is improved.

• The client’s popliteal, posterior tibial, and dorsalis pedis pulses remain intact while stockings are in place.

• The client has good circulation while stockings are in place, as evidenced by warm skin temperature, capillary return within normal limits, sensation within normal limits, and no edema in either extremities.

DOCUMENTATION

Nurses’Notes

• Document use of stockings

• Document skin integrity, any presence of venous problems, and circulatory status of extremities.

• Document equality of pedal pulses.

• Document size and length of stockings.

CRITICAL THINKING SKILL

Introduction Application of antiembolic stockings takes some planning.

Possible Scenario A client has antiembolic stockings ordered; however, he has been up in the chair for several hours. His legs and ankles are swollen with edema.

Possible Outcome Getting the stockings on will be an arduous task for both the nurse and the client. If the client’s experience with the stockings is very negative, future compliance could be poor.

Prevention To prevent this experience from being unpleasant for both the client and the nurse, have the client lie in bed for one hour before applying stockings. Apply cornstarch to the client’s legs and feet. Remind the client to apply the stockings in the morning, before getting up in the chair.

NURSING TIPS

• Check stockings for proper placement at least every two hours or more often if needed.

• Stocking may roll and cause constricitons. Readjust periodically.

• Check lower extremities for circulatory status.

• If the client has peripheral vascular disease, check with the physician or qualified practitioner to ascertain that antiembolic stockings are not contraindicated. • Remove stockings daily and have client exercise feet and toes.

APPLYING A PNEUMATIC COMPRESSION DEVICE

OVERVIEW OF THE SKILL

Pneumatic compression devices (PCD), also known as sequential compression devices (SCD), are used to minimize lower extremity venous stasis. They are used in clients who are immobile for an extended period of time and who are at risk of developing deep venous thrombosis as well as in clients with lower extremity edema. Cuffs or stockings that inflate and de- flate at alternating intervals are applied to the lower extremities. The stockings inflate in a sequence that promotes blood flow back to the heart and decreases pooling of the blood in the lower extremities. Because the cuffs cause compression of vessels they are contraindicated in disorders of arterial insufficiency and preexisting venous thrombosis.

ASSESSMENT

1. Assess the condition of the client’s lower extremities, noting edema, color, temperature, intact skin, ulcers, or infections. Establishes a baseline for comparison.

2. Assess the quality and equality of peripheral pulses in the legs (either dorsalis pedis or posterior tibial pulses) to determine circulatory status.

3. Assess the client’s understanding of the reasons for, and the use of, sequential compression devices to determine the amount of client teaching required.

4. Assess the client for signs and symptoms of deep vein thrombosis such as a positive Homans’ sign and increased calf size to determine the appropriateness of the sequential compression device placement.

DIAGNOSIS

Risk for Impaired Skin Integrity

Impaired Physical Mobility

PLANNING

Expected Outcomes:

1. The client’s venous circulation will be improved as evidenced by a circulatory assessment.

2. The client will not develop deep venous thrombosis as evidenced by the lack of Homan’s sign and the lack of redness or swelling in the extremity.

3. The client’s skin will remain intact.

Equipment Needed (see Figure 10-5-2A–C):

• Pneumatic sequential compression device and accompanying stockings

• Electrical outlet

• Tape measure

Pneumatic compression devices

OVERVIEW OF THE SKILL

CLIENT EDUCATION NEEDED:

1. Explain to the client that the compression device must be worn while lying down.

2. Demonstrate the correct method of putting the compression device on. Be sure to explain that the device must be snug but not so tight that it compromises circulation.

3. Reinforce the need for leg exercises to promote venous return despite the use of the compression device.

4. Educate the client to notify the nurse if he develops pain or tenderness in his calf or leg.

EVALUATION

• The client does not exhibit any signs or symptoms of deep vein thrombosis.

• The skin on the client’s lower extremities is intact.

• The circulation to the client’s lower extremities is not compromised.

Nurses’Notes

• The first time the compression device is placed document the size and type of cuff used, all findings regarding deep vein thrombosis and circulatory impairment, and the client’s tolerance regarding the use of the device in the narrative notes.

• Document subsequent assessments and any changes you have noted.

CRITICAL THINKING SKILL

Introduction Careful client assessment can prevent serious problems.

Possible Scenario You are in Mrs. Flowers’ room to put on her PCD. As you smooth the elastic stockings she will be wearing underneath the device, to remove any wrinkles, she complains of pain in her left calf.

Possible Outcome You assure Mrs. Flowers that she is just a little stiff from being in bed. You proceed to rub the area to relieve the pain. Mrs. Flowers begins to complain of shortness of breath and becomes cyanotic. You immediately request assistance and Mrs. Flowers is treated emergently. After she has been treated and transferred to the intensive care unit, you are told that Mrs. Flowers had deep vein thrombosis in her left calf and apparently a portion of the clot had broken off and migrated to her lungs.

Prevention You should have stopped to assess her condition. You would have detected that she had developed deep venous thrombosis. Instruct Mrs. Flowers to remain in bed while you notify her physician regarding this new finding. >

NURSING TIPS

• Compression stockings may become loose when clients are restless and move in bed. Approximately every two hours check that stockings are tight enough and properly positioned.

• Check skin integrity and circulation every 4–8 hours.

• Be sure to monitor for deep vein thrombosis and fluid overload.

APPLYING ABDOMINAL, T-, OR BREAST BINDERS

OVERVIEW OF THE SKILL

In the past, abdominal binders were primarily used to provide support and comfort for an incision following abdominal surgical procedures. Today binders are most often used to hold dressings in place, to support soft tissue, or to suppress lactation. Single and double T-binders hold rectal or perineal dressings in place. Abdominal binders support the abdomen and hold abdominal dressings in place. Stretch net binders are not designed for support, but simply to hold dressings in place. Scultetus binders are multitailed binders that are wrapped tail tucked under tail to support the abdomen. They are not often used today. A breast binder or a tight bra is used as a nonpharmacologic device to aid in lactation suppression. The binder is placed over the breast to prevent breast and nipple stimulation. The support offered by binders and bras prevents the let-down reflex and discourages milk flow. Ice packs are used in conjunction with breast binders to relieve discomfort associated with breast engorgement. Proper placement of any binder is essential for optimum comfort and effect. The binder must be smooth,must be the right size for the client,must not interfere with circulation, and must not put too much pressure on the bound area.

ASSESSMENT

1. Assess the reason the binder is needed to determine the correct binder and correct placement.

2. Assess the client’s skin condition for rashes, in- flammation, open areas, or dressings to provide a baseline for future assessments.

3. Assess and measure the client to determine what size binder will be needed.

4. Assess for any special circumstances that may affect the placement of the binder such as dressings, tubing, catheters or IV lines to determine a plan for binder placement.

5. Assess the client’s understanding of the reasons for the binder and the method of placing the binder to determine how much client teaching will be needed.

DIAGNOSIS

Interrupted Breastfeeding

Impaired Physical Mobility

PLANNING

Expected Outcomes:

1. For breast binder, lactation will be suppressed.

2. Binder will provide support for dressings or soft tissue.

3. Binder will not be too tight, or compress the skin.

4. T-binder in a male patient will not compress the testicles.

5. Client will assist in the placement of the binder as much as possible.

Equipment Needed (see Figure 10-6-2):

• Correct binder for intended purpose

• Safety pins or fasteners

CLIENT EDUCATION NEEDED:

1. Explain to the breast binder client that lactation may continue for up to 16 days.

2. If safety pins are used as fasteners, pin the binder in a place where, if the pins inadvertently open, the client can reach them easily.

3. Advise the breast binder client that, for adequate suppression and support, the binder should be worn 24 hours a day.

4. With a breast binder, allow the client to express her concerns regarding the cessation of lactation. It is important for her to voice questions or concerns, and to receive satisfactory response.

5. With a breast binder, remind clients of the signs and symptoms of both breast engorgement and mastitis.

6. Remind the client that if breathing is difficult with a binder on, the binder should be adjusted for a more comfortable fit.

7. Discuss the signs and symptoms of skin breakdown, and encourage the client to report signs of skin irritation. Encourage the client to examine the skin beneath the binder each day that the binder is in use.

EVALUATION

• For breast binder, lactation is suppressed.

• Binder provides support for dressings or soft tissue.

• Binder is not too tight and does not compress the skin.

• T-binder on a male client does not compress the testicles.

• Client assists in the placement of the binder as much as possible. >

DOCUMENTATION

Nurses’Notes

• Document the time, date, and type of binder.

• Document any difficulty that the client experienced with the procedure. >

CRITICAL THINKING SKILL

Introduction Your client, a 13-year-old primipara, is complaining of sore, heavy breasts on postpartum day 2. You offer her a breast binder for comfort, but as you start to explain how it is applied, she bursts into tears. She states that she has tried to breastfeed, but her boyfriend (the baby’s father) does not want her to continue. She is anxious and indecisive.What do you do?

Possible Scenario Now is not a good time to discuss the need for a breast binder, because this client has not made up her mind regarding breastfeeding. This is a critical moment for additional nursing assessment. This client has psychosocial needs surrounding the birth of the child, changes to her relationship, and changes to her body. A visit by a psychosocial care provider may answer questions that she and her partner have regarding breastfeeding and other issues related to the pregnancy.

Possible Outcome Your timely nursing intervention allows the client and her boyfriend to discuss their fears and uncertainties regarding the baby and the decision to breastfeed. Later that day, you continue with education regarding the breast binder and other methods to reduce discomfort.

Prevention The stress of having a child, especially among very young mothers, may precipitate distress related to breastfeeding and/or the need for lactation suppression. Be alert for verbal and nonverbal cues and practice therapeutic communication as needed.

NURSING TIPS

• There are commercially made breast binders that can be ordered from medical or surgical supply companies. However, these may be a more costly alternative to using a bra binder or other type of breast binder.

• A good bra often provides both lactation suppression and support.

• If abdominal binders are used, periodically assess for tightness and adjust if the binder impedes respiration.

• Use a bra binder if the client does not have another individual at home to help her apply other types of breast binders.

• If the stretch net binder rolls when the client moves about in bed, consider taping it to the skin with paper tape in one or two strategic places.

APPLYING SKIN TRACTION—ADHESIVE AND NONADHESIVE

OVERVIEW OF THE SKILL

Traction is designed to align or immobilize parts of the body. Traction may be used to reduce or immobilize fractures or to reduce muscle spasms. Traction is applied using weight or force to gently pull on the body parts. There are two basic types of traction— skin traction and skeletal traction. This skill deals with the application, use, and evaluation of various types of skin traction. Skin traction uses the client’s skin as the anchor point of the weight or force. The traction is anchored to the skin using either adhesive tapes, Velcro straps, or a fitted brace. Some types of skin traction employ a brace or other rigid garment to apply gentle force to the client’s body. Others use weights, ropes, and pulleys to apply force to the client’s body. Traction often requires specialized equipment for support and proper alignment. Many hospitals employ technicians who are trained to set up and maintain traction equipment and to fit braces. The nurse may be called upon to measure and fit some types of traction, as well as assess and maintain traction devices. Following are some of the more common types of skin traction: Buck’s traction: This is straight traction placed on the lower extremity to help reduce a hip or femur fracture. Buck’s traction can also reduce or prevent muscle spasms caused by a hip or femur fracture. Buck’s traction can be applied with adhesive tape secured with an elastic bandage and attached to a pulley and weight. A manufactured “boot” is also available. The boot wraps around the leg and is secured with straps. It is then attached to the pulley and weight system in the same way as the adhesive traction. Care must be taken to maintain alignment and watch for any skin breakdown that may occur. Maintenance of the pulley system is very important. The line must not become tangled in the bed linen and the weights must hang freely. Bryant’s traction: This is very similar to Buck’s traction and is used for reduction of femur fractures or to immobilize the hip joints in children who weigh less than 40 pounds. In Bryant’s traction both the child’s legs are wrapped and a spreader bar is placed to separate the limbs. Two sets of pulleys and weights are then attached overhead to lift the child’s buttocks off the mattress by about 1–2 inches. This traction maintains alignment, helps reduce any fracture, and immobilizes the child. Bryant’s traction places the child’s skin at risk in several areas. The client’s back, elbow, coccyx, and head are vulnerable to skin irritation and breakdown and must be closely monitored. This position also raises concerns regarding elimination, feeding, and hydration. All these basic needs must be met, as well as the child’s mental and emotional needs related to immobility, and the need for stimulation. Russell’s traction: This is a balanced traction arrangement of pulleys, lines, slings, and weights used to treat knee or hip injuries in adults and to reduce femur fractures in children. Russell’s traction is applied to the client’s lower leg. A sling is placed under the client’s knee and two pulley and weight setups are applied to support the knee sling. Assessment of the skin is critical in this type of traction because of the possibility of skin breakdown on the coccyx, back, elbows, head, and parts of the noninjured extremity, especially the heel. Footdrop is also a risk and exercises as well as foot support should be used. A client in this type of traction is also at risk for deep vein thrombosis, respiratory complications, and constipation. Cervical traction: Cervical traction can be applied in several different ways. Medics often apply a hard cervical collar on clients with suspected cervical injury. This type of collar is generally used only for short periods of time. Care must be taken to maintain good alignment when placing this type of collar. The soft cervical collar or Philadelphia collar is used primarily for soft tissue or ligament damage. It is often prescribed for comfort and support of the neck and head. It is not used for fracture alignment or immobilization. Care should be taken to properly fit this collar. It can cause skin breakdown if not fitted correctly and will not provide proper support if it is too large or too small. Cervical traction can also be applied using a cloth collar attached to a weight and pulley system. It is primarily used to relieve muscle spasms and nerve compression in the neck. Neurologic assessment and skin assessment are extremely important in this type of traction due to the vulnerability of the area. The client is not usually placed in this traction for long periods of time. Pelvic belt or girdle: This type of traction is used to relieve pain caused by muscle spasm or nerve impingement in the lower back. A girdle is placed around the client’s hips and a pulley and weight system is then attached to the girdle, extending down over the foot of the bed. This maintains alignment of the back, hips, and legs and provides gentle pulling on the lower back. Pelvic traction can be used in the home setting. The nurse should reinforce client teaching regarding the proper use of this type of traction. Humerus traction: Humeral traction is used to stabilize upper arm fractures and shoulder dislocations. The upper arm is held at a 90° angle from the body and the forearm is flexed. Traction is placed to pull on the hand and the elbow. This allows for a gentle pull to realign the fracture or dislocation. Any client in traction is at risk for skin breakdown at the injury site and also in areas with a thin layer of skin over bony prominences such as the shoulder, back, coccyx, heels, and head. A thorough skin assessment must be performed regularly to prevent skin breakdown.

ASSESSMENT

1. Assess skin integrity to evaluate and treat any actual or potential skin breakdown in the traction area.

2. Assess neurovascular status in the affected areas to evaluate any potential or actual neurovascular compromise.

3. Assess the client’s understanding of and need for the treatment to provide any client education and support needed.

4. Assess for complications of traction and immobility in order to determine a plan of treatment. >

DIAGNOSIS

Pain

Impaired Physical Mobility

Risk for Impaired Skin Integrity

Anxiety

PLANNING

Expected Outcomes:

1. The affected body part will have adequate neurovascular perfusion as evidenced by color, capillary refill, movement, and sensation.

2. The client will understand the reason for the traction and be able to cooperate in his care and treatment.

3. The client will experience a minimum of discomfort and trauma secondary to the traction.

Equipment Needed (see Figure 10-7-2):

• Pain medication, if necessary

• Overhead traction bars if needed

• Weights in various pounds

• Traction line and pulleys

• Skin traction device as ordered by the physician or qualified practitioner

• Adhesive traction tape and elastic bandage, if appropriate

• Razor, if needed

• Benzoin solution, if needed

CLIENT EDUCATION NEEDED:

1. Explain the need for the traction. Discuss the continuing injury to the tissues, muscles, and blood supply that can occur without immobilization.

2. Assure the client that this is a necessary, but usually temporary, procedure that will aid in the healing process and that every measure will be taken to make the client as comfortable as possible during the procedure.

3. Explain the procedure step by step and ask questions. This will help the client anticipate what will occur. Asking questions will provide a sense of control and help alleviate anticipatory anxiety.

4. Explain that some discomfort may occur, and outline options for pain control.

5. Explain the possible complications of traction and prolonged immobilization. Teach the client to self-assess for these complications and to report them to the staff. This increases the client’s sense of autonomy and control.

6. Teach the client appropriate range of motion exercises to prevent muscle atrophy as much as possible.

EVALUATION

• The affected body part has adequate neurovascular perfusion as evidenced by color, capillary refill, movement, and sensation.

• The client understands the reason for the traction and is able to cooperate in his care and treatment.

• The client experiences a minimum of discomfort and trauma secondary to the traction. >

CRITICAL THINKING SKILL

Introduction Client education is critical to client compliance.

Possible Scenario A middle-aged female client is in pelvic traction for lower back pain. She has bathroom privileges and has been taught how to apply and remove the pelvic traction girdle by herself. Upon starting your shift you note that this client is lying in bed, watching TV without her pelvic traction. When you ask her about it she notes that her back does not hurt right now and she is tired of being pulled down in bed all of the time.

Possible Outcome You counsel the client regarding wearing her traction whenever she is in bed. She reapplies the pelvic girdle and you gently reapply the weight to the pelvic traction. The next time you check on the client she is once again lying in bed without her traction. She explains that she had just returned from the bathroom and was about to replace her traction. You note that she appears to have been lying in bed without her traction for some time. You assist the client to reapply the traction but you are concerned that she will remove it again after you have left the room. In report the next day you find out that this client has had an increase in lower back pain and is scheduled for a myelogram and possibly a lumbar laminectomy due to the exacerbation in her symptoms.

Prevention Explain to the client the need for keeping the traction in place even if the symptoms have eased. The traction is probably the reason the symptoms initially decreased and discontinuing the traction could lead to a return of symptoms or possibly increased damage to the area.

NURSING TIPS

• Get adequate help when turning any client while in traction or in a supportive brace.

• Make certain that nutrition and elimination issues are addressed; many clients become constipated because of pain medication and inactivity, adding to their discomfort.

• Adequate pain relief is essential in dealing with clients in traction.Muscle spasms and bone pain can be excruciating if the pain is not being properly addressed.

• The basic principle of traction is proper alignment. If the body part is not in alignment the pain will increase considerably.Make certain that all lines are straight, all weights are free to move, all extremities are straight and, if indicated, client should be properly supported by pillows and other supportive devices.

• Make certain that body jackets or braces are properly fitted and no skin is caught in the sides or pinched where the jacket fits together.

• Gain client compliance by taking the time to teach all the important points of dealing with traction or a brace. Listen to the client’s concerns and take time to answer the client’s needs.

• Recreational therapy can offer diversional activities to clients who are in traction for long periods of time.

ASSISTING WITH THE INSERTION OF PINS OR NAILS

OVERVIEW OF THE SKILL

Sometimes traction or fixation is applied directly to the bone using specialized equipment, such as Crutchfield tongs, Steinmann pins, or Kirschner wire, nails, or screws. Connecting traction directly to the bone immobilizes the affected bone, and/or allows more precise alignment of the fractured bone fragments. It provides a stronger steady pull, and allows longer periods of traction. Skeletal traction can be used for short-term treatment of the fracture, until it is openly reduced and internally or externally fixated during surgery. Often, traction directly to the bone is used when the skin or tissue is not intact, such as an open fracture, and casting might increase the risk of infection. There are several types of skeletal traction, including balanced suspension traction, halo traction, external fixation, and skull tongs. External fixation uses pins implanted into the bone, and held in place by an external metal frame. Halo traction provides support for cervical injuries using pins placed in the skull, which are then attached to external metal bars fixed on a rigid chest vest. The arrangement allows client mobility while preventing flexion, extension, or rotation of the cervical spine. The placement of the pin(s) for traction or external fixation is done by the orthopedic surgeon. A potentially serious complication with pins inserted into the bone and exiting through the skin is osteomyelitis. This occurs when infection starting at the skin moves down the pin into the tissue, and into the bone. Another consideration with pins and nails is pain associated with the fracture and with pin placement.

ASSESSMENT

1. Assess the client’s knowledge of the procedure. Answer questions regarding previous personal experiences or friends and family who have been placed in traction. Helps provide education about the procedure.

2. Assess knowledge base, discuss the risk of continuing injury to the tissue, muscles, and blood supply that can occur without the aid of immobilization. Helps the client accept the need for traction.

3. Assess the client’s general health, allergies, and skin condition. Inspect the skin for evidence of atrophy, abrasions, edema, and other circulatory disturbances. Helps to decrease the risk of skin breakdown and infection.

4. Document the neuromuscular status of the extremity and any evidence of skin problems to record baseline assessments.

5. Assess the client’s current level of mobility. Consider how the pins will affect the client’s mobility and self-care ability. Helps plan interventions to maintain as much independence in self-care as possible. >

DIAGNOSIS

Impaired Physical Mobility, related to mechanical devices restricting mobility

Risk for Injury

Body Image Disturbance due to immobility

PLANNING

Expected Outcomes:

1. Client will have pins placed under the direction of the medical caregiver.

2. Client will experience a decrease in the amount discomfort related to the fracture.

3. Client will be able to perform activities of daily living, positioning, and communication with assistance.

Equipment Needed:

• Pain medication

• Sterile pins (see Figure 10-8-2) and a sterile pin insertion kit

• Local anesthetic obtained from the pharmacy per physician’s or qualified practitioner’s orders

• A topical cleanser such as povidone-iodine for cleaning the insertion site

• Sterile drapes and clean pads to protect bed linen and maintain a sterile field

• Traction equipment if required (see Figure 10-8-3)

CLIENT EDUCATION NEEDED:

1. Explain the need for the pins. Discuss the continuing injury to the tissues, muscles, and blood supply, which can occur without immobilization.

4. Explain that some discomfort may occur, and outline options for pain control.

5. Prepare the client for the procedure and explain that there will be discomfort and pain during the placement of the pin, but the pain is transitory. Discuss pain management measures.

6. Reinforce the need for frequent position changes and the need to give skin a chance to rest to reduce the risk of complications.

EVALUATION

• Client had pins placed, under the direction of the medical caregiver.

• Client experiences a decrease in the amount of discomfort related to the fracture.

• Client is able to perform activities of daily living, positioning, and communication, with assistance. >

DOCUMENTATION

Nurses’Notes

• Pre- and post-evaluation of all observations previously discussed is vitally important for the oncoming shifts to give them a baseline for observations. Documenting the condition of the traction, pins, weights, as well as the client’s emotional status, is important.

Medication Administration Record

• Type, amount, time, and route of pain medication used before and during pin insertion. >

CRITICAL THINKING SKILL

Introduction Check the equipment prior to beginning the procedure.

Possible Scenario The nurse gathers all the equipment at the bedside to assist the client to apply traction. During the middle of the procedure, she reaches for the weighted sandbags with eyehooks. One of the weights she has brought to the bedside is very worn, and it tears at the connection point.

Possible Outcome The procedure is interrupted while the nurse fetches another weight, causing anxiety and frustration for all parties.

Prevention Make sure the equipment at the bedside is in good condition.

NURSING TIPS

• Maintenance pain medication may be different and may sustain the client over a longer period of time than initial procedure medications.

• Giving medication prior to any other procedure, i.e., bed changing, position changes, or x-rays, etc., is helpful in controlling pain problems.

• Make certain all lines of traction are not knotted or jammed in the bed or pulley and are not laying on the floor. These errors decrease the effectiveness of the procedure and may delay surgery.

• Always make certain that you have an adequate number of pillows available at all times for position changes and for comfort measures.

• Premedicate prior to the procedure and during difficult bed changes or during x-rays.

• Use of overhead traction bars aids clients in helping themselves to reposition, to sit on a bedpan, and to maintain proper alignment of the affected leg.

• Stay with the client during the procedure, even if several physicians or qualified practitioners are there observing; it is important that you pay attention to the client and not the procedure, using the trust that you have already obtained to comfort and communicate with the client.

• Evaluate anxiety frequently. Although the procedure was successful the client may still be disturbed by the immobility and sensations imposed by the traction. It is important to show the client his abilities, and not focus on the limitations.

• If halo traction is used, keep traction removal equipment at the bedside in case rapid removal of the halo vest is necessary to perform cardiopulmonary resuscitation (CPR).

MAINTAINING TRACTION

OVERVIEW OF THE SKILL

Traction is used to hold the skeleton in the proper position for healing, to reduce pain, and to reduce deformity. Traction is the force applied to the skeleton needed to overcome the pull in the opposite direction from the muscle groups. The two most common types of traction are skin traction and skeletal traction. Skin traction is noninvasive and relatively comfortable for the client. The disadvantage is that it offers less support, and cannot be used with heavy weights. It can cause abrasions, skin irritation, and skin breakdown, and it is used only for the short term. Skeletal traction is used when more support is needed and heavier weights are necessary to reduce the fracture and to ensure alignment of the bones. Skeletal traction is attached to the bones via wires, pins, or tongs inserted by the orthopedic physician under aseptic techniques. Managing pain and preventing complications are two key nursing tasks in maintaining traction. The client may experience pain when traction is placed and when changing position in bed. Good pain management is essential. Complications related to the traction and associated decreases in mobility may occur, especially if the client is obese, cachectic, elderly, juvenile, diabetic, or smokes cigarettes. Respiratory complications, skin breakdown, nerve damage in the affected limb, and decreased circulation in the lower extremities are all possible complications of traction. Acute compartment syndrome can occur when the one or more compartments (muscles, blood vessels, and nerves supported by inelastic fascia) in the extremity fill with blood or fluid and swell. This internal edema, combined with pressure from the tight traction or other dressings, creates a tourniquet effect that starves the lower areas of the extremity of blood. This condition is serious and requires immediate intervention by the qualified practitioner to reduce the pressure on the vessels and restore circulation. There are many types of traction but the principles of maintaining traction apply to all.

ASSESSMENT

1. When assessing traction or preparing for the reapplication of traction, assess the client for pain, position, alignment, skin condition, overall health considerations, circulation, sensation, and movement of the injured extremity. This will help determine changes from baseline, and help detect any emerging complications from the traction.

2. Assess pain location, intensity, and duration. Discuss steps the client has taken to relieve the pain. Allows pain management and client input into pain management.

3. Assess the client’s position to make sure that it supports the traction.

4. Assess alignment to reduce pain and support the extremity.

5. Conduct an initial assessment of the general skin condition of the injured extremity to establish the baseline parameters prior to and during traction. It is important to record any changes in the skin color, edema, skin breakdown, erythema, or blisters.

6. Assess the client’s overall health condition to aid in determining the plan of care for the client.

7. Assess sensation and movement to note any change from baseline. >

DIAGNOSIS

Impaired Physical Mobility

Pain

Risk for Impaired Skin Integrity

PLANNING

Expected Outcomes:

1. Client traction will be maintained for a given period of time.

2. Client will maintain body alignment while in traction.

3. Client will maintain good skin condition, circulation, and sensation in the extremity in traction.

Equipment Needed (see Figure 10-9-2):

• Pain medication

• Traction equipment

CLIENT EDUCATION NEEDED:

1. Explain to the client the need for traction, the need for maintaining body alignment, and the overall care plan. If appropriate, remind the client that the traction is a temporary measure prior to surgery.

2. Teach the client to report any changes in feeling and sensation in the limb, especially increases in pain, numbness, tingling, or coldness.

3. Discuss with the client common emotional feelings that can occur with immobility, including sensory deprivation, loss of control, and decreased socialization.

EVALUATION

• Client traction is maintained for a given period of time.

• Client maintains body alignment while in traction.

• Client maintains good skin condition, circulation, and sensation in the extremity in traction.

DOCUMENTATION

Nurses’Notes

• In addition to the assessment of the client and establishment of a baseline, describe the type of traction, type of pin inserted into the bone, the amount of weights placed on the traction device, and when the procedure was completed.

• Document any medication that was given for the procedure and how effective that pain medication was in decreasing the pain.

• Document what the insertion sites look like and that pin care was completed.

CRITICAL THINKING SKILL

Introduction Assessment is an ongoing procedure.

Possible Scenario Mr. Dominguez was placed into traction for a lower extremity injury. The nurse was aware of the importance of monitoring the extremity for circulation, movement, and sensation. Mr. Dominguez was fine through most of the shift. The nurse checked his traction early in her shift, but she was busy attending to a number of different things the rest of the day.

Possible Outcome Near the end of the shift, Mr. Dominguez began to request pain medication more frequently. He insisted that the medication was not effective. The nurse did not examine the extremity and instead attributed the complaints of the client to just being “cranky” and not liking the traction. Mr. Dominguez continued to complain of increased pain but the nurse continued to ignore the problem. On routine rounds, the charge nurse assessed Mr. Dominguez and discovered edema in the leg and what appeared to be a compartment syndrome. The physician was immediately notified and the client was taken to surgery to open the compartments and reduce the pressure. The leg was ultimately saved, but tissue damage did occur, and as a result Mr. Dominguez’ stay in the hospital was extended.

Prevention Make the appropriate assessment, notify the physician or the charge nurse, or ask a colleague for a second opinion.

NURSING TIPS

• Organize the traction prior to application. Having all the parts of the traction set up at the bedside will make application easier and the process smoother.

• Premedicate the client. This will aid in compliance, increase trust, and make the task easier for all participants.

• Educate the client prior to applying the traction. This helps in compliance and understanding goals.

• Perform routine pin care, or as ordered to reduce the risk of infection at the pin site, and reduce the client’s length of stay.

• Assess the pin site for redress, as needed.

• Pillows can be used generously to support the fractured limb, maintain the client’s position, and promote comfort.

ASSISTING WITH CASTING— PLASTER AND FIBERGLASS

OVERVIEW OF THE SKILL

Casts are placed to provide stability to a fracture, dislocation, or soft-tissue injury while it heals. Casts have traditionally been made of plaster of paris, but more and more are now made with fiberglass. The physician or qualified practitioner will decide which type of cast to use, depending on many factors, including the age of the client, the reason for the cast, and the location of the cast. The primary goals of the nurse assisting with the procedure and caring for a client with a new cast are to:

• Assist the physician, qualified practitioner, or technician in rapid and correct placement of the cast, including assembling all necessary equipment at the bedside so the cast can be applied without interruption.

• Assess and intervene to reduce pain during reduction of the fracture and placement of the cast.

• Prevent vascular compromise from swelling after the cast is placed.

• Provide intravenous access, if necessary, so the client can be medicated for pain.

• Give clear information as to what the client should expect during the procedure. >

ASSESSMENT

1. Assess the client for acute pain or anxiety to determine the need for medications or possible conscious sedation during the procedure.

2. Assess the neurovascular status of the injured area before and after the cast is applied to determine changes in status. Neurovascular checks include skin color, skin temperature, capillary refill, pulses, touch, movement, and sensation.

3. Understand the kind of injury and the type of cast being applied. Helps recognize potential complications to watch for.

4. Assess the skin that will soon be inaccessible under the cast. Note any bruising, abrasions, incisions, or skin conditions that might contribute to discomfort, infection, drainage, or skin breakdown after the cast is applied.

5. Assess the client’s understanding of the injury and the casting procedure to determine what teaching is needed.

DIAGNOSIS

Pain

Altered Tissue Perfusion

Risk for Impaired Skin Integrity

PLANNING

Expected Outcomes:

1. The cast will maintain good bone alignment.

2. A cast will be applied to the fracture rapidly with minimal pain and anxiety to the client.

3. There will be no vascular compromise to the client during or after the procedure.

Equipment Needed (see Figure 10-10-2):

• Appropriate size cotton (for plaster) or synthetic (for fiberglass) cast padding such as Webril

• Stockinette, cut approximately 6 inches longer than the part to be casted

• Appropriate size plaster or sealed fiberglass rolls

• For plaster casts: Ace wraps, two or three inch sizes, two to three rolls

• For plaster casts: bucket of warm water

• For plaster casts: roll of three to four inch tape

• Protective clothing for yourself

• Disposable gloves (nonsterile)

• Special supplies: Shoulder immobilizer for arm fractures, crutches for lower limb fractures, finger traps for arm fractures that need to be reduced

CLIENT EDUCATION NEEDED:

1. Instruct the client on the need to help maintain correct alignment and positioning of the affected body part during the procedure.

2. Inform the client that when the casting material is placed, it will feel warm as it sets.

3. Instruct the client not to bear weight on the cast while it is drying. Plaster casts take up to 48 hours to dry. Fiberglass casts dry in about an hour.

4. Remind the client to communicate any pain during the procedure so pain intervention can be provided.

5. Provide instruction on cast care after the procedure is completed.

6. Instruct the client receiving a plaster cast that the plaster will feel warm for several minutes as it sets, then cool for several hours as it dries.

7. After the cast is applied, provide instructions on the following: care of the cast, elevation of the affected extremity, keeping the cast dry, checking for warmth and movement of the exposed extremity, observing the color of the exposed extremity, and comfort and pain measures that can be used by the client.

EVALUATION

• The cast maintains good bone alignment.

• A cast was applied to the fracture rapidly with minimal pain and anxiety to the client.

• There is no vascular compromise to the client during or after the procedure.

DOCUMENTATION

Nurses’Notes

• Document the type of cast and where it was applied.

• Document any medications used during the procedure.

• Document any specific aids used after the cast was applied, e.g., use of crutches or slings.

• Document client teaching. Document neurovascular status.

CRITICAL THINKING SKILL

Introduction Nurses must be able to evaluate effective and adequate circulatory status, thus preventing vascular compromise.

Possible Scenario A cast has been placed on the arm of an accident client newly transferred to the floor. The nurse’s initial assessment showed a warm extremity, good movement of the fingers, and good capillary refill. The nurse concluded that the client had adequate circulatory status. It was a busy night, and she did not get back for a second assessment for almost three hours. By then the client was complaining of severe pain and cold fingers.

Possible Outcome The client developed compartmental syndrome and needed surgical intervention.

Prevention The client sustained vascular compromise to the extremity. This could have been prevented by proper elevation of the affected part after casting and placing ice on the area of the fracture.More frequent evaluation of the client’s circulatory status, especially knowing that the client had a recent injury and a new cast, would have alerted the nurse to the worsening vascular status in the limb.

NURSING TIPS

• To promote good body mechanics, and for comfort, be sure the bed or stretcher is at a comfortable height during the procedure.

• Have all supplies prepared in advance of the cast application. Have the padding and stockinette rolls ready as well as the plaster.

• Overestimate the amount of materials to have on hand; often the person applying the cast will use extra supplies to shape or reinforce the cast.

• Be sure that sharp scissors are available to cut the plaster if needed.

• If client complains of tingling, numbness, pain, or smell at the site of the cast, report these immediately to the physician or qualified practitioner.

• Continue to talk to the client during the procedure to assess his response to the procedure and to decrease anxiety.

• If family or friends stay with the client, educate them in advance on what to expect during the procedure. Keep an eye on them for signs of dizziness or emotional upset, and assist as needed. Remind them to stay sitting down during the procedure, and to request help if they start to feel “funny.”

• Do not dispose of plaster or plaster water in a regular sink, as it can clog the plumbing. Dispose of it following institutional policy.

CAST CARE AND COMFORT

OVERVIEW OF THE SKILL

A cast is placed on a fractured or dislocated bone or soft tissue injury for six to eight weeks in order to provide stabilization while it heals. Casts are made of plaster of Paris or of fiberglass. Casts covering forearms or lower legs are called short arm or short leg casts. A long leg cast covers the entire leg and a hanging cast covers the entire arm. A body cast covers the chest and abdomen and the Minerva cast covers the chest, neck, and head with openings for the ears, face, and arms. The spica or hip spica cast covers the hips and one or both legs. A cast should fit snugly and support the fracture. It may be changed several times during the healing process if reduction in swelling or loss of muscle tone causes it to become too loose. During the first 24 hours after the application of a cast, edema can create a tourniquet effect and inhibit circulation to the tissue, which can cause irreversible damage. The abdominal area can also expand as a result of eating or drinking. The nurse should assess the cast site for healing and/or irritation to the skin. The skin under a cast may need special care, such as with an open wound, an infection, or a surgical incision. A window can be cut in the cast to facilitate skin care, to relieve discomfort over a bony prominence, to relieve nerve compression, or to reduce the weight of a cast.

ASSESSMENT

1. Assess the circulation, movement, and sensation every eight hours because changes in circulation, sensation, and movement may signal the development of compartmental syndrome, a medical emergency.

2. Assess for color, temperature, edema, pain, skin irritation, capillary refill, and drainage. These changes may indicate that edema is causing restriction of circulation.

3. Assess for severe pain over bony prominences in order to prevent the risk of skin ulceration.

4. Assess the condition of the cast in order to determine need for client education.

5. Assess the skin for bruising, abrasion, or incision in order to monitor for discomfort, infection, drainage, or skin breakdown.

6. Assess the client’s understanding of the cast and its care so that client education can be tailored to his needs. >

DIAGNOSIS

Impaired Skin Integrity

Impaired Physical Mobility

Pain

Altered Tissue Perfusion

PLANNING

Expected Outcomes:

1. There will be no vascular compromise to the client while the cast is in place.

2. The cast will remain intact.

3. The client will be comfortable while the cast is in place.

Equipment Needed:

• Tape

• Pen to mark drainage

• Padding

CLIENT EDUCATION NEEDED:

1. Teach isometric exercises to prevent muscle atrophy.

2. Instruct client regarding skin care while the cast is in place.

3. Instruct the client to keep the cast dry.

4. Teach the client to report a cast that “doesn’t feel right.” Ignoring it may lead to skin breakdown.

5. Teach the client to report any foul odor because it may indicate skin breakdown or infection under the cast.

6. Use an oversized cotton glove on a forearm fiberglass cast when doing gardening or housework to keep the edges clean.

7. Never try to clean the edges of a cast or remove dirty edges because of the risk of removing the necessary padding.

8. Reassure clients that they may be able to do more activities such as tying their shoes or combing their hair as they become accustomed to the cast and as the swelling resolves.

9. Remind the client that premature removal of a cast can lead to dysfunction of the extremity and increased pain by delaying healing.

EVALUATION

• There is no vascular compromise to the client while the cast is in place.

• The cast remains intact.

• The client is comfortable while the cast is in place. >

DOCUMENTATION

Nurses’Notes

• Document condition of skin, circulation, and neurovascular assessment. >

CRITICAL THINKING SKILL

Introduction Clients may complain of itching of the skin under a cast. Care should be taken to prevent skin breakdown while attempting to relieve the itching.

Possible Scenario A man with a cast complained of itching of the skin under his short arm cast, so he tied cotton twill tape to a wire and ran it through the cast. He removed the wire and then looped the twill tape and tied the ends together. When the itching bothered him, he tugged on the tape to pull it in a circle so it would gently scratch the itchy spot.

Possible Outcome The wire scratched his skin slightly as he pulled it through the cast and the twill tape irritated the skin more as he pulled it to relieve the itching. The skin began to break down and the padding was curled up with the tape movement.

Prevention Clients should be instructed about what objects may or may not be allowed between the skin and the cast.Medication may be needed to control itching.

NURSING TIPS

• Place a bedboard under the mattress of a client with a spica cast to provide firm support.

• Use a pen to mark drainage on the cast and write the date and time.

• Do not use a hair dryer to speed plaster cast drying because it may cause cracks.

• Check cast protection devices such as rubber bands used around plastic bags to be sure they do not act like a tourniquet.

CAST BIVALVING AND WINDOWING

OVERVIEW OF THE SKILL

Bivalving, or windowing a cast, is done to improve circulation, allow for skin care, and relieve pressure, while continuing to maintain alignment of the bones for proper healing. Bivalving or windowing can occur immediately, or with an older cast on a fracture that is partially healed. Edema is very common after surgery or after a traumatic injury to a limb. During the first 24 hours after the application of a cast, edema can create a tourniquet effect and inhibit circulation to the tissue. This can cause irreversible damage. The abdominal area can also expand as a result of eating. Sometimes the skin under a cast needs care—an open wound, an infection, or a surgical incision, for example. Finally, discomfort and skin breakdown over a bony prominence, nerve compression, and discomfort due to the weight of the cast are all reasons for bivalving or cutting a window in the cast. >

ASSESSMENT

1. After a cast has been applied, assess circulation, movement, and sensation q1 hour 3 4, q2 hour 3 4, q4 hours 3 4, then q8 hours 3 24. Changes in circulation, sensation, and movement (CSM) may indicate the development of compartmental syndrome, which would require immediate medical attention.

2. Assess pain, color, temperature, sensation, edema, pain, skin irritation from the cast, capillary refill and drainage. Changes in these parameters could indicate that edema is causing a restriction in circulation. Calling the physician or qualified practitioner immediately if any of these parameters changes significantly is crucial to prevent further tissue damage.

3. Pain that is severe and unrelieved by medication or by repositioning, and is not proportional to the severity of the injury, requires immediate investigation by the physician or qualified practitioner. This could signal the development of a compartmental syndrome.

4. Assess for severe pain over bony prominences (which can be a warning signal of a pressure sore), odor,or drainage on the cast. These symptoms can indicate skin breakdown or infection under the cast. >

DIAGNOSIS

Pain

Risk for Impaired Skin Integrity

Altered Tissue Perfusion

PLANNING

Expected Outcome:

1. If the purpose of the procedure is to relieve pressure, complaints and signs of pressure will diminish.

2. If the purpose of the procedure is to expose the underlying skin, then the correct area will be exposed.

3. The cast will not be cracked or damaged during the procedure.

Equipment Needed (see Figure 10-12-2):

• Cast cutter

• Cast spreaders

• Bandage scissors

• Surgical or plaster knife

CLIENT EDUCATION NEEDED:

1. Inform the client why the cast is being modified.

2. Explain that the cast cutter sounds and looks like a small saw, but is only a vibrating machine and will not cut the skin or do painful damage. Explain that the scissors being used are designed not to cut the skin.

3. Demonstrate the action of the blade against the palm of your hand showing that it will not hurt. Demonstrate the scissors being used.

4. Explain that after the cast is modified, it will not harm the alignment of the fracture and will continue to give proper support so that healing will occur.

EVALUATION

• If the purpose of the procedure was to relieve pressure, complaints and signs of pressure have diminished.

• If the purpose of the procedure was to expose the underlying skin, then the correct area was exposed.

• The cast was not cracked or damaged during the procedure.

DOCUMENTATION

Nurses’Notes

• Indicate the signs and symptoms that preceded the cast cutting, and the neurovascular and skin evaluation following the event.

CRITICAL THINKING SKILL

Introduction Decisions regarding cast alterations must be based on all available information.

Possible Scenario The client complained of post surgical pain in the right lower extremity, which increased significantly after getting up to ambulate 48 hours after surgery. Assessments were made including capillary refill, ability to move toes, color of toes, temperature, drainage, etc., which all appeared to be normal and unchanged. The pain was relieved by elevation and ice. The nurse practitioner, erring on the side of caution, bivalved the cast anyway.

Possible Outcome The cast was bivalved unnecessarily. The physician opted to replace the cast prior to the client’s discharge the next day.

Prevention Assessment must include all the information available. The surgical report, neurovascular status, fever, pain, drainage, and the overall condition of the client must be taken into consideration to form an overall picture prior to implementing any procedure. If the pain did not subside and there were other abnormal findings upon assessment, then further investigation by the physician or nurse practitioner would have been necessary.

NURSING TIPS

• Make sure cast is lined with soft material before cutting it.

• Fully describe the procedure to the client.

• Premedicate as needed.

• Familiarize yourself with all the tools and equipment prior to implementing the procedure.

• Assessment of the client is imperative.

CAST REMOVAL

OVERVIEW OF THE SKILL A cast is placed on a fracture generally for a time frame of six to eight weeks. A cast should fit snugly and support the fracture and may be changed several times during the healing process, as reductions in swelling or loss of muscle tone cause it to become loose. Removal of the cast involves taking off the cast and instructing clients what to expect when the cast is removed (and possible replacement of the cast). Assess the cast site for healing and/or irritation to the skin. If the cast is fairly new and is being replaced, assess for condition, length of time the cast has been on, and the need for further client education in the care of the cast. If the cast has been replaced several times already and is now being removed permanently, the client will already be familiar with the procedures, while clients with new casts being replaced will need information on what procedures will be done. Once the case is off, check the injury site for signs of healing, continued problems, or new problems at the injury site.

ASSESSMENT

1. Determine if the client is having the cast removed for good or if a new cast is being applied. Knowing this information will assist you in having the proper supplies available during the cast removal and the amount of information the client will need about the procedures.

2. Determine if there is any suspected disruption in skin integrity under the cast. This will determine how carefully the cast needs to be removed, and what skin care will be needed. It may affect how a cast is reapplied.

3. Determine how many weeks the fracture has been healing. This will determine how carefully the cast needs to be removed.

4. Determine the condition of the cast. This will tell you how much additional client education is necessary if the cast is being replaced and was not being properly cared for.

5. If this is a final cast removal do a range of motion and muscle strength test. This will give you an idea of what further care and rehabilitation the client will need. The client may need assistance moving without the cast.

DIAGNOSIS

Impaired Skin Integrity

Impaired Physical Mobility

Pain

PLANNING

Expected Outcomes:

1. Cast will be removed successfully from the client.

2. Client will remain safe after the removal of the cast.

3. Proper equipment will be given to the client on discharge.

Equipment Needed (see Figure 10-13-2):

• Cast removal saw

• Protective towel or waterproof pad

• Bandage scissors

• Cast splitter

• Water, washcloth, towels, basin, or sink

CLIENT EDUCATION NEEDED:

1. Educate the client that the saw is noisy.

2. Educate the client that he will feel warmth and vibration, but the saw will not cut the skin.

3. Demonstrate by holding the saw against the skin.

4. Educate the client on the need to hold the cast still.

5. Educate the client on how the affected limb will look and feel after the cast is removed. Remind the client that the skin will be pale and thin looking, hair growth may have occurred, and there might be a buildup of dead skin cells.

6. Caution the client that the area might feel tender and the muscles previously under the cast might feel weak.

7. Review cast care instructions with the client if there is any evidence of improper care or signs that the client has tampered with the cast.

8. Educate the client after cast removal on the care of the skin and the use of affected area.

9. During early stages of healing, cast manipulation may cause the injury to ache, even though it has not been painful before manipulation. Discuss pain control techniques, elevation, and restricting range of movement with the client.

EVALUATION

• Cast was removed successfully from the client.

• Client remains safe after the removal of the cast.

• Proper equipment was given to the client on discharge.

DOCUMENTATION

Nurses’Notes

• Document what type of cast was removed and where it was removed.

• Make a notation on how the extremity looks, its range of motion, and strength.

• Document any specific aids that the client will use after cast removal, e.g., slings, immobilizers, and crutches.

CRITICAL THINKING SKILL

Introduction Nurses must be able to evaluate range of motion and muscle strength of an extremity.

Possible Scenario Your client has a cast removed from his leg. You are called out of the room before you can assess the range of motion or strength of the extremity. The client decides he needs a drink of water and gets off the table.

Possible Outcome The client falls and refractures the leg.

Prevention Client teaching about decreased use of the fractured extremity is important. You should evaluate strength and range of motion of extremity and communicate results with the client.

NURSING TIPS

• The saw is loud; prepare your client for its sound.

• Assure the client that the saw will not cut him.

• Save the cast, especially for children; they may want it for a souvenir.

ASSISTING WITH A CONTINUOUS PASSIVE MOTION DEVICE

OVERVIEW OF THE SKILL

Clients recovering from surgical procedures to synovial joints, fractures, contractures, and general immobility may benefit from continuous passive motion (CPM). CPM facilitates joint range of motion (ROM), promotes wound healing, prevents formation of adhesions, decreases edema, and decreases the effects of immobility. The parameters of the CPM device include the amount of time it is to be used each day, the amount of ROM prescribed, and the speed of passive movement generated by the unit. The CPM device includes a single-use client softgoods kit to comfortably position the involved extremity in the unit. The unit also has a stop and go switch so the client can turn off the unit if extreme discomfort is produced. There are many different types and models of CPM units available, so be sure to familiarize yourself with the softgoods kit and the control parameters of your unit before attempting to apply it to the client. Neurovascular assessment of the client using the CPM unit is essential. This assessment confirms that the client’s vascular and neural structures are not compromised by postsurgical complications, client positioning in the unit, or by excessive ROM positions during the procedure. The presence of edema in the involved extremity may greatly limit the ability of the client to achieve prescribed ROM goals. Therefore edema must be monitored and adjustments made accordingly to unit control settings. Any indications of vessel disease, thrombophlebitis, or infections must be noted and cleared with the physician or qualified practitioner prior to administration.

ASSESSMENT

1. Assess orders for CPM usage including frequency, duration, degree of range of motion (ROM), and restrictions to ROM for the involved extremity to verify that the correct procedure is being followed.

2. Neurovascular assessment of the involved extremity prior to the start of CPM usage includes sensation,skin color, temperature, presence of pulses, and presence of edema and reflexes, especially deep tendon reflexes (DTR).Establishes a baseline for future comparisons.

3. Assess movement of the involved extremity to determine if the procedure is appropriate.

4. Pay attention to client’s report of pain and discomfort. Pain assessment is helpful in reports to the physician or qualified practitioner to determine if treatment is appropriate.

DIAGNOSIS

Impaired Physical Mobility

Activity Intolerance

PLANNING

Expected Outcomes:

1. Will facilitate joint range of motion, minimal to eventually optimal, depending on client’s potential for development.

2. Will promote wound healing.

3. Will prevent formation of adhesions.

4. Edema, both peripheral and central will decrease.

5. Effects of immobility will decrease.

Equipment Needed:

• CPM device

• CPM softgoods

• Tape measure

• Goniometer

CLIENT EDUCATION NEEDED:

1. Client should understand reason for and use of CPM.

2. Client should understand plan to increase duration, speed, and ROM of CPM.

3. Client should understand use of CPM stop and go button.

4. Client should understand signs and symptoms to report related effects or changes in physical condition.

EVALUATION

• Facilitates joint range of motion, minimal to eventually optimal, depending on client’s potential for development.

• Promoted wound healing.

• Prevented formation of adhesions.

• Edema, both peripheral and central was decreased.

• Effects of immobility were decreased.

DOCUMENTATION

Nurses’Notes

• Duration of CPM usage, including start and stop time

• CPM control parameters used, including ROM achieved

• Client’s tolerance of procedure

• Neurovascular status of client’s involved extremity

• Skin integrity

CRITICAL THINKING SKILL

Introduction Client understanding and cooperation is essential to the use of the CPM machine.

Possible Scenario Mrs. Frank has just returned to the unit following knee surgery with orders for a CPM machine. As you place the machine and explain its purpose you note that Mrs. Frank is still sleepy. Mrs. Frank’s knee and leg remain in good alignment during the routine postoperative checks and she is resting quietly. After the routine postoperative checks are completed, another patient returns from surgery, and it is several hours before you check on Mrs. Frank again. When you do return to check on Mrs. Frank you find that she has tried to roll over in her sleep. Because she is still groggy she didn’t realize the CPM machine was in place and she has twisted her leg sideways in the machine. Her leg is now out of alignment and rubbing against the hinge of the machine.

Possible Outcome Mrs. Frank has an open area where her leg has been rubbing against the hinge resulting in a prolonged recovery time and unnecessary pain.

Prevention Be sure the client is capable of understanding the reasons for the CPM machine and cooperating with its use. Wait until the client is more attentive or have a family member stay at the bedside to watch the client.

NURSING TIPS

• Familiarize yourself with the CPM unit prior to applying it to a client.

• Make sure client’s involved extremity is correctly and comfortably positioned in CPM unit.

• Make sure client’s joints correctly align with the CPM’s hinge joints.

• Check control settings prior to applying CPM to client.

• Regularly monitor neurovascular status of client’s involved extremity.

• Measure, such as with goniometer, the effects of care over time.

ASSISTING WITH CRUTCHES, CANE, OR WALKER

OVERVIEW OF THE SKILL Independence is an important part of a client’s recovery process. Being able to move about in the environment can spell the difference between living at home and living in a health care facility. Being able to move independently improves a client’s emotional, mental, and physical well-being. Client’s who cannot safely walk unassisted can use devices designed to aid them in walking independently. The three most common devices used are crutches, canes, and walkers. The appropriate device for each client is determined by the client’s physician, qualified provider, physical therapist, or nurse. Often these caregivers work together to determine which device works best for the client. This decision is based on the client’s ability to bear weight on his legs, his upper arm strength, his stamina, and the presence or absence of weakness on one side. Crutches can be used by clients who cannot bear any weight on one leg, clients who can only bear partial weight on one leg, and clients who have full weight bearing on both legs. There are several types of crutches available, depending on the length of time the client will require the assistance and the client’s upper body strength. A cane is used by clients who can bear weight on both legs but one leg or hip is weaker or impaired. There are several types of canes as well. The standard, straight cane is used most often. There are also canes with three or four legs on the end to increase a client’s stability as he walks. Walkers are used by clients who require more support than a cane provides. Walkers are available with or without wheels.Walkers without wheels provide the most stability but they must be lifted with each step. Walkers with wheels are somewhat less stable but a client who does not have the upper body strength to lift the walker repeatedly can push it along while walking.Mobility is an important part of everyone’s life. The ability to get around can contribute greatly to a client’s well-being.

ASSESSMENT

1. Assess the reason the client requires an assistive device. Is it a long-term need or a short-term need? This helps determine which device to use.

2. Assess the client’s physical limitations. How much weight is the client able to bear? Can he bear weight on both legs or just one? Is his upper body strength good? Does he tire easily? Safety and comfort assessment.

3. Assess the client’s physical environment. Is he at home or in a medical facility? Is his environment suited to his assistive needs and the assistive device he will be using? Are the hallways wide enough? Well lit? Are the doorways wide enough? Do the doors swing open far enough? Safety and comfort assessment.

4. Assess the client’s ability to understand and follow directions regarding use of an assistive device. Can he understand the instructions? Can he remember them? Has he used this device in the past? Is there a language barrier that might limit understanding? Safety, educational, comfort, and effectiveness assessment.

DIAGNOSIS

Impaired Physical Mobility

Risk for Trauma

Knowledge Deficit, related to using assistive devices for mobility

PLANNING

Expected Outcomes:

1. The client will be able to demonstrate safe and independent ambulation with the assistance of crutches, a cane, or a walker.

2. The client will feel confident and safe while using the assistive device.

Equipment Needed (see Figure 10-15-2):

• Gait belt

• Assistive device: crutches, cane or walker

CLIENT EDUCATION NEEDED:

1. Reinforce teaching regarding holding a cane on the “good” side rather than the weak side.

2. Teach the client not to allow the crutch pad to rest in the axilla. This can cause damage to the client’s arm.

3. If the client’s walker has wheels, teach the client not to let the walker get too far ahead of his centre of gravity.

EVALUATION

• Assess if the client is able to demonstrate safe and independent ambulation with the assistance of crutches, a cane, or a walker.

• Assess if the client feels confident and safe while using the assistive device.

DOCUMENTATION

Nurses’Notes

• Document the type of device the client is using, the level of understanding regarding the use of the device, how far the client is able to walk using the device, and the client’s response to the activity.

Kardex

• Any information that is pertinent to nurses or therapists regarding type of device or a particular client’s needs should be noted.

CRITICAL THINKING SKILL

Introduction Cane to good side not bad side.

Possible Scenario While assisting Mr. Lujan to ambulate using his cane, you note that he is holding the cane on his weaker side.

Possible Outcome If Mr. Lujan also has weakness in his arm on that side he is at greater risk for falling. His weaker arm will tire more easily and is more likely to give way. By keeping the cane close to the weaker foot, Mr. Lujan is using the cane as a substitute limb. This does not help strengthen the weak leg through use. It also negates any wide-stance stabilizing effect from the cane. This is a safety concern as it puts Mr. Lujan at risk of falling.

Prevention The cane is present to increase stability, not to act as a replacement limb. By holding the cane on the stronger side the client has more control and strength for using it. Also the client has a 3-point, wider stance with the cane and the affected leg farther apart. The wider stance promotes stability and good body mechanics. By using the cane as a replacement limb, Mr. Lujan does not get any strengthening benefit in his weaker leg. By using the cane for stability, Mr. Lujan’s weaker leg can gain strength through use.

NURSING TIPS

• Be sure there is about 2 inches or 3 fingers width of distance between the client’s axilla and the top of the crutch.

• Be sure the client is holding his cane on the good side for optimal effect.

• Be sure that the client’s walker is just below waist level. This allows the client’s arms to be slightly bent when standing in the walker. This is a stronger arm position than with the arms totally straight.

• Check the rubber tips on all assistive devices frequently. They can become worn quickly.Worn rubber tips can lead to instability and falls.

• When measuring the height of a cane be sure the client stands erect, not hunched or bent over.

• When teaching a client to stand up prior to using a walker have him use the armrest on the chair not the walker, for support. The walker is less stable and the client could pull it over.

• Provide a robe or other covering and shoes with firm, nonslip soles to provide for modesty and safety.

• Label the client’s equipment so he will not wind up with equipment measured for another person.