Steps

Rationale/Points of Emphasis

1 Perform hand hygiene. Don gloves if necessary.

Reduces transmission of microorganisms.

2a Assess the child for pain using an age-appropriate measure.

Pain assessment is completed concurrently with all other assessments to determine if palpation and movement of the extremity elicit verbal and nonverbal indications of pain. Age-appropriate measures are needed to ensure reliability of data acquired. Some pain at fracture site is normal. Pain or burning sensation distal to the fracture may be associated with tissue ischemia. Pain on passive movement may indicate compartment syndrome, a condition that involves the compression of nerves and blood vessels within an enclosed space. This leads to impaired blood flow and muscle and nerve damage. Extreme pain, especially on passive motion, is the most significant subjective finding of probable neurovascular deficiency of the extremity. The pain usually becomes more severe even with the use of narcotics.

2b Use pharmacologic and biobehavioral pain management interventions (see Chapter 7 ).

Pain management techniques should not be limited to a single intervention. Combining pharmacologic relief with measures such as distraction, position changes, and massage will provide the most effective pain relief. Cold therapy and elevation of the extremity can reduce pain, especially after the child has been active. Pain that is progressive, out of proportion to the type of injury, or not relieved by analgesia or with ice and elevation may be indicative of compartment syndrome and requires immediate attention.

3a Perform neurovascular assessment (see Chapter 3 ).

Promotes early identification of and intervention to compromised circulation and oxygenation of tissues.

3b Assess pulses above and below the injured area.

Gradual weakening or absent pulse may indicate compartment syndrome. Absence of pulse is a late symptom. Subtle nagging change will often indicate an impending complication at its earliest stage. Neurovascular impairment is most often caused by pressure on the nerve or vascular supply to an extremity. Assessment of both extremities will give a baseline for comparison.

3c Assess capillary refill by pressing on child’s fingers and toes and observing time of capillary refill.

Normal capillary refill is 1 to 2 sec. A delayed capillary refill may indicate insufficient circulation to the distal extremity and/or compartment syndrome. Greater than 3 seconds is indicative of inadequate arterial supply. A cool room may cause the fingers and toes to be cool to the touch.

3d Determine sensation in extremities by gently touching the fingers and toes and by asking the child if he or she feels the sensation of your touch. Describe responses as absent, impaired, or normal.

Absence of sensation may indicate swelling beneath the cast or signs of a pressure sore. Changes in sensation may indicate paresthesia and are a sign of compartment syndrome. If a child’s nerves are intact, he or she should feel your touch at areas of innervation above and below the injury.

KidKare For the younger child, play a game like “Simon Says” to assess toe and finger sensation and mobility.

3e Assess motor function by having child move the fingers and toes. Direct the child to demonstrate flexion, extension, abduction, and adduction, if possible.

Motion distal to the fracture would be documented as normal range of motion, impaired, or absent. Pain during motor function activities is also noted. Muscle weakness may be caused by pressure within the muscle compartment and may result in loss of movement. With nerve damage comes the loss of sensation and loss of motion, which can damage muscle tissue. After 4 to 12 hours of ischemia, permanent and irreversible muscle damage can occur.

4a Perform skin assessment.

Promotes early identification of and interventions to prevent disruptions to skin integrity.

4b Assess and compare the color and temperature on both limbs; be sure to check above and below the injury site.

Skin that looks shiny and stretched or muscles that appear taut and bulging may indicate compartment syndrome. Tightness of the compartment may be experienced by the child and may also be palpated upon examination.

Temperature of a limb may be affected by a cool room or decreased body temperature, vasoconstriction, or peripheral edema. A pale or white skin color may indicate inadequate arterial supply to the area.

4c Assess swelling of fingers or toes distal to fracture or surgical site.

Swelling peaks within 24 to 48 hours. Swelling in the extremity may be indicative of inadequate venous return. Delay in attending to swelling, even for as little as 4 to 6 hours, can lead to compartment syndrome and partial or full paralysis.

4d Assess skin areas around cast edges every shift for irritation, rash, or skin breakdown.

Area around cast edges can break down because of rubbing on rough edges of cast.

4e Assess skin integrity over bony prominences for redness, tingling, and sensation.

Areas over the buttocks, back, and elbows are most vulnerable for any signs of skin irritation. Signs and symptoms of pressure sores include a burning sensation or pain, local heat, odor, staining through the cast, and pyrexia.

5a Implement interventions to promote skin integrity as indicated.

Prevents skin breakdown.

5b Petal cast edges with cloth tape or moleskin if they are rough (Figure 26-2).

• Cut several strips of adhesive tape or moleskin 3 to 4 inches in length. Use 1-inch tape for smaller areas.

• Round one end of each strip to keep the corners from rolling.

• Apply the first strip by tucking the straight end inside the cast and by bringing the rounded end over the cast edge to the outside.

• Repeat the procedure, overlapping each additional strip, until all rough edges are completely covered.

Decreases skin irritation and protects edges of cast from excessive wear.

5c If itching occurs, instruct the child to use one of the following techniques to relieve the itching:

• Blow cool air from a blow dryer into the cast.

• Rub the skin around the cast edges.

• Rub the opposite arm or leg.

• Tap on the cast over the itchy areas.

The child should never put anything down the cast to try to scratch an area because these objects may become stuck underneath the cast.

Figure 26-2 Petaling of cast.

5d Provide daily tub bath or sponge bath without getting cast wet. Wash fingers or toes near the cast with a damp washcloth.

Keeps accessible skin areas clean and may decrease skin irritation and itching. Even a fiberglass cast can irritate skin when wet.

5e Provide perineal care for children with casts extending close to genital area.

The casted area around the genital area is at high risk for contamination with urine and feces.

5f Use measures to protect cast from urine and feces (see Chart 26-1 ).

In the young child, this area can become contaminated by urine and feces if care is not taken. A wet cast will irritate the skin, soften, and fail to hold the leg and hip in the correct position. For the infant, a one-piece T-shirt with snaps in the crotch can be used to hold diapers in place.

caREminder

Do not cut a diaper to make it fit the groin opening of the cast; the raw edges of the diaper give off debris that can get under the cast and irritate the skin.

6a Assess integrity of the cast.

A cast that is not intact may impair healing.

6b Expose wet cast to room air to dry, elevating cast on pillows up to 4 inches above the level of the heart, handling the cast with only the palms of the hands.

Plaster casts take 24 to 48 hours to dry. Synthetic casts dry within 30 to 60 minutes. The larger and thicker the cast, the longer the drying time. Soft flexible surfaces protect the cast from heat entrapment and from becoming dented or flattened and thereby prevent pressure on bony prominences. Ensure pillows are not covered in a rubber or plastic material. Placing the newly applied cast on disposable pillows allows the heat to dissipate and allows the cast to air dry. High elevation of the limb can be harmful in some circumstances (such as compartment syndrome). An elevation of 4 inches is unlikely to interfere with oxygenation unless the circulation is fragile.

KidKare Having the child sit in a chair with his or her leg resting on a stool does not provide for adequate elevation of the leg above the heart. Using a bean bag chair with the injured leg elevated 4 inches above the level of the heart provides a comfortable seating alternative for the child.

6c Explain need for limited activity while the cast dries.

Angles of the cast must be maintained during the drying process to prevent pressure on bony prominences.

6d Inspect cast for cracks, softening, excessive flaking, or flattening.

A soft, flaking, or cracked cast will not give the needed support to maintain alignment of the fracture. Flaking and flattening of the cast can cause skin irritation and undue pressure on bony prominences.

6e Inspect cast for signs of drainage or odor from wound underneath cast, using a flashlight as needed to view the areas more effectively. Mark the circumference of the drainage on the cast.

After a surgical procedure, drainage may occur. Drainage or odors may be indicative of infection or foreign object imbedded under cast. Blood or drainage from the wound will stain a plaster cast. Marking the circumference provides a baseline parameter for future assessments.

6f Apply sodium bicarbonate (baking soda) to an odoriferous cast. Odor eaters can be taped to the cast to keep down odors.

Baking soda will help absorb body odors on cast.

6g Check to see that the cast is not too tight by running your finger inside the cast.

Neurovascular compromise, skin breakdown, and malalignment can occur if the cast is not fitting properly. A well-fitted cast has approximately a finger’s width of clearance between the cast and the child’s skin.

6h Clean the surface of the cast as needed. A cast made of plaster may be cleaned with a small amount of toothpaste or dry white cleanser on a slightly dampened cloth. Dry it with a hair dryer set on cool. Fiberglass casts can be cleaned with a damp cloth.

Keeps cast appearance clean. Use of a hair dryer on a hot setting can burn the skin.

6i Instruct child not to put items down the cast and not to scratch under the cast with an object.

Do not put anything inside the cast. Do not use hangers, knitting needles, pens, pencils, or any other object to scratch under the cast. Do not put powder down a cast because it will become moist and pasty inside the confines of the cast.

Items caught under the cast can lead to pressure sores.

7 Assist child to perform passive and active range of motion of all extremities at least every shift (see Chapter 95 ).

Prevents weakness in extremities and stiffness of joints. Assists to maintain functional ability of the extremities. With immobilization, there can be loss of muscle strength of up to 3% per day. Passive and active range-of-motion exercises should be completed three or four times a day. Exercises could include wiggling fingers/toes, bending elbow/knee, and moving the shoulders/hips.

8a Assist child to ambulate or perform vertical transfer as needed.

Children in casts should be encouraged to be up and out of bed once the cast has dried and pain is well-managed. Some leg casts are made for weight bearing so that the child may walk with or without crutches.

KidKare Reclining wheelchairs can be used to accommodate the child in a spica cast. Wagons can be used for smaller children to assist them to be more mobile.

8b If the child is cooperative and can bear weight with lower extremities, utilize mobility aids such as a walker, crutches, or walking boot to assist with ambulation. The walking boot should be worn during waking hours.

Provides child mechanisms to be more mobile.

8c If the child is not cooperative, use assistive devices such as friction-reducing devices and/or a mechanical lift to move or transfer the child.

Ensure the affected limb maintains good alignment at all times.

8d If the child has an impaired upper or lower extremity and weighs less than 35 lbs (15.9 kg), the caregiver may provide limb support while the child moves unassisted to the side of the bed. If the child weighs more than 35 lbs, then a limb support strap/sling with a mechanical lift is used to provide limb support while the child moves unassisted to the side of the bed (Waters et al., 2009).

If a caregiver is required to lift more than 35 lbs of a patient’s weight, then the patient is considered to be fully dependent and an assistive device should be used to move or lift the patient (Waters, et al., 2009).

9 Collaborate with the technician to provide teaching about crutch walking to the child.

Do not allow the child or another person to lift, kick, or hit anything with the cast. The cast must be handled carefully because it can be cracked or chipped. Extreme or forceful movements of the cast may cause injury to the already impaired limb.

Crutch teaching assists the child to learn correct method for using the equipment.

10 Provide diversional activities for the child on limited activity.

Activity level needs to be adjusted to the developmental level of the child.

11a Position the child for comfort.

A limb in a cast will weigh more and should be positioned for comfort and to prevent swelling of the extremity. Once the cast is dry, use pillows or rolled blankets to support cast on leg. Use sling to support arm cast. Elevate the child’s arm or leg no more than 4 inches above the level of the child’s heart.

11b Keep blankets from being pulled taut across an extremity.

Taut bed sheets can put pressure on the toes and cause poor mobility, circulation, and skin breakdown.

12 Implement interventions to prevent complications of immobility and promote healing.

Ongoing nursing activities focus on assessment and interventions for complications of immobility that include constipation, inadequate nutrition, and pulmonary stasis.

13 Notify healthcare provider of any abnormal findings.

Early identification of an abnormal finding is key in the prevention and treatment of complications of fractures. Subtle findings will often indicate an impending complication at the earliest stage.