Question

Janice Watts, a 24-year-old female client, is admitted after a motor vehicle crash for a closed reduction of the left fibula and tibia fractures and application of a cylinder plaster cast because of the edema present. The client had previously used crutches and has a pair of crutches. She will be non–weight-bearing. The vital signs are T, 98° F; BP, 120/70 mm Hg; HR, 78 beats/ minute; RR, 20 breaths/minute. She stated the pain is relieved after the narcotic analgesic was provided 30 minutes earlier and that she is comfortable. The client had suffered a concussion as well and will remain in the hospital for the next 24 hours. The client has no known allergies. She has no previous hospitalizations and does not take any medications. The LPN/LVN will need to take care of the client after she has the cast applied in the casting room.

Questions:

1. What nursing management is needed right after a plaster cast has been applied? (Learning Objective 1)
2. Four hours after the client arrived to the orthopedic floor she complains that her leg and foot hurts more than before the cast was applied. She rates the pain 10/10 despite having pain medication 30 minutes earlier. She has numbness and tingling in the leg. What is probably happening? (Learning Objective 3)
3. What should the LPN/LVN do? (Learning Objective 3)

Answer 1

Janice Watts who is 24year old met with a road traffic accident and had fracture of tibia and fibula, admitted to hospital.As there is edema in the fractured leg cylindrical cast has been applied. She also had concussion and will be remained in hospital. As per data available her vital signs are stable and pain is relieved by narcotic analgesic and she is comfortable. She has a pair of crutches with her.

1) The immediate nursing management as follows

- Cast takes 24-48 hours to dry completely so have to take extra care.

- Leg should be properly positioned to prevent surface depression.

- Limb elevation to be given with pillow to reduce edema.

- Regularly monitor distal part for bluish discolouration and check pulse and sensation.

- Watch for blood spots over cast may be caused due to bleeding .

- Patient may feel discomfortand itching inside the cast, in such case any foreign objects should not be put inside.

- Avoid depression over cast as it will create pressure points.

- patient should take bed rest as she had concussion and narcotic analgesics and regularly check for vital signs.

- Watch for warning signs like sudden increase of pain and altered sensorium.

- Walking with crutches may be allowed under supervision.

- Cast shouldnot be painted and should be kept dry.

2) After 4 hours Janice Watts complaints of severe pain and tingling sensation which may be caused due to compartment syndrome.

- The nurse should assess vital signs and record it.

- Check Dorsalis pedis pulse, and sensation distal to cast.

- inform the treating doctor.

- Cast may be removed.

Compartment syndrome

It is a life threatning condition in which pressure builds in muscles, mainly caused due to bleeding or collection of fluids following injury. Fluids compress the adjecent vessels and nerves which causes pain and loss of sensation. ( in this case client had oedema when she brought to hospital)

The symptoms of compartment syndrome include Pain, Pallor(pale),Parasthesia(numbness),Pulselessness, Paralysis(weakness). 5P's

Compartment syndrome may occur in 2-9%approximately in lower limb cast.

The cast should be removed immediately and limb elevation to be given.

If symptoms persists Fasciotomy to be done.( Surgically opening of the skin and draining the fluid/blood and thus relieving the pressure).