Cast Care in Neonates

Definition

Cast care in neonates refers to the specialized management and monitoring of orthopedic casts applied to newborns for conditions such as fractures or congenital musculoskeletal disorders. It involves skin protection, neurovascular assessments, hygiene maintenance, and ensuring proper positioning to prevent complications and promote healing.

Key Aspects of Neonatal Cast Care

• Parental Education: Teaching caregivers about proper cast care at home.
• Skin Integrity: Preventing pressure sores and irritation.
• Neurovascular Monitoring: Ensuring adequate circulation and sensation.
• Hygiene Maintenance: Keeping the cast dry and clean.
• Positioning and Comfort: Elevating the limb to reduce swelling.

Materials Used for Cast Application

• Gauze strips and bandages impregnated with plaster of Paris.
• Synthetic lightweight, water-resistant materials (e.g., fiber glass and polyurethane resin).

Types of Casts Used in Neonates

• Plaster Casts: Traditional but heavier; used for immobilization.
• Fiberglass Casts: Lightweight and more durable; allows better X-ray visibility.
• Spica Casts: Used for hip dysplasia or femur fractures.

Preparation

• Before cast application, perform baseline neurovascular assessment for comparison after immobilization. Following are to be included:
• Color (note cyanosis or other discoloration).
• Movement (note inability to move fingers or toes).
• Sensation (note whether loss of sensation is present).
• Premedicate as ordered to reduce pain when manual traction is applied to align the bone.

Procedure

• A nurse may assist in cast application by holding the extremity in alignment.
• A tube of stockinette is stretched over the area to be casted and bony prominences are padded with soft cotton sheeting.
• Dry rolls of gauze impregnated with the open end of the roll angled downward to allow soaking of the bandage.
• The wet plaster rolls are applied in bandage fashion and molded to the extremity.
• A heat-producing chemical reaction occurs between the plaster and water as plaster becomes a crystalline gypsum.
• During application of the cast, the underlying stockinette is pulled over the raw edges of the cast and secured with a layer of wet plaster 1-2.5 cm below the rim to form a smooth, padded edge to protect skin.

Post procedure Care

• The cast must remain uncovered to allow it to dry from the inside out.
• Turning the baby in a plaster cast at least every 2 hours will help to dry a body cast evenly and prevent complications related to immobility.
• Position the baby with casted extremity elevated on pillows.
• Use of a regular fan or a hair dryer on the cool setting to circulate air may be helpful when the humidity is high.
• A wet plaster cast should be handled using the palms of the hands to prevent indenting the cast and creating pressure areas and should be supported by a pillow covered with plastic.
• The cast and involved extremity are observed frequently to assess neurovascular integrity and detect any signs of compromise.

Nursing Considerations

• A dry plaster of Paris can produce a hollow sound when tapped with the finger.
• During the first few hours after a cast is applied, the chief concern is that the extremity may continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and producing neurovascular complications.
• One measure to reduce the likelihood of this potential problem is to elevate the body part and thereby increase venous return.
• If edema is excessive, casts are bivalved (cut to make anterior and posterior halves that are held together with elastic bandage).
• Once the cast has dried, “hot spots” felt on the cast surface or foul-smelling areas of the cast may indicate infection underneath and should be further evaluated. Often the cast is windowed over the area of suspicion to directly observe and treat the area if necessary.
• When a cast is applied to an extremity that has sustained an open fracture, a window is often left over the wound area to allow for observation and dressing of the wound.

Assisting with Cast Removal

Newborn may be frightened by cast removal. Prepare the newborn

• The cast cutter will make a loud noise.
• The skin or extremity will not be injured (demonstrate by touching the cast cutter lightly to your palm).
• The newborn will feel warmth or vibration during cast removal.

Home Care of Baby with Cast

Caring for a baby with a cast at home requires gentle handling, monitoring for complications, and ensuring comfort. Here are some essential tips:

1. Keeping the Cast Dry

• Avoid water exposure: Use plastic covers during baths.
• Check for moisture: If the cast gets wet, dry it with a hairdryer on a cool setting.

2. Monitoring for Swelling or Discomfort

• Elevate the limb: Helps reduce swelling, especially in the first few days.
• Check circulation: Observe for cold toes/fingers, discoloration, or numbness.

3. Preventing Skin Irritation

• Avoid inserting objects: Do not put anything inside the cast to scratch.
• Use a hairdryer on cool: Helps relieve itching.

4. Ensuring Proper Hygiene

• Keep the cast clean: Prevent dirt and food from getting inside.
• Check for odors: Foul smells may indicate infection or trapped moisture.

5. Encouraging Safe Mobility

• Support movement: Assist with repositioning to prevent stiffness.
• Use soft padding: Helps prevent pressure sores.

6. Educating Caregivers

• Watch for warning signs: Increased pain, swelling, or foul odor.
• Follow-up appointments: Ensure timely check-ups for cast removal.

Call the physician if:

• The casted extremity is cool to touch.
• The child cannot move the fingers or toes.
• Severe pain occurs when the child attempts to move the fingers or toes.
• Persistent numbness or tingling occurs.
• There is drainage or a foul smell comes from the cast.
• Severe itching occurs inside the cast.
• The child runs a high fever >101°F for longer than 24 hours.
• Skin edges are red and swollen or exhibit breakdown.
• The cast gets wet or cracked, split or softened.

Special Considerations

• Avoid Wetting the Cast: Moisture can weaken the cast and cause skin irritation.
• Monitor for Tightness: Swelling can make the cast too tight, requiring medical attention.
• Assist with Mobility: Encourage gentle movement of unaffected limbs to prevent stiffness

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
6. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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