Casts care in Paediatrics

Cast Application

Casts Care: casts are constructed of a hard material (traditionally plaster), which is used to immobilize a bone that has been injured or a diseased joint.

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

• Long leg cast (LLC)
• Short leg cast (SLC)
• Bilateral LLC
• Full spica cast
• 11/2 spica cast
• Single spica
• Short arm cast (SAC)
• Long arm cast (LAC)

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)
• Edema
• Quality of pulses.
• Obtain cooperation from the child and reduce his/her anxiety by showing the child the cast materials and using an age-appropriate approach to describe cast application.
  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 child 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 child 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.
• Teach the child to use crutches in case of lower extremity immobilization so that the child can maintain mobility.

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

Children may be frightened by cast removal. Prepare the child using age-appropriate terminology:

• 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 child will feel warmth or vibration during cast removal.

Home Care Management of Child with Cast

• For the first 48 hours, elevate the extremity above the level of the heart and apply cold therapy for 20-30 minutes, then after 1 hour and repeat.
• Assess for swelling and have the child wiggle the fingers or toes hourly.
• For itching inside the cast:
• Never insert anything into the cast for the purposes of scratching.
• Blow cool air in from a hair dryer set on the lowest setting.
• Do not use lotions or powders.
• Check the skin at the cast edges daily for irritation.
• Protect the cast from wetness.
• Apply a plastic bag around cast and tape securely for bathing or showering.
• 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.

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. 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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