Alexa-Rae P.

Zagado
BSN-III
NCM 104 – Skills Lab
Ma’am Calinawan, RN, MN
April 29, 2020

Assignment

1. Discuss the following diagnostic tests: EMG, CSF/synovial fluid determination/serum

electrolyte test.

2. Discuss and give the nursing management of the clients with the following alterations:
*casts, splints, bandages
*traction(skin and skeletal)
*crutches(single and double)

1. EMG Test:

Electromyography (EMG) is a diagnostic test that measures how well the muscles
respond to the electrical signals emitted to specialized nerve cells called motor nerves.

A doctor may order an EMG test if a person has symptoms of a muscular or neurological
condition, such as numbness or unexplained weakness in the limbs.
Doctors often conduct EMG tests in conjunction with nerve conduction velocity (NCV)
tests. An NCV test is another type of electrodiagnostic test that doctors can use to identify
damaged or impaired nerves.

EMG and NCV tests are safe procedures that pose little risk of serious side effects or
complications. However, they may cause discomfort and bruising at the entry point of the
needle.

Purpose:
Motor nerve cells, or neurons, transmit electrical signals from the central nervous system
to the muscles. The electrical signals from the nerves trigger muscle contractions. Motor
nerves control skeletal muscle activity, such as walking, speaking, and breathing.
Damaged or diseased muscle fibers do not function or respond to nerve impulses
appropriately.

If the motor nerves are damaged or diseased, they can send abnormal electrical signals to
the muscles.

A doctor may order an EMG test if a person has symptoms of a muscle or nerve
condition. Such symptoms may include:
• muscle weakness or stiffness
• muscle wasting
• twitching, cramping, or spasms
• loss of fine motor control
• difficulty speaking, chewing, or swallowing
• persistent pain in the feet, legs, arms, or hands
• numbness, tingling, or paralysis in the limbs

EMG tests also provide information that doctors can use to determine the location and
extent of muscle and nerve damage.

Procedure:
EMG is an outpatient procedure that can take place at a hospital or an office clinic.
Neurologists and physical medicine and rehabilitation physicians perform EMG tests.
Neurologists specialize in treating, diagnosing, and managing conditions affecting the
nervous system.
A neurologist can administer an EMG test alone or with the help of a specially trained
technician.

How to prepare
A neurologist will explain how the procedure works and what to expect during and after
the test. At this point, a person can bring up any questions they have with the neurologist.
A person should notify the neurologist if they:

• take any over-the-counter or prescription medications, especially blood thinners

• have a bleeding disorder
• have a cardiac defibrillator or pacemaker
To prepare for the test, a person should:
• Bathe or take a shower the night before or the morning of the test to remove
excess oil from the skin.
• Avoid applying lotions, creams, or body oils for a few days before the test.
• Dress in comfortable, loose-fitting clothes.
• Remove any jewelry, watches, eyewear, or other metal objects before the
procedure.

During the procedure:

The following sections describe what to expect from needle EMG and NCV tests.
Needle EMG procedure A needle EMG test measures how well the muscles respond to
electrical impulses. A neurologist or assisting technician will insert one or more thin,
sterile needles into the muscle. This may cause some minor discomfort in some people.

The needles detect the electrical activity of muscles at rest and while contracted.
The needle electrodes transmit this information to a device called an oscilloscope, which
displays electrical signals as waves.
Once the test is finished, the neurologist or technician will remove the needle or needles.
This test usually examines several nerves and muscles and lasts about 1 hour, but it may
take longer depending on how many nerves the neurologist wants to test.

NCV procedure:
A neurologist will most often administer an EMG test alongside an NCV test, according
to the National Institutes of Health (NIH).
An NCV test measures the strength and speed of electrical impulses as they move
through nerves. Doctors often use these results alongside those of an EMG test to get a
full picture of what is going on with a person’s nerves.

During an NCV test, the neurologist will ask a person to sit or lie down. Once the person
is ready, they will attach a recording electrode to the skin above the nerve or nerves under
investigation. They will attach a second electrode about 20 millimeters away. This
electrode emits low voltage electric shocks that activate the nerve.

Some people may experience mild discomfort during this part of the test. However, the
electric shocks should not cause pain, and any discomfort usually resolves once the test is
over.
The recording electrode detects the electrical impulse as it passes through the nerve and
transmits the response to a computer monitor.

After the procedure:

After an EMG test, the neurologist or technician will clean the skin, and a person should
be able to return to their normal activities.
However, they may experience some soreness and bruising for a few days afterward.

Risks:
EMG tests carry minimal risk of severe complications or side effects. However, many
people do experience muscle pain during or after a needle EMG.
Resting and taking over-the-counter pain relievers can help relieve muscle pain faster, but
this side effect usually resolves on its own within a few days.

In very rare cases, a person may experience swelling of the soft tissues (lymphedema) or
a skin infection near the puncture site after a needle EMG test.
Some people may experience more discomfort or pain during an NCV test.

In fact, in one 2014 study, researchers surveyed 200 people who received both EMG and
NCV tests, and 58.5% of them said that the NCV test was more uncomfortable.

Results:
If the neurologist who ordered the EMG test is present, they may review a person’s
results immediately. However, if a different healthcare professional administers the test,
the person will not get to see their results until they schedule a follow-up appointment
with their neurologist.
Both EMG and NCV tests can help doctors identify the underlying cause of any
neuromuscular symptoms.

EMG test results:

If the muscles are healthy, an EMG test should detect little electrical activity when the
muscle is relaxed.
A burst of electrical activity, or a “motor unit action potential,” appears when a nerve
stimulates a muscle contraction.
If an EMG test detects electrical activity in a relaxed muscle, it may be due to:
• neuropathy
• carpal tunnel syndrome
• inflammation of the muscle tissue (myositis)

If an EMG test shows sporadic, random activity during a muscle contraction, it may
indicate:
• amyotrophic lateral sclerosis
• spinal muscular atrophy
• carpal tunnel syndrome

EMG and NCV tests provide valuable information that doctors can use to diagnose
muscle and nerve conditions. Once they make a diagnosis, a doctor can recommend
different treatment options.

Cerebrospinal Fluid (CSF) Analysis:

Cerebrospinal fluid (CSF) analysis is a way of looking for conditions that affect your
brain and spine. It’s a series of laboratory tests performed on a sample of CSF. CSF is
the clear fluid that cushions and delivers nutrients to your central nervous system
(CNS). The CNS consists of the brain and spinal cord.

CSF is produced by the choroid plexus in the brain and then reabsorbed into your
bloodstream. The fluid is completely replaced every few hours. In addition to
delivering nutrients, CSF flows around your brain and spinal column, providing
protection and carrying away waste.
A CSF sample is commonly collected by performing a lumbar puncture, which is also
known as a spinal tap. An analysis of the sample involves the measurement of and
examination for:

• fluid pressure
• proteins
• glucose
• red blood cells
• white blood cells
• chemicals
• bacteria
• viruses
• other invasive organisms or foreign substances
•
Analysis can include:
• measurement of the physical characteristics and appearance of CSF
• chemical tests on substances found in your spinal fluid or comparisons to
levels of similar substances found in your blood
• cell counts and typing of any cells found in your CSF
• identification of any microorganisms that could cause infectious diseases

CSF is in direct contact with your brain and spine. So CSF analysis is more effective
than a blood test for understanding CNS symptoms. However, it’s more difficult to
obtain a spinal fluid sample than a blood sample. Entering the spinal canal with a
needle requires expert knowledge of the spine’s anatomy and a clear understanding
of any underlying brain or spinal conditions that might increase the risk of
complications from the procedure.

How CSF samples are taken:

A lumbar puncture generally takes less than 30 minutes. It’s performed by a doctor
who is specially trained to collect CSF.
CSF is usually taken from your lower back area, or the lumbar spine. It’s very
important to remain completely still during the procedure. This way you avoid
incorrect needle placement or trauma to your spine.

You may be seated and asked to lean over so that your spine is curled forward. Or
your doctor may have you may lie on your side with your spine curved and your
knees drawn up to the chest. Curving your spine makes a space between your bones
in the lower back.
Once you’re in position, your back is cleaned with a sterile solution. Iodine is often
used for cleaning. A sterile area is maintained throughout the procedure. This
reduces the risk of infection.

A numbing cream or spray is applied to your skin. Your doctor then injects
anesthetic. Once the site is fully numb, your doctor inserts a thin spinal needle
between two vertebrae. A special type of X-ray called fluoroscopy is sometimes used
to guide the needle.
First, the pressure inside the skull is measured using a manometer. Both high and
low CSF pressure can be signs of certain conditions.
Fluid samples are then taken through the needle. When fluid collection is complete,
the needle is removed. The puncture site is cleaned again. A bandage is applied.

You’ll be asked to remain lying down for about one hour. This reduces the risk of a
headache, which is a common side effect of the procedure.

Related procedures:
Sometimes a person can’t have a lumbar puncture because of a back deformity,
infection, or possible brain herniation. In these cases, a more invasive CSF collection
method that requires hospitalization might be used, such as one of the following:

• During a ventricular puncture, your doctor drills a hole into your skull and
inserts a needle directly into one of the ventricles of your brain.
• During a cisternal puncture, your doctor inserts a needle into the back of
your skull.
• A ventricular shunt or drain can collect CSF from a tube that your doctor
places in your brain. This is done to release high fluid pressure.
CSF collection is often combined with other procedures. For example, dye might be
inserted into your CSF for a myelogram. This is an X-ray or CT scan of your brain
and spine.

Risks of lumbar puncture:

This test requires a signed release that states you understand the risks of the
procedure.
Primary risks associated with lumbar puncture include:

• bleeding from the puncture site into the spinal fluid, which is called a
traumatic tap
• discomfort during and after the procedure
• an allergic reaction to the anesthetic
• an infection at the puncture site
• a headache after the test

People who take blood thinners have a heightened risk of bleeding. Lumbar

puncture is extremely dangerous for people who have clotting problems such as a
low platelet count, which is called thrombocytopenia.

There are serious additional risks if you have a brain mass, tumor, or abscess. These
conditions put pressure on your brain stem. A lumbar puncture could then
cause brain herniation to occur. This can result in brain damage or even death. Brain
herniation is a shifting of structures of the brain. It’s usually accompanied by high
intracranial pressure. The condition eventually cuts off blood supply to your brain.
This causes irreparable damage. The test won’t be done if a brain mass is suspected.
Cisternal and ventricular puncture methods carry additional risks. These risks
include:

• damage to your spinal cord or brain

• bleeding within your brain
• disturbance of the blood-brain barrier

Why the test is ordered:

CSF analysis may be ordered if you’ve had CNS trauma. It may also be used if you
have cancer and your doctor wants to see if the cancer has spread to the CNS. In
addition, CSF analysis may be ordered if you have one or more of the following
symptoms:

• severe, unremitting headache

• stiff neck
• hallucinations, confusion, or dementia
• seizures
• flu-like symptoms that persist or intensify
• fatigue, lethargy, or muscle weakness
• changes in consciousness
• severe nausea
• fever or rash
• light sensitivity
• numbness or tremor
• dizziness
• speaking difficulties
• trouble walking or poor coordination
• severe mood swings
• intractable clinical depression

Diseases detected by CSF analysis:

CSF analysis can accurately distinguish between a wide range of CNS diseases that
can otherwise be difficult to diagnose. Conditions found by CSF analysis include:

Infectious diseases:
Viruses, bacteria, fungi, and parasites can all infect the CNS. Certain infections can be
found by CSF analysis. Common CNS infections include:

• meningitis
• encephalitis
• tuberculosis
• fungal infections
• West Nile virus
• eastern equine encephalitis virus (EEEV)

Hemorrhaging:
Intracranial bleeding can be detected by CSF analysis. However, isolating the exact
cause of bleeding may require additional scans or tests. Common causes
include high blood pressure, stroke, or an aneurysm.

Immune response disorders:

CSF analysis can detect immune response disorders. The immune system can cause
damage to the CNS through inflammation, destruction of the myelin sheath around
the nerves, and antibody production.
Common diseases of this type include:
• Guillain-Barré syndrome
• sarcoidosis
• neurosyphilis
• multiple sclerosis

Tumors:
CSF analysis can detect primary tumors in the brain or spine. It can also detect
metastatic cancers that have spread to your CNS from other body parts.

CSF analysis and multiple sclerosis:

CSF analysis may also be used to help diagnose multiple sclerosis (MS). MS is a
chronic condition in which your immune system destroys the protective covering of
your nerves, which is called myelin. People with MS may have a variety of symptoms
that are constant or come and go. They include numbness or pain in their arms and
legs, vision problems, and trouble walking.

CSF analysis may be done to rule out other medical conditions that have symptoms
similar to MS. The fluid may also show signs that your immune system isn’t
functioning normally. This can include high levels of IgG (a type of antibody) and the
presence of certain proteins that form when myelin breaks down. About 85 to 90
percent of people with MS have these abnormalities in their cerebral spinal fluid.

Some types of MS progress quickly and can be life-threatening within weeks or

months. Looking at the proteins in CSF may enable doctors to develop “keys” called
biomarkers. Biomarkers can help identify the type of MS you have earlier and more
easily. Early diagnosis could allow you to get treatment that could extend your life if
you have a form of MS that’s rapidly progressing.

Interpreting test results:

Normal results mean that nothing abnormal was found in the spinal fluid. All
measured levels of CSF components were found to be within normal range.
Abnormal results may be caused by one of the following:

• a tumor
• metastatic cancer
• hemorrhaging
• encephalitis, which is an inflammation of the brain
• an infection
• inflammation
• Reye’s syndrome, which is a rare, often fatal disease affecting children that’s
associated with viral infections and aspirin ingestion
• meningitis, which you can get from fungi, tuberculosis, viruses, or bacteria
• viruses such as West Nile or Eastern equine
• Guillain-Barré syndrome, which is an autoimmune condition that causes
paralysis and occurs after viral exposure
• sarcoidosis, which is a granulomatous condition of unknown cause affecting
many organs (primarily the lungs, joints, and skin)
• neurosyphilis, which happens when an infection with syphilis involves your
brain
• multiple sclerosis, which is an autoimmune disorder that affects your brain
and spinal cord

Following up after a CSF analysis:

Your follow-up and outlook will depend on what caused your CNS test to be
abnormal. Further testing will most likely be required in order to get a definitive
diagnosis. Treatment and outcomes will vary.

Meningitis caused by a bacterial or parasitic infection is a medical emergency.

Symptoms are similar to viral meningitis. However, viral meningitis is less life-
threatening.

People with bacterial meningitis may receive broad-spectrum antibiotics until the
cause of the infection is determined. Prompt treatment is essential to save your life.
It can also prevent permanent CNS damage.

Synovial Fluid Determination:

Synovial fluid analysis is also known as joint fluid analysis. It helps diagnose the
cause of joint inflammation.

Each of the joints in the human body contains synovial fluid. This fluid is a thick
liquid that lubricates the joint and allows for ease of movement. In joint diseases like
arthritis, the synovium of the joint is the main place where inflammation occurs.
Limited mobility in the joint, or pain and stiffness with movement, are often the first
signs of joint disorders. Joint inflammation is more common as you age.

Why the test done:

A synovial fluid analysis is performed when pain, inflammation, or swelling occurs
in a joint, or when there’s an accumulation of fluid with an unknown cause. Taking a
sample of the fluid can help diagnose the exact problem causing the inflammation. If
the cause of the joint swelling is known, a synovial fluid analysis or joint aspiration
may not be necessary.

Some potential diagnoses include infection, gout, arthritis, and bleeding. In some

cases with excess fluid, simply removing some fluid can help relieve pain in the
affected joint. Sometimes synovial fluid analysis is used to monitor people with
known joint disorders.

Synovial fluid analysis process:

Your doctor will recommend a synovial fluid analysis if you have signs of joint
inflammation, redness, swelling, or injury to help diagnose the condition. You won’t
need to do anything in preparation for the test, but let your doctor know if you’re
taking blood thinners. They can affect results.

The synovial sampling process will be done at your doctor’s office. This process
doesn’t require any incisions and will only take a couple of minutes. Your doctor will
clean the area and prepare it for injections. If you’re getting anesthesia, your doctor
will inject it into the site to limit pain and discomfort.

Once the area has been numbed, your doctor will insert a larger needle into the joint
and draw fluid into the syringe. This process of removing fluid from a joint is called
arthrocentesis. Your doctor will send the fluid sample to the laboratory for
examination. A lab technician will look at the color and thickness of the fluid and
assess red and white blood cells under a microscope. The technician will also look
for crystals or signs of bacteria and measure:

• glucose
• proteins
• uric acid
• lactic dehydrogenase (an enzyme that increases in cases of inflammation and
tissue damage)

The fluid sample will also be cultured to test for bacteria.

What to expect:
A synovial fluid analysis may be mildly uncomfortable, but the whole process lasts
only a few minutes. You might receive a local anesthesia to numb the area. You may
feel a prick and burning sensation from the anesthesia at the site of entry.
A larger needle will then be inserted into the joint to withdraw the synovial fluid. If
you receive anesthesia, you should feel minimal discomfort. If you don’t receive
anesthesia, the needle may cause slight pain and discomfort. You might feel pain if
the tip of the needle touches bone or a nerve. Following the procedure, apply ice to
reduce any pain or swelling.

What the test results mean:

Normal synovial fluid is straw-colored, clear, and slightly sticky or stringy.
Abnormal synovial fluid may be cloudy and thicker or thinner than normal fluid.
Cloudiness could mean there are crystals, excess white blood cells, or
microorganisms in the fluid.

If you have gout, the fluid will contain crystals. Less stringiness in the fluid could
signal inflammation. Excess fluid in the joint could be a predictor of osteoarthritis.
Reddish-colored fluid could mean blood is present.

Blood in the fluid could point to a bleeding injury in the joint or a more serious
bleeding problem throughout the body, such as hemophilia. Absent or ineffective
clotting factors cause hemophilia. Cloudy fluid, blood in the fluid, or excess fluid are
all signs of a problem in or around the joint, such as:

• gout
• arthritis
• infection
• autoimmune disorders
• injury to the joint
•
This procedure is highly effective in diagnosing gout by identifying crystals in the
fluid.

The risks of synovial fluid analysis:

A synovial fluid test carries minimal risks. The most common risks are bleeding or
infection in the joint. It’s normal to experience soreness or stiffness in the joint.
Complications from this procedure are rare.

Serum Electrolyte Test:

Electrolytes are electrically charged minerals that help control the amount of fluids

and the balance of acids and bases in your body. They also help control muscle and
nerve activity, heart rhythm, and other important functions. An electrolyte panel,
also known as a serum electrolyte test, is a blood test that measures levels of the
body's main electrolytes:

• Sodium, which helps control the amount of fluid in the body. It also helps
your nerves and muscles work properly.
• Chloride, which also helps control the amount of fluid in the body. In
addition, it helps maintain healthy blood volume and blood pressure.
• Potassium, which helps your heart and muscles work properly.
• Bicarbonate, which helps maintain the body's acid and base balance. It also
plays an important role in moving carbon dioxide through the bloodstream.

Abnormal levels of any of these electrolytes can be a sign of a serious health

problem, including kidney disease, high blood pressure, and a life-
threatening irregularity in heart rhythm.

Other names: serum electrolyte test, lytes, sodium (Na), potassium (K), chloride (Cl),
carbon dioxide (CO2)

What it is used for:

An electrolyte panel is often part of a routine blood screening or a comprehensive
metabolic panel. The test may also be used to find out if your body has a fluid
imbalance or an imbalance in acid and base levels.
Electrolytes are usually measured together. But sometimes they are tested
individually. Separate testing may be done if a provider suspects a problem with a
specific electrolyte.

Why it is needed:
You may need this test if you have symptoms indicating that your body's
electrolytes may be out of balance. These include:

• Nausea and/or vomiting

• Confusion
• Weakness
• Irregular heartbeat (arrhythmia)
•
What happens during an electrolyte panel:
A health care professional will take a blood sample from a vein in your arm, using a
small needle. After the needle is inserted, a small amount of blood will be collected
into a test tube or vial. You may feel a little sting when the needle goes in or out. This
usually takes less than five minutes.

What the results mean:

Your results will include measurements for each electrolyte. Abnormal electrolyte
levels can be caused by several different conditions, including:

• Dehydration
• Kidney disease
• Heart disease
• Diabetes
• Acidosis, a condition in which you have too much acid in your blood. It can
cause nausea, vomiting, and fatigue.
• Alkalosis, a condition in which you have too much base in your blood. It can
cause irritability, muscle twitching, and tingling in the fingers and toes.

Your specific results will depend on which electrolyte is affected and whether levels
are too low or too high. If your electrolyte levels were not in the normal range, it
doesn't necessarily mean you have a medical problem needing treatment. Many
factors can affect electrolyte levels. These include taking in too much fluid or losing
fluid because of vomiting or diarrhea. Also, certain medicines such as antacids
and blood pressure medicines may cause abnormal results.

Additional information:
Your health care provider may order another test, called an anion gap, along with
your electrolyte panel. Some electrolytes have a positive electric charge. Others have
a negative electric charge. The anion gap is a measurement of the difference
between the negatively charged and positively charged electrolytes. If the anion gap
is either too high or too low, it may be a sign of a serious health problem.
2. Casts, Splints, Bandages:

In cases of traumatic fracture or luxation, temporary limb immobilization improves

patient comfort, controls regional soft tissue swelling, provides a protective
covering for open wounds, and can prevent closed fractures from becoming open
fractures via skin penetration by sharp fracture fragments. Most fractures distal to
the elbow (front limb) or stifle (hindlimb) are best treated with temporary
coaptation until definitive treatment can be performed. The coaptation must
immobilize the joint above and below the fracture zone.

The Robert Jones bandage (RJB) is a highly versatile, soft, padded bandage for first
aid management of many traumatic limb injuries, and the choice between its use
and the use of temporary first aid splinting is largely one of personal preference and
available supplies. The RJB does not require any splinting materials and is highly
cost effective, but it does require the manual skill necessary to manage thick cotton
rolls. Temporary first aid splints, on the other hand, use small rolls of cast padding
that are easier to manage, but require various splint materials and the manual skill
to manage them. The RJB is not suitable for treatment of fractures proximal to the
elbow or stifle; application of a spica splint is necessary if temporary coaptation is
deemed appropriate for these fracture locations.

The ability to properly apply casts, and splints is a technical skill easily mastered
with practice and an understanding of basic principles. The initial approach to this
requires a thorough assessment of the injured extremity for proper diagnosis.

Once the need for immobilization is ascertained, casting and splinting start with
application of stockinette, followed by padding.

Splinting involves subsequent application of a noncircumferential support held in

place by an elastic bandage. Splints are faster and easier to apply; allow for the
natural swelling that occurs during the acute inflammatory phase of an injury; are
easily removed for inspection of the injury site; and are often the preferred tool for
immobilization in the acute care setting. Disadvantages of splinting include lack of
patient compliance and increased motion at the injury site.

Casting involves circumferential application of plaster or fiberglass. As such, casts

provide superior immobilization, but they are more technically difficult to apply and
less forgiving during the acute inflammatory stage; they also carry a higher risk of
complications. Compartment syndrome, thermal injuries, pressure sores, skin
infection and dermatitis, and joint stiffness are possible complications of splinting
and casting. Patient education regarding swelling, signs of vascular compromise,
and recommendations for follow-up is crucial after a cast or splint application.

Nursing Management:
1. Prepare the client for cast application.
 Explain the procedure and what to expect.
 Obtain informed consent if surgery is required.
 Clean the skin of the affected part thoroughly.
2. Assist the health care provider during application of the cast as needed.
3. After the cast application, provide cast care.
 Support an exposed cast, with the palms of your hands to prevent
indentations.
 Ensure that the stockinet is pulled over rough edges of the cast.
 Elevate the casted extremity above the level of the heart.
 Provide covering and warmth to uncasted areas.
 Expose the fresh plaster cast to circulating air, uncovered, until dry
(24 to 72 hours). Expose the fresh synthetic cast until it is completely set
(about 20 minutes).
 Instruct the client to avoid wetting the cast. Instruct him to dry a
synthetic cast with a hair dryer on cool setting if it gets wet.
4. Initiate pain relief measure if indicated.
 Encourage position changes.
 Elevate the affected body part.
 Provide analgesics as appropriate.
 Promote nonpharmacologic pain relief measures, such as guided
imagery, relaxation and distraction.
5. Observe for signs and symptoms of cast syndrome with clients who are
immobilized in large casts, such as a body or hip spica cast.
 Report abdominal pain and distention, nausea and vomiting, elevated
blood pressure, tachycardia, and tachypnea which are physiologic effects of
cast syndrome.
 Any client who is claustrophobic is at risk for psychological cast
syndrome, which includes acute anxiety and possible irrational behavior.
6. Provide nursing care for compartment syndrome, if indicated. Observe for
signs and symptoms and discuss and assist with treatments.
7. Notify the health care provider immediately if signs or symptoms of other
neurovascular complications occur.
8. Notify the health care provider if “hot spots” occur along the cast; they may
indicate infection under cast.
9. Provide client and family teaching.
 Encourage isometric exercises to strengthen muscles covered by the
cast. Promote muscle-strengthening exercises for the upper body if
crutches are to be used.
 Advise the client to promptly report cast breaks and signs and
symptoms of complications (i.e. circulatory compromise, cast syndrome,
and hot spots).
 Warn the client against inserting sharp objects (e.g. coat hanger to
scratch itchy skin under the cast). Instruct him to use a cool air from a
dryer to help alleviate the itch.
 Teach the client appropriate cast care, depending on the type of cast.
  Encourage safety precautions (e.g. avoid walking on wet floors, watch
throw rugs, be careful with stairs).
 Teach the client skin care and muscle-strengthening exercises for the
affected body part after cast removal.
 Encourage mobility and active participation in self-care.
 Reinforce health care provider instructions on the amount of eight
bearing allowed.

Traction (Skin and Skeletal)

In the medical field, traction refers to the practice of slowly and gently pulling on a
fractured or dislocated body part. It’s often done using ropes, pulleys, and weights. These
tools help apply force to the tissues surrounding the damaged area.
The purpose of traction is to guide the body part back into place and hold it steady.
Traction may be used to:

• stabilize and realign bone fractures, such as a broken arm or leg

• help reduce the pain of a fracture before surgery
• treat bone deformities caused by certain conditions, such as scoliosis
• correct stiff and constricted muscles, joints, tendons, or skin
• stretch the neck and prevent painful muscle spasms

The two main types of traction are skeletal traction and skin traction. The type of traction
used will depend on the location and the nature of the problem.

Skeletal Traction:
Skeletal traction involves placing a pin, wire, or screw in the fractured bone. After one of
these devices has been inserted, weights are attached to it so the bone can be pulled into
the correct position. This type of surgery may be done using a general, spinal, or local
anesthetic to keep you from feeling pain during the procedure.
The amount of time needed to perform skeletal traction will depend on whether it’s a
preparation for a more definitive procedure or the only surgery that’ll be done to allow
the bone to heal.
Skeletal traction is most commonly used to treat fractures of the femur, or thighbone. It’s
also the preferred method when greater force needs to be applied to the affected area. The
force is directly applied to the bone, which means more weight can be added with less
risk of damaging the surrounding soft tissues.

Skin Traction:
Skin traction is far less invasive than skeletal traction. It involves applying splints,
bandages, or adhesive tapes to the skin directly below the fracture. Once the material has
been applied, weights are fastened to it. The affected body part is then pulled into the
right position using a pulley system attached to the hospital bed.
Skin traction is used when the soft tissues, such as the muscles and tendons, need to be
repaired. Less force is applied during skin traction to avoid irritating or damaging the
skin and other soft tissues. Skin traction is rarely the only treatment needed. Instead, it’s
usually used as a temporary way to stabilize a broken bone until the definitive surgery is
performed.

Cervical Traction:
During cervical traction, a metal brace is placed around your neck. The brace is then
attached to a body harness or weights, which are used to help correct the affected area.
Cervical traction is performed using a general anesthetic, so you’ll be asleep throughout
the entire procedure.
Cervical traction might be used in two different situations. First, it may be done to gently
stretch the neck muscles so muscle spasms can be relieved or prevented. It may also be
performed to immobilize the spine after a neck injury.

If you’re treated with traction, you’ll probably need to participate in an inpatient or an

outpatient treatment program. These programs often consist of physical and occupational
therapy to help you regain your strength and relearn skills that may have been affected by
your injury. A therapist can also teach you new skills to compensate for any pain,
weakness, or paralysis you may have experienced as a result of being injured.
The first few days after traction is performed can be difficult. The muscles are often weak
since you must spend a lot of time in bed after traction is performed. Moving around and
walking may be challenging and can make you tired. However, it’s important to stick
with any rehabilitation program so that you can improve your chances of making a
complete recovery.

There are risks involved in all surgical procedures. These risks include:

• an adverse reaction to the anesthesia

• excessive bleeding
• an infection of the pin site
• damage to the surrounding tissue
• nerve injury or vascular injury from too much weight being applied

Traction used to be considered a state-of-the-art treatment. In recent years, however,

other surgical techniques have become more advanced and more effective in correcting
fractures, damaged muscles, and spinal conditions. Traction also doesn’t allow for much
movement after surgery, so the recovery time is often much longer. Today, it’s used
primarily as a temporary measure until the definitive procedure is done. Traction saved
many lives during World War II by allowing soldiers to be transported safely without
injury to their surrounding tissues.

However, traction can be beneficial in treating certain conditions. It’s very effective in
providing temporary pain relief in the early stages of treatment after trauma.

Nursing Management:

Maintain skin integrity

• Patient’s legs, heels, elbows and buttocks may develop pressure areas due to
remaining in the same position and the bandages.
• Position a rolled up towel/pillow under the heel to relieve potential pressure.
• Encourage the patient to reposition themselves or complete pressure area care
four hourly.
• Remove the foam stirrup and bandage once per shift, to relieve potential pressure
and observe condition patients skin. 
• Keep the sheets dry.
• Document the condition of skin throughout care in the progress notes and care
plan
• Ensure that the pressure injury prevention score and plan is assessed and
documented. 

Traction care
• Ensure that the traction weight bag is hanging freely, the bag must not rest on the
bed or the floor
• If the rope becomes frayed replace them
• The rope must be in the pulley tracks
• Ensure the bandages are free from wrinkles
• Tilt the bed to maintain counter traction

Observations
• Check the patient’s neurovascular observations hourly and record in the medical
record. 
• If the bandage is too tight it can cause blood circulation to be slowed. 
• Monitoring of swelling of the femur should also occur to monitor for
compartment syndrome.
• If neurovascular compromise is detected remove the bandage and reapply
bandage not as tight. If circulation does not improve notify the orthopaedic team. 
Pain Assessment and Management
• Assessment of pain is essential to ensure that the correct analgesic is administered
for the desired effect 
• Paracetamol, Diazepam and Oxycodone should all be charted and administered as
necessary.
• Pre-emptive analgesia ensures that the patient’s pain is sufficiently managed and
should be considered prior to pressure area care.
• Assess and document outcomes of pain management strategies employed

Activity
• The patient is able to sit up in bed and participate in quiet activities such as craft,
board games and watching TV. Play therapy will be beneficial for patients in traction
long term.  
• Non-pharmacological distraction and activity will improve patient comfort. 
• The patient is able to move in bed as tolerated for hygiene to be completed.
• Patients who are in traction for a number of weeks may require a referral to the
education department/kinder. 
Theatre time
• The patient should be transported to theatre in traction to reduce pain and
maintain alignment. 

Crutches (Single and Double)

Crutches are a type of Walking Aids that serve to increase the size of an

individuals Base of support. It transfers weight from the legs to the upper body and
is often used by people who cannot use their legs to support their weight (ie short-
term injuries to lifelong disabilities).

Crutch Type
There are three types of crutches; Axilla crutches, Elbow crutches and Gutter
crutches.

• Axilla or underarm crutches: They should actually be positioned about 5 cm

below the axilla with the elbow flexed 15 degrees, approximately. The design
includes an axilla bar, a handpiece and double uprights joined distally by a single
leg. They are adjustable in height, both the overall height and handgrip height can be
adjusted (adjustable approximately 48 to 60 inches (12 to 153 cm).

• Forearm crutches (or lofstrand, elbow or Canadian crutches): Their design

includes a single upright, a forearm cuff and a handgrip. The height of the forearm
crutches are indicated from handgrip to the floor (adjustable from 29 to 35 inches
or 74 to 89 cm).

• Gutter Crutches (or adjustable arthritic crutches, forearm support crutches):

These are additional types of crutches, which is composed of padded forearm
support made up of metal, a strap and adjustable hand-piece with a rubber ferrule.
These crutches are used for patients who are on partial weight bearing like
Rheumatoid disease.

These crutches can be used as a single or double depending on the injury.

Measurement
It is essential that crutches are measured and adjusted to suit every patient they are
given to. There are various methods to measure both the canes.

Walking Pattern
There are several different walking patterns that an individual using crutches may
use, including:
• 2 point: the crutches and the fractured leg are one point and the uninvolved
leg is the other point. The crutches and fractured limb are advanced as one unit, and
the uninvolved weight-bearing limb is brought forward to the crutches as the
second unit . this gait pattern is less stable as only two points are in contact with
floor and good balance is needed to walk with 2 points crutch gait .
• 3 point: this gait pattern is used when one side lower extremity (LE) is
unable to bear weight (due to fracture, amputation, joint replacement etc). It
involves three points contact with the floor, the crutches serve as one point, the
involved leg as the second point, and the uninvolved leg as the third point. Each
crutch and the weight-bearing limb are advanced separately, with two of the three
points maintaining contact with the floor at any given time.
• 4 point: this gait pattern is used when there's lack of coordination, poor
balance and muscle weakness in both LE, as it provides slow and stable gait pattern
with three points support on it, point one is the crutch on the involved side, point
two is the uninvolved leg, point three is the involved leg, and point four is the crutch
on the uninvolved side. The crutches and limbs are advanced separately, with three
of the four points on the ground and bearing weight any given time.
• Gait to: the fractured limb is advanced, and then the intact limb brought to
the same position. When weight-bearing status is restricted to partial, toe-touch, or
as tolerated, crutches or a walker are necessary and help the patient step to the
fractured limb by pushing down with the upper extremities, thus transferring
weight from the fractured limb to the assistive device.
• Gait through: the intact leg is advanced, and then the fractured leg is
advanced past it. With restricted weight bearing, crutches are used instead of the
injured limb, and the patient steps past the crutches with the weight-bearing lower
extremity; the gait assumes a two-point or three-point pattern.

Nursing Management:

With properly fitted crutches, the patient is almost ready to learn ambulation with
crutches. Prepare the patient for instruction by doing the following:
 
• Explain the procedure to the patient and determine if the patient has the upper
body strength and ability to ambulate.
 
• Ensure that the patient is fully clothed and wearing non-skid slippers or shoes.
 
• Assist the patient to stand. Have the patient grasp both crutches in one hand at the
handgrip, then push off from the bed with the free hand using the crutches for support.
 
• Instruct the patient to stand in correct body alignment with the tip of the crutches
6 inches in front and 6 inches to the side of the feet. (This is the tripod position.) The
hands and arms, not the axillae, should bear the weight. The elbows should be flexed
about 30°.
 
• Teach the prescribed gait.