Case Study, Chapter 40, Musculoskeletal Care Modalities

1. June Frankel, a 23-year-old patient, presents to the emergency

department with a sports-related fracture injury to her right arm and
receives a long-arm fiberglass cast. (Learning Objective 2)

a. What nursing assessment should the nurse provide after the

cast has been applied?

pulse, temperature of extremity, coloration of extremity and sensation

and capillary refill as compared to opposite extremity, and presence of
edema. Report any change in sensation with other supportive
assessment findings immediately, such as numbness, tingling, loss of
sensation, or pain unrelieved by administration of narcotic analgesic.
Vital signs and presence of pain should be assessed. The pain
assessment includes quality, radiation, strength of pain as rated on a
pain scale, and time the pain started and the duration.

b. What nursing interventions should the nurse provide?

 Provide discharge instructions (verbal and written) to

patient/family and assess understanding by having the
patient/family provide the instructions in their own words. Have
the patient/family demonstrate proper usage of sling and how to
elevate the extremity on pillows above the heart and assess the
neurovascular status of the affected limb.

 Keep the cast dry. Use a plastic bag secured with tape when
bathing and keep casted arm out of water. Use a hair dryer on a
cool setting to dry the cast if it becomes wet. If the cast does
not dry within 24 hours or less, call the physician.
 Elevate the affected limb using the sling or pillow supports,
keeping the extremity above the level of the heart to promote
circulation and decrease the risk for swelling.
 Do not stick anything down into the cast to scratch your skin.
Do not apply lotion or powder into the cast either.
 Do not bang the cast or cut it or pull it apart.
 Do not wash the cast.
 Call the physician immediately if you develop any of the
following:
 Tingling, numbness in your arm
 Severe pain unrelieved by the prescribed pain medication
 Feeling that your cast is too tight or becomes too loose
 If your fingers become swollen, cold, turn pale or become blue
  If your cast gets damaged or develops rough edges that irritate
your skin
 Instruct the patient on the activity restrictions and follow-up
care as directed by the physician.
 Instruct the patient on prescribed medications, including side
effects to report to the physician.

2. Sue Newhart, a 55-year-old patient, is admitted to the medical-

surgical unit after a total hip arthroplasty due to osteoarthritis.
(Learning Objectives 5 and 6)

a. What considerations should the nurse follow when positioning

the patient in bed after hip surgery?

• When positioning the patient in the supine position, the nurse should
use the abductor splint or pillow support to prevent dislocation of the
prosthesis.
• When turning the patient, two nurses help the patient: one nurse
supports the affected leg, keeping the leg abducted and straight, as
the second nurse turns the patient to the unaffected side. The
abductor pillow or splint is used. A pillow support is used to keep the
leg abducted.
• When sitting the patient up in bed, raise the head of the bed 60
degrees or less, as directed by the surgeon to prevent dislocation of
the hip prosthesis.

b. What nursing interventions should the nurse provide the

patient?

 Assess vital signs, incision site and portable suction drainage device,
neurovascular checks on right hip and leg, and pain assessment as
ordered
 Use fracture pan and instruct the patient to flex the left leg and hip
and use the trapeze bar to get onto the bedpan or to get off the
bedpan and not to place pressure or flex the right knee and hip in the
process
 Keep a draw sheet under the patient from head to feet to use in
turning or moving the patient up in the bed, and use the help of two
nurses
 Instruct the patient to perform exercises that the physical therapist
prescribed to prevent contractures and to promote mobility
 Provide thromboembolism-prevention measures, including the usage
of prescribed anti-embolism hose, sequential compression boots, and
low molecular weight heparin such as enoxaparin (Lovenox)
 Instruct the patient to use the incentive spirometer, cough and deep
breathe every two hours while awake. Report any change in the
coloration of sputum and signs of respiratory infection immediately to
the physician.
 Promote early ambulation as ordered:
 Monitor for orthostatic hypotension.
 Transfer to standing with walker per physical therapist protocol as
ordered by surgeon.
 Ambulate to chair using the walker by advancing the walker, then the
operated extremity, and then the nonoperated extremity. (Follow
weight-bearing restrictions).
 When sitting in the chair, do not sit for longer than 30 minutes. Flex
the hip less than 90 degrees.
 When sitting, keep the knees apart and do not cross the legs.
 Avoid bending forward while sitting in a chair.
 Do not flex the hip when putting on clothing articles. Use a long-
handled reaching device to help dress.
 Use elevated seat cushion in the chair and a raised toilet seat to help
prevent over flexion of the hip joint.