Fundamental Nursing Chapter 25 Mechanical Immobilization Inst.: Dr. Ashraf El - Jedi

Some clients are inactive and physically immobile as a result of an overall debilitating condition. For others, mobility impairment results from trauma or its treatment. Such is the case for clients with orthoses, which are orthopedic devices that support or align a body part and prevent or correct deformities.

Examples of orthoses include splints, immobilizers, and braces. Other clients have limited mobility when use of slings, casts, traction, and external fixators is necessary. Caring for clients who are mechanically immobilized with orthopedic devices requires specialized nursing skills described in this chapter

Purposes of Mechanical Immobilization Mechanical immobilization of a body part accomplishes the following: Relieves pain and muscle spasm Supports and aligns skeletal injuries Restricts movement while injuries heal Maintains a functional position until healing is complete Allows activity while restricting movement of an injured area Prevents further structural damage and deformity

Mechanical Immobilizing Devices

Splints which is a device that immobilizes and protects an injured body part. Splints are used before or instead of casts or traction.

Emergency Splints Splints often are applied as a first-aid measure for suspected sprains or fractures (Fig. 25-1). See Nursing Guidelines 25-1. Figure 25-1 • Emergency first aid splinting immobilizes the injured leg to the uninjured leg with a make-shift splint, such as a board, broom handle, or golf club. Neckties, belts, or scarves keep the splint in place

Examples include inflatable splints, traction splints, immobilizers, molded splints, and cervical collars. Inflatable and traction splints are intended for short-term use: they usually are applied just after the injury and are removed shortly after more thorough assessment of the injury. Immobilizers and molded splints are used for longer periods.

Inflatable Splints are immobilizing devices that become rigid when filled with air (Fig. 25-2). In addition to limiting motion, they control bleeding and swelling. When air is infused, the splint molds to the contour of the injured part, preventing movement.

Traction splints are metal devices that immobilize and pull on contracted muscles One example is a , which requires special training for its application to prevent additional injuries (Fig. 25-3). Figure 25-3 • ( Thomas splint. ( ) Thomas splint applied to the lower extremity.

Immobilizers are commercial splints made from cloth and foam and held in place by adjustable straps (Fig. 25-4). Figure 25-4 • Leg immobilizer.

Molded Splints are orthotic devices made of rigid materials and used for chronic injuries or diseases (Fig. 25-5). They maintain the body part in a functional position to prevent contractures and muscle atrophy during immobility.

Cervical Collars is a foam or rigid splint placed around the neck. It is used to treat athletic neck injuries and other trauma that results in a neck sprain or strain (Fig. 25-6). Figure 25-6 Foam cervical collar Rigid cervical collar.

Slings A sling is a cloth device used to elevate, cradle, and support parts of the body. Slings are applied commonly to the arm (Fig. 25-8), Figure 25-8 • A sling used for arm suspension. (Copyright B. Proud.(

Braces Braces are custom-made or custom-fitted devices designed to support weakened structures. Figure 25-9 • A rehabilitative brace that ensures appropriate control of knee motion following an operative procedure.

Casts A cast is a rigid mold placed around an injured body part after it has been restored to correct anatomic alignment. The purpose of the cast is to immobilize the injured structure. Casts usually are applied to fractured (broken) bones. They are formed using either wetted rolls of plaster of Paris or premoistened rolls of fiberglass (Table 25-1).

Types of Casts There are basically three types of casts: cylinder, body, and spica.

1. Cylinder Cast encircles an arm or leg and leaves the toes or fingers exposed. The cast extends from the joints above and below the affected bone. This prevents movement, thereby maintaining correct alignment during healing.

2. Body Cast A body cast is a larger form of a cylinder cast and encircles the trunk of the body instead of an extremity. It generally extends from the nipple line to the hips.

3. Bivalved Cast one that is cut in two pieces lengthwise. Creating a front and a back for a body cast facilitates bathing and skin care.

A bivalved cast on an extremity (Fig. 25-10) is created when Swelling compresses tissue and interferes with circulation. The client is being weaned from the cast. A sharp x-ray is needed. Painful joints need to be immobilized temporarily in a client with arthritis.

Figure 25-10 • ( A) A bivalved cast. ( B) The two halves are rejoined

4. Spica Cast encircles one or both arms or legs and the chest or trunk. It generally is strengthened with a reinforcement bar. When applied to the upper body, the cast is referred to as a one applied to the lower extremities is called a (Fig. 25-11). When applied to a lower extremity, the cast is trimmed in the anal and genital areas to allow elimination of urine and stool.

Figure 25-11 • Hip spica cast. (Timby, B. K. , Smith, N. [2007] Figure 25-11 • Hip spica cast. (Timby, B. K., Smith, N. [2007]. Introductory medical-surgical nursing [9th ed., p. 1191]. Philadelphia: Lippincott Williams & Wilkins.)

Cast Application The nurse prepares the client, assembles the cast supplies and help the physician during application (skill 25-2)

Basic Cast Care The nurse is responsible for caring for the cast and making appropriate assessments to prevent complications. See Nursing Guidelines 25-2.

Figure 25-12 • Assessing capillary refill. (Copyright B. Proud.(

Figure 25-13 • Checking mobility.

Figure 25-14 • Assessing sensation in exposed fingers

Figure 25-15 • Soft edges of cast minimize risk for skin irritation.

Figure 25-16 • Applying ice pack to minimize pain

Cast Removal casts are removed when they need to be changed and reapplied or when the injury has healed sufficiently that the cast is no longer necessary. A cast is removed prematurely if complications develop. Most casts are removed with an electric cast cutter, an instrument that looks like a circular saw (Fig. 25-17).

Figure 25-17 • Cast removal. The cast is bivalved with an electric cast cutter. ( The cast is split. ( The padding is manually cut.

Proper use of an electric cast cutter, however, leaves the skin intact. When the cast is removed, the unexercised muscle is usually smaller and weaker. The joints may have a limited range of motion. The skin usually appears pale and waxy and may contain scales or patches of dead skin. The skin is washed as usual with soapy warm water, Applying lotion to the skin adds moisture and tends to prevent the rough skin edges from catching on clothing.

Traction Traction is a pulling effect exerted on a part of the skeletal system. It is a treatment measure for musculoskeletal trauma and disorders. Traction is used to accomplish the following: Reduce muscle spasms Realign bones Relieve pain Prevent deformities

The pull of the traction generally is offset by the counterpull from the client's own body weight. Except for traction exerted with the hands, application of traction involves the use of weights connected to the client through a system of ropes, pulleys, slings, and other equipment.

Types of Traction

1. Manual Traction Manual traction means pulling on the body using a person's hands and muscular strength (Fig. 25-18). It most often is used briefly to realign a broken bone. It also is used to replace a dislocated bone into its original position within a joint.

Figure 25-18 • Manual traction

2. Skin Traction Skin traction means a pulling effect on the skeletal system by applying devices, such as a pelvic belt and a cervical halter, to the skin (Fig. 25-19). Other names for commonly applied forms of skin traction are Buck's traction and Russell's traction (Fig. 25-20).

Figure 25-19 Pelvic belt. Cervical halter.

Figure 25-20 • (A) Buck's traction. (B) Russell's traction.

3. Skeletal Traction Skeletal traction means pull exerted directly on the skeletal system by attaching wires, pins, or tongs into or through a bone (Fig. 25-21). Skeletal traction is applied continuously for an extended period.

Figure 25-21 • The application of skeletal traction Figure 25-21 • The application of skeletal traction. (A) A pin transects the bone. (B) Traction is applied.

Traction Care Regardless of the type of traction used, its effectiveness depends on the application of certain principles during the client's care (Box 25-1). See Nursing Guidelines 25-3.

Box 25-1 • Principles for Maintaining Effective Traction Traction must produce a pulling effect on the body. Countertraction (counterpull) must be maintained. The pull of traction and the counterpull must be in exactly opposite directions. Splints and slings must be suspended without interference. Ropes must move freely through each pulley. The prescribed amount of weight must be applied. The weights must hang free

External Fixators external fixator is a metal device inserted into and through one or more broken bones to stabilize fragments during healing (Fig. 25-22). During recovery, the nurse provides care for the pin site (location where pins, wires, or tongs enter or exit the skin). to prevent infection

Figure 25-22 • An external fixator Figure 25-22 • An external fixator. Metal rods exert traction between two sets of skeletal pins.

Nursing Implications Acute Pain Impaired Physical Mobility Risk for Disuse Syndrome Risk for Peripheral Neurovascular Dysfunction Impaired Bed Mobility Risk for Impaired Skin Integrity Risk for Ineffective Tissue Perfusion Self-Care Deficit: Bathing/Hygiene