LEARNING OBJECTIVE: Evaluate the needs of the orthopedic patient.
Patients receiving orthopedic services are those who require treatment for fractures, deformities, and diseases or injuries of some part of the musculoskeletal system. Some patients will require surgery, immobilization, or both to correct their condition.
The basic principles and concepts of care for the surgical patient will apply to orthopedic patients. The majority of patients not requiring surgical intervention
will be managed by bed rest, immobilization, and rehabilitation. Many of the basic concepts of care of the medical patient are applicable for orthopedic patient care. In the military, the usual orthopedic patient is fairly young and in good general physical condition. For these patients, bed rest is prescribed only because other kinds of activity are limited by their condition on admission.
Rehabilitation is the ultimate goal when planning the orthopedic patient’s total management. Whether the patient requires surgical or conservative treatment, immobilization is often a part of the overall therapy. Immobilization may consist of applying casts or traction, or using equipment (such as orthopedic frames). During the immobilization phase, simple basic patient care is extremely important. Such things as skin care, active-passive exercises, position changes in bed (as permitted), good nutrition, adequate fluid intake, regularity in elimination, and basic hygiene contribute to both the patient’s physical and psychological well-being.
Lengthy periods of immobilization are emotionally stressful for patients, particularly those who are essentially healthy except for the limitations imposed by their condition. Prolonged inactivity contributes to boredom that is frequently manifested by various kinds of acting-out behavior.
Often, the orthopedic patient experiences exaggerated levels of pain. Orthopedic pain is commonly described as sore and aching. Because this condition requires long periods of treatment and hospitalization, the wise management of pain is an important aspect of care. Constant pain, regardless of severity, is energy consuming. You should make every effort to assist the patient in conserving this energy. There are times when the patient’s pain can and should be relieved by medications. There are, however, numerous occasions when effective pain relief can be provided by basic patient-care measures such as proper body alignment, change of position, use of heat or cold (if permitted by a physician’s orders), back rubs and massages, and even simple conversation with the patient. Meaningful activity also has been found to help relieve pain. Whenever possible, a well-planned physical/occupational therapy regimen should be an integral part of the total rehabilitation plan.
CAST FABRICATION.—As mentioned previously, immobilization is often a part of the overall therapy of the orthopedic patient, and casting is the most common and well-known form of long-term immobilization. In some instances, a medical technician may be required to assist in applying a cast or be directed to apply or change a cast. In this section, we will discuss the method of applying a short and long arm cast, and a short leg cast.
In applying any cast, the basic materials are the same: webril or cotton bunting, plaster of Paris, a bucket or basin of tepid water, a water source (tap water), protective linen, gloves, a working surface, a cast saw, and seating surfaces for the patient and the medical technician. Some specific types of casts may require additional material.
SHORT ARM CAST.—A short arm cast extends from the metacarpal-phalangeal joints of the hand to just below the elbow joint. Depending on the location and type of fracture, the physician may order a specific position for the arm to be casted. Generally, the wrist is in a neutral (straight) position, with the fingers slightly flexed in the position of function.
Beginning at the wrist, apply three layers of webril (fig. 2–2A). Then apply webril to the forearm and the hand, making sure that each layer overlaps the other by a third (as shown in figure 2–2B). Check for lumps or wrinkles and correct any by tearing the webril and smoothing it.
Dip the plaster of Paris into the water for approximately 5 seconds. Gently squeeze to remove excess water, but do not wring out. Beginning at the wrist (fig. 2–2C) wrap the plaster in a spiral motion, overlapping each layer by one-third to one-half. Smooth out the layers with a gentle palmar motion. When applying the plaster, make tucks by grasping the excess material and folding it under as if making a pleat. Successive layers cover and smooth over this fold. When the plaster is anchored on the wrist, cover the hand and the palmar surface before continuing up the arm (figs. 2–2D and 2–2E). Repeat this procedure until the cast is thick enough to provide adequate support, generally 4 to 5 layers. The final step is to remove any rough edges and smooth the cast surface (fig. 2–2F). Turn the ends of the cast back and cover with the final layer of plaster, and allow the plaster to set for approximately 15 minutes. Trim with a cast saw, as needed.
LONG ARM CAST.—The procedure for a long arm cast is basically the same as for a short arm cast, except the elbow is maintained in a 90° position, the cast begins at the wrist and ends on the upper arm below the axilla, and the hand is not wrapped.
Figure 2–2.—Applying a short arm cast.
SHORT LEG CAST.—In applying a short leg cast, seat the patient on a table with both legs over the side, flexed at the knee. Instruct the patient to hold theaffected leg, with the ankle in a neutral position (900). Make sure that the foot is not rotated medially or laterally. Beginning at the toes, apply webril (figs. 2–3A, 2–3B, and 2–3C) in the same manner as for the short arm cast, ensuring that there are no lumps or wrinkles. Apply the plaster beginning at the toes (fig. 2–3E), using the same technique of tucks and folds and smoothing as for the short arm cast. Before applying the last layer, expose the toes and fold back the webril. As the final step, apply a footplate to the plantar surface of the cast, using a generous thickness of plaster splints secured with one or two rolls of plaster (fig. 2–3F). This area provides support to the cast and a weight-bearing surface when used with a walking boot.
Figure 2–3.—Applying a short leg cast.
Whenever a cast is applied, you must give the patient written and verbal instruction for cast care and circulation checks (i.e., numbness, cyanosis, tingling of extremities). Instruct the patient to return immediately should any of these conditions occur.
When a leg cast is applied, the patient must also receive instructions in the proper use of crutches. The cast will take 24 to 48 hours to completely dry, and it must be treated gently during this time. Since plaster is water-soluble, the cast must be protected with a waterproof covering when bathing or during wet weather. Nothing must be inserted down the cast (e.g., coat hangers) since this action can cause bunching of the padding and result in pressure sores. If swelling occurs, the cast may be split and wrapped with an elastic wrap to alleviate pressure.
A cast can be removed in two ways: by soaking in warm vinegar-water solution until it dissolves, or by cutting. To remove by cutting, cast cutters, spreaders, and bandage scissors are necessary. Cuts are made laterally and medially along the long axis of the cast, then widened with the use of spreaders. The padding is then cut with the scissors.