1. Mechanical Immobilization
Nursing Fundamentals
Chapter 25

2. Orthoses
Orthopedic devices that support or align a body part and prevent or correct deformities

3. Examples of orthoses
Splints
Immobilizers
Braces

4. Wrist Immobilizer(AV)

5. Shoulder Immobilizer(AV)

6. Airboot Immobilizer(AV)

7. Sling(AV)

8. Purposes of Mechanical Immobilization
Most people who need mechanical immobilization have suffered trauma to the musculoskeletal system
These type of injuries are painful and heal less rapidly than injuries to skin or soft tissue

9. Mechanical Immobilization
Pt who are recovering from injury require a period of inactivity to allow new cells to restore integrity to the damaged area

10. General Purposes for Mechanical Immobilization
*Relieves pain and muscle spasm
*Supports and aligns skeletal injuries
*Restricts movement while injury heals
*Aids in maintaining a functional position until healing is complete
*Allows activity while restricting movement of an injured area
*Prevents further structural damage and deformity

11. Examples of Immobilizing Devices
WE WILL DISCUSS:
Splints
Slings
Braces
Casts
Traction

12. Splints This device immobilizes and protects an injured body part
Splints are used before or instead of application of casts or traction

13. Emergency Splints
These are applied as a first aid measure for suspected sprains or fractures
These are placed on the pt by the paramedic or while at the E.R.

14. Commercial Splints These are available in various designs Examples:
*Inflatable splints
*Traction splints
*Immobilizers
*Molded splints
*Cervical collar

15. Inflatable Splints These are also called pneumatic splints
These become rigid when filled with air
In addition to limiting motion, they control bleeding and swelling

16. Inflatable Splint
You place the injured part in the deflated portion of the splint. When air is infused, the splint molds to the contour of the injured part, preventing movement
Once this type of splint is placed on a pt, the injury should be examined and treated within minutes after application , otherwise, circulation may be affected

17. Traction Splints These splints are usually made of metal
They are applied to immobilize and pull on muscles that are in a state of contraction
This type of splint is meant to be temporary

18. Immobilizers
These are usually made of cloth and foam and are usually held in place with adjustable Velcro straps
These are used to limit motion in the area of healing the injury

19. Immobilizers
These limit motion in the area of a painful but healing injury such as the neck and knee
Immobilizers are removed for brief periods during hygiene and dressing

20. Molded Splints
These are made of rigid plastic and are used for chronic injuries or diseases
They may be appropriate for pts with repetitive motion disorders such as carpal tunnel syndrome

21. Molded Splints
These provide prolonged support and limit movement to prevent further injury and pain
These maintain the body part in a functional position to prevent contractures and muscle atrophy during immobility

22. Cervical Collar
Is a foam or rigid splint that is placed around the neck
It is usually used to treat athletic neck injuries or other trauma that results in a neck sprain or strain

23. Neck Strain Is sometimes referred to as “whiplash”
Whiplash in athletics has decreased mainly d/t better supportive equipment.
In auto accidents, the use of shoulder harnesses and neck supports has also caused a decrease in whiplash

24. A cervical collar reminds the pt to limit the movements of the head and neck
These collars need to be fitted before application of them

25. Applying an Emergency Splint (1-11)
1. Keeping the injured parts in place prevents additional injuries so avoid changing the position of the injured part even if its grossly deformed
2. Leave high top shoes or ski boots in place, these help to limit movement and reduce pain and swelling
3. Cover open wounds to prevent entrance of microorganisms
4. Select a rigid splinting material such as a flat board, broomstick or rolled up newspaper, this will help restrict movement

26. Applying an emergency splint
5. Pad bony prominences with soft material, padding prevents friction and pressure
6. Apply the splint so that it spans the injured area from the joint above the injury to beyond the joint below the injury
7. Use wide tape or wide strips of fabric to confine the injured part to the splint. Securing the body part prevents displacement and reduces the risk of compromising circulation

27. Applying an emergency splint
8. Loosen the splint or the material used to attach it if the fingers or toes are pale, blue, or cold. Loosening the splint allows for better circulation
9. Elevate the immobilized part so the lowest or end part is higher than the heart, this reduces venous flow back to the heart
10. Keep the pt warm and safe
11. Seek assistance in transporting the pt to a health care facility

28. Slings
This is a cloth device used to elevate, cradle and support parts of the body
Slings are commonly applied to the arm
Many pts use a commercial type of arm sling

29. Braces
These are designed to support weakened structures during weight bearing
Any improperly fitting brace can cause discomfort, deformity and pressure sores
There are 3 categories of braces: ………

30. Braces
1. Prophylactic braces – those used to prevent or reduce the severity of a joint injury
2. Rehabilitative braces – those that allow protected motion of an injured joint that has been treated surgically
3. Functional braces – those that provide stability for an unstable joint

31. Wearing a brace
Because pts generally wear a brace during active periods, they are always made of sturdy materials such as metal
Leg braces may be incorporated into a shoe for added support
Some back braces are made with fabric or metal staves or strips for support

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

33. Types of bone fractures

34. Compound Fracture
Open fracture What risk factors present with this type of fracture

35. Types of Casts
Cylinder cast
Body cast
Spica cast
Bivalved cast

37. Cylinder Cast
Encircles an arm or leg and leaves the toes and fingers exposed. The cast extends from the joints above and below the affected bone. This prevents movement by maintaining correct alignment during healing. As healing progresses, the cast may be trimmed or shortened

38. Body Cast
This is just a larger form of a cylinder cast that encircles the trunk of the body instead of an extremity
A body cast extends from the nipple line to the hips
For pts with spinal problems, the body cast extends from the back of the head and chin area to the hips with modifications made for exposing the arms

39. Spica Cast
PURPOSE: used to keep the hips and legs from moving after surgery.
This type of cast encircles one or both arms or legs and the chest or trunk
It is generally strengthened with a reinforcement bar (never grab the bar)
When applied to the upper body, its called a shoulder spica, when applied to the lower extremity, its called a hip spica

40. Spica Cast
Spica casts of the lower extremity are heavy, hot and frustrating because they severely restrict movement and activity
These casts are trimmed in the genital and anal area to allow for elimination of urine and stool
These pts cannot sit so the nurse must care for the cast and the pt frequently

41. Hip Spica
What are nursing concerns that you have for this person?

42. Reduction of an injury
If a bone is broken, it must be reduced, fixed, or put back into place
Reduction can be :
Open Or
Closed

43. MEDLINE PLUS
You had a fracture (break) in the femur, also called the thigh bone, in your leg. You may have needed surgery to repair the bone. You may have had surgery called an open reduction. Your surgeon used special metal devices to hold your bones in place while they heal. These devices are called internal fixators.
The complete name of this surgery is open reduction and internal fixation (ORIF).
In the most common surgery to repair a femur fracture, the surgeon inserts a rod or large nail into the center of the bone. This rod helps support the bone until it heals. The surgeon may also put a plate next to your bone that is attached by screws to a frame outside your leg

44. Open Reduction
An incision is made near the affected broken area and the use of pins to help keep the part aligned, are used
The affected area is then casted for immobilization
ORIF – open reduction internal fixation, no pins to clean, it’s all inside

45. Closed Reduction
There is NO incision, the affected bone is repositioned (reduced back to normal) and may be held with screws on the outside or is casted to keep bone in place

46. Care of the Patient with a spica cast
Plastic wrap is tucked around any opening of the cast
Gauze is also used and the pt must use a fractional bed pan

47. Shoulder Spica

48. Bivalved Cast
This is a cast that started out as a cylinder type cast and it was then cut into 2 pieces, lengthwise, so that one layer fits on the underside of the arm (for example) and the top piece fits over the upper arm
This type of cast promotes bathing of the body part

49. Who uses a bivalved cast?
*Pts with a lot of swelling that interferes with circulation
*If a pt is being weaned from the cast
*If many x-rays are needed
*If pt has painful joints that need to be immobilized temporarily as in pts with arthritis

50. Cast Application Requires more than 1 person
The Dr. repositions the affected bone and then applies the cast
The nurse prepares the pt and supplies then assists the Dr.
A light-curred fiberglass cast requires exposure to UV light to harden

51. Casting (AV)

52. Cast Removal
A cast is removed when it needs to be changed or when the injury has healed sufficiently
A cast removed prematurely can cause complications
Casts are removed with an electric cast cutter that looks like a saw
Pts become frightened by the noise of the saw and the feeling that their limb will be cut in to

53. Cast Care (AV)

54. Cast Care part 1(AV)

55. Cast Care part 2(AV)

56. Biggest problem that can occur when casted?
Compartment syndrome
A condition in which nerves and tendons under the skin are constricted due to the edema that occurs after injury and casting. What can this lead to?

57. Remove Casting (AV)

58. Post cast care
*The unexercised muscle of the affected part is usually weak and smaller than it used to be
*The joints have limited range of motion
*The skin usually appears pale and waxy and may contain scales or patches of dead skin
*The area is washed with warm soapy water and lotion is sometimes applied to add moisture, eventually, the dead fragments will slough off

59. Care of the pt with a newly applied cast
A pt can bear weight within minutes after the application of a cast
Plaster casts remain wet for hrs depending on the level of humidity in the air
The nurse should use the palms of the hand to move the affected part
A fan can be used to speed drying
Do not cover the casted area with linens
Change positions of the casted area to allow all parts to dry
Heat lamp may be used to dry cast
The casted area is then elevated to avoid swelling

60. Windowing (AV)

61. Care of the casted pt
One of the major problems with the application of a cast is swelling which affects circulation…bad
Once the cast is applied and swelling has occurred, the Dr. must be notified to “window” the cast
A cut is made in the cast to relieve the swelling

62. Windowed Cast

63. What to assess when one is casted
*Perform the blanch test by pressing on the skin around the cast
*Assess nailbeds of affected limb for circulation
*Keep casted area elevated above the heart
*Assess the edges of the cast for roughness, if so, tuck gauze into cast around edges
* assess pulses if you can
*Follow Dr. orders for circ checks, starts out to be Qhr x 24 hrs, then Q4hr for 2-3 days then Q shift

64. Cast Assessment
What are the important things to assess related to the cast?

65. Drs. Orders Follow Drs. Orders at all times
Certain Drs. Will order particular care or treatment

66. Pedal edges of cast so crumbs won’t get down into cast
NEVER ALLOW THE PT TO STICK ANYTHING INTO CAST TO SCRATCH,
No coat hangers, pencils, pens, rulers, forks, knives, mail openers, straws…NOTHING
If skin tears or breaks, dark, warm, moist area inside the cast, what will happen?????

67. Traction
Is a pulling effect that is exerted on a part of the skeletal system
Traction is used for musculoskeletal trauma remember that traction is used for:
Reduce muscle spasms
Realign bones
Relieve pain
Prevent deformities

68. Traction
The pull of the traction is offset by the counterpull from the client’s own body weight
Application of traction uses weights connected to the pt through a system of ropes, pulleys, slings and other equipment

69. Types of Traction
Manual Traction
Skin Traction
Skeletal Traction

70. Manual Traction
Means pulling on the body using a person’s hands and muscular strength
It is most often used briefly to realign a broken bone
It is also used to replace a dislocated bone into its original position within a joint

71. 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
Other names for skin traction is Buck’s traction and Russell’s traction

72. Skeletal traction
Means pull exerted directly on the skeletal system by attaching wires, pins, or tongs into or through a bone
Skeletal traction is applied continuously for an extended period

73. External Fixation
Is a metal device inserted into and through one or more broken bones to stabilize fragments during healing
This external fixator immobilizes the area of injury, the pt is encourages to be active and mobile
OREF – open reduction external fixation, pins to clean

74. External Fixation
What are the special nursing needs for this patient?

75. External Fixation(AV)

76. Internal Fixation
What are your nursing concerns?

77. Pin Care
Care must be given to the pins that are sticking out of the skin to prevent infection and to promote healing
Usually cotton tip applicators are soaked in H2O2 – hydrogen peroxide, and the nurse swabs around the pins to clean them
We used to place bacitracin around the pin entrance site, but stagnant bacitracin has been known to cause growth of bacteria at the pin site

78. Traction

80. Skin Traction (AV)

81. Set up for Traction (AV)

82. Pin Care for Skeletal Traction (AV)

83. Moving with Cast(AV)

85. Halo traction

86. Passive Motion Machine(AV)
Provides a constant motion of bending and straightening to keep joints from stiffening
Causes pain to pt, medicate pt well well

87. The use of an abductor pillow

88. ACE WRAPS

89. What is an ACE wrap? A.K.A. compression bandage
An ace wrap is an elastic bandage that comes in different sizes.
The wrap comes in a roll with metal clips, with tape to fasten it in place, or Velcro™ .
The bandage may be from 2 to 6 inches (5 to 15 cm) wide and 4 to 6 feet (1.2 to 1.8 m) long.
Elastic bandages can be bought at any medical supply or drug store.
Your caregiver will help you choose the best bandage for you.

90. PURPOSE:
An ace wrap puts gentle pressure on the tissue around an injury providing support
To help reduce swelling of an injured area of the body.
To hold wound bandages in place.
To wrap around an arm or leg splint during healing.
To improve blood flow to a limb like an arm or leg.
To hold cold or hot packs in place on a body part, such as an arm.

91. How to put an ACE wrap on…
Hold the rolled bandage with one hand and with the other hand put the loose end on top of the foot.
While holding the loose end, wrap the bandage twice around the foot. Be sure to overlap the ace wrap.
After the foot has been wrapped twice, move your hand to the heel.
Wrap the bandage moving toward the ankle. The bandage should be wrapped in a spiral way like making a figure 8.
Leave the heel uncovered.
Cross the bandage over the foot, moving upward, and pass it behind the ankle.
Move the bandage down and cross it over the top of the foot.
Wrap the bandage under the foot to complete the 8 figure. Repeat this one more time.
Pass the bandage around your calf and start wrapping it toward the knee.
Stop wrapping below the knee. You don't need to start coming down again.
The end of the bandage can be fastened with tape or metal clips.

92. NANDA Diagnoses Acute Pain Impaired physical mobility
Risk for disuse syndrome
Risk for impaired skin integrity
Risk for ineffective tissue perfusion
Self care deficit

93. The End