The nurse teaching the client with a cast about home care includes which instruction?

Note: This guideline is currently under review. 

• Introduction
• Aim
• Definition of Terms
• Assessment
• Management
• Discharge Planning and Assessment
• Family Centered Care
• Special Considerations
• Companion Documents
• Links 
• Evidence Table

Introduction

A hip spica is a plaster cast that extends from the torso down to the feet and is applied in theatre under general anaesthetic. The objective of the hip spica is to immobilise the hip, pelvis and/or femur to correct and maintain hip deformities. A spica cast can be used for stabilisation of pelvic or femur fractures, or post reduction/reconstruction for developmental dysplasia of the hip (DDH).  Children having a closed/open reduction to correct hip dysplasia may have the cast on for 12 weeks, with a change of plaster occurring after 6 weeks. 
Before surgery, some children may be placed in traction, which is aimed at decreasing muscular contractions, to increase the chances of a successful closed reduction in DDH, or to stabilize and promote realignment of a fracture. Hip spicas are generally used for children from 6 months to 6 years of age. 
The nurse plays a pivotal role in the acute post-operative management and in the education and support for families. Postoperative care involves pain management, assessment of neurovascular status, hygiene and nutrition needs. One of the most challenging aspects of caring for an incontinent child in a hip spica is keeping the cast clean and dry and maintaining healthy skin integrity. Nurses have an important role in preparing parents for discharge. The hip spica can stay in situ for 6 weeks to 6 months, depending on the medical condition. Caring for the child in a hip spica at home can be very stressful, therefore it is essential that nurses provide the appropriate support and discharge education.

Aim

• To guide clinicians on the assessment and management of children with a hip spica
• To minimise complications
• To minimise patient discomfort
• To ensure parents are provided education and prepared for discharge

Definition of terms

Bivalve: Splitting the plaster cast in two complete pieces to relieve swelling, pressure or neurovascular compromise, or to allow for frequent assessment

Closed reduction: The hip is gently manipulated into the acetabulum by flexion, traction and abduction under a general anaesthetic and then immobilised in a hip spica cast. An adductor tenotomy, which involves percutaneous lengthening of tendons, may also be performed.

Developmental Dysplasia of the Hip (DDH): An abnormality in the development of the hip joint. The size, shape, orientation, or organisation of the femoral head, acetabulum or both can be affected. The abnormality may be congenital or may develop during infancy or childhood. 

Femoral/Pelvic osteotomies: Usually performed on children with DDH greater than 18 months. The cutting and repositioning of bone required to reconstruct and safely maintain the hip in the reduced position.

Hip Spica: A plaster of Paris covering the torso and continuing down to the ankle on the affected side and to the knee on the unaffected side or covering bilateral legs to the ankle. There is an opening around the perineal area for toileting. Used to immobilise and maintain optimal position for abduction and flexion of the hips, pelvis, and/or femur.

Open Reduction: Usually performed after failed closed reduction in children greater than 2 years. Involves lengthening tendons, removing obstacles to reduction and tightening the hip capsule. 

Assessment

Physical assessment

Patient assessment

• Routine post-operative observations. Routine Post Anaesthetic Observation Nursing Guideline
  
• Frequency of ongoing observations depends on age, analgesia & patient condition. Please see the Observation and Continuous Monitoring and Nursing Assessment Clinical Guidelines
  
• Infants under the age of 6 months with an opioid infusion will require continuous pulse oximetry until ceased. See Indications for pulse oximetry
  
• Post-operative x-ray or CT is required to check the patient’s position in the cast and is usually performed in theatre, or post-operatively. 
  

Neurovascular assessment

• Neurovascular observations should be conducted hourly for the first 24 hours then 2-4 hourly for the next 48 hours depending on condition. 
  
• Document findings on appropriate limb observation flowsheet. 
  
• See Neurovascular observations RCH CPG
  

Pain assessment

• Patients require regular pain assessment using an age appropriate assessment tool. See Pain Assessment and Measurement
  
• Patients who have had a closed reduction usually only require oral analgesia. Patients who have sustained a fracture or who have had open reduction or osteotomy will usually require an opioid infusion and/or epidural. (Refer to epidural guideline and Opioid Infusion guide for further information).
  
• Pain scores, interventions, and evaluation of interventions performed, should be documented in the observation flowsheet.
  

Skin and plaster assessment

• Evaluate patients’ skin integrity regularly. Observe for any redness, irritation or burning sensation.
  
• In the acute post-operative period swelling can occur and a tight cast can potentially cause neurovascular compromise. Children who have had an open reduction or osteotomy may have significant swelling in the groin area. Monitor swelling and plaster to ensure the cast is not too tight.
  
• Cold packs can be used to help with swelling and pain, ensuring that ice/cold packs do not come in direct contact with skin due to risk of burns and/or tissue injury.
  
• The cast may require trimming. Nurses must check with medical officer before trimming cast.
  
• Limbs should be elevated with pillows to increase venous return, decrease swelling and reduce the risk of compartment syndrome. 
• See RCH CPG Nursing assessment 
• Pressure Injury Prevention and Management 
• Revised Glamorgan Reference Guide.pdf 
  

Management

Acute management

Hydration and Nutrition

• Once the patient is alert enough they may commence clear fluids unless contraindicated. If tolerating clear fluids, diet can be upgraded as tolerated. 
  
• Monitor and document fluid input and output on Flowsheets. 
  
• If the patient normally receives enteral feeds at home, see CPG Enteral feeding and medication administration for further guidelines. 
  
• RCH Clinical Guideline-Intravenous Fluids
  
• Peripheral Intravenous Device Management
  

Positioning

• Children in hip spicas cannot move themselves easily. Regular pressure area care is necessary due to the risk of pressure injury. The child should be repositioned 2-4 hourly, during the day and night. The child can be placed supine, prone or on their side if comfortable, and must be supported with pillows and/or towels to alleviate any pressure from the plaster, and to provide support. Ensure the child is supervised while lying prone to ensure monitoring of airway.
  
• With each change of positioning, check that the plaster is not causing pressure, and is not too tight around the edges (torso, ankles, groin and knees). 
  
• Make sure the child's heels/feet can move freely after each position change. Ensure their feet and toes are not pressed into the mattress or chair as this could cause pressure sores, especially when in prone position. 
  
• Pressure Injury Prevention and Management

Transferring patient  

• 1 to 3 people may be required to support safe patient transfer/ depending on size and weight of the child 
  
• Smart Move Smart Lift trainer, Physiotherapy and Occupational Therapy assessments may be required to determine the equipment requirements for older or heavier children. Mobile hoist and over-head tracking available to support safe transfers. 
  
• It is important to ensure that the child’s pain is adequately controlled before attempting movement. It can also be helpful for the child when the nurse and carers provide reassurance prior to, and during, the transfer.
  
• Key things to consider to ensure safe transfers
  
  • A child should be encouraged to be as independent as possible, according to age and capability.  
    
  • Plan transfer with handlers and child prior to transfer
    
  • Move patient to edge of bed – use slide sheets
    
  • Keep load close to handler
    
  • Support the back with and legs during transfer.
    
  • Younger infants/children may require neck and head support 
    
  • More than one handler may be required, depending on patient’s size and cooperation.
    
  • Remember to plan the transfer and use body mechanics to prevent injury.
    
  • Follow RCH Smart Move Smart Lift program
    
  • Ensure mandatory Smart Move Smart Lift competencies are completed annually.
    

Toileting

• Nappies need to be checked every 2 hours during the day and 3-4 hourly overnight. They must be changed as soon as they are soiled or wet to prevent soiling/ wetting the plaster, and to avoid skin breakdown and irritation. 
  
• Newborn nappies or incontinence pads should be tucked into the front and back of the toileting area and covered with a larger disposable nappy.
  
• Children who are continent can use a bed pan and/or urinal bottle. When using a bedpan, elevate the child’s head and shoulders with pillows and/or bed mechanics. This will help prevent urine and/or faeces from running backward and inside the cast. A gauze or cloth pad or small folded towel placed on the back and front rims of the bedpan will absorb any moisture and help keep the cast dry. The pad is removed with the bedpan. 
  

Cast care

• Keeping the cast clean and dry is essential as wetness or soiling encourages microbial growth, which can cause skin irritation, odour and compromise the integrity of the cast.
  
• Plaster can take up to 24- 48 hours to dry post application. If plaster is taking a long time to dry, the patient can be placed prone to help circulate air.
  
• A dry plaster cast produces a hollow sound when tapping with finger. Once the plaster is dry, it needs to be waterproofed using sleek tape and scotched with fibreglass.
  
• Observe the cast for cracks, dents, softening, increasing tightness or looseness, or drainage on the cast.
  

Sleeking or Petaling

• is performed by applying sleek tape around the edges of the plaster in the groin area.
• Using waterproof tape cut several 10 cm long pieces and tuck one end of the tape under the cast and pull the free end over the cast surface.
• It is easier to start from the underside of the cast and then bring the loose edge to the front pressing firmly to ensure adhesion.
• Continue to overlap strips of tape until a complete waterproof edge is formed ( See figure 1).
• May need to wait for swelling to decrease before sleeking.

• It is preferable not to apply sleek to the top of the hip spica around the abdomen due to risk of causing sweating and rashes. Orthopaedic felt can be used to cushion the area, and is usually in situ post-operatively. 

 Figure 1. Applying waterproof tape to edges of the perineal area

Scotching

• Scotching is completed by applying a thin layer of fibreglass over the plaster to make it stronger. Plaster should be dry before scotching usually 24-48hrs post-surgery. See Figure 2.
  
• More than 1 person may be required to assist the safe manual handling of the patient during scotching. 
  

Figure 2. Applying waterproof tape to edges of perineal area and scotching the plaster.

Dressings

• Patients post open reduction may have 2 small groin dressings which are to remain intact until follow up. If wounds are visible, ensure dressings are clean, dry and intact, perform regular wound and dressing assessments, and notify medical team of any oozing, bleeding, or signs of infection.
• See RCH CPG Wound care

Hygiene and skin care

• A daily sponge bath of exposed areas with a mild soap is required avoiding contact with cast or lining.
• Regular skin assessment for breakdown or pressure areas should be completed.
• The use of lotions and powders under and near the cast and perineal area should be avoided as these can soften and irritate the skin and lead to breakdown.

Diet/Constipation

• Child should not commence new foods to avoid the risk of intolerance and loose stools.  
• Place child upright during meals. Small frequent meals should be recommended if the child is uncomfortable after eating due to the pressure on the stomach from the hip spica.
• Constipation can occur due to immobility and medication use therefore aperients may be required and parents should be encouraged to ensure good oral intake and foods high in fibre.
• See Post-operative bowel management
  

Ongoing Management

Allied Health Referrals

Physiotherapy

• All children requiring fitting of stroller or pram, and/or wheelchair should be referred to physiotherapy.

Occupational Therapy 

• Children older than 24 months should be referred to an orthopaedic occupational therapist, as there are typically other areas to be addressed, such as toileting, bathing and mobility.
  
• If difficulties are encountered by bedside nurse and are unable to be resolved by AUM or Platypus Orthopaedic Care Manager, a referral can be made to the orthopaedic occupational therapist. 
  

Potential Complications

Pressure areas

• Pressure areas can develop on parts of the body where the blood flow is reduced because of prolonged pressure caused by the application of a hip spica.
  
• A pressure area under the cast will cause a burning sensation, local heat and an offensive smell. 
  
• See Pressure Injury Prevention and Management
  

Pruritus

• Pruritus may be relieved by the administration of low dose naloxone in the first instance if it is suspected to be opioid induced.
• Please note that when antihistamines are used concurrently with opioids the risk of excessive sedation and respiratory depression is increased. The pathophysiology of opioid-induced pruritus is not fully understood and current evidence suggests that the main pathway involves μ-opioid rather than histamine receptors.
• Patients should avoid using lotions or powders under casts. Blowing cool air from a hair dryer can relieve itchiness.
  

Neurovascular compromise 

• See RCH CPG Neurovascular observations
  Compartment syndrome is considered a surgical emergency and patients must be reviewed urgently by the surgeon if compartment syndrome is suspected.
  

Plaster issues

• Hip spicas are not routinely changed due to soiling of plaster. Plasters can crack or dint and need to be assessed regularly.
  
• If neurovascular compromise occurs, the cast may need to be bi-valved by making a longitudinal cut to divide the cast into two pieces, to relieve pressure or to assess skin.

Mesenteric Artery Syndrome / Cast Syndrome

 Mesenteric artery syndrome/cast syndrome can occur isas a rare complication secondary to pressure of the cast around the abdomen.  It is associated with proximal duodenal obstruction resulting in the external compression of the third portion of the duodenum by the superior mesenteric artery.  Signs and symptoms are general and unpredictable in nature and can include emesis which is frequently bilious, and may contain partially digested food, nausea, early satiety, and abdominal pain. Diagnosis occurs by performing upper gastrointestinal imagingseries withusing contrast. 
Constant monitoring of the cast is essential.

Parents and carers need to be aware of this complication before the child is discharged from hospital. If, after the child is at home, the cast is found to be too tight around the abdomen, the child needs to attend their closest hospital emergency department as soon as possible. A small round hole can be cut into the cast to relieve the pressure on the child’s stomach.

Discharge Planning and assessment

Car seating and transportation

1. assessing the child's restraint needs
   
2. selecting the most appropriate child restraint
   
3. completing an RCH Medical Car Seat Letter and the OT Car Seat Letter.

• Children must be fitted into a safe and appropriate car seat. Parents needs to be advised to bring their car seat and pram to the ward as soon as possible. Car seats often need to be modified with padding or an extendable crotch strap, see figure 3. 
  
• Possible modifications to restraints include the use of an extended crotch strap to overcome the extra height of the hip spica, or short-term use of towels or foam to raise the child's hips and move their trunk forward in the restraint. However, if the latter is prescribed, parents should be advised the child will be at greater risk of a spinal injury in a collision.
  
• An RCH Medical Car Seat letter and OT Car Seat Letter MUST be completed and provided to the carer prior to discharge.
  
• The child must be upright, fitting snugly into the car seat without any gaps between the plaster and car seat. Flexion of the neck must be avoided. Towels or support wedges may be used for positioning.
  
• Once fitted, these supports should be placed under the lining of the car seat. All padding should then be taped down with micropore or Elastoplast™ to ensure it stays secure for 6 weeks.
  
• Appropriate paperwork must be completed and given to the parent. Specific instructions should be communicated to parents before discharge by the child seat technician (nurse/OT) to ensure proper fit and function during subsequent transport.
  
• If unsure how to fit a patient into a car seat, contact the Platypus nurse in charge, Platypus Orthopaedic Care Managers or Occupational Therapy (if the child meets OT referral criteria).

Figure 3: padding used for infant in car seat.

Fitting car seats and restraint modifications 

It is neither legal nor safe for parents to use the following information to make changes to their child's restraint without the advice of a trained health care professional. In Victoria, it is compulsory for children travelling in a vehicle to be restrained appropriately for their age and height, with a child restraint that complies with the Australian/NZ Standard 1754. 
Please see the vicroads website for current information vicroads-child restraints
See also Product Safety Australia- Child restraints for use in motor vehicles

• The following flowchart is a general guide on how to determine appropriate car seat hire/modification ‘Prescription or Modification of Car Restraints for Children with Orthopaedic Conditions. A Guide for Nursing Staff.’ (To be revised 2018)
  
• If the car seat is modified in any way by nursing or OT staff, the RCH Medical Car Seat Letter must be completed. See section Completing Letters in EMR (LINK)
  
• A template for this letter can also be located on the RCH TOCAN resources (Transportation of Children with Additional Needs) Website /tocan/resources/Resources/.
  

If the patient is unable to be fitted into an appropriate restraint they must be transferred home via non-emergency patient transport and follow up transfer for outpatient appointments to be organised by the patient’s GP.

• If children are unable to fit into a compliant child restraint due to a physical, mental or emotional medical condition, they must be assessed to determine whether they need a special purpose child restraint, or if their current restraint can be modified, to ensure they are safely restrained in a way that is appropriate for their age, size and medical condition.
  

Completing Letters in EMR

If using EMR, there are two letters available in the Communication Management Activity. Both letters need to be completed and provided to the parent/carer before the patient is discharged. The RCH Medical Car Seat Letter is to be accessed, printed and signed by the medical team. The OT car seat letter is to be completed by the OT or nurse fitting the car seat as well as the parent/carer. 
Follow this process to complete both the RCH Medical Car Seat Letter and the OT car seat letter

1. Select Communication on the Communication Management Activity (or it may be listed under ‘More’ Activity. 
   
2. Select ‘New Communication’
   
3. Type of communication is ‘other’ 
   
4. Search ‘çar seat’ and select ‘OT car seat letters’. 
   
5. Complete all sections that are highlighted or that contain***
   

Once completed, print by clicking preview and print.

Further information can be located on the TOCAN website /tocan/ 
Car seating guidelines are specific to the Royal Children’s Hospital, Melbourne 

Fitting prams/strollers/ wheelchairs 

The child in a hip spica needs to be assessed to determine if they fit into their pram. Please refer to physiotherapy for fitting of all prams/strollers and wheelchairs. If the child does not fit into their own pram, an alternative pram can be fitted by physiotherapy and then hired from EDC. Older children may require a reclining wheelchair which can also be hired from EDC.

Refer to TOCAN Case Studies for examples of troubleshooting car-seating and restraints for individual medical conditions  /tocan/case_studies/Case_Studies/

Education

• Parents need to understand the full implications of care. Parent education and discharge planning needs to begin early.
  
• Parents should be given Kids Health Information handouts which provide written and visual care instructions ( What to expect in hospital & Care at home)
  
• The hip spica care books located on Platypus ward are also good educational resources for parents.
  

Follow-up / Review

• The patient will normally require a follow-up appointment 6 weeks post-surgery, with an x-ray to be performed prior to seeing the doctor. 

Family centered care

• Providing care for a child with a hip spica at home can be very stressful and nurses should ensure parents have appropriate family and social supports.
  
• Education should be provided highlighting the importance of involving children in activities. 
  
• Educate and involve parents in ADL’s and positioning early in care.
  
• Document education provided in the Education section in the ADT Navigators Activity
  
• Early discharge planning and education is best to increase parental confidence.
  

Special considerations

• Occupational Health and Safety: There is a risk of sustaining or exacerbating musculoskeletal injuries to the carer and health professional through incorrect moving and handling. 
  
• Nurses should complete annual Smart Move Smart Lift Competency. RCH Workplace Health & Safety Policies & Procedures should be followed in the care and manual handling of all patients in hip spicas. LINK RCH Policies & Procedures
  
• Patients may require 1-3 people to transfer or the use of a hoist. 
  
• Refer to Worksafe Victoria manual handling pdf.
  
• Correct transferring techniques also need to be taught to parents and carers.
  
• Patients who are developmentally delayed or have spastic muscular conditions are at higher risk of developing complications secondary to immobilisation in plaster.
  
• Special considerations must be given for the parent with sensory or learning deficits as well as those with language barriers.
  
• Immunisations: Administration of vaccines to children in spica casts should be avoided. See RCH CPG-Immunisation of inpatients
  
• Multi language Wong Baker and Numeric tools are available if needed. See Wong Baker Faces Pain Rating Scale-List of available language translations
  

Companion documents

• RCH Kids Health Info Fact Sheet-Hip spica plaster 1-What to expect in hospital
  
• RCH Kids Health Info Fact Sheet Hip spica plaster 2 Care at home
  
• RCH Transportation of Children with Additional Needs (TOCAN) /tocan/resources/Resources/.
  
• Prescription or Modification of Car Restraints for Children with Orthopaedic Conditions. A Guide for Nursing Staff Flowsheet. (To be revised 2018)
  
• Orthopaedic factsheets: BROOMSTICK-PLASTERS.pdf
  
• RCH CPG (Nursing)-Falls prevention
  
• RCH CPG (Nursing) Pressure Injury Prevention and Management

Links

• /tocan/
• http://www.kidsafevic.com.au
• www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_Assessment/
• Acute pain management CPMS
• Routine Post Anaesthetic Observation Nursing Guideline
• Opioid Infusion
• /anaes/pain_management/Postoperative_Nausea_Vomiting_PONV/
• /anaes/pain_management/Epidural_Infusion/
• Neurovascular observations
• WorkSafe Victoria Manual Handling (Code of Practice No.25, 2000) http://www.worksafe.vic.gov.au/__data/assets/pdf_file/0003/9426/COP25_manualhandling.pdf
• /kidsinfo/fact_sheets/Hip_spica_plaster_1_What_to_expect_in_hospital/
• /kidsinfo/fact_sheets/Hip_spica_plaster_2_Care_at_home/
• Revised Glamorgan Reference Guide.pdf
• Pressure Injury Prevention and Management
• Post-operative bowel management
• RCH CPG Wound care
• Wong Baker Faces Pain Rating Scale-List of available language translations
• https://blogs.rch.org.au/pharmacy/2015/04/10/rch-adr-committee-treatment-of-opioid-induced-pruritis/
  
• https://www.vicroads.vic.gov.au/safety-and-road-rules/vehicle-safety/child-restraints/choose-the-right-child-restraint
• https://www.vicroads.vic.gov.au/~/media/files/documents/safety%20and%20road%20rules/childrestraintsboosterseatsandadultseatbelts.ashx
  

Evidence table

Please click here to view the evidence table. 

The revision of this nursing guideline was coordinated by Kiralee Ciampa, RN, Platypus Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2018.  

Which cast care instructions should the nurse provide to a client?

What cast care instructions would the nurse give to the client with a plaster cast to the right forearm?

Which cast instructions should the nurse provide to a patient who just had a plaster cast applied select all that apply?

Which of the following is the recommended method of drying the client's cast?