Plan for the first day
During the first 24 to 48 hours after casting, swelling under the rigid cast is the main threat. It is controlled by elevating the limb above heart level and applying ice at the sides of the cast, provided neurovascular checks stay normal. His checks are normal at 1 and 2 hours: toes pink and warm, capillary refill 2 seconds, palpable pulse, intact movement and sensation, and pain easing from 4/10 to 3/10 after analgesia. With normal, stable neurovascular checks, the leg is elevated above the heart with ice packs at the sides of the cast.
Why elevation and ice reduce swelling
A fresh fracture causes bleeding and inflammation, and a plaster cast cannot expand. If swelling builds, pressure inside the cast rises and can compress vessels and nerves. Elevation above the heart uses gravity to promote venous and lymphatic return. Cold causes vasoconstriction and reduces fluid leakage and pain. Ice packs are placed at the sides of the cast in plastic bags so the plaster stays dry and is not dented, and they are applied intermittently.
| Position and therapy | Effect | Assessment |
|---|
| At heart level, with ice | Used when compartment syndrome is suspected | Not indicated; checks are normal |
| Above heart level, with ice | Reduces early swelling | Correct |
| Above heart level, with warm pack | Heat dilates vessels | Increases early swelling |
| Below heart level, with ice | Dependent position | Edema gathers under the rigid cast |
When the plan changes
Watch out! If compartment syndrome is suspected, the limb is kept at heart level, not elevated, because elevation lowers arterial pressure to the compartment and can reduce perfusion further. Warning signs include pain out of proportion to the injury, pain on passive stretch of the toes, increasing pain despite analgesia, numbness or tingling, and, later, pallor, coolness, and loss of pulse. The nurse reports these at once; the cast may need to be split or removed. In this client, pain is decreasing and all checks are normal, so elevation is appropriate.
Ongoing nursing care
The nurse continues neurovascular checks at the frequency ordered, supports the wet plaster cast on pillows with the palms rather than the fingertips to avoid dents, leaves it uncovered to dry, and teaches the client to report increasing pain, numbness, or color change immediately.
Exam takeaway
Key point! Fresh cast with normal checks: elevate above the heart and apply ice for the first 24 to 48 hours. Suspected compartment syndrome: heart level and urgent report. Never apply heat or keep the limb dependent in the early period.