The home care nurse is visiting a client with diabetes who has a new cast on the arm. On assessment, the nurse finds the client's fingers to be pale, cool, and slightly swollen. Which is the nurse's first intervention?
a. Elevate the arm above the level of the heart.
b. Encourage active and passive range of motion.
c. Apply heat to the affected hand.
d. Place a window or bivalve the cast.
A
Arm casts can impinge on circulation when the arm is in the dependent position. The nurse should immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and should reassess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the client is upright. Heat would cause increased edema and should not be used. En-couraging range of motion would not assist the client as much as elevating the arm. If the cast is assessed to be too tight, it could be bivalved.
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