List nursing interventions and preventative management related to skeletal traction.
As what we had discussed, traction is the application of pulling force to a part of the body. There are two types of traction, the skin traction and the skeletal traction.
In skeletal traction, the traction is directly applied to the bone by the use of metal pin or wire.
To maintain an effective traction, the nurse must check the traction apparatus. Make sure that the ropes are positioned properly in the pulley track, ropes are not ragged, the weights hang freely and the knots in the rope are tied securely and make sure that the skeletal traction equipment are tight. Check the pins to be sure they are secure and tight, and insert the small finger or the index finger between the vest and the patient’s skin to be sure the vest if comfortable and not too tight. The nurse must also maintain the position of the patient. Inspect the patient’s proper body alignment every 2 hours. Avoid foot drop, inward rotation and outward rotation. The foot of the patient may be supported in a neutral position.
Monitor neurovascular status of the patient at least every 4 hours. The patient must report to the nurse if there are any changes in his sensation or movement. The immobilized patient is risk for DVT. So, encourage the patient to do active flexion and extension of the extremities and isometric contraction of the calf. Also, anti-embolism stockings, anti-coagulant therapy may also be used to prevent thrombus formation. Instruct the patient to exercise to maintain strength and tone of his muscle. Also, this will help in patient’s rehabilitation.
Pin at the insertion site may be risk for infection or the development of osteomyelitis. Pin care should be performed 1 or 2 times a day. Clean the site with chlorhexidine solution or water and saline. The nurse must inspect the pin every 8 hours for infection. When pins are stable for 48- 72 hours, weekly pin site care is suggested.
The nurse must prevent skin breakdown by inspecting the elbows and heels for pressure ulcers. A trapeze can be used to help the patient move about in the bed without the use of elbows and heels. The nurse must keep the bed dry and free from crumbs and wrinkle for patient who is unable to change positions.
Discuss a component of cast care for the pediatric client or adult client. Identify manifestations of compartment syndrome.
General cast care includes avoid getting cast wet, especially padding under cast-cause skin breakdown as plaster casts become soft. Moisture weakens plaster and damp padding next to the skin can cause irritation. Advise the patients that do not cover a leg cast with plastic or rubber boots, as this causes condensation and wetting of the cast. Also, avoid weight bearing or stress on plastic cast for 24 hours. Report to the physician if the cast cracks or breaks, instructs the patient not to fix it himself. To clean the cast, remove surface soil with slightly damp cloth, rub soiled areas with household scouring powder, and wife off residual moisture.
For pediatric patient there are some additional cast cares. The child is usually more troubled by immobilization than the adult. A special attempt should be made to ensure that his activities are as normal as possible and that full use is made of his unaffected joints and muscles. The younger child may not be able to understand why the cast is necessary. He may attempt to remove it. Allow the child to work through his question and feelings via play like giving her a doll with a cast. Children may be frightened by the removal of the cast. They often think of cast as part of their body and may be helped by analogies of having fingers nails or hair cut. Age- appropriate explanations and demonstrations should be provided. Parents should be instructed in care following cast removal. Daily soaking of the area may be necessary to remove desquamated skin and secretions. Oil or lotion may provide comfort to the child. Exercise should be done as prescribed to increase strength and function.
Manifestations of compartment syndrome:
In acute compartment syndrome:
The classic sign is pain in the injury site. Stretching the muscles increases the pain.
There will be tingling or burning sensation in the skin.
The muscle will feel tight.
The late sign of compartment syndrome is paralysis indicating permanent tissue damage.
In chronic compartment syndrome:
There is pain and cramping during exercise. The pain usually subsides when the activity stops.
Difficulty moving the foot
Visible muscle bulging
Compare the nursing needs of a total hip replacement patient with those of a total knee replacement patient.
In patient who had undergone hip replacement, nursing intervention focuses on preventing dislocation of hip prosthesis. The nurse must instruct the patient to position his leg in abduction because this may prevent dislocation of the prosthesis. A wedge pillow is usually placed between the legs to remain the legs abducted. Also, the hip of the patient should never be flexed for more than 90 degrees. When the patient sits, advice him than his hips should be higher that his knees. The patient’s affected leg should not be elevated and the knee may be flexed. Emphasize to the patient that he should maintain his legs in abducted position, to avoid internal and external rotation, hyperextension and acute flexion. Due to invasive procedure, there will be fluid and blood being accumulated. The nurse must remember that drainage is still normal if 200-500 ml of fluid were drained for the first 24 hours and after 48 hours it usually decreases to 30 ml or less. Report to the physician if the volume of the drainage is greater than expected. Risk for deep vein thrombosis is common after the hip replacement because of immobility. Anti-embolic stockings, anti-thrombolytic medication can be used as preventive measures. Advise the patient to report any signs of calf pain, swelling and tenderness because it may indicate DVT. One of the serious complications after hip replacement is infection; it may occur within 3 months after surgery and associated with hematomas. Use of aseptic technique for dressing changes should be observed and implemented to avoid introducing organisms. Severe infections may require surgical debridement or removal of the prosthesis.
In patient who had undergone knee replacement, nursing intervention should focus on mobilizing the patient. While in hip replacement the patient’s legs should be abducted, in knee replacement the patient is encourage to do active flexion of the foot every hour when the patient is awake. Like in hip replacement, knee replacement is also risk for deep vein thrombosis. Active range of motion, anti- embolic stocking and anti-coagulant can be used to prevent DVT. Also, knee replacement is an invasive procedure and its fluid had accumulated in the joint. Drainage of this replacement may ranges from 200-400 ml during the first 24 hours and less than 35 ml by 48 hours. If extensive bleeding happens, an autotransfusion drainage system may be used during postoperatively. Change in the characteristics and amount of drainage is promptly reported to the physician. Encourage the patient to use a continuous passive motion device with physical therapy to improve patient’s knee mobility, decreased hospital stay and minimize the intake of analgesic agents. The nurse must assist the patient to get out of the bed on the second postoperative day and start ambulating as tolerated.
Discuss methods to avoid dislocation after hip replacement surgery.
Dislocation of the hip is a serious complication of surgery that causes pain and necessitates reoperation to correct the dislocation. The desirable positions such as abduction neutral rotation and flexion of less than 90 degrees must be emphasized during the patient teaching. Instruct the patient to keep the knees apart at all times by putting a pillow between the legs to keeps hip in abduction and in neutral position to prevent dislocation. The patient should never cross his/ her legs while sitting. Avoid bending forward while sitting in a chair. The patient should not flex the hip to put on clothing such as pants, stockings or socks. Use a high-seated chair and a raised toilet seat.
You are caring for a patient who has had skeletal traction placed to treat a fractures femur. Discuss nursing interventions and assessment techniques related to this type of treatment.
Fracture of the femur usually is treated with some form of traction to prevent deformities and soft- tissue damage. Skeletal traction is used to align the fracture in the preparation for the future reduction. Traction restricts patient’s mobility and independence; therefore the nurse must assess and monitor the patient’s anxiety level and psychological responses to traction.
Since the patient requires assistance with self-care activities, the nurse must help the patient to eat, bathe, dress and toilet. Assess the patient and the traction set-up to determine the best method for changing the bed linen. Eliminate any factors that reduce the traction pull or alter its direction. Ropes and pulleys should be in straight alignment and the ropes should be unobstructed. The nurse must inspect the body part that is placed in traction and its neurovascular status to determine if there is sign of inflammation. Because the patient is confined to bed, the nurse must implement measures to prevent complications of immobility and inactivity.
One of the complications in patient to skeletal traction is atelectasis and pneumonia due to immobility. To assess respiratory status, the nurse auscultates the patient’s lungs every 4-8 hours. Teach the patient deep exercises to fully expand the lungs and to clear out secretions. Constipation is also a complication due to decreased peristalsis, a high fiber diet and fluids may help stimulate gastric motility. Urinary infection is also a common complication because of incomplete emptying the bladder due to the uncomfortable effects of voiding into a bed pan. The nurse must encourage the patient to drink large quantities of water and to void every 3-4 hours. DVT is also a serious complications, nurse must assist the patient in foot and ankle exercise. Also, drinking a lot of fluids makes the patients hydrated and prevents homoconcentration which can contribute to stasis.
A patient is being discharged with an external fixator for a fractured humerus. Discuss home care instructions for this patient.
These are the instructions that the nurse must teach to the patient before discharge:
Patient must inspect each pin site for signs of infection and loosening of pins. Watch for pain, soft tissue swelling and drainage and consult a physician when it occurs.
Cleanse around each pin daily, using aseptic technique to prevent contamination of bacteria leading to infection. Do not touch wound with your bare hands.
Clean fixator daily to keep it free of dust and contamination.
Do not tamper with clamps or nuts because it can alter compression and misalign fracture.
Encourage the patient to follow rehabilitation regimen because it is helpful in teaching the patient to use ambulatory aid safely, adjust to weight- bearing limits and altered gait patterns.
Identify various types of traction and the principles of effective traction.
The first type of traction is the running traction, it is a form of traction in which the pull is exerted in one plane; it may be either skin or skeletal traction and Buck’s extension traction is an example of running skin traction. The other type of traction is balanced suspension traction, which uses additional weights to counterbalance the traction force and floats the extremity in the traction apparatus. The line of pull on the extremity remains fairly constant despite changes in the patient’s position.
According to our discussion, to achieve an effective traction, countertraction, a force acting to the opposite direction, is applied. The patient body weight and positioning in bed supply the counterforce; Traction must be continuous to reduce and immobilize fracture; Skeletal traction is never interrupted; weight are not removed unless intermittent traction is prescribed; any factor that reduces pull must be eliminated; ropes must be unobstructed and weight must hang freely and knots or the foot plate must not touch the foot of the bed.
Discuss the use of Buck’s traction, its uses and the involved nursing considerations.
Buck’s traction is skin traction to the lower leg. It is used to immobilize fractures of the proximal femur before surgical fixation.
It can be use for hip and knee contracture, preoperative and postoperative positioning and immobilization of hip fractures, muscle spasm, joint rest.
Ensure skin integrity by avoiding pressure on heel, dorsum of foot, fibular head, or malleolus.
Maintain countertraction by elevating foot of the bed or keeping head of bed flat.
Encourage independence with use of trapeze.
Do not put a pillow under the affected limb.
Observe skin by removing traction, with someone holding the leg in alignment with manual traction, at least once every shift.
A maximum of 10 lb of traction should be used.
Discuss the nursing care for a patient undergoing orthopedic surgery.
Preoperative nursing care:
In relieving the pain of the patient, elevation of the edematous extremities promotes venous return and reduces discomfort. Also, the use of ice relieves swelling and reduces discomfort by diminishing nerve stimulation. The physician may order analgesic to control the acute pain of the musculoskeletal injury. The nurse must also maintain adequate neurovascular function by assessing color, temperature, capillary refill, sensation and motion of the extremities. For the nurse to promote health to the patient, th nurse should assist the patient in performing activities that promote health during the perioperative period. The nurse also assesses nutritional status and hydration. The goal of the nurse in the preoperative period is to focus on helping the client to experienced reduced pain; continue to be active, mobile and injury free; and practice measures to reduce the potential for postoperative wound infection.
Postoperative nursing care:
The nurse assesses the patient’s level of pain since pain is common after orthopedic surgery. the use of repositioning, relaxation, distraction and guided imagery may help in reducing the patient’s pain. The physician must order patient- controlled analgesia and epidural analgesia to relieve the pain. In maintaining an adequate neurovascular function, the nurse must instruct the patient to perform muscle- setting, ankle, and calf-pumping exercise hourly while awake to enhance circulation. Encourage the patient to increase intake of foods that is rich in protein and vitamins because it is essential for wound healing. Positioning the patient at least every 2 hours can minimize pressure ulcer and skin break down. The patient may use assistive device for postoperative mobility.
There are potential complications that may arise after the surgery. The goal of the nurse is to the patient is to exhibit absence of complication. The patient is risk having pneumonia and atelectasis, the nurse must instruct the patient to deeply breath and cough every 2 hours to expand the lungs and mobilize secretions; encourage the use of incentive spirometry to increase respiratory effort; turning the patient at least every 2 hours to prevent pooling of secretions and auscultate lung sounds every 4 hours to note for breath sounds. The patient is also risk for infection. When changing the dressing of the patient and performing pin care, the nurse must use aseptic principle to reduce microorganisms that may go into the wound and incision; keep the wound drainage system below the level of incision to prevent backflow of the drainage; and administer prescribe antibiotics to control the infection. The patient is also risk for deep vein thrombosis. The nurse encourage the patient to use ankle and calf- pumping exercises, anti embolism stockings. To avoid constipation, the nurse encourages the patient to increase fluid intake to 2000 ml/ day unless contraindicated to prevent fecal impaction.
Brunner, Suddarths et al. (2008). Medical- Surgical Nursing 12th edition. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins
Mahler, Salmond et al. (2005). Orthopaedic Nursing. Philadelphia, Pennsylvania: W.B Saunders Company
Timby and Smith (2003). Introductory Medical- Surgical Nursing 8th edition. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins
1. Find a research article addressing health teaching needs for the patient with a cast. Explain your findings in a one-page paper.
The nurse must instruct their patient to rest and keep the affected extremity elevated on a one or two pillow as much as possible during the first 24 hours. The use of crutches may be suggested for your patients with a leg cast or a sling for patients with an arm cast for use during the first 24-48 hours.
Remind your patient that the cast must be dry at all times. Advise them that water or any liquids will cause the plaster to weaken and it may lead to skin irritation. While bathing, instruct your patient to cover the cast with a plastic bag, tape the opening shut, and hang the cast outside the tub. Even when covered with plastic, you should not place the cast in water or allow water to run over the area. If the cast becomes wet, your patient can dry it with a hair dryer on the cool setting. Do not use the warm or hot setting because this can burn the skin. Your patient can also use a vacuum cleaner with a hose attachment to pull air through the cast and speed drying.
To decrease swelling and pain in the first 24-48 hours, your patient should place crushed ice in a plastic bag, covered with a pillow case or towel, on the cast over the injury every 15 minutes per hour while awake. Do not apply ice directly to the skin. Dents or compression of the cast can cause pressure or irritation to the skin beneath the dressing, which may develop sores or ulcers.
The nurse must teach the patient to reposition his body every two hours during the first 24 hours to allow even drying of the cast and every two hours when awake thereafter to avoid developing pressure sores on the skin. Do not place anything inside the cast, even for itchy areas. Sticking items inside the cast can injure the skin and lead to infection. Using a hair dryer on the cool setting may help soothe itching. The cast should be inspected regularly. If it develops cracks or soft spots, the physician should be notified.
The patient should never attempt to remove the cast. The physician will remove the cast at the appropriate time with a special saw that cuts through the casting material but will not damage skin.
Advise the patient that a serious complication can occur after cast application which is known as compartment syndrome. Instruct your patients to call the physician at once if any of the following signs or symptoms appear such as increased pain combined with the feeling that the cast is too tight, numbness and tingling in the hand or foot, burning and stinging sensations, excessive swelling in the part of the limb below the cast and inability to actively move the toes or fingers
Advise your patient to seek for medical help if there are sores areas or a foul odor from the cast, cracks or breaks in the cast, or the cast feels too tight, if there is swelling that causes pain, if the patient’s fingers or toes are blue or cold or the cast becomes soaking wet and does not dry with a hair dryer or vacuum.