Nursing care of patient on traction
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Nursing care of patient on traction Document Transcript

  • 1. Limistéar Lár Tíre GL No: R.O.U.012. Midland Area Revision No: 0 Page:1 Department Orthopaedic No of Pages: 9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. Written by: Title: Nursing staff of the Regional Orthopaedic Unit. Approved by: Title: Ms. Fiona McMahon. D.N.M. 1.0 Purpose 1.1 To provide guidance to nursing staff and nursing students (under supervision of a registered nurse) on the care of a patient on Traction. 2.0 Scope 2.1 This guideline applies to the registered nurse and the nursing student (under the supervision of a registered nurse) within the Midland Regional Hospital Tullamore. 3.0 Definition. 3.1 Traction is the application of a pulling force to a part of the body with countertraction a pull in the opposite direction. More specifically, orthopaedic traction occurs when “ A pulling force is exerted on a part or parts of the body”(Davis, 1996). 3.2 Traction has several purposes: 3.2.1 To reduce a fracture and realign bone fragments by overcoming muscle spasms. 3.2.2 To maintain skeletal length and alignment. 3.2.3 To reduce and treat dislocations. Document Routing Draft Released Approved Distribution Date: October 03 Date: November Date: January 04 Date: March, 03 2005 Sign: F. McMahon. Sign: F. Sign: F. McMahon. Sign: W. McMahon. Harding QA Template 002 Rev 2 January 2005 This is a controlled document and may be subject to change at any time.
  • 2. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 2 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. 3.2.4 To immobilise and to prevent further tissue damage. 3.2.5 To prevent the development of contractures when there is a pathologic condition that causes the muscles to contract. 3.2.6 To relieve muscle spasms that occur as a reaction to musculoskeletal trauma in the absence of a fracture such as cervical sprain or low back pain. 3.2.7 To lesson deformities, such as with arthritis. 3.2.8 To rest a diseased joint. 3.3 Classification of Traction. 3.3.1 Skin Traction: is attached directly to the patient’s skin to immobilise a body part continuously or intermittently over a short or extended period. The direct application of a pulling force to the patients skin and soft tissues may be accomplished by using adhesive or nonadhesive traction tape or other skin traction devices such as a cast, a boot, a belt or a halter. (Schoen 2000) 3.3.2 Skeletal Traction: is attached directly to the patients skeletal system to immobilise a body part. The direct application of the pulling force may be accomplished by attaching pins, screws, wires or tongs. (Schoen 2000) 3.3.3 Manual Traction: is traction that is accomplished by a persons hands exerting a pulling force. It is utilised to reduce fractures and dislocations and to apply a steady pull while mechanical traction is released for adjustment or while a cast is being applied. (Schoen 2000) 3.3.4 Fixed Traction: The pull is exerted against a fixed point; for example, the tapes are tied to the crosspiece of a Thomas splint and pull the leg down. (Apley 1993) 3.3.5 Balanced Traction: The pull is exerted against an opposing force provided by the weight of the body when the foot of the bed is raised. (Apley 1993) QA Template 002 Rev 2 January 2005 This is a controlled document and may be subject to change at any time.
  • 3. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 3 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. 4.0 Responsibility 4.1 It is the responsibility of the Divisional Nurse Manager and Nursing Administration to ensure this guideline is in place on the appropriate wards and that relevant staff are informed of their responsibilities in relation to this document. 4.2 It is the responsibility of the C.N.M.11. on any ward with an Orthopaedic patient to ensure that staff providing care to that patient are aware of the requirements of this guideline. 4.3 It is the responsibility of all Nursing Staff providing care to an Orthopaedic patient to ensure that their practise is in line with this guideline document. 5.0 Guideline Action. Rationale. Knowledge Deficit. 5.1 Explain the purpose of traction • Providing information helps related to injury and healing alleviate anxiety and enables the process. Explain the traction patient to retain further apparatus. For skeletal traction information and instructions. explain pin insertion and removal procedures and care of pin-sites. Maintaining activities of daily living while in traction. Pain Management. • To monitor the effectiveness of 5.2 Assess the patient’s level of the prescribed analgesia pain and administer analgesia as prescribed. • Patient’s treated in traction have pain due to soft tissue and bone 5.3 Explain that traction trauma. decreases muscle spasms and will gradually help lessen pain. • Diversionary activities (books,
  • 4. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 4 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. 5.4 Eliminate additional sources games, television etc), heat or of pain by providing comfort cold treatments and position measures. changes. • Incorrect positioning and 5.5 Assess for correct positioning malalignment can be sources of of traction and alignment of pain. affected extremity. Risk for Impaired Skin Integrity • Frequent repositioning is 5.6 The patient’s Waterlow Score required to alleviate pressure is assessed. Assess skin over pain and discomfort. A thorough bony prominences (sacrum, skin assessment should be trochanters, scapulae, elbows, carried out each time the heels, inner and outer patient is repositioned. malleolus, inner and outer knees and back of head). Areas where skin is stretched tautly over bony prominences are at a greater risk for breakdown because the possibility of ischeamia to skin is high due to compression of skin capillaries between a hard surface (mattress, chair,) and the bone. • These measures help to minimise the risk of 5.7 The decision to nurse the complications of skin patient on a pressure-relieving breakdown. mattress depends on the nurse’s clinical judgement. • Pressure areas and skin irritation 5.8 Maintain correct padding for can develop under or at the edge affected extremity in traction, of traction device. keep bed-linen wrinkle free and dry. • The urea in urine turns into
  • 5. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 5 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. ammonia within minutes, and is 5.9 Assess for faecal or urinary caustic to the skin. Faeces may incontinence, clean and dry skin contain enzymes that cause skin daily. breakdown. • To promote independence. Impaired Physical Mobility. 5.10 Instruct in the use of assistance devices i.e. Monkey • Exercises should be active to pole. prevent muscle atrophy and joint stiffness, which occur quickly in 5.11 Teach strengthening exercises the situation of reduced mobility. to affected limb and other limbs as appropriate. • To promote independence. 5.12 Encourage activities of self- care and the use of the trapeze if the patient’s arms will allow. • The traction system should be checked thoroughly at least daily High risk of injury. and always after interventions Traction Device: such as physiotherapy and x-ray. 5.13 Keep weights hanging freely, tighten all traction equipment and secure all knots. • To maintain a safe environment. 5.14 Cords should be checked daily for fraying, particularly where they pass over pulleys. • To protect the patient from accidental injuries. 5.15 Pointed ends of pins or wires • For comfort, and to ensure free should be covered with cork or running of traction cords. adhesive tape. 5.16 Bed aids such as cradles
  • 6. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 6 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. should be used to keep • Promotes early detection and bedclothes away from the prompt treatment. patient as necessary. Pin-sites: • To prevent infection. 5.17 Continuously assess the pin- sites for migration, assess the skin around the pin for tears and assess for pain at the pin-sites. • Careful monitoring enables early detection. The traction 5.18 Maintain asepsis during pin- equipment may through site dressing. See guidelines on increased pressure on nerves pin-site care/dressing. and blood vessels cause temporary or permanent 5.19 Monitor the patient for signs damage. and symptoms of neurovascular compromise, comparing findings to the unaffected limb. ü Surgical trauma causes swelling and oedema, which can compromise circulation and compress nerves. a) Check for diminished or absent pedal pulses. (See appendix 1) ü Prolonged capillary refill time points to diminished capillary perfusion. b) Check for capillary refill time >3 seconds. ü These signs may indicate compromised circulation. c) Observe for pallor, blanching, cyanosis and coolness of ü These symptoms may result extremity. from nerve compression. d) Check for complaints of ü Tissue and nerve ischaemia abnormal sensations, e.g. produces a deep, throbbing tingling and numbness. unrelenting pain. e) Observe for increased pain not
  • 7. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 7 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. controlled by medication. • Compartment syndrome results from severe tissue swelling that decreases blood flow, causes 5.20 Assess the affected extremity ischaemia and may cause for signs and symptoms of altered permanent motor/sensory perfusion of compartment damage. syndrome. (See guideline on Compartment Syndrome.) Risk for Deep venous thrombosis/Pulmonary • Elastic stockings have been embolus. shown to reduce the risk of D.V.T. by about 25% 5.21 Ensure anti-embolic stockings (Todd&Sitzman 1998). are fitted on both limbs. Compression stockings must be used correctly, otherwise they 5.22 Continuously assess the may become a cause rather than patient for signs and symptoms a deterrent of D.V.T. (Evans, of: 1991). Deep Venous Thrombosis Positive Homan’s Sign (See appendix 2) Swelling of leg, • Early detection and treatment. Tenderness in calf. Pulmonary Embolus. Dyspneoa, Chest pain, Tachycardia, Haemoptysis, Cyanosis, Anxiety, Pyrexia of unknown origin. 5.23 Give anti-coagulant i.e.Innohep/Clexane s/c Daily at 6pm.
  • 8. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 8 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. • To prevent complications of deep venous thrombosis or pulmonary embolus. Risk for Infection. 5.24 Assess pin-sites daily for signs of infection, assess skin tension at pin-sites. 5.25 Maintain asepsis for dressing • To promote early detection and changes, catheter care and treatment if necessary. handling, and peripheral intravenous access • To prevent infection. management. 5.26 Observe the colour of respiratory secretions. • Yellow or yellow green sputum is 5.27 Observe the appearance of indicative of respiratory urine. infection. • Cloudy or foul smelling urine is Risk for Constipation. indicative of urinary tract 5.28 Assess usual pattern of infection. elimination. Evaluate usual dietary habits and compare with hospital regime. • Changes in mealtimes, types of food and anxiety related to hospitalisation can lead to 5.29 Evaluate current medication constipation. usage, which may contribute to constipation e.g.narcotics, antacids, antidepressants, iron • To prevent constipation. and calcium supplements. 5.30 Encourage and provide a daily
  • 9. Limistéar Lár Tíre GL No: R.O.U. 012. Midland Area Revision No: 0 Page: 9 Department Orthopaedic No. Of Pages:9 Guideline Date: January 04 Guideline Title: Nursing care of a patient on Traction. fluid intake of 2-3 litres per day (if not medically contra- • To promote healing and well indicated). Encourage a high being. fibre diet e.g. fruit, vegetables, bran etc. 6.0 References 6.1 Apley, A.G., Solomon, L. (1993) Apley’s System of Orthopaedics and Fractures. 7th Edition.Butterworth Heinemann. 6.2 Black, Matassarin, Jacobs (1993). An Introduction to Orthopaedic Nursing 2nd Edition. Naon Productions. 6.3 Davis, P.S. (1996) Nursing the Orthopaedic Patient. Churchill Livingstone. 6.4 Evans A. (1991) Sensible Stockings. Nursing Times 87 (51) 40-41. 6.5 Todd B.,Sitzman M.D. (1998) Prevention of Perioperative Deep Vein Thrombosis and Pulmonary Embolism. 6.6 Schoen D.C. (2000). Adult Orthopaedic Nursing.1st Publication Philadelphia Lippincott. 7.0 Appendices 7.1 Pedal Pulse: The posterior Tibialis pulse is located behind and just above the medial malleolus of the ankle. The dorsalis pedis pulse is located on the mid-dorsum of the foot above the second third digit. (Black, Matassarin, Jacobs 1993). 7.2 Homans sign: Forced dorsiflexion of the foot causing discomfort in the upper calf. (An Introduction to Orthopaedic Nursing 2nd Edition) Naon Productions.