Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 9-18

Applying Skin Traction and Caring for a

Patient in Skin Traction (Continued)

Comments

13.Check the boot for placement and alignment. Make sure

the line of pull is parallel to the bed and not angled

downward.

14. Place the bed in the lowest position that still allows the
    weight to hang freely.


15. Remove PPE, if used. Perform hand hygiene.

Caring for a Patient With Skin Traction

16. Perform a skin-traction assessment per facility policy. This
    assessment includes checking the traction equipment, exam-
    ining the affected body part, maintaining proper body align-
    ment, and performing skin and neurovascular assessments.


17. Remove the straps every 4 hours per the physician’s order
    or facility policy. Check bony prominences for skin break-
    down, abrasions, and pressure areas. Remove the boot, per
    physician’s order or facility policy, every 8 hours. Put on
    gloves and wash, rinse, and thoroughly dry the skin.


18. Assess the extremity distal to the traction for edema, and
    assess peripheral pulses. Assess the temperature, color, and
    capillary refill, and compare with the unaffected limb.
    Check for pain, inability to move body parts distal to the
    traction, pallor, and abnormal sensations. Assess for indi-
    cators of deep-vein thrombosis, including calf tenderness,
    and swelling.


19. Replace the traction and remove gloves and dispose of
    them appropriately.


20. Check the boot for placement and alignment. Make sure
    the line of pull is parallel to the bed and not angled
    downward.
    21.Ensure the patient is positioned in the center of the bed,
    with the affected leg aligned with the trunk of the patient’s
    body.


21. Examine the weights and pulley system. Weights should
    hang freely, off the floor and bed. Knots should be secure.
    Ropes should move freely through the pulleys. The pulleys
    should not be constrained by knots.


22. Perform range-of-motion exercises on all unaffected joint
    areas, unless contraindicated. Encourage the patient to
    cough and deep breathe every 2 hours.


23. Raise the side rails. Place the bed in the lowest position
    that still allows the weight to hang freely.


24. Remove PPE, if used. Perform hand hygiene.

ExcellentSatisfactoryNeeds Practice