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 Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 9-19

Caring for a Patient in Skeletal Traction

Goal:The traction is maintained with the appropriate

counterbalance and the patient is free from complications

of immobility. Comments

1. Review the medical record and the nursing plan of care to
   determine the type of traction being used and the prescribed
   care.


2. Perform hand hygiene. Put on PPE, as indicated.


3. Identify the patient. Explain the procedure to the patient,
   emphasizing the importance of maintaining counterbalance,
   alignment, and position.


4. Perform a pain assessment and assess for muscle spasm.
   Administer prescribed medications in sufficient time to allow
   for the full effect of the analgesic and/or muscle relaxant.


5. Close curtains around bed and close the door to the room,
   if possible. Place the bed at an appropriate and comfortable
   working height.


6. Ensure the traction apparatus is attached securely to the
   bed. Assess the traction setup, including application of the
   ordered amount of weight. Be sure that the weights hang
   freely, not touching the bed or the floor.
   7.Check that the ropes move freely through the pulleys.
   Check that all knots are tight and are positioned away
   from the pulleys. Pulleys should be free from the linens.


7. Check the alignment of the patient’s body, as prescribed.


8. Perform a skin assessment. Pay attention to pressure
   points, including the ischial tuberosity, popliteal space,
   Achilles’ tendon, sacrum, and heel.


9. Perform a neurovascular assessment. Assess the extremity
   distal to the traction for edema and peripheral pulses. Assess
   the temperature and color 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.


10. Assess the site at and around the pins for redness, edema,
    and odor. Assess for skin tenting, prolonged or purulent
    drainage, elevated body temperature, elevated pin site tem-
    perature, and bowing or bending of the pins.

ExcellentSatisfactoryNeeds Practice