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 17-4

Caring for a Patient in Halo Traction

Goal:The patient maintains cervical alignment. Comments

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


2. Gather the necessary supplies and bring to the bedside
   stand or overbed table.


3. Perform hand hygiene and put on PPE, if indicated.


4. Identify the patient.


5. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do and why you
   are going to do it to the patient.


6. Assess the patient for possible need for nonpharmacologic,
   pain-reducing interventions or analgesic medication before
   beginning. Administer appropriate prescribed analgesic.
   Allow sufficient time for analgesic to achieve its effectiveness
   before beginning the procedure.


7. Place a waste receptacle at a convenient location for use
   during the procedure.


8. Adjust bed to comfortable working height, usually elbow
   height of the caregiver if the patient will remain in bed
   (VISN 8 Patient Safety Center, 2009). Alternatively, have
   the patient sit up, if appropriate.


9. Assist the patient to a comfortable position that provides
   easy access to the head. Place a waterproof pad under the
   head if patient is lying down.


10. Monitor vital signs and perform a neurologic assessment,
    including level of consciousness, motor function, and sen-
    sation, per facility policy. This is usually at least every 2
    hours for 24 hours, or possibly every hour for 48 hours.


11. Examine the halo vest unit every 8 hours for stability,
    secure connections, and positioning. Make sure the
    patient’s head is centered in the halo without neck flexion
    or extension. Check each bolt for loosening.


12. Check the fit of the vest. With the patient in a supine posi-
    tion, you should be able to insert one or two fingers under
    the jacket at the shoulder and chest.

ExcellentSatisfactoryNeeds Practice