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 17-4

Caring for a Patient in Halo Traction (Continued)

Comments

13. Put on nonsterile gloves, if appropriate. Remove patient’s
    shirt or gown. Wash the patient’s chest and back daily.
    Loosen the bottom Velcro straps.


14. Wring out a bath towel soaked in warm water. Pull the
    towel back and forth in a drying motion beneath the front.
    Do not use soap or lotion under the vest.


15. Thoroughly dry the skin in the same manner with a dry
    towel. Inspect the skin for tender, reddened areas or
    pressure spots. Lightly dust the skin with a prescribed
    medicated powder or cornstarch.


16. Turn the patient on his or her side, less than 45 degrees if
    lying supine, and repeat the process on the back. Close the
    Velcro straps. Assist the patient with putting on a new
    shirt, if desired.


17. Perform a respiratory assessment. Check for respiratory
    impairment, such as absence of breath sounds, the
    presence of adventitious sounds, reduced inspiratory
    effort, or shortness of breath.


18. Assess the pin sites for redness, tenting of the skin,
    prolonged or purulent drainage, swelling, and bowing,
    bending, or loosening of the pins. Monitor body
    temperature.


19. Perform pin-site care. (See Skills 9-19 and 9-20.)


20. Depending on physician order and facility policy, apply the
    antimicrobial ointment to pin sites and apply a dressing.


21. Remove gloves and dispose of them appropriately. Raise
    rails, as appropriate, and place the bed in the lowest posi-
    tion. Assist patient to a comfortable position.


22. Remove additional PPE, if used. Perform hand hygiene.

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