Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U.012. Revision No: 0 Page:1 No of Pages: 9 Date: January 04

Guideline Title: Nursing care of a patient on Traction. Written by: Nursing staff of the Regional Orthopaedic Unit. Approved by: Ms. Fiona McMahon.
1.0 1.1 Purpose To provide guidance to nursing staff and nursing students (under supervision of a registered nurse) on the care of a patient on Traction.

Title: Title: D.N.M.

2.0 2.1

Scope This guideline applies to the registered nurse and the nursing student (under the supervision of a registered nurse) within the Midland Regional Hospital Tullamore. Definition. 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).

3.0 3.1

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. Sign: W. McMahon. McMahon. Harding
QA Template 002 Rev 2 January 2005 This is a controlled document and may be subject to change at any time.

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 2 No. Of Pages:9 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 patients 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.

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 3 No. Of Pages:9 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. 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. 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.

4.2 4.3

5.0

Guideline Rationale. Providing information helps alleviate anxiety and enables the patient to retain further information and instructions.

Action. Knowledge Deficit. 5.1 Explain the purpose of traction related to injury and healing process. Explain the traction apparatus. For skeletal traction explain pin insertion and removal procedures and care of pin-sites. Maintaining activities of daily living while in traction. Pain Management. 5.2 Assess the patients level of pain and administer analgesia as prescribed. 5.3 Explain that traction decreases muscle spasms and will gradually help lessen pain.

To monitor the effectiveness of the prescribed analgesia Patients treated in traction have pain due to soft tissue and bone trauma.

Diversionary activities (books,

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 4 No. Of Pages:9 Date: January 04

Guideline Title: Nursing care of a patient on Traction.

5.4 Eliminate additional sources of pain by providing comfort measures. games, television etc), heat or cold treatments and position changes. Incorrect positioning and malalignment can be sources of pain.

5.5 Assess for correct positioning of traction and alignment of affected extremity. Risk for Impaired Skin Integrity 5.6 The patients Waterlow Score is assessed. Assess skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer 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. 5.7 The decision to nurse the patient on a pressure-relieving mattress depends on the nurses clinical judgement.

Frequent repositioning is required to alleviate pressure pain and discomfort. A thorough skin assessment should be carried out each time the patient is repositioned.

These measures help to minimise the risk of complications of skin breakdown.

5.8 Maintain correct padding for affected extremity in traction, keep bed-linen wrinkle free and dry.

Pressure areas and skin irritation can develop under or at the edge of traction device. The urea in urine turns into

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 5 No. Of Pages:9 Date: January 04

Guideline Title: Nursing care of a patient on Traction.

ammonia within minutes, and is caustic to the skin. Faeces may contain enzymes that cause skin breakdown. To promote independence. Exercises should be active to prevent muscle atrophy and joint stiffness, which occur quickly in the situation of reduced mobility. To promote independence.

5.9 Assess for faecal or urinary incontinence, clean and dry skin daily.

Impaired Physical Mobility. 5.10 Instruct in the use of assistance devices i.e. Monkey pole.

5.11 Teach strengthening exercises to affected limb and other limbs as appropriate. 5.12 Encourage activities of selfcare and the use of the trapeze if the patients arms will allow. High risk of injury. Traction Device: 5.13 Keep weights hanging freely, tighten all traction equipment and secure all knots. 5.14 Cords should be checked daily for fraying, particularly where they pass over pulleys. 5.15 Pointed ends of pins or wires should be covered with cork or adhesive tape. 5.16 Bed aids such as cradles

The traction system should be checked thoroughly at least daily and always after interventions such as physiotherapy and x-ray. To maintain a safe environment.

To protect the patient from accidental injuries. For comfort, and to ensure free running of traction cords.

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 6 No. Of Pages:9 Date: January 04

Guideline Title: Nursing care of a patient on Traction.

should be used to keep bedclothes away from the patient as necessary. Pin-sites: 5.17 Continuously assess the pinsites for migration, assess the skin around the pin for tears and assess for pain at the pin-sites. 5.18 Maintain asepsis during pinsite dressing. See guidelines on pin-site care/dressing. 5.19 Monitor the patient for signs and symptoms of neurovascular compromise, comparing findings to the unaffected limb. Promotes early detection and prompt treatment. To prevent infection.

Careful monitoring enables early detection. The traction equipment may through increased pressure on nerves and blood vessels cause temporary or permanent damage.

Surgical trauma causes swelling and oedema, which can compromise circulation and compress nerves. a) Check for diminished or absent Prolonged capillary refill time pedal pulses. (See appendix 1) points to diminished capillary perfusion. b) Check for capillary refill time >3 seconds. These signs may indicate compromised circulation. c) Observe for pallor, blanching, cyanosis and coolness of These symptoms may result from nerve compression. extremity. d) Check for complaints of Tissue and nerve ischaemia produces a deep, throbbing abnormal sensations, e.g. unrelenting pain. tingling and numbness. e) Observe for increased pain not

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 7 No. Of Pages:9 Date: January 04

Guideline Title: Nursing care of a patient on Traction.

controlled by medication. 5.20 Assess the affected extremity for signs and symptoms of altered perfusion of compartment syndrome. (See guideline on Compartment Syndrome.) Compartment syndrome results from severe tissue swelling that decreases blood flow, causes ischaemia and may cause permanent motor/sensory damage.

Risk for Deep venous thrombosis/Pulmonary embolus. 5.21 Ensure anti-embolic stockings are fitted on both limbs. 5.22 Continuously assess the patient for signs and symptoms of: Deep Venous Thrombosis Positive Homans Sign (See appendix 2) Swelling of leg, 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.

Elastic stockings have been shown to reduce the risk of D.V.T. by about 25% (Todd&Sitzman 1998). Compression stockings must be used correctly, otherwise they may become a cause rather than a deterrent of D.V.T. (Evans, 1991).

Early detection and treatment.

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 8 No. Of Pages:9 Date: January 04

Guideline Title: Nursing care of a patient on Traction.

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 changes, catheter care and handling, and peripheral intravenous access management. 5.26 Observe the colour of respiratory secretions. 5.27 Observe the appearance of urine. Risk for Constipation. 5.28 Assess usual pattern of elimination. Evaluate usual dietary habits and compare with hospital regime. 5.29 Evaluate current medication usage, which may contribute to constipation e.g.narcotics, antacids, antidepressants, iron and calcium supplements. 5.30 Encourage and provide a daily

To prevent complications of deep venous thrombosis or pulmonary embolus.

To promote early detection and treatment if necessary. To prevent infection.

Yellow or yellow green sputum is indicative of respiratory infection. Cloudy or foul smelling urine is indicative of urinary tract infection. Changes in mealtimes, types of food and anxiety related to hospitalisation can lead to constipation. To prevent constipation.

Limistar Lr Tre Midland Area

Department Orthopaedic Guideline

GL No: R.O.U. 012. Revision No: 0 Page: 9 No. Of Pages:9 Date: January 04

Guideline Title: Nursing care of a patient on Traction.

fluid intake of 2-3 litres per day (if not medically contraindicated). Encourage a high fibre diet e.g. fruit, vegetables, bran etc.

To promote healing and well being.

6.0 6.1 6.2 6.3 6.4 6.5 6.6

References Apley, A.G., Solomon, L. (1993) Apleys System of Orthopaedics and Fractures. 7th Edition.Butterworth Heinemann. Black, Matassarin, Jacobs (1993). An Introduction to Orthopaedic Nursing 2nd Edition. Naon Productions. Davis, P.S. (1996) Nursing the Orthopaedic Patient. Churchill Livingstone. Evans A. (1991) Sensible Stockings. Nursing Times 87 (51) 40-41. Todd B.,Sitzman M.D. (1998) Prevention of Perioperative Deep Vein Thrombosis and Pulmonary Embolism. Schoen D.C. (2000). Adult Orthopaedic Nursing.1st Publication Philadelphia Lippincott. Appendices

7.0

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.