A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take? (Select all that apply.)
A.
Position weights against the foot of the bed,
B.
Examine the skin under the traction splint.
C.
Monitor peripheral pulses in the affected extremity.
D.
Assess the temperature of the affected extremity.
E.
just the prescribed weights every shift.
The Correct answer and Explanation is:
When caring for a client in Buck’s traction, the nurse should focus on actions that ensure the effectiveness of the traction and the safety and comfort of the client. Buck’s traction is a type of skin traction used to immobilize and align the lower limb, typically used for managing fractures or muscle spasms. It involves a system of weights and pulleys applied to the limb via a traction boot or splint.
Here are the correct actions the nurse should take:
B. Examine the skin under the traction splint.
C. Monitor peripheral pulses in the affected extremity.
D. Assess the temperature of the affected extremity.
Explanation:
B. Examine the skin under the traction splint: The skin under the traction splint should be regularly inspected for any signs of irritation, pressure sores, or breakdown. Prolonged use of traction can cause skin issues due to the constant pressure and friction. By examining the skin, the nurse can identify and address any potential problems early, ensuring the integrity of the skin and preventing complications such as pressure ulcers.
C. Monitor peripheral pulses in the affected extremity: Monitoring peripheral pulses is crucial to assess the circulation in the affected limb. Buck’s traction can affect blood flow, and impaired circulation can lead to serious complications, including ischemia. Regular assessment of peripheral pulses helps in detecting any circulatory issues promptly, enabling timely intervention.
D. Assess the temperature of the affected extremity: The temperature of the affected limb should be assessed to check for any signs of inadequate blood flow or infection. A limb that is colder than the other or feels unusually warm may indicate circulatory problems or an infection. Regular temperature checks help in monitoring the limb’s condition and ensuring proper circulation.
Incorrect Actions:
A. Position weights against the foot of the bed: This action is incorrect. Weights should never be positioned against the foot of the bed or on the floor. They should hang freely to maintain the proper alignment and traction. Positioning weights against the foot of the bed can alter the traction force and compromise the effectiveness of the treatment.
E. Adjust the prescribed weights every shift: Adjusting the prescribed weights is not the nurse’s responsibility unless directed by a physician. The weight amount is determined based on the clinical condition and treatment plan, and changing it without proper orders can lead to complications.
In summary, the nurse’s role involves ensuring the correct application of traction, monitoring for signs of complications, and maintaining the overall health of the affected limb. Regular skin checks, pulse monitoring, and temperature assessment are essential for the effective management of Buck’s traction.