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traction lecture

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									King Saud University
College of Nursing
Medical surgical Nursing



Course Number: NUR 245


          Prepared By:
                            lecturer/ Magda          Bayoumi




          Lecturer/ Magda Bayoumi                              1:09:31 AM
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            http://faculty.ksu.edu.sa/73577
Traction:
    DEFINITION
    PURPOSE
    PRINCIPLES OF EFFECTIVE TRACTION
    TYPES
    Nursing Process: The patient in Traction:




Lecturer/ Magda Bayoumi                    1:09:31 AM
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Traction is the application of a pulling force to a part of the body       .



Purpose:
Traction is used to minimize muscle spasms; to reduce, align, and immobilize fractures; to reduce
deformity; and to increase space between opposing surfaces. Traction must be applied in the
correct direction and magnitude to obtain its therapeutic effects. As muscle and soft tissues relax,
the amount of weight used may be changed to obtain the desired effect.
At times, traction needs to be applied in more than one direction to achieve the desired line of pull.
When this is done, one of the lines of pull counteracts the other. These lines of pull are known as
        the vectors of force                                                                         .




Traction is used primarily as a short-term intervention until other modalities, such as external or
internal fixation, are possible. This reduces the risk of disuse syndrome and minimizes the length of
hospitalization, often allowing the patient to be cared for in the home setting.


PRINCIPLES OF EFFECTIVE TRACTION

          Lecturer/ Magda Bayoumi                                                1:09:31 AM
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 Whenever traction is applied, countertraction must be used to achieve effective traction.
 Countertraction is the force acting the opposite direction. Usually, the patient's body weight and bed position
 adjustments supply the needed countertraction.

 The following are additional principles to follow when for the patient in traction:

 Traction must be continuous to be effective in reducing immobilizing fractures.
 Skeletal traction is never interrupted.
 Weights are not removed unless intermittent traction is prescribed.
 Any factor that might reduce the effective pull or alter its resultant line of pull must be eliminated:
     -The patient must be in good body alignment in the center of the bed when traction is applied.
     -Ropes must be unobstructed.
     -Weights must hang free and not rest on the bed or floor.
    -Knots in the rope or the footplate must not touch the pulley or the foot of the bed.


 Types:
 1-     Straight or running reaction: applies the pulling force in a straight line with the body
        part resting on the bed. Buck's extension traction is an example of straight traction.




2- Balanced suspension traction: the affected extremity off the bed and allows for some patient


            Lecturer/ Magda Bayoumi                                                      1:09:31 AM
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movement without disruption of the line of pull.




Traction may be applied to the skin (skin traction) or directly to the bony skeleton
(skeletal traction). The mode of application is determined by the purpose of the traction.
Traction can be applied with the hands (manual traction). This is temporary traction that may be
used when applying a cast, giving skin care under a Buck's extension foam boot, or adjusting the
traction apparatus.

Skin Traction:
    Skin traction is used to control muscle spasms and to immobilize an area before surgery.
    Skin traction is accomplished by using a weight to pull on traction tape or on a foam boot
     attached to the skin. The amount of weight applied must not exceed tolerance of the skin.
    No more than 2 to 3.5 kg (4.5 to 8 lb) of traction can be used on an extremity. Pelvic traction is
     usually 4.5 to 9 kg (10 to 20 lb), depending on the weight of the patient.
    Types of skin traction: used for adults include Buck's extension traction (applied to the lower
     leg), the cervical head halter (occasionally used to treat neck pain), and the pelvic belt
     (sometimes used to treat back pain).




.Complication of skin traction:


           Lecturer/ Magda Bayoumi                                               1:09:31 AM
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  Skin breakdown, results from irritation caused by contact of the skin with the tape or foam
   and shearing forces. Older adults are at greater risk for this complication because of their
   sensitive, fragile skin.
  Nerve pressure, results from pressure on the peripheral nerves, Footdrop may occur if
   pressure is applied to the peroneal nerve at the point at which it passes around the neck of
   the fibula just below the knee.
  Circulatory impairment is manifested by cold skin temperature, decreased peripheral pulses,
   slow capillary refill time, and bluish skin. Deep vein thrombosis (DVT), a serious circulatory
   impairment, is manifested by calf tenderness, swelling, and a positive Homans' sign.
 Nursing Intervention:
  Ensuring Effective Traction:
  To ensure effective skin traction, it is important to avoid wrinkling and slipping of the traction
  bandage and to maintain counter traction. Proper positioning must be maintained to keep the
  leg in a neutral position. To prevent bony fragments from moving against one another, the
  patient should not turn from side to side; however, the patient may shift position slightly with
  assistance.

  Monitoring and Managing potential Coplication:
 1- Skin breakdown; During the initial assessment, the nurse identifies sensitive, fragile skin
    (common in older adults). The nurse also closely monitors the reaction of the skin in contact
    with tape or foam to ensure that shearing forces are avoided. The nurse performs the
    following procedures to monitor and prevent skin breakdown:
  Removes the foam boots to inspect the skin, the ankle, and the Achilles tendon three
    times a day. A second nurse is needed to support the extremity during the inspection and
    skin care.
  Palpates the area of the traction tapes daily to detect underlying tenderness.
  Provides back care at least every 2 hours to prevent pressure ulcers. The patient who
    must remain in a supine position is at increased risk for development of a pressure ulcer.
  Uses special mattress overlays (eg, air-filled, high-density foam) to minimize the
    development of skin ulcers.
 2- Nerve Pressure:
    Skin traction can place pressure on peripheral nerves. When traction is applied to the
    lower extremity, care must be taken to avoid pressure on the peroneal nerve at the point
    at which it passes around the neck of the fibula just below the knee. Pressure at this point
    can cause footdrop. The nurse questions the patient about sensation and asks the patient
    to move the toes and foot. DorsiRexion of the foot demonstrates function of the peroneal
    nerve. Weakness of dorsiflexion of foot movement and inversion of the foot might indicate
    pressure on the common peroneal nerve. Plantar flexion demonstrates function of the tib-
    ial nerve.
    The following are important points to keep in mind when caring for the patient
    in traction:
     Regularly assess sensation and motion.
    Immediately investigate any complaint of burning sensation under the traction bandage
    or boot.
    Promptly report altered sensation or motor function.
3- Circulatory Impairment:



         Lecturer/ Magda Bayoumi                                               1:09:31 AM
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 After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to
 30 minutes and then every 1 to 2 hours. Circulatory assessment consists of the following:
 Peripheral pulses, color, capillary refill, and temperature of the fingers or toes
 Indicators of DVT, including calf tenderness, swelling, and a positive Homans' sign
   The nurse also encourages the patient to perform active foot exercises every hour
   when awake.

Skeletal Traction:
 Skeletal traction is applied directly to the bone.
 This method of traction is used occasionally to treat fractures of the femur, the tibia, and
 the cervical spine. The traction is applied directly to the bone by use of a metal pin or wire
 that is inserted through the bone distal to the fracture, avoiding nerves, blood vessels,
 muscles, tendons, and joints. Tongs applied to the head are fixed in the skull to apply
 traction that immobilizes cervical fractures.
 Skeletal traction is balanced traction,
 When skeletal traction is discontinued, the extremity is gently supported while the weights
 are removed. The pain is cut close to the skin and removed by physician. Internal fixations,
 casts, or splints or splints are then used to immobilize and support the healing bone.
 Nursing Interventions:
 Maintaining Effective Traction:
 The nurse checks the apparatus to see that the ropes are in the wheel grooves of the
 pulleys, that the ropes are not frayed, that the weights hang free, and that the knots in the
 rope are tied securely.
 The nurse evaluates the patient's position, because slippling down in bed results in
 ineffective traction.
 Maintaining Positioning:
 The nurse positions the patient's foot to avoid footdrap (planter flexion), inward rotation
 (inversion), and out ward rotation (eversion). The patient's foot may be supported in a
 natural position by orthopedic devices (eg; foot support).
 Preventing Skin breakdown;
 The nurse should protect the elbows and heels and inspect them for pressure areas.
 Encourage movement without using the elbows or heels, the nurse can suspend a trapeze
 overhead within easy reach of the patient.
 The nurse must keep the bed dry and free of crumbs and wrinkles.
 A pressure relieving air-filled or high-density foam mattress overlay may reduce the risk of
 pressure ulcer.
 Monitoring Nurological Status:
 The nurse assesses the neurovascular status of the immobilized extremity at least every hour
 initially and then every 4 hours.
 The nurse instructs the patient to report any changes in sensation or movement immediately so
 that they can be promptly evaluated.
 DVT is a significant risk for the immobilized patient. The nurse encourages the patient to do
 active flexion-extension ankle exercises and isometric contraction of the calf muscles (calf-
 pumping exercises) 10 times an hour while awake to decrease venous stasis. In addition, elastic
 stockings, compression devices, and anticoagulant therapy may be prescribed to help prevent
 thrombus formation.
 Providing Pin Site Care:
 The wound at the pin insertion site requires attention. The goals is to avoid infection and


         Lecturer/ Magda Bayoumi                                             1:09:31 AM
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developing osteomyelitis.
Initially, the site is covered with sterile dressing.
The nurse must keep the area clean. Slight serous oozing at the pin site is expected, but
crusting should be prevented.
The nurse assesses the pin site and drainage for signs of infection, such as redness,
tenderness, and purulent drainage.

Promoting exercise:
Active exercises include pulling up the trapeze, flexing and extending the feet, and rang of
motion and weight resistance exercise for noninvolved joint.
Isometric exercise of the immobilized extremity are important.

Nursing Process: The patient in Traction:
Assessment:
The nurse must evaluate the body part to be placed in traction and neurovascular status
(ie, color, temperature, capillary refill, edema, pulses, ability to move, and sensation) and
compare it to the unaffected extremity.
The nurse also assesses skin integrity along with body system functioning for baseline data.
Ongoing assessment is indicated for the patient in traction. Immobility-related problems
may include pressure ulcers, stasis pneumonia, constipation, loss of appetite, urinay statis,
urinary tract infections, and venous stasis.

Diagnosis:
Nursing Diagnosis:
 Based on the nursing assessment, the patient's major nursing diagnoses related to traction
 may include the following:
 Deficient knowledge related to the treatment regimen
 Anxiety related to health status and the traction device
 Acute pain related to musculoskeletal disorder
 Self-care deficit: feeding, bathing/hygiene, dressing/grooming, and/or toileting
 related to traction
 Impaired physical mobility related to musculoskeletal disorder and traction

Potential complication:
  Based on the assessment data, potential complications that may develop include the following:
 Pressure ulcer
 Pneumonia
 Constipation
 Anorexia
 Urinary stasis and infection
 Venous stasis with DVT




Planning and Goals:
The major goals for the patient in traction may include understanding of the treatment regimen,
reduced anxiety, maximum comfort, maximum level of self-care, maximum mobility within the

        Lecturer/ Magda Bayoumi                                             1:09:31 AM
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therapeutic limits of traction, and absence of complications.

Nursing Intervention:
1- promoting understanding of treatment regimen:
2- Reducing Anxiety.
3- Achieve a maximum level of comfort.
4- Achieving Maximum self care.
5- Attaining maximum Mobility with traction.
6- Monitoring and managing potential complication:
       Pressure ulcer.
       Pneumonia: The nurse auscultates the patient's lungs every 4 to 8 hours to de-
          termine respiratory status and teaches the patient deep-breathing and coughing
          exercises to aid in fully expanding the lungs and moving pulmonary secretions
       Constipation: Reduced gastrointestinal motility results in constipation anorexia. A
          diet high in fiber and fluids may help to stimulate gastric motility. If constipation
          develops, therapeutic measures might include stool softeners, laxatives,
          suppositories, and enemas. To improve the patient's appetite, the nurse identifies
          and includes the patient food preferences, as appropriate, within the prescribed
          therapeutic diet.
       Urinary stasis and infection:
        Incomplete emptying of the bladder to positioning in bed can result in urinary stasis
        and infection. In addition, the patient may find use of the bedpan uncomfortable
        and may limit fluids to minimize the frequency of urination. The nurse monitors the
        fluid intake and the character of the urine. The nurse teaches the patient to
        consume adequate amounts of fluid and to void every 3 to 4 hours. If the patient
        exhibits signs or symptoms of urinary tract infection, the nurse notifies the
        physician.
       Venous stasis and deep venous thrombosis:
        Venous stasis occurs with immobility. The nurse teaches the patient to perform
      ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours
      when awake to prevent DVT, which may result from venous stasis. The patient is
      encouraged to drink fluids to prevent dehydration and associated hem concentration,
      which contribute to stasis. The nurse monitors the patient for signs of DVT, including
      calf tenderness, warmth, redness, swelling( increased calf circumference ), and a
      positive homans' sign (discomfort in the calf when the foot is forcibly dorsiflxed ).
      The nurse promptly reports findings to the physician for definitive evaluation and
      therapy.




        Lecturer/ Magda Bayoumi                                             1:09:31 AM
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Evaluation:
  Patient outcomes may include:
  1.Demonstrates knowledge of traction regimen
  a.Describes purpose of traction b. Participates in plan of care
  2.Exhibits reduced anxiety
  a.Appears relaxed
  b.Uses effective coping mechanisms
  c.Expresses concerns and feelings
  d. Engages in diversional activities
  3.States increased level of comfort
  a.Requests occasional oral analgesia b. Repositions self frequently
  4.Performs self-care activities
  a.Requires minimal assistance with feeding, hygiene, dressing/grooming, and/or toileting
  b. Uses assistive devices safely
  5.Demonstrates increased mobility
  a.Performs prescribed exercises
  b. Repositions self within limits of traction
  6.Experiences no complications
  a.Has intact skin
  b.Has clear lungs
  c.Does not report shortness of breath
  d.Does not have a productive cough
  e.Exhibits a regular bowel evacuation pattern




        Lecturer/ Magda Bayoumi           Page                              1:09:31 AM
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