Nursing Process: The Patient in Traction

NURSING PROCESS: THE PATIENT IN TRACTION

Assessment

The nurse must consider the psychological and physiologic im-pact of the musculoskeletal problem, traction device, and immobility. Traction restricts one’s mobility and independence. The equipment often looks threatening, and its application can be frightening. Confusion, disorientation, and behavioral problems may develop in patients who are confined in a limited space for an extended time. Therefore, the nurse must assess and monitor the patient’s anxiety level and psychological responses to traction.

It is important to evaluate the body part to be placed in traction and its neurovascular status (ie, color, temperature, capillary refill, edema, pulses, ability to move, and sensations) and compare it to the unaffected extremity. The nurse also assesses skin integrity along with body system functioning for baseline data. Ongoing as-sessment is indicated for the patient in traction. Immobility-related problems may include pressure ulcers, stasis pneumonia, constipa-tion, loss of appetite, urinary stasis, urinary tract infections, and venous stasis. Early identification of preexisting or developing problems facilitates prompt interventions to resolve them.

Diagnosis

NURSING DIAGNOSES

Based on the nursing assessment, the patient’s major nursing di-agnoses 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/groom-ing, and/or toileting related to traction

·      Impaired physical mobility related to musculoskeletal dis-order and traction

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

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 under-standing of the treatment regimen, reduced anxiety, maximum comfort, maximum level of self-care, maximum mobility within the therapeutic limits of traction, and absence of complications.

Nursing Interventions

PROMOTING UNDERSTANDING OF THE TREATMENT REGIMEN

The patient must understand the problem being treated and the rationale for the traction therapy. The nurse may need to repeat and reinforce the information. With increased understanding of the therapy, the patient becomes an active participant in health care.

REDUCING ANXIETY

Before any traction is applied, the patient needs to be informed about the procedure, its purpose, and its implications. The nurse encourages the patient to participate in decisions that affect care.

Increasing the patient’s sense of control reduces feelings of help-lessness, allays apprehension, and fosters coping.

After being in traction for a while, the patient may react to being confined to a limited space. Frequent visits by the nurse can reduce feelings of isolation and confinement. The nurse should encourage family and friends to visit frequently for the same rea-son. The nurse encourages diversional activities that can be per-formed within the limits of the traction.

ACHIEVING A MAXIMUM LEVEL OF COMFORT

Because the patient is immobilized in bed, the mattress needs to be firm. Special mattresses or mattress overlays designed to min-imize the development of pressure ulcers may be placed on the bed before the traction is applied. The nurse can relieve pressure on dependent body parts by turning and positioning the patient for comfort within the limits of the traction and by making sure the bed linens remain wrinkle-free and dry.

ACHIEVING MAXIMUM SELF-CARE

Initially, the patient may require assistance with self-care activities. The nurse helps the patient eat, bathe, dress, and toilet. Convenient arrangement of items such as telephone, tissues, water, and assis-tive devices (eg, reachers, overbed trapeze) may facilitate self-care. With resumption of self-care activities, the patient feels less depen-dent and less frustrated and experiences improved self-esteem.

Because some assistance is required throughout the period of immobility, the nurse and the patient can creatively develop rou-tines that maximize the patient’s independence.

ATTAINING MAXIMUM MOBILITY WITH TRACTION

During traction therapy, the nurse encourages the patient to ex-ercise muscles and joints that are not in traction to guard against their deterioration. The physical therapist can design bed exer-cises that minimize loss of muscle strength. During the patient’s exercise, the nurse ensures that traction forces are maintained and that the patient is properly positioned to prevent complications resulting from poor alignment.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Pressure Ulcers

The nurse examines the patient’s skin frequently for evidence of pressure or friction, paying special attention to bony promi-nences. It is helpful to reposition the patient frequently and to use protective devices (eg, elbow protectors) to relieve pressure. If the risk of skin breakdown is high, as in a patient with multiple trauma or a debilitated elderly patient, use of a specialized bed is considered to prevent skin breakdown. If a pressure ulcer devel-ops, the nurse consults with the physician and the wound care nurse specialist.

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. If the patient history and baseline assessment indicate that the patient is at high risk for develop-ment of respiratory complications, specific therapies (eg, incentive spirometer) may be indicated. If a respiratory problem develops, prompt institution of prescribed therapy is needed.

Constipation and Anorexia

Reduced gastrointestinal motility results in constipation and 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 ene-mas. To improve the patient’s appetite, the nurse identifies and includes the patient’s food preferences, as appropriate, within the prescribed therapeutic diet.

Urinary Stasis and Infection

Incomplete emptying of the bladder related 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 Vein Thrombosis

Venous stasis occurs with immobility. The nurse teaches the pa-tient 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 hemo-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 dorsiflexed). The nurse promptly reports findings to the physi-cian for definitive evaluation and therapy.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected 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, bathing/ 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

f)      Has a normal appetite

g)     Voids clear, yellow, nonconcentrated urine of adequate amount

h)    Does not exhibit signs or symptoms of venous stasis