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The nurse is caring for a patient who requires skeletal traction after a back injury. Which of the following are appropriate nursing interventions?

Explanation

• When injury involves fracture-dislocation of the cervical spine, cervical tongs like Crutchfield tongs may be used for skeletal traction to achieve alignment and immobilization.

• To ensure effectiveness, the nurse should maintain traction at all times. Failing to maintain traction can cause further damage to the fractured bone and surrounding tissue.

• A skin assessment should be performed whenever the patient is repositioned (which should be at least every 2-3 hours) due to risk of skin breakdown from ischemia and compression of tissue when immobilized.

• Pin sites are susceptible to infection, so the sites should be assessed for increased redness, swelling, pain, or drainage.

• The traction weights should never be supported; they need to hang freely in order to be effective.

• Stool softeners should be administered to prevent postoperative constipation and obstruction.

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