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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

• To ensure effectiveness of skeletal traction, 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) because of the risk of skin breakdown from ischemia and compression of the tissue when immobilized

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

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

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

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