Goal: The traction is maintained with the appropriate counterbalance and the patient is free from complications of immobility.
1. Review the medical record and the nursing plan of care to determine the type of traction being used and the prescribed care.
2. Perform hand hygiene. Put on PPE, as indicated.
3. Identify the patient. Explain the procedure to the patient, emphasizing the importance of maintaining counterbalance, alignment, and position.
4. Perform a pain assessment and assess for muscle spasm. Administer prescribed medications in sufficient time to allow for the full effect of the analgesic and/or muscle relaxant.
5. Close curtains around bed and close the door to the room, if possible. Place the bed at an appropriate and comfortable working height.
6. Ensure the traction apparatus is attached securely to the bed. Assess the traction setup, including application of the ordered amount of weight. Be sure that the weights hang freely, not touching the bed or the floor.
7. Check that the ropes move freely through the pulleys. Check that all knots are tight and are positioned away from the pulleys. Pulleys should be free from the linens.
8. Check the alignment of the patient’s body, as prescribed.
9. Perform a skin assessment. Pay attention to pressure points, including the ischial tuberosity, popliteal space, Achilles’ tendon, sacrum, and heel.
10. Perform a neurovascular assessment. Assess the extremity distal to the traction for edema and peripheral pulses. Assess the temperature and color and compare with the unaffected limb. Check for pain, inability to move body parts distal to the traction, pallor, and abnormal sensations. Assess for indicators of deep-vein thrombosis, including calf tenderness, and swelling.
11. Assess the site at and around the pins for redness, edema, and odor. Assess for skin tenting, prolonged or purulent drainage, elevated body temperature, elevated pin site temperature, and bowing or bending of the pins.
12. Provide pin site care.
a. Using sterile technique, open the applicator package and pour the cleansing agent into the sterile container.
b. Put on the sterile gloves.
c. Place the applicators into the solution.
d. Clean the pin site starting at the insertion area and working outward, away from the pin site.
e. Use each applicator once. Use a new applicator for each pin site.
13. Depending on physician order and facility policy, apply the antimicrobial ointment to pin sites and apply a dressing.
14. Remove gloves and any other PPE, if used. Perform hand hygiene.
15. Perform range-of-motion exercises on all joint areas, unless contraindicated. Encourage the patient to cough and deep breathe every 2 hours.
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