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CHAPTER I

INTRODUCTION

1.1 Background

Traction is the application of a pulling force to a part of the body. 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.
Many patients with musculoskeletal dysfunction undergo surgery to correct the condition.
Conditions that may be corrected by surgery include unstabilized fracture, deformity, joint
disease, necrotic or infected tissue, and tumors. Frequent surgical procedures include open
reduction with internal fixation (ORIF) and closed reduction with internal fixation (fracture
fragments are not surgically exposed) for fractures; arthroplasty, meniscectomy, and joint
replacement for joint conditions; amputation for severe extremity conditions (eg, gangrene,
massive trauma); bone graft for joint stabilization, defect filling, or stimulation of bone healing;
and tendon transfer for improving motion.

1.2 Purpose

The purpose of Organizing Concept in Management Nursing is:

1. To understand The Principles of Effective Traction


2. To understand The Traction
3. To Understand The Nursing Intervention
CHAPTER II

PRINCIPLES OF EFFECTIVE TRACTION


Whenever traction is applied, countertraction must be used to achieve effective traction.
Countertraction is the force acting in the opposite direction. Usually, the patients body weight
and bed position adjustments supply the needed countertraction. The following are additional
principles to follow when caring for the patient in traction:
Traction must be continuous to be effective in reducing and 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 freely 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 OF TRACTION
There are several types of traction. Straight or running traction applies the pulling force in a
straight line with the body part resting on the bed. Bucks extension traction (Fig. 67-5) is an
example of straight traction. Balanced suspension traction (Fig. 67-6) supports the affected
extremity off the bed and allows for some patient 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 Bucks 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 the 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 Bucks extension traction (applied to the lower leg) (described below), the cervical head
halter (occasionally used to treat neck pain), and the pelvic belt (sometimes used to treat back
pain).

Bucks Extension Traction


Bucks extension traction (unilateral or bilateral) is skin traction to the lower leg. The pull is
exerted in one plane when partial or temporary immobilization is desired. It is used to
immobilize fractures of the proximal femur before surgical fixation. Before the traction is
applied, the nurse inspects the skin for abrasions and circulatory disturbances. The skin and
circulation must be in healthy condition to tolerate the traction. The extremity should be clean
and dry before the foam boot or traction tape is applied. To apply Bucks traction, one nurse
elevates and supports the extremity under the patients heel and knee while another nurse places
the foam boot under the leg, with the patients heel in the heel of the boot. Next, the nurse
secures Velcro straps around the leg. Traction tape overwrapped with elastic bandage in a spiral
fashion may be used instead of the boot. Excessive pressure is avoided over the malleolus and
proximal fibula during application to prevent pressure ulcers and nerve damage. The nurse then
passes the rope affixed to the spreader or footplate over a pulley fastened to the end of the bed
and attaches the prescribed weightusually 5 to 8 poundsto the rope.

Nursing Interventions
Ensuring Effective Traction
To ensure effective skin traction, it is important to avoid wrinkling and slipping of the traction
bandage and to maintain countertraction. 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 Complications
Skin Breakdown. During the initial assessment, the nurse identifies sensitive, fragile skin
(common in older adults). The nurse also closely monitors the status 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, highdensity foam) to prevent pressure
ulcers.
Nerve Damage. 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
foot drop. The nurse regularly questions the patient about sensation and asks the patient to move
the toes and foot. The nurse should immediately investigate any complaint of a burning sensation
under the traction bandage or boot. Dorsiflexion of the foot demonstrates function of the
peroneal nerve. Weakness of dorsiflexion or foot movement and inversion of the foot might
indicate pressure on the common peroneal nerve. Plantar flexion demonstrates function of the
tibial nerve. In addition, the nurse should promptly report altered sensation or impaired motor
function.
Circulatory Impairment. After skin traction is applied, the nurse assesses circulation of the foot
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 deep vein thrombosis (DVT), including unilateral calf tenderness, warmth,
redness, and swelling
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 (eg, Steinmann pin, Kirschner wire) that is inserted through
the bone distal to the fracture, avoiding nerves, blood vessels, muscles, tendons, and joints.
Tongs applied to the head (eg, Gardner-Wells or Vinke tongs) are fixed to the skull to apply
traction that immobilizes cervical fractures. The orthopedic surgeon applies skeletal traction,
using surgical asepsis. The insertion site is prepared with a surgical scrub agent such as
povidoneiodine solution. A local anesthetic agent is administered at the insertion site and
periosteum. The surgeon makes a small skin incision and drills the sterile pin or wire through the
bone. The patient feels pressure during this procedure and possibly some pain when the
periosteum is penetrated. When skeletal traction is discontinued, the extremity is gently
supported while the weights are removed.

Nursing Interventions

Maintaining Effective Traction


The nurse must never remove weights from skeletal traction unless a life-threatening situation
occurs. Removal of the weights completely defeats their purpose and may result in injury to the
patient.

Maintaining Positioning
The nurse must maintain alignment of the patients body in traction as prescribed to promote an
effective line of pull. The nurse positions the patients foot to avoid footdrop (plantar flexion),
inward rotation (inversion), and outward rotation (eversion). The patients foot may be supported
in a neutral position by orthopedic devices (eg, foot supports).

Preventing Skin Breakdown


The patients elbows frequently become sore, and nerve injury may occur if the patient
repositions by pushing on the elbows

Monitoring Neurovascular 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 flexionextension ankle
exercises and isometric contraction of the calf muscles (calf-pumping exercises) 10 times an
hour while awake to decrease venous stasis.
Providing Pin Site Care. The wound at the pin insertion site requires attention. The goal is to
avoid infection and development of osteomyelitis. For the first 48 hours after insertion, the site
is covered with a sterile absorbent nonstick dressing and a rolled gauze or Ace-type bandage.
After this time, a loose cover dressing or no dressing is recommended. (A bandage is necessary if
the patient is exposed to airborne dust.) Pin site care is performed initially one or two times a
day. The frequency of pin care needs to be increased if mechanical looseness of pins or early
signs of infection are present (eg, edema, purulent drainage, erythema, tenderness).

Open Reduction & Internal Fixation Surgery

An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken bones.

This is a two-part surgery:

First, the broken bone is reduced or put back into place.

Next, an internal fixation device is placed on the bone to hold it together. This can be done with
screws, plates, rods or pins.

What to expect during ORIF surgery

The typical ORIF procedure

Every ORIF surgery is different because of the location and type of fracture and, potentially,
other personal factors.

In most cases though, ORIF surgeries follow these general steps:

1. A breathing tube may be placed to help you breathe while youre asleep.
2. The surgeon will wash your skin with an antiseptic and make an incision.
3. Then, the broken bone will be put back into place.
4. Next, a plate with screws, a pin or rod that goes through the bone will be attached to the
bone to hold the broken parts together.
5. The incision will then be closed with staples or stitches.
6. Finally, a dressing and/or cast will be applied.

After an ORIF procedure

Immediately after your surgery, youll be taken to a recovery room for observation.

There, your blood pressure and breathing will be monitored. Your pulse and the nerves close to
the broken bone will also be checked.

Post-procedure care in the hospital

After surgery, you can expect to:

Be given nutrition through an IV until youre able to eat and drink


Need to get out of bed and walk 2 or 3 times each day to prevent complications
Begin physical therapy to learn how to move during your recovery, as well as to learn exercises
that will help you regain muscle strength and range of motion
Learn how to properly use any assistance devices, such as a wheelchair or crutches
Be asked to cough and breathe deeply to prevent lung problems
Have your affected limb elevated above your heart to decrease swelling
REFERENCES

Brunner & Suddarths textbook of medical-surgical nursing. 12th ed. / Suzanne C. Smeltzer ... [et al.].

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