Chapter 17: Traction, cast care, and immobilization

2. The patient is in Buck's traction for a fractured femur. What should the nurse do to minimize any muscle spasms of the affected leg? a.Apply traction gradually, gently, and completely. b.Assess the affected leg with the "four Ps" criterion. c.Eliminate potential pressure points from the traction. d.Ensure unobstructed countertraction to the patient's pelvis.

a.Apply traction gradually, gently, and completely. Muscle spasms associated with a fracture occur because nerves are irritated by bone fragments and occur more frequently at the initiation of therapy. The nurse attaches weight to the traction slowly, gradually, and completely to help prevent and eliminate muscle spasms of the affected leg. The weight, hanging freely, usually creates enough pull on the muscle to release the spasm without increasing pain. Countertraction to the pelvis is contraindicated in Buck's traction. Assessing the four Ps (pounds, pull, pulleys, and pressure) ensures that traction is applied correctly. Eliminating potential pressure points is important but not related to muscle spasms.

28. The patient is complaining of increasing pain several hours after a cast was applied for a severe lower leg injury. What actions should the nurse implement after giving additional pain medication with no relief? a.Call the physician and order a cast saw to the bedside. b.Elevate the leg as high as possible and put ice on the cast. c.Administer half of a dose of additional pain medication and check vital signs. d.Try to distract the patient and have nursing assistive personnel (NAP) stay with him or her.

a.Call the physician and order a cast saw to the bedside. The patient is experiencing symptoms of compartment syndrome, which is a medical emergency. The physician must be notified, and the cast saw made available because the cast will need to be split (bivalved) so the leg can be assessed. Ice is contraindicated, as is placing the leg high. There is already decreased circulation of the extremity, and nothing should be done to further impair it. The nurse cannot alter the prescribed dose of medication that may be given to the patient without consulting the healthcare provider. Distracting the patient is not a useful response to this situation. The nurse should remain at the patient's bedside until the emergency situation is addressed.

7. The nurse is caring for a patient who is in skeletal traction for a femoral fracture and notes that patient assessment data include dyspnea, hypoxia, petechial rash on chest, and hypotension. Which should the nurse implement? a.Initiate emergency treatment measures and call the healthcare provider at once. b.Medicate the patient for severe pain and reevaluate in 30 minutes. c.Place the patient in semi-Fowler's position and listen to bowel sounds. d.Review the list of patient medications and ask about any coughing.

a.Initiate emergency treatment measures and call the healthcare provider at once. These patient data are consistent with clinical indicators for a pulmonary embolism; accordingly the nurse institutes emergency treatment for the patient to restore adequate oxygenation, ventilation, and perfusion and preserve vital organ function. If the patient is stable enough for transport, the healthcare team provides empirical treatment, including supplemental oxygen, fluid resuscitation, and anticoagulation, before performing diagnostic tests to determine the nature of the patient's problem. The patient is not complaining of pain. If chest pain occurs from the pulmonary embolus, the nurse can administer morphine sulfate intravenously to provide pain relief but not at the expense of the respiratory rate or blood pressure. Asking the patient about coughing and repositioning in a semi-Fowler's position are reasonable nursing interventions but are not a priority at this time. The most important nursing intervention is to initiate emergency care related to the symptoms of embolism.

24. A patient with Buck's traction complains of increased pain after the traction is applied and pain medication is given. After loosening the traction slightly, the nurse assesses the extremity and can find nothing wrong, although the patient is still complaining of pain at a level of 4 on a scale of 0 to 10. What action should the nurse initiate next? a.Notify the healthcare provider. b.Administer additional pain medication. c.Explain that an x-ray film of the leg might be taken. d.Have the patient describe the pain in detail.

a.Notify the healthcare provider Once pain medication is given and the traction is loosened, the healthcare provider must be notified because of the chance of a neurovascular deficit. Administering additional pain medication is inappropriate since it may mask the problem. The need for an x-ray film is up to the healthcare provider to explore with the patient; speculating is inappropriate. If the patient is still experiencing pain, the healthcare provider needs to be called, regardless of the description of the pain.

20. A patient with fractures of the femur and pelvis is restless and has a heart rate of 112 and a respiratory rate of 28. What actions should the nurse take? a.Notify the healthcare provider and check vital signs. b.Restrict physical activity and elevate the head of the bed. c.Reposition the patient and administer pain medication. d.Listen to the lung sounds and give a muscle relaxant

a.Notify the healthcare provider and check vital signs. The patient is experiencing the signs and symptoms of a fat embolus and needs emergency treatment by the physician. The nurse should stay and monitor the patient. This patient already has restricted mobility as a result of the injuries. Elevating the head of the bed may help the respiratory effort, but the first action should be to notify the healthcare provider of the emergency. There are no data to indicate the need to administer either pain medication or a muscle relaxant.

26. The nurse is preparing a patient for discharge after application of a plaster cast. What information does the nurse include in the patient teaching? a.Report any changes in sensation or mobility. b.Use a cool blow dryer to dry a wet cast. c.Use only soft objects to scratch inside the cast. d.Trim the cast if the skin becomes irritated.

a.Report any changes in sensation or mobility. The nurse instructs the patient to report changes in sensation or inability to move the affected tissues because these clinical indicators are consistent with neurovascular impairment, usually resulting from a compressed or irritated nerve. This potentially results from excessive intracast pressure from bleeding, edema, or compartment syndrome. The patient can facilitate cast drying by using a standard, household fan positioned 45 cm (18 inches) or more from the cast.

6. The nurse is teaching a patient about pin site care. Which of the following should the nurse include in patient teaching for self-care at home? a.Use a new sterile applicator for each pin. b.Wrap the pins with sterile gauze saturated in an antibiotic. c.Use a new clean swab for each pin site. d.Use cotton swabs with hydrogen peroxide to clean the pins.

a.Use a new sterile applicator for each pin. The nurse teaches the patient to cleanse each pin with an individual sterile applicator using the prescribed antiseptic. If gauze is placed around the pin, it must remain dry. Only sterile objects such as applicators may touch the pin sites. Hydrogen peroxide is no longer used because of potential damage to healthy skin around the pin.

9. During the removal of a synthetic cast to the lower leg, the patient complains of heat inside the cast. Which response by the nurse is most appropriate to the patient? a."Do you feel some heat inside the cast?" b."The heat that you feel inside the cast is expected." c."What is your pain level on a scale of 0 to 10?" d."The heat that you feel will dissipate by tomorrow."

b."The heat that you feel inside the cast is expected." The nurse instructs the patient that the heat is normal and is generated by the vibrating saw. Reflecting the patient's message is a reasonable response; however, the nurse responds properly by informing the patient that the heat is expected. A pain assessment is a reasonable response but does not address the patient complaint. The nurse should also state that the heat should diminish as the cast dries or within 20 to 30 minutes.

10. The nurse is preparing an 11-year-old patient to have a synthetic cast placed on the arm after a fracture. What question should the nurse include to promote the child's acceptance of the cast? a."Are you right or left handed?" b."Would you like a green or a blue cast?" c."How do you usually do in school?" d."Do you like to play sports after school?"

b."Would you like a green or a blue cast?" A colored cast is often more appealing to children and aids in maintaining the appearance of the cast. Dominance doesn't apply to the application of the cast. It will deal more with how the child adjusts with activities of daily living. School performance should not be impeded by the cast, even if on the dominant arm, and sports activities after school will be limited because of the injury; neither of these issues promotes acceptance of the cast.

3. A patient complains of a slight tingling in the toes of the affected leg 2 hours after the application of Buck's traction with a foam boot with Velcro straps. Which nursing intervention will prevent potential complications related to the patient complaint? a.Apply warm blankets to the feet and reassess. b.Check the fit of the traction device near the knee. c.Medicate the patient for pain with an opioid analgesic. d.Reassure the patient that this is a common complaint.

b.Check the fit of the traction device near the knee. Tingling in tissue distal to a potential constriction indicates neurovascular impairment caused by nerve compression or irritation. The nurse should inspect the patient's knee area because this area is most likely to be affected by pressure from the traction device. Nursing intervention can prevent a potential complication of neurovascular impairment such as nerve damage by detecting the source of the pressure and eliminating the pressure. Warm blankets might be applied to increase regional tissue warmth and comfort, but they do not address the possible constriction. Although effective for pain, opioid analgesic agents are ineffective therapy for tingling unless administered in excessive doses that alter the level of consciousness. Addressing the cause of the tingling is more important. It is inappropriate to assure the patient that the complaint is common since tingling is a sign of nerve compression and the compression needs to be alleviated.

8. The nurse provides discharge patient teaching for a patient with an external skeletal fixation device on a leg fracture. What does the nurse include in patient teaching? a.Increase your intake of vitamins and red meat to heal the bone more quickly. b.Notify the healthcare provider if there is a change in the color of the pin site drainage. c.Cleanse the pin site once in the morning and before bed with mild soap and water. d.Increase the speed at which you ambulate around the house to prepare for increased physical activity.

b.Notify the healthcare provider if there is a change in the color of the pin site drainage. Any change in drainage from the pin site needs to be reported to the healthcare provider since it could indicate an infection. Vitamins and red meat help provide good nutrition, but more than that is needed for proper bone healing. Soap and water are not used to cleanse the pin site; only prescribed solution applied with sterile applicators is used. As long as the patient is steady when ambulating and ambulates regularly, the speed at which he or she moves is irrelevant. Sufficient activity prevents complications caused by immobility.

23. The nurse is assisting an adolescent female with a Milwaukee back brace for treatment of scoliosis. Nursing care is correct if the nurse takes which action? a.Has the patient take a Betadine shower before the brace is placed b.Removes any wrinkles from the patient's thin cotton shirt under the brace c.Asks the patient when her menstrual period is next due d.Instructs the patient on how to loosen the brace for comfort

b.Removes any wrinkles from the patient's thin cotton shirt under the brace The nurse checks the thin cotton shirt under the brace so there are no wrinkles that could cause skin irritation. The shirt protects the skin from irritation and absorbs moisture. There is no need for a betadine shower before placing the brace. The menstrual cycle can be an annoyance when the brace is in place, but the skin integrity is priority. The brace must remain tight at certain points for it to work properly. The skin will be checked when it is removed daily.

1. The nurse prepares to place the patient in skin traction. Which is the nurse's main concern before applying the skin traction? a.Obtain informed consent from patient. b.Verify that the patient assessment is complete. c.Prepare a sterile field for pin insertion. d.Assemble the overhead frame and pulleys.

b.Verify that the patient assessment is complete. The priority nursing intervention before the patient goes into skin traction is to ensure that the patient assessment is completed because the nurse relies on baseline data collected before the procedure to compare with postprocedure neurovascular and skin assessments. Without baseline data, the nurse cannot determine whether assessment findings after application of skin traction are new findings or the patient's baseline status. The healthcare provider provides informed consent to the patient because he or she performs the procedure. The nurse prepares a sterile field for pin insertion for application of skeletal traction, not skin traction. Assembling the overhead frame is generally a function performed by technical personnel. If the nurse must be involved, frame assembly can wait until after patient assessments are complete.

17. The nurse plans care for a patient who has just received a prescription for a leg brace and crutches. Which of the following is the nurse's priority in the patient's plan of care? a.Assisting the patient to a supine position to apply the leg brace b.Asking which device the patient prefers and uses most often c.Determining patient experience with a leg brace and crutches d.Assessing how the leg brace affects ambulation with crutches

c.Determining patient experience with a leg brace and crutches The most important nursing intervention is to establish baseline data on patient knowledge and experience with the brace and crutches because this determines the teaching, assessments, preparation, and collaboration that the nurse plans and provides. The baseline data help the nurse to identify knowledge gaps, prevent complications, and provide effective care. When this is completed, the nurse applies the leg brace properly by positioning the patient in a supine position. The prescription provides instruction for the use of a leg brace with crutches. After fitting the patient with a brace, the nurse collaborates with physical therapy to teach or reinforce crutch walking with the brace before allowing the patient independent ambulation to provide patient safety and prevent injury.

21. The nurse is instructing nursing assistant personnel (NAP) about caring for a patient with bilateral plaster long leg casts. Which activity can the nurse delegate to NAP? a.Use a warm blow dryer to assist in drying the cast faster. b.Hold the bed linens away from the patient's cast until it is dry. c.Position the patient's legs above his or her heart level. d.Teach the patient how to identify potential indicators of infection.

c.Position the patient's legs above his or her heart level The patient's legs should be positioned above the level of the patient's heart. Warm air from a blow dryer dries the cast from the outside, which is counterproductive. The cast must dry from inside to outside. Linens are not placed over the cast until it is completely dry. The nurse retains responsibility for turning a patient with an incompletely dry hip spica cast because the task requires critical thinking and nursing judgment. While turning or repositioning the patient, the nurse must maintain proper bone and cast alignment to allow the cast to dry and provide effective therapy. The nurse instructs the NAP about clinical indicators of infection for a patient in a hip spica cast, including fever and foul odors.

15. The nurse provides teaching for the family of a 5-year-old patient who has a one-and-a-half hip spica cast. Which of the following recommendations should the nurse include in patient teaching? a.The patient can sit in a chair with a dry cast if propped carefully. b.Large casts dry from the outside to the inside. c.Several people are needed to safely turn and move the patient. d.Turn and position the patient with the abduction bar.

c.Several people are needed to safely turn and move the patient The nurse instructs the patient's family to involve several people when turning or moving the patient to prevent injury and maintain cast integrity because the combined weight of the patient and cast material can make the patient too awkward and heavy for one person to handle safely. Patients are unable to sit in a hip spica cast because the hip and legs are casted in straight alignment. Casts dry from the inside to the outside. The nurse instructs the family to avoid using the abduction bar for turning because the bar is designed to maintain leg position. Turning or positioning with the bar increases the risk of damaging the integrity of the cast and causing patient injury.

18. The parent of a 4-year-old patient with bilateral leg splints calls the office nurse and reports that the child is "more restless than usual, and I've found the splint straps partially loosened." Which response by the nurse is most appropriate? a."Orthotic devices provide needed support." b."Manufacturers use flexible materials for comfort of the splints." c."Check the skin around the splints." d."Bring the child in for us to see either today or tomorrow."

d."Bring the child in for us to see either today or tomorrow." Restlessness can indicate pain or discomfort, and, because children grow, the splint might need adjusting. The child's growth and development necessitate adjusting the splint to accommodate changes in anatomy and increased weight. As the child outgrows the splint, the risks of impaired tissue integrity, patient discomfort, ineffective therapy, and injury increase. If the child is loosening the splint straps, this may indicate discomfort. The parent is not knowledgeable regarding all aspects to be checked; the child needs to be checked by a medical professional. Manufacturers make splints to withstand daily activity over time; they use sturdy materials such as leather, steel, and strong, molded plastic. Accordingly the nurse teaches the caregivers to observe patient skin for redness and examine the splint for integrity.

12. A 5-year-old child comes to the healthcare provider for cast removal. Which of the following should the nurse implement to minimize the child's fears of the cast saw? a.Premedicate with an opioid analgesic. b.Encourage the caregiver to leave the room. c.Instruct the caregiver to avoid restraint. d.Show that the saw does not cut into skin.

d.Show that the saw does not cut into skin. The nurse demonstrates that the saw does not cut into skin to help minimize the child's fear of the noisy saw and provide first-hand evidence of how the saw functions. The nurse avoids administration of an opioid because the procedure is unlikely to cause pain. The nurse encourages the caregiver to remain with the child during cast removal to provide the child with the security of the caregiver's presence and to be available immediately after successful cast removal. The caregiver is advised to restrain the child gently to maintain patient safety during the cast removal.

4. The nurse assesses the traction boot for a proper fit. Which observation by the nurse verifies that the patient has a properly fitting Buck's traction boot? a.The heel rests firmly on the inner heel padding of the boot. b.The leg slips out of the boot after applying weight. c.The pain level increases from a level of 6 to 7 on a scale of 10. d.The traction boot fits snugly without pressure points.

d.The traction boot fits snugly without pressure points. The nurse observes a snug fit without prolonged exposure to pressure for leg protection against traction forces; the boot maintains adequate neurovascular function and provides effective traction to the affected region. The nurse should also observe a well-seated heel in the boot and baseline neurovascular assessment findings. Padding at the heel of a traction boot is contraindicated because the boot is manufactured to distribute pressure over the heel and leg. If the leg slips out of the boot when weight is applied, the boot is too loose. After application of the traction, pain should decrease.

16. The nurse completes patient teaching about synthetic cast care at home. What does the nurse instruct the patient to report about the cast? a.If it becomes dry and stiff b.Any softening of the cast c.If the exterior becomes soiled d.If the exterior feels rough

b.Any softening of the cast The nurse instructs the patient to report any defects in cast integrity. If the cast softens, it loses its ability to maintain bone alignment; the nurse instructs the patient to report this because it may warrant further investigation by the nurse. A synthetic cast should be dry, stiff, and rough. For soiling, the patient can rinse the cast in warm water and dry thoroughly.

2. The nurse is performing pin site care using evidence-based guidelines. Those guidelines recommend using __________ solution to clean the pin sites.

chlorhexidine The level of evidence for pin site care is low, but guidelines and reports from an integrative review of the literature provide recommendations for clinical practice (Lagerquist et al., 2012; Timms and Pugh, 2012; Voda, 2011): Perform pin care daily or weekly after the first 48 to 72 hours. Weekly pin care is supported for noninfected pins. Clean pin sites with chlorhexidine 2 mg/mL solution.

19. The nurse is assisting with the application of a long arm plaster cast. Which action should the nurse take for this patient? a.Apply an ice pack along the top of the cast. b.Handle the wet cast with the fingertips. c.Maintain the extremity below the heart level. d.Fold the stockinette over the outer edge of the cast.

d.Fold the stockinette over the outer edge of the cast. The nurse folds the stockinette over the outer edge of the cast, secured with an additional layer of casting material, to protect the regional tissue from irritation. Ice bags are placed on both sides of the cast to ensure effective cooling. The nurse handles a wet cast with the palms of the hands. After completing the cast, the nurse positions the extremity above the heart to promote venous drainage from the affected tissue

11. The patient receives a plaster cast for an ulnar fracture. What would the nurse expect to see on the first day after cast application? a.The fingers are slightly edematous. b.The fingers are cool, pale, and dry. c.The fingertips blanch slowly. d.Skin is bulging over the cast edge.

a.The fingers are slightly edematous. The nurse expects mild edema after a fracture as evidence of the immune response to tissue trauma. It should be 1+ or less. Cool, pale, dry skin and slow blanching are consistent with clinical indicators of impaired perfusion; the nurse expects adequate perfusion with warm, pink, dry skin and swift blanching. Bulging skin at the top of a cast is consistent with clinical indicators for excessive edema; the nurse does not expect this patient datum because excessive edema potentially impairs perfusion and nerve function from tissue compression

5. The nurse assesses a patient 22 hours after skeletal traction was applied to the femur. Which clinical finding is inconsistent with the patient's baseline data but acceptable to the nurse? a.A decreased sensation in the affected foot b.An increase in patient anxiety after procedure c.Lower leg pallor with a weaker pedal pulse d.A small amount of clear drainage from the pin sites

d.A small amount of clear drainage from the pin sites Clear drainage after pin insertion is an acceptable clinical finding after an invasive procedure because it reflects the process of drainage produced with punctures. Decreased sensation is consistent with clinical indicators for neurovascular impairment from nerve compression or irritation. Lower leg pallor and a weaker pedal pulse indicate compression of the affected leg from edema and the original trauma. Patient anxiety related to a procedure is more common before the procedure; however, exposure to new therapy can cause patient anxiety.

27. The nurse is preparing to help with removal of a long arm plaster cast. What information should the nurse include in patient preparation for plaster cast removal? a."Stretch your arm and wrist as soon as the cast is removed." b."I'll get a nail brush to help remove dead cells from your skin." c."This is the enzyme wash we'll use to remove dead skin cells." d."The cast saw causes a little discomfort and a burning sensation."

c."This is the enzyme wash we'll use to remove dead skin cells." The nurse instructs the patient to use a cool enzyme wash to facilitate dead cell removal as long as the skin is intact because the skin under a cast becomes dry and flaky. The patient is advised to resume full range of motion gradually to prevent discomfort and patient injury. A nail brush is too rough to use on scaly, dry skin and could cause discomfort. The saw causes no discomfort, although a burning sensation can occur with the removal of a synthetic cast.

13. The patient asks what to expect immediately after removal of a long leg cast. What is the most accurate response by the nurse? a."The skin will look smooth and moist." b."You will be able to stand on both legs easily." c."Your joints will have full range of motion." d."The skin will be dry and scaly but intact."

d."The skin will be dry and scaly but intact." Skin cells normally sloughed off with basic hygiene accumulate under a cast, giving the skin a scaly appearance on cast removal; the accumulating cells cause the area to itch while the cast is in place. Bathing, gentle exfoliation, and moisturizing lotion remove dead cells within a few days of cast removal to restore the normal appearance of the skin. Because muscles atrophy with lack of use, patients generally do not have complete weight-bearing ability or full range of motion after cast removal. Depending on the nature of the injury, patients increase weight bearing over days or weeks until it returns to baseline function. The joints will be stiff from immobilization as a result of casting.

1. The first sign that a neurovascular deficit is developing in a patient who is immobilized in a traction device after a fracture is ___________on passive range of motion.

pain It is essential to monitor the five Ps (pain, pallor, paralysis, paresthesia, and pulselessness) of neurovascular status because permanent damage results if circulation is not maintained and restored. Pain on passive motion is often the first clinical manifestation when a neurovascular deficit is developing. Promptly report the development of compromised neurovascular status to the patient's healthcare provider.

25. During assessment of an African-American patient, the nurse notes that the fingernails on the hand casted in plaster are an ashen-gray color. What information should the nurse collect next? a.Whether the patient is experiencing numbness or tingling in the affected hand b.How pink the fingernails were before the application of the cast c.Whether the patient has an allergy to latex or medications d.The color of the toenail beds for a comparison

a.Whether the patient is experiencing numbness or tingling in the affected hand Numbness and tingling are symptoms that correlate with a decrease in circulation, which can be manifested as an ashen-gray color in this patient. The color of the fingernails before the application of the cast is important to know, but information about the current status is more important. Allergies are checked, but they would not be manifested only on the affected extremity. Toenail beds can alert the nurse if a systemic cardiopulmonary problem is occurring. The comparison would be between the two hands.

14. The patient tells the nurse that the top of the plaster cast feels rough and is scratching the skin. Which intervention should the nurse implement? a.Explain that this is an expected outcome. b.Trim away sharp areas and edge with tape. c.Medicate the patient with a prescribed analgesic. d.Speak with the healthcare provider about a cast change

b.Trim away sharp areas and edge with tape. All plaster casts have rough edges before they are "finished," and the nurse finishes the edge to prevent skin breakdown and infection. To finish the cast, the nurse carefully trims away the thin, uneven edge and reinforces the edge with tape. If the cast is finished with stockinette, the healthcare provider folds the stockinette over the edge of the cast and makes a final loop with the casting material around the cast to hold the stockinette in place. Pain medication can become necessary; however, the priority is to prevent skin breakdown and infection. The discomfort will resolve after the edge is finished and edema subsides. A cast change is not indicated.

22. The nurse is preparing for the initial placement of an orthotic device onto the patient's lower leg. Which of the following is the priority nursing intervention? a.Instruct the patient how to care for the orthotic device. b.Provide patient teaching before ending the visit. c.Ensure that the orthotic device is free of patient clothing. d.Obtain a baseline observation of the affected skin area.

d.Obtain a baseline observation of the affected skin area. The most important nursing intervention is to obtain a baseline assessment of the area where the orthotic device will be placed. It is important to accomplish this before regular use of the orthotic because a pressure point potentially leads to skin breakdown and can result in patient inability to use the device. Providing patient education on maintaining the device occurs before ending the visit, but the first priority should be to establish the baseline assessment before the initial placement.