Caring for a Patient in Halo Traction

A nurse is caring for a client in halo traction. Place the following steps in the correct order. Use all options.

1) Administer prescribed analgesic as needed. 2) Assess neurological status. 3) Check the fit of the halo vest. 4) Wash the client's chest and back. 5) Perform respiratory assessment. 6) Assess pin sites for redness. Pin care may cause pain for some clients, so it is best to offer an analgesic to the client before beginning, if needed and as prescribed. Changes in the neurologic assessment could indicate spinal cord trauma, which would require immediate intervention. Checking the fit prevents compression on the chest, which could interfere with respiratory status. Daily cleaning prevents skin breakdown and allows assessment. The halo vest limits chest expansion, which could lead to alterations in respiratory function. Pin sites provide an entry for microorganisms. Assessment allows for early detection and prompt intervention should problems arise.

The acute care nurse is caring for a client who is in halo traction. The health care provider tightened the skull pins 15 minutes ago, and the client now reports a new onset of headache. Which action by the nurse is appropriate?

Assess for jaw pain: If absent, administer a prescribed analgesic. It is common for a client being treated with halo traction to experience a headache after the skull pins have been tightened. The nurse should obtain a prescription for and administer an analgesic. However, if the pain is associated with jaw movement, the nurse should notify the health care provider immediately, because the pins may have slipped onto the temporal plate. There is no need to activate the facility's rapid response team, as this is not an emergency. Loosening the anterior portion of the halo vest should only be performed in the event that the client requires cardiopulmonary resuscitation, which is not the case here. Clipping the halo pins could cause stress to the frame, resulting in misalignment of the spine and straining or tearing of the skin, and thus should not be done.

The nurse cares for a client in halo traction. Which nursing action is most important?

Auscultate breath sounds bilaterally. The halo vest limits chest expansion and spinal cord injuries can lead to pulmonary embolism. Airway and breathing are frequently assessed for this client, so auscultating breath sounds bilaterally is the most important action. The next priority is skin care and infection prevention, followed by ensuring the pins remain in place correctly. If the skin is not cared for and kept dry, breakdown and irritation are likely. Pin sites are closely monitored to prevent problems such as malposition or infection, which can lead to osteomyelitis, a bone infection.

The nurse is caring for a client who is in halo traction. The client states, "I don't know why I feel this way, but I think I look like the Frankenstein monster." Based on this statement, the nurse should select which nursing diagnosis for the client's plan of care?

Disturbed Body Image Based on this statement, the client is clearly concerned about how the halo has negatively affected his or her appearance, or body image. There is no indication in the client's statement of impaired physical mobility, deficient knowledge, or anxiety, although these conditions may be present.

A nurse is providing care to a client in halo traction. As part of the care, the nurse assesses the pin sites. Which finding would lead the nurse to suspect that the client may be developing a problem? Select all that apply.

Swelling at the pin site, Loosening of the pins, Skin tenting, Pin bowing Pin sites provide an entry for microorganisms. Therefore, the nurse would assess the pin sites for redness, tenting of the skin; prolonged or purulent drainage; swelling; and bowing, bending, or loosening of the pins. Any of these findings could suggest an infection and should be reported to the health care provider.