NF 39 Promoting Musculoskeletal Function PDF

ch a p te r 39 Promoting Musculoskeletal Function http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Discuss the effects of inactivity on respiratory exchange and airway clearance. 2. Describe appropriate car...

ch a p te r 39 Promoting Musculoskeletal Function http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Discuss the effects of inactivity on respiratory exchange and airway clearance. 2. Describe appropriate care of a cast as it dries. 3. Verbalize the differences among an air luidized bed, low air loss bed, and continuous lateral rotation bed, listing the reasons for their use. 4. Name at least four pressure relief devices that help prevent skin injury in immobile patients. 5. Describe how to perform a neurovascular assessment on an immobilized extremity. 6. Discuss the use of bandages and slings to immobilize a body part. Clinical Practice 1. Devise a plan of care for meeting the psychosocial needs of the alert, immobile patient. 2. Correctly care for the patient undergoing skin traction. 3. Use lift sheets and roller or slide devices to move immobilized patients. 4. Teach a patient to properly care for a cast following discharge. 5. Correctly apply an elastic bandage to a stump after an amputation. 6. Transfer a patient using a mechanical lift. 7. Assist a patient with the use of each of the following: walker, crutches, cane, brace, prosthesis, and wheelchair. Skills & Steps Skills Steps Skill 39.1 Cast Care 802 Skill 39.2 Care of the Patient in Traction 804 Skill 39.3 Transferring With a Mechanical Lift 810 Steps 39.1 Use of a Continuous Passive Motion Machine 798 Steps 39.2 Applying of an Elastic Bandage 805 Steps 39.3 Applying a Triangular Bandage Sling 809 Key Terms bivalved (BĪ-vălvd, p. 794) blanch (p. 799) cast (p. 794) counter traction force (p. 794) dorsum (DŎR-sŭm, p. 799) external fixator (p. 795) hemiparesis (hĕm-ē-pă-RĒ-sĭs, p. 799) hemiplegia (hĕm-ē-PLĒ-jă, p. 799) hydrotherapy (hī-drō-THĔR-ă-pē, p. 806) hypostatic pneumonia (hī-pō-STĂT-ĭk noo-MŌ-nē-ă, p. 790) immobilization (ĭ-mō-bĭl-ī-ZĀ-shŭn, p. 790) isometric exercises (ī-sō-MĔT-rĭk, p. 790) kinetic (p. 796) moleskin (p. 795) over-the-bed frame (p. 793) paraplegics (păr-ă-PLĒ-jĭks, p. 809) paresthesia (păr-ĕs-THĒ-zē-ă, p. 799) perfusion (pĕr-FŪ-zhŭn, p. 799) prosthesis (prŏs-THĒ-sĭs, p. 809) quadriplegics (kwŏd-rĭ-PLĒ-jĭks, p. 809) sling (p. 793) spica casts (SPĪ-kă, p. 794) splint (p. 792) traction (p. 790) trapeze bar (tră-PĒZ, p. 793) 789 790 UNIT VIII Care of the Surgical and Immobile Patient Concepts Covered in This Chapter • • • • • • • Anxiety Functional ability Infection Mobility Nutrition Pain Patient education Many conditions, such as strokes, fractures, surgery, and neuromuscular disorders, require bed rest for the patient to heal and recover. These periods of bed rest may result in immobilization (prevention or restriction of normal body movement) of the patient. Problems caused by immobilization include pressure injuries, pneumonia, loss of bone mass, and permanent loss of function in the immobilized part. Many supportive or corrective measures necessary for treatment, such as traction (exertion of a pulling force), casts, or braces, also restrict mobility and may cause the same types of problems (Fig. 39.1). Good nursing care is critical in preventing complications for immobilized patients. SYSTEMIC EFFECT OF IMMOBILIZATION Decrease in muscle strength and coordination, generalized weakness, stiff joints, constipation, and abdominal distention begin within a few days of immobility. Table 39.1 presents the more severe problems that may occur when lack of activity occurs for a longer period of time. Pressure injuries are a frequent consequence of immobility and are presented in Chapter 19. One of the major concerns when a patient’s movement is restricted is the development of respiratory complications. Physical activity causes people to breathe more deeply, expanding their lungs and encouraging clearing of secretions. Without adequate physical activity, these secretions can collect in the lower airways, leading to congestion and ultimately to respiratory illness, particularly hypostatic pneumonia (pneumonia caused by stasis of secretions due to inactivity) or hospital-acquired pneumonia. Range-of-motion (ROM) exercises (Chapter 18), frequent turning, and use of deep breathing exercises can help to prevent pneumonia and increase general oxygenation. Patients experiencing pain may be reluctant to move and breathe deeply; therefore, pain control is essential. However, medications used to control pain may cause sleepiness and further reduce the patient’s desire to move about. Opioid analgesics, such as codeine, may depress respirations and further inhibit respiratory clearing (Chapter 31). Measures to promote respiratory function must be included in the plan of care for the immobile patient. Circulation is also affected by immobilization. Normal movement assists in venous return by compression of the muscles against the venous walls when the FIGURE 39.1 Patient with a leg brace or splint. muscles are in motion. Healthy, irm muscles provide general support for the venous walls. This is important throughout the body, but especially in the legs, where the force of blood low is reduced because of the distance from the heart. Various conditions (such as a fracture, trauma, or debilitating illness) and treatments (such as casts, traction, or bed rest) can impair circulation and predispose the patient to pressure injury and permanent loss of function. For these reasons, you must monitor the general circulatory status of the patient and blood low to the affected areas of the body on a regular basis. Increasing luids to at least 3000 mL/day, encouraging adequate nutritional intake, and increasing dietary iber help prevent gastrointestinal system complications. The luid increase also helps prevent urinary complications. Stool softeners and laxatives are ordered as needed for constipation. Life Span Considerations Older Adult • Advanced age compromises the respiratory and circulatory systems, which can lead to even greater risk for complications from immobility. • Inactivity tends to cause anorexia. Interventions for adequate nutritional care should be added to the care plan of the immobile older adult. Frequent small feedings and bedtime nourishments may be needed. Having their favorite foods brought in by family and friends can also be helpful. Performing active or passive ROM exercises to maintain joint mobility and muscle integrity is the standard of practice for bed rest care. Encouraging active movement of the unaffected extremities throughout the day assists in maintaining muscle tone. When the patient is on extended periods of bed rest, isometric exercises (exercises performed against resistance) may be beneicial. Turning the patient every 2 hours, keeping the skin clean and dry, providing smooth and clean linens, and using pressure relief devices help prevent Promoting Musculoskeletal Function CHAPTER 39 Table 39.1 791 Effects and Problems of Immobility BODY PART OR SYSTEM Cardiovascular system EFFECT OF IMMOBILITY Venous stasis Increased cardiac workload Blood pressure alterations PROBLEM OR COMPLICATION Thrombus formation Thrombophlebitis Pulmonary embolus Orthostatic hypotension Increased pulse rate Respiratory system Stasis of secretions Decreased elastic recoil Decreased vital capacity Hypostatic pneumonia Bacterial pneumonia Atelectasis Decreased gas exchange Gastrointestinal tract Anorexia Metabolic change to catabolism and negative nitrogen balance Decreased peristalsis Weight loss Protein deiciency Abdominal distention Constipation Musculoskeletal system Decreased muscle mass and muscle tension Shortening of muscle Loss of calcium from bone matrix Decrease in bone weight Fibrosis of connective tissue Atrophy Weakness Joint contracture Osteoporosis Bone pain Urinary system Stasis of urine Urinary tract infection Kidney stones Precipitation of calcium salts Frequency Dysuria Skin Decreased circulation from pressure Ischemia and necrosis of tissue Skin breakdown Pressure injuries Brain/psychological Decreased mental activity Decreased sensory input Decreased socialization Decreased independence Disorientation Confusion Boredom Anxiety Depression Loneliness pressure injuries. Perform a skin assessment at least every 8 hours and more frequently for the patient at high risk for skin breakdown. QSEN Considerations: Teamwork and Collaboration Teamwork VALUE THE PERSPECTIVES AND EXPERTISE OF ALL HEALTH TEAM MEMBERS The systemic effects of immobility can be managed by utilizing multiple members of the health care team. Respiratory therapists, physical therapists, unlicensed assistive personnel, wound, ostomy, and continence nurses (WOCNs), and dietary personnel are all vital members of the patient’s health care team. PSYCHOSOCIAL EFFECTS OF IMMOBILIZATION Immobilized patients may experience a variety of emotional responses. For example, they may be afraid that they will not be able to return to work and support themselves and those who depend on them. They may fear abandonment by those they love if they cannot function as they did before. Patients who are facing permanent loss, or their signiicant others, may need professional counseling or support groups. Provide support, use therapeutic techniques of communication that focus on listening, and allow the patient to verbalize concerns. When signs of fear and stress are observed, take time to listen, and refer these patients to social service as appropriate. QSEN Considerations: Teamwork and Collaboration Collaborative Care APPRECIATE IMPORTANCE OF INTRAPROFESSIONAL AND INTERPROFESSIONAL COLLABORATION Patients with prolonged immobility or permanent loss may need professional help in dealing with depression. Collaborate with appropriate health care providers to address the psychosocial effects of immobilization and your patient’s emotional needs. Another frequent problem for the alert immobile patient is boredom. Not all patients like television or enjoy reading, and even those who do will become bored with nothing else to do. Chat with patients about things that interest them while providing care. Some patients may want a diversion through the use of a laptop computer or smartphone, or may want to 792 UNIT VIII Care of the Surgical and Immobile Patient do something creative, such as crocheting or crafts. Encourage family and friends to space visits so the patient avoids long periods of loneliness. Family members can also help by contacting friends and relatives and asking them to send notes and cards on a regular basis. Cards, texts, phone calls, emails, and visits increase the patient’s sense of value to others and feelings of self-worth. Positive feelings are known to play an important role in the healing process. For the immobile patient being cared for at home, it may be helpful to move the bed into the living room or family room to reduce social isolation. This may also save many steps for those providing care, especially if bedrooms are on separate loors. Visits by home health aides and friends or respite caregivers can provide a chance for the caregiver to get out of the house and do errands or spend some time at leisure. Remember that the nonalert or comatose patient also needs emotional support. Always assume that patients can hear and understand, even when they cannot respond or they respond inappropriately. Talk to the patient in a kind and caring voice. Explain what is being done before and during procedures, and apologize for any unavoidable pain the care may be causing. Talk to the patient about what is going on in the world. If cards or letters arrive, read them to the patient. Patients who have recovered from unconscious states have been known to describe in great detail things that happened while they were unconscious and have expressed thanks to those staff members who continued to treat them as valuable human beings. Life Span Considerations Older Adult Following a stroke, hip fracture, or other condition that causes immobility, older adults may worry about becoming a burden to their families. This feeling may be so strong that they feel that it would be better if they died, and they become depressed. Encouragement and praise from the staff, kindness and patience when they attempt self-care or learn a new task, frequent family visits, and expressions of hope for recovery can help reestablish their sense of self-worth. Consultation with social services may lead to solutions for inancial concerns. TYPES OF IMMOBILIZATION SPLINTS A splint is a device that protects an injured part of the body by immobilizing or limiting its movement. A splint may be used as a irst aid measure before a cast or traction is applied to an injured part, or it may be used instead of a cast. Box 39.1 presents the guidelines for applying a splint. Several types of commercial splints are available: molded splints, immobilizers, inlatable splints, cervical collars, and traction splints (Fig. 39.2). First aid splints are fashioned from materials at hand and require only some rigid material, Box 39.1 Applying a First Aid Splint to an Extremity When a serious injury or fracture occurs in the home or outdoor setting, it is advisable to render first aid by splinting the injured part. To apply a splint to an extremity: • Handle the injured part gently and do not change its position in any way. This decreases the chance of nerve injury and further bleeding. • Cover any open wounds with material as clean as can be found to help prevent infection. • Use a rigid splinting material to immobilize the injured part. Flat boards, broom handles, rolled up newspaper, or similar materials are appropriate. The splint should be long enough to span the joint above and below the injury. • Pad bony prominences with soft material to prevent pressure wounds. • Secure the splint with wide bands of material to stabilize the injured limb within the splint. • Elevate the injured part to decrease edema and swelling. • Check circulation distal to the injury and loosen the splint ties if tissue becomes pale, cold, or blue. • Keep the person warm and seek transport to a medical facility. FIGURE 39.2 Wrist and forearm splint. (From deWit, S. C. [2009]. Medical-surgical nursing: Concepts and practice. Philadelphia, PA: Saunders.) padding, and something to secure the splint in place. Inlatable splints help control bleeding, as well as immobilize the injured part. The splint should be inlated until ingertips can only indent the device 1½ inches (3.8 cm). Immobilizers are made of cloth and foam with Velcro straps. They are often used on an injured knee to prevent movement while an injury heals or during activity to prevent further injury. Molded splints keep the body part in a functional position to prevent contracture and maintain functional ability. They are used for chronic disorders. Traction splints are applied and hooked to traction ropes, pulleys, and weights to maintain pull on a fracture. TRACTION Traction is the application of a pulling force, and it is used to maintain parts of the body in extension and alignment. It is used to realign bone ends following fracture and to relieve pain and nerve impairment caused by compression or muscle spasm. There are three types of traction: manual, skin, and skeletal. The amount of traction is determined by the pull exerted by weights at the end of the traction ropes. Promoting Musculoskeletal Function CHAPTER 39 Table 39.2 793 Principles of Traction with Nursing Interventions PRINCIPLE Ropes and weights must be free of friction. NURSING INTERVENTION Keep ropes free of entanglement in the linens. Maintain the correct line of pull. Keep the patient centered in the bed with the body in good alignment. Weight and pull of the traction must be continuous and as ordered by the primary care provider. Remove or add weights only by medical order. Do not interrupt the pull of traction to provide care. Suficient counter traction must be maintained. Keep the patient from sliding down in the bed when in leg or back traction. Keep the patient in sidearm traction in the center of the bed. The amount of weight must be ordered by the primary care provider and often changes over the course of treatment. Initially the muscles tend to be tight and may go into spasm. A heavier weight is required to overcome the muscular pull and allow the body to resume a normal alignment. As times goes on, the muscles tire and relax; the amount of weight is then reduced. The care provider will leave orders concerning if, and how much, the head of the bed may be raised. The head of the bed should be no higher than 20 degrees (unless ordered) to keep the patient from sliding down in bed and to keep the weights hanging free. A slight Trendelenburg position may be ordered to keep the patient from slipping down in the bed. Tape a sign to the head of the bed indicating any restrictions related to bed positioning. The weights should swing freely without touching the bed or loor. The ropes must move freely through the pulleys to prevent injury to the patient and alteration in the effects of the traction. Principles to be followed for traction are listed in Table 39.2. The patient in traction should have an over-thebed frame (rectangular frame to which traction equipment may be attached) with a trapeze bar (overhead bar that patient can grab) attached to the bed (see Fig. 18.9A). The trapeze bar can be grasped by the patient to assist in repositioning. Teach the patient how to tell when body alignment is correct in the bed so that as he becomes more active, he can place himself in correct alignment to maintain the traction. Manual Traction In this form of treatment, the hands are used to aid in the realignment of fractured bones. This method should only be used on stable, clean fractures or dislocations. FIGURE 39.3 Buck extension. (From Elkin, M. K., Perry, A. G., & Potter, P. A. [2008]. Nursing interventions & clinical skills [4th ed.]. St Louis, MO: Mosby.) It is typically performed by the physician prior to placing the affected extremity into a splint or cast. Skin Traction In patients with hip fractures, recent studies have shown that skin traction has the same effect on pain relief as placing a pillow under the affected extremity. However, skin traction does offer short-term pain relief from muscle spasms due to muscles and tendons pulling the extremity into a shortened position. QSEN Considerations: Evidence-Based Practice Decreased Use of Skin Traction Nurses must differentiate clinical opinion from research and evidence summaries. Recent studies of patients with hip fractures showed that those with skin traction asked for pain medications at the same frequency as those with a pillow propping up the affected extremity In skin traction a Velcro boot (Buck traction), belt, halter, or sling (bandage for supporting a part) is applied snugly to the skin, and the traction is attached to the appliance (Fig. 39.3). Skin traction has the advantage of being noninvasive, and its main purpose is to decrease muscle spasm that accompanies fractures. Damage from skin traction includes blisters, rashes from irritation by adhesives, and skin tears and tissue injuries from the shearing effects of the lateral pull across the skin surface. The amount of weight that can be applied is limited to a maximum of 10 to 15 pounds. Skin traction should not be used if the fracture requires 794 UNIT VIII Care of the Surgical and Immobile Patient 5 pounds (2.7 kg) or more of tractive weight. Skin traction is generally not used with older adults because of their fragile skin. Check the skin frequently for any indications of injury, and report any problems or skin pain immediately to the primary care provider or traction technician. Safety Alert Safety With Immobilization Whenever a patient is in an immobilization device, be sure to check for adequacy of circulation in the affected extremity by assessing skin temperature and color, capillary reill when appropriate, and sensation. Skeletal Traction Although external ixation is used more frequently for fractures today, skeletal traction is occasionally used for some injuries. Skeletal traction requires the surgical placement of pins, tongs, screws, or wires that are anchored to or through the bone and therefore pierce the skin. Traction is thus applied directly to the bone, which can support more weight than the skin. As much as 30 pounds (14 kg) of tractive force can be used for this type of traction. An orthopedic technician may set up the traction. The LPN/LVN is responsible for maintaining the correct weight and alignment of the traction and for maintaining a balance between traction pull and counter traction force (the weight pulling against the weight of the traction). Counter traction is provided by the weight of the patient and the position of the bed. Care of the skin around the openings for the pins, tongs, or wires is performed according to the medical order. Sterile technique is used when performing pin care (Box 39.2). After the sites are healed, they may be left open to the air. Clear luid drainage is expected initially. Follow the medical order and the policies of the facility, and report immediately any indication of infection at the wound or pin sites. Circulation checks are performed every hour for the irst 24 hours and every 4 hours thereafter. Think Critically What interventions would you use to prevent skin breakdown on the back and buttocks of the patient in traction? CASTS Patients may be placed directly into a cast (a stiff plaster of Paris, iberglass, or polyester dressing used to immobilize) following a fracture or a variety of orthopedic procedures, or a cast may be applied following a period in traction. The skin is cleansed and inspected and any wounds are treated before a cast is applied. A layer of stockinette is applied irst, followed by a thin layer of cotton or synthetic padding and then the cast material. Most casts are made of iberglass, polyester resin, or thermoplastic material. Plaster of Paris casts are often applied to a lower extremity because they will withstand weight bearing better than the synthetics. Heat Box 39.2 Guidelines for Pin Care Always follow the primary care provider’s orders for cleansing or antiseptic solution and use or nonuse of antimicrobial ointment. • Using sterile swabs, cleanse closest to the pin in a circular motion. Use one swab for each circle. Work your way out in succeeding circles until 1½ inch from the pin. • Apply antimicrobial ointment with a sterile swab, if ordered. • Dress with sterile gauze, if ordered. • Secure ends of wires with cork. • Monitor for infection, assessing for increased pain, redness, edema, tenderness, or purulent drainage. may be felt as the casting material is applied, especially with plaster of Paris. Plaster casts can take from a few hours to a couple of days to dry and be fully hardened. Casts made of synthetic material dry rather quickly (7 to 20 minutes) and may be hardened enough to be durable within 30 minutes. It is critical to protect the cast from uneven pressure during the drying period because the shape or position can be inadvertently changed. Clinical Cues When handling the cast during the drying period, use the palm and lat parts of the ingers rather than the ingertips. Dents in the cast can lead to circulatory impairment and pressure injuries, and changes in alignment can alter the position of the healing parts or impede circulation. Swelling of the tissues is common during the irst days after a cast is applied, and if left uncontrolled, this can impair the circulation and cause a pressure injury. A casted extremity should be elevated on pillows. If not padded suficiently, the edges of the cast may rub or push against bony areas, causing pain and injury. The stockinette may be folded over the outside edge of the cast and taped to protect from chaing, or the cast edge may be “petaled” with waterproof tape. Changing position may relieve the problem, or adding extra padding beneath the edge of the cast may help. If the cast becomes too tight, it may be bivalved (cut in half lengthwise) to relieve the pressure on the tissues. If there is a wound under the cast that needs observation, a window may be cut in the cast over the wound area. When edema has decreased, the cast is secured with outside bandaging or by more casting material. Sometimes after edema subsides, the cast is too loose and must be replaced. Hip spica casts can be particularly challenging for both the patient and caregiver. Hip spica casts encase a portion of the trunk and part or all of both legs (Fig. 39.4). A spreader bar is placed between the legs to maintain the desired angle at the hip and incorporated into the cast. Do not use the spreader bar as a handle for lifting and turning the patient. It may be dislodged, ruining the cast and causing pain and possible injury to the patient. Grasp the cast over the leg to assist in turning. Because of their size and thickness, hip spica casts often take longer to dry. Frequent turning is necessary, including prone positioning to ensure complete and uniform drying. Promoting Musculoskeletal Function CHAPTER 39 795 FIGURE 39.5 An external ixator holding fractured bones in place. (From McCance, K. L. [2009]. Pathophysiology: The biologic basis for disease in adults and children [6th ed.]. St Louis, MO: Mosby.) FIGURE 39.4 Hip spica cast. (Courtesy Zimmer, Inc., Warsaw, IN.) Clinical Cues A hair dryer set on low may be used to assist in drying the plaster of Paris cast. Just be sure to uniformly dry all areas of the cast and lightly touch the cast frequently to make certain that it is not becoming so hot that it will burn the patient’s skin. Toileting can be dificult for the patient with a hip spica cast. Ingenuity is needed to protect the cast from soiling. Using disposable plastic wrap around the perineal opening is one method of protection. Maintaining skin integrity of an incontinent patient in a spica cast is a great challenge for the orthopedic nurse. Most patients can go home soon after cast placement. If the cast is not yet dry before discharge, instruct the patient and family or caregiver in the proper care of the cast to ensure uniform drying. When elevating a wet cast with pillows, use cloth-covered pillows because plastic-covered ones hamper drying. Show the patient and family how to check the cast edges for rough spots or crumbling, how to use pillows to elevate the extremity and prevent swelling, and how to pad the rough edges using tape or moleskin (thick, durable form of adhesive material). Assess cast condition every 8 hours, checking for cracks, crumbling, or rough edges. A damaged cast may need to be replaced. Safety Alert Precautions When the Patient Has a Cast Caution patients not to place a foreign object under the cast (e.g., wire hanger or stick to scratch an itch). Blowing cool air under the cast with a can of electronic air cleaner may help decrease itching. Discomfort can sometimes be relieved by directing the air of a hair dryer set on “cool” into the cast. Cast Comfort spray is a commercial product that delivers a soothing layer of talc under the cast. A major concern for patients with casts is bathing. Plaster casts must be kept dry, or they can disintegrate. Even iberglass casts are a problem if they become thoroughly wet. The outside material tolerates water, but the padding inside tends to stay wet, causing irritation to the skin. Small casts, such as those that immobilize the forearm or lower leg, can often be covered with a large plastic bag taped in place to allow the patient to shower. However, larger casts usually require that the patient take sponge baths until the cast is removed. When a child is sent home with a cast, it is important to stress the dangers of placing small items inside the cast. These can cause pressure necrosis and infection. Casts are removed using an oscillating saw. The saw is noisy and may frighten the patient. The saw does not cut down to the skin, and the patient needs reassurance about this. After separating the cast material, scissors are used to cut through the stockinette and padding and the cast is removed. Clinical Cues Prior to cast removal, inform the patient that the skin underneath will be dry and dirty in appearance, with an unpleasant odor. Washing with warm soapy water, rinsing, and applying cream or lotion removes dead skin cells and helps the skin return to normal. Vitamin E or other recommended ointment rubbed over the healed incisions may also improve appearance. EXTERNAL FIXATORS An external fixator is a metal device, such as a pin, screw, or tong that is inserted into or through one or more bones to stabilize fragments of a fracture while it heals (Fig. 39.5). The metal inserts are attached to a metal frame. This type of immobilization allows the patient to be more active during healing while maintaining immobilization of the fractured area. The pins, screws, or tongs and the frame should be checked for stability every 4 hours. The insertion of the metal device through the skin provides a break in skin integrity that requires regular pin care to prevent infection, which is a common complication of external ixators (see Box 39.2). Pin care is included in Skill 39.2 later in this chapter. 796 UNIT VIII Care of the Surgical and Immobile Patient patients with unstable spines or patients who are ambulatory. To maximize the beneicial effects of the therapy, the unit should be in the luidized mode at all times. Exceptions would be during patient transfer in and out of the bed or during nursing procedures for which the patient needs to be in one stable position for the intervention. Low Air Loss Beds Low air loss support is achieved by distributing air through multiple cushions connected in a series. The cushions are calibrated to provide maximum pressure relief for the individual patient. Shear and friction are reduced or eliminated because the cushions give with the patient during movement or rest. A low airlow through the cushion controls moisture on the skin. Segments of cushions may be delated for patient care. The head of the bed can be raised. This bed is contraindicated for the patient with an unstable spine. FIGURE 39.6 Clinitron-Elexis air-luidized therapy unit. (Copyright 2011 Hill-Rom Service, Inc., reprinted with permission. All rights reserved.) DEVICES USED TO PREVENT PROBLEMS OF IMMOBILITY SPECIALTY BEDS On occasion, illness or injury may result in long-term or permanent immobility. The potential complications from permanent immobility can worsen a patient’s condition and may require additional interventions. Kinetic (moving) and air luidized beds can be used to help decrease the incidence of these complications. Because their use is very expensive, thorough ongoing documentation of needing this type of bed is essential. Air Fluidized Beds Air luidized beds have tiny silicone beads contained within the bed under a lexible, air permeable ilter sheet (Fig. 39.6). Warmed air passes through the small particles, setting them into motion so that they act as a luid that suspends the patient free from contact with any stationary, hard surface. The lotation or buoyancy of the patient on the air luidized beads prevents pressure occlusion of blood vessels and shearing of tissues against the mattress during movement, unlike conventional mattresses. The loose ilter sheet reduces friction, and the warm air protects the skin from damage by wetness. Air luidized therapy is effective in the prevention of pressure injury and helps reduce generalized body pain common among bedridden patients. The indications for use include those patients with full-thickness or multiple pressure injuries, fresh grafts, or lap repairs of injuries and immobile patients whose general condition puts them at high risk for skin breakdown. Air luidized therapy is not recommended for Continuous Lateral Rotation Beds Lateral-rotation therapy beds, such as the RotoRest bed, are believed to decrease the incidence of lung collapse and hospital-acquired pneumonia, facilitate normal urine low, and reduce the risk for deep vein thrombosis and pulmonary embolism by encouraging venous low. This intervention may have a signiicant positive effect on various body systems of the critically ill patient and improve the overall patient outcome. Skin breakdown is reduced by the pressure reduction foam and gel pack surface. The patient is secured in position on the bed by multiple cushion wedges (Fig. 39.7). The bed turns in an arc up to 80 degrees and can be set to pause on either side for up to 30 minutes. The rotation is stopped and the wedge cushions removed as needed for bathing, procedures, or toileting. There is a built-in scale to allow patient weighing. The degree and rate of movement are programmed to meet the individual patient’s requirements. The constant side-to-side movement prevents the accumulation of respiratory secretions and promotes respiratory clearing. Other lateral rotation beds are combined with low air loss technology to provide relief of tissue pressure. Think Critically What types of problems, if any, do you think you might encounter when caring for a patient in a kinetic or air luidized bed? PRESSURE RELIEF DEVICES There are a variety of accessories that aid in the reduction of skin trauma from pressure for patients in standard hospital beds. These include foam and gel pads, sheepskin pads, and heel and elbow protectors. Pulsating air pads and water mattresses lie on top of the regular mattress, providing additional pressure relief (Figs. 39.8 and 39.9). Promoting Musculoskeletal Function CHAPTER 39 Foam arm support 797 Head and shoulder support assembly Thoracic side support Head pack Shoulder pack Base pack Knee assembly Abductor pack Disposable leg support Safety strap Arm support Side leg support Safety strap Drive Foot support FIGURE 39.7 RotoRest Delta kinetic therapy bed. (RotoRest Delta Advanced Kinetic Therapy System, Courtesy KCI Licensing, Inc.) FIGURE 39.8 Alternating air mattress pad. (Courtesy Medline Industries Inc., Mundelein, IL.) CONTINUOUS PASSIVE MOTION MACHINE After orthopedic surgery to replace a joint, continuous passive motion (CPM) is often ordered to restore joint function. A purpose of the machine is to exercise the extremity and joint, thus preventing contracture, muscle atrophy, venous stasis, and thrombus formation. The dressing to the extremity must be intact before attaching the patient’s extremity to the device. Once in place, the CPM machine extends and lexes the extremity to prescribed angles for a speciic period of time. The machine operates continuously as long as it is switched on. Follow Steps 39.1 to initiate therapy. As the degree of joint motion is tolerated, the settings are altered to increase the mobility of the joint (Fig. 39.10). Clinical Cues Assess pain level and medicate with ordered analgesia before initiating treatment with this machine. Closely monitor for need of more analgesia throughout exercise. The use of the machine is initially quite painful. Pain is controlled best when it is treated before it becomes severe. THERAPEUTIC EXERCISE FIGURE 39.9 Heel protector helps to prevent skin breakdown. (Copyright AliMed) Physical therapy is often ordered for the patient who is immobilized for an extended period of time. The primary care provider indicates what the problems are for the patient, and the therapist performs an evaluation and then designs an exercise program to help the patient and to prevent further musculoskeletal problems from occurring. Full ROM exercises should be 798 UNIT VIII Care of the Surgical and Immobile Patient Steps 39.1 Use of a Continuous Passive Motion Machine The most common use of a CPM machine is for the knee following knee replacement surgery. The nurse is responsible for making certain the machine is attached properly and that the settings are what the surgeon ordered. 6. Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) 1. Check the surgeon’s order for lexion and extension limits, speed, and extremity involved. (Provides data for setting up machine.) 2. Place machine on the bed on the affected side. Place directly on sheet-covered mattress. (Provides a stable surface. No extra mattress pad should be under the machine.) 3. Connect the control box to the CPM machine and set the limits of lexion, extension, and speed control. (Prepares machine for function.) 4. Let machine run through one complete cycle then stop the machine at the end of extension. (Ensures that the CPM is working properly.) 5. Ensure dressing to wound or incision is intact before attaching extremity to machine. Center the extremity on machine with sheepskin beneath the extremity and adjust the machine to it the patient. Align patient’s joint with the machine joint and strap the extremity in place. (Prepares machine 7. 8. 9. 10. 11. to work on the joint properly. Avoids pressure on the extremity and protects skin. Intact dressing prevents rubbing directly against wound or incision.) Start the machine. When it reaches full lexion, stop the machine and check the degree of lexion. (Ensures that machine is not lexing the joint more than desired, preventing complications.) Set the cycle rate, start the machine, and observe for two full cycles. (Ensures that machine is functioning correctly. Cycle rate is usually between 2 and 10 cycles per minute.) Raise side rail at the foot of the bed to keep CPM machine in place. Keep bed lat with head raised only 20 degrees if necessary. (Ensures that machine can function as ordered and patient’s body will remain in alignment.) Assess patient’s comfort level. (CPM therapy may initially be painful. Patient should be medicated regularly as ordered for pain. Good pain control allows patient to tolerate increases in speed and lexion.) Assess the operative site for bleeding and evaluate alignment of extremity and placement of straps every 2 to 4 hours. (Prevents complications and promotes patient’s adherence with therapy.) Assess skin condition over bony prominences and provide skin care every 2 hours. (Helps prevent pressure injuries from occurring.) CPM, Continuous passive motion. APPLICATION OF THE NURSING PROCESS FIGURE 39.10 Continuous passive motion machine for the knee joint. (From DeWit, S. C. [2017]. Medical-surgical nursing [3rd ed.]. St. Louis, MO: Mosby.) performed either actively or passively several times a day (Chapter 18). To prevent joint injury while performing passive ROM exercises, support the limb to be exercised above and below the joint. When the physical therapist is not available, the nurse assists the patient to perform these exercises. A family member or signiicant other can also be shown how to assist the patient with exercise. ASSESSMENT (DATA COLLECTION) When performing head-to-toe assessment of the immobilized patient, be alert to indicators of circulatory impairment such as reddened areas, pale or blue skin, coldness, or diminished or absent pulses. Look for signs of respiratory impairment such as shallow breathing, rapid or depressed respiratory rate, cough, abnormal lung sounds, use of accessory muscles, retractions or grunting, generalized paleness, duskiness, or cyanosis. In addition to regular assessment, you should determine which activities of daily living (ADLs) the immobilized patient can perform and with which assistance is needed. Incorporate assistance needs into the nursing care plan. Continually assess for pain and discomfort. Perform a neurovascular assessment for any patient with a cast or traction device (Box 39.3). Assess for cultural beliefs and customs that should be considered in planning care. When the patient is in traction, assess the pulleys and ropes for proper function and free movement. Ensure that the weights are hanging free and the correct Promoting Musculoskeletal Function CHAPTER 39 Box 39.3 799 Neurovascular Assessment Neurovascular assessment is performed for every patient who has experienced a fracture, whether treated with a cast or traction. It should be performed every hour for the first 24 hours, and after the cast is dry, every 4 to 8 hours. Check agency protocol for specific time schedule. Skin: Inspect area distal to the injury, noting color. Compare to other extremity. Palpate skin temperature with dorsum (back) of the hand; compare with opposite extremity or site. Movement: Have patient move area distal to the injury, or move it passively. There should be no discomfort. Sensation: Inquire about feelings of numbness or tingling (paresthesia). Check sensation with a paper clip and compare bilaterally. Sensation should be the same. Pulses: Palpate pulses distal to the injury. Compare bilaterally if possible. Capillary refill: Using your thumbnail, press the nail beds distal to the injury to blanch (to become pale) and judge time for capillary reill to occur after releasing pressure. Should be within 3 seconds, or within 5 seconds in the older adult. Pain: Inquire about the degree, location, nature, and frequency of pain, noting any increase in intensity or change in type of pain. amount of weight is applied. Assess the pin, the wire, or the tong insertion sites for indications of infection. For the patient in a cast, observe and document any foul or musty odor from the cast. Other indicators of infection are an elevated temperature, purulent drainage, and/or an elevated white blood cell (WBC) count or increased complaints of pain. All assistive devices and equipment must be checked for structural problems prior to use. Assess the assistive device for correct length or height in relation to the patient’s height and posture. Evaluate the patient’s ability to use the device correctly and determine if the device provides adequate stability for your patient’s safety. Check the foot of the crutch or cane for an intact rubber tip or the walker for properly functioning wheels if they are present (Fig. 39.11). NURSING DIAGNOSIS Common nursing diagnoses for patients with immobility are as follows: • Impaired physical mobility related to hemiparesis or hemiplegia (one-sided weakness or one-sided paralysis, respectively) • Impaired physical mobility related to fractured extremity in traction or a cast • Ineffective peripheral tissue perfusion (circulation of blood through tissue) related to decreased circulation in the lower extremities • Impaired tissue integrity related to skin disruption • Acute pain related to tissue or bone injury or muscle spasm FIGURE 39.11 Assess the gait of the patient learning to use a walker. • Ineffective airway clearance related to inactivity and bed rest • Risk for disuse syndrome • Risk for peripheral neurovascular dysfunction related to fracture and cast application Nursing diagnoses related to the psychosocial needs of the immobile person are as follows: • Social isolation related to immobility • Disturbed body image related to brace or cast • Deicient diversional activity related to immobility and bed rest • Situational low self-esteem related to inability to perform usual roles PLANNING Planning care for the immobile patient requires careful consideration of the time needed to assist the patient with various aspects of ADLs, the time needed for treatments, and time to be spent providing diversional activity and socialization. Expected outcomes for some of the above nursing diagnoses might be that the patient will: • Demonstrate the ability to cope with physical mobility limitations as evidenced by resumption of as many self-care activities as possible within 10 days. • Remain free of pressure-related injuries. • Have pain controlled with medication and alternative techniques. • Maintain good respiratory status as evidenced by effective airway clearing and clear breath sounds bilaterally. • Not experience contracture or muscle atrophy from immobilization. • Show no evidence of peripheral neurovascular dysfunction from swelling and/or cast application. 800 UNIT VIII Care of the Surgical and Immobile Patient • Maintain regular contact with signiicant others, participating in diversional activities. • Maintain interest in events occurring in the outside world. • Evidence self-esteem by positive self-statements and voluntary participation in self-care and attention to grooming. IMPLEMENTATION Appropriate interventions related to the identiied nursing diagnoses would include regular turning and positioning, use of pressure relief devices, coughing and deep breathing exercises, ROM exercises, assisted ambulation, and visitation or activities addressing the psychosocial needs of the immobile patient. Nursing Care Plan 39.1 presents interventions for a speciic patient. When caring for a patient in a fresh plaster cast, elevate the cast on pillows if possible. This places a soft, yielding surface against the plaster that is less likely to alter the shape of the cast. Elevating the extremity will reduce the likelihood of swelling. Turn the patient hourly so the cast rests on a different area of its surface and will dry evenly. Skill 39.1 presents the points of care for the patient with a cast. For the patient going home with a cast in place, review cast care and assessment of problems with the patient and caregiver. Patient Education Fracture and Cast Care To promote healing of your fracture and care for your cast: • Keep the casted limb elevated above heart level whenever possible to prevent swelling. • Call the primary care provider if your ingers or toes become numb, tingle, turn blue, or are cold to the touch. • Call the primary care provider if you develop a fever, have unusual pain in the casted extremity, or notice a bad odor coming from the cast. These could be signs of infection. • Regularly perform the exercises your care provider or physical therapist has taught you. These will help you retain your muscle strength while the bone heals. • If the cast becomes loose or slides, call the primary care provider because it probably needs changing. • Do not get a plaster cast wet. Check with your care provider about bathing or swimming if you have a synthetic cast. • Do not insert any object inside the cast to relieve an itch. Doing so may damage the skin and result in an infection. • Do not bear weight on the cast unless your primary care provider has advised you to do so. may also be used to provide support to a wound and hold dressings in place. Elastic bandages are made in rolls of varying widths; the heavy stretch material conforms to the body part and provides support (Box 39.4). Steps 39.2 show the technique for application of an elastic bandage. The same technique is used for gauze roller bandages. Different bandaging techniques are applied depending on the part to be bandaged. Circular turn. Circular turns are used to anchor the bandage and to terminate the wrap. This turn is useful for bandaging the proximal aspect of the inger or wrist. Simply hold the free end of the rolled material in one hand and wrap it about the area, bringing it back to the starting point (Fig. 39.12A). Spiral turn. This turn is used to bandage parts of the body that are uniform in circumference, such as the upper arm or upper leg. The spiral turn partly overlaps the previous turn. The amount of overlap varies from one-half to three-fourths of the width of the bandage (see Fig. 39.12B). Spiral reverse turn. Spiral reverse turns are used to bandage body parts that are not uniform in circumference, such as the lower leg or forearm. After securing the bandage with circular turns, bring the bandage upward at a 30-degree angle. Place the thumb of the free hand on the upper edge of the bandage to hold it in place while it is reversed on itself. Unroll the bandage approximately 6 inches (15 cm) and turn the hand so that the bandage falls over itself. Continue the bandage around the extremity, overlapping each previous turn by twothirds the width of the bandage. Make each turn at the same position on the extremity so that the turns of the bandage are all aligned (see Fig. 39.12C). Take care not to apply undue pressure over a major blood vessel. Care of the patient in traction is time consuming because the patient’s mobility is severely limited. Skill 39.2 presents the points of care for the patient in traction. Figure-of-eight turn. Figure-of-eight turns are used to bandage and stabilize an elbow, knee, or ankle or to immobilize and hold a fractured clavicle in position. Anchor the bandage with two circular turns. Bring the bandage above the joint, around it, and then below it, making a igure-of-eight. Continue bandaging above and below the joint, overlapping the previous turn by one-third to two-thirds the width of the bandage (see Fig. 39.12D). Secure the bandage above the joint with two circular turns and fasten it. Bandages Used to Support, Apply Pressure, or Immobilize Elasticized bandages are applied to immobilize a joint, or to apply pressure to reduce swelling. They Recurrent turn. This turn is used to cover distal parts of the body, such as the end of a inger, the skull, or the stump left by amputation. Anchor the bandage by two circular turns. Then fold it back on itself and bring Text continued on page 805 Promoting Musculoskeletal Function CHAPTER 39 801 Nursing Care Plan 39.1 Care of the Patient Immobilized by a Stroke SCENARIO Millie Palmer, age 76, is admitted after suffering an apparent stroke. She has left sided hemiparesis and poor bladder control. She is confused and somewhat groggy. A computed tomography (CT) scan of the brain shows that the problem is from a thrombosis (clot), and she is started on heparin to prevent further thrombi from forming. PROBLEM/NURSING DIAGNOSIS Stroke with left sided weakness/Impaired physical mobility related to weakness of left extremities. Supporting Assessment Data Objective: Weakness of left arm and left leg; stroke. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Patient will maintain muscle tone in all muscles. Patient will maintain joint mobility in all joints. Passive ROM to left extremities tid. Passive ROM will help maintain muscle function and joint mobility. ROM performed. Patient will maintain muscle tone in all muscles. Active ROM to other joints Active ROM will preserve bid. muscle tone and joint funcEncourage to perform ADLs tion. as possible. Is muscle tone being maintained? Some tone to muscle. Actively moving other extremities and joints. Assess for muscle spasm each shift. Progressing toward expected outcomes. Continue plan. Muscle spasm may occur with hemiparesis and can be painful. PROBLEM/NURSING DIAGNOSIS Unable to reposition self/Risk for impaired skin integrity related to decreased mobility and incontinence. Supporting Assessment Data Objective: Left sided weakness, confusion; incontinent of urine. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Skin will remain intact. Assess skin each shift and when turning, with special attention to pressure points. Frequent inspection of skin reveals reddened areas before pressure injuries form. Is skin intact? Skin remains intact; area of redness over right ankle; heel protector applied to protect ankle. Use cushioning devices under pressure points as needed. Cushioning reduces pressure over bony prominences. Offer bedpan q 2 h. Opportunity to void q 2 h helps prevent incontinence. Check absorbent undergarment frequently and change quickly when wet; clean and dry the skin. Reposition q 2 h. Moisture contributes to skin breakdown. Keeping skin clean and dry prevents breakdown. Meeting expected outcomes. Continue plan. Repositioning prevents pressure injuries and provides comfort for joints. PROBLEM/NURSING DIAGNOSIS Clot interrupting blood low in brain/Risk for ineffective cerebral tissue perfusion related to thrombosis. Supporting Assessment Data Objective: Cerebral thrombus demonstrated on CT scan. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Neurologic deicits will not increase. Neurologic assessment and vital signs q 2 h. Assessment will reveal deteriorating condition in a timely fashion. Are there neurologic deicits? Left sided weakness present. 802 UNIT VIII Care of the Surgical and Immobile Patient Nursing Care Plan 39.1 Care of the Patient Immobilized by a Stroke—cont’d Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Monitor heparin IV administration. Heparin IV will help prevent formation of further thrombi. No change in neurologic status. Monitor PTT for therapeutic response to heparin. PTT levels will demonstrate whether heparin dose is suficient. Progressing toward outcomes. Continue plan. PROBLEM/NURSING DIAGNOSIS Incontinent of urine/Functional urinary incontinence related to stroke. Supporting Assessment Data Objective: Left sided weakness, confusion; incontinent of urine. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Patient will regain continence. Institute bladder training program in 2 days. Bladder training regimen can reinstitute urinary continence in many stroke patients. Is patient continent? Not completely; some intermittent uncontrolled voiding. Offer bedpan q 2 h. Opportunity to void q 2 h helps prevent incontinence. Voids in bedpan after meals. Obtain order for bedside commode. With hemiparesis it is easier to transfer to the bedside commode than walk to the bathroom to void. Check absorbent undergarment frequently; change when wet. Progressing toward outcomes. Continue plan. CRITICAL THINKING QUESTIONS 1. How might incontinence affect this patient psychologically? 2. If Mrs. Palmer says that she is too tired to do the exercises and all she feels like doing is sleep, how would you respond? ADLs, Activities of daily living; PTT, partial thromboplastin time; ROM, range-of-motion; tid, three times daily. Skill 39.1 Cast Care Casts may be applied to almost any area of the body. The larger and thicker the cast, the longer it takes to dry fully. Hip spica and full body casts may take 1 to 2 days to dry completely. Synthetic material casts dry much more quickly than plaster casts. SUPPLIES • Tape or moleskin • Pen for marking drainage • Lamb’s wool for padding Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) Assessment (Data Collection) 1. Examine cast for any dents. Handle the cast gently with the lats of the ingers and the palms, not the ingertips. (Dents may cause compression on underlying tissues. Fingertip pressure more easily dents the cast because pressure is on a small area rather than spread over a broader surface.) 2. Examine cast for any areas where blood may have seeped through. Circle any such areas in ink and write the date and time on the cast. (Bloodstains seeping through the cast are a common occurrence when surgery has preceded the application of a cast. Marking provides a way to judge further bleeding.) 3. Assess cast for rough edges and excessive tightness by running a inger along all cast edges and under the edges next to the skin. (A inger should slip easily under the edge of cast. Checking helps to discover problem areas.) Promoting Musculoskeletal Function CHAPTER 39 803 Skill 39.1 Cast Care—cont’d Planning 4. Plan to reassess a new cast every hour for the irst 24 hours and every 4 to 8 hours thereafter or per agency policy. (Swelling may occur in the period after injury or surgery and may cause pressure on nerves and vessels.) often itches. Using such items to scratch can injure skin. If itching is severe, ask for an order for medication to control it.) 11. Smell the open edges of the cast to assess for infection under the cast. (Skin injuries may become infected or necrotic and cause a foul or musty odor.) Implementation 5. Pad any rough edges by petaling with 1½- to 2-inch pieces of tape or moleskin. Place lamb’s wool beneath cast to pad under rough spots. (Rough spots will cause skin chaing, abrasion, and breakdown.) Evaluation 12. Evaluate the cast by inspecting for crumbling or cracks. Ask yourself: Is there any discomfort under the cast? Is the cast rubbing the skin anywhere? Are the edges smooth? Is the cast drying evenly? Is swelling in the tissues subsiding? (Answers to these questions tell whether the interventions are successful in meeting the expected outcomes.) Documentation 13. Document assessment indings and interventions. (Veriies that assessment has been performed and interventions carried out.) Step 5 6. Notify the orthopedic technician or primary care provider if any area of cast is too tight. (Cast may need to be cut to relieve pressure.) 7. Elevate the casted extremity so that the hand or foot is at or above heart level. (Aids in reducing or preventing swelling.) 8. For patients in large casts (e.g., hip spica and body), place the bed in a slight Trendelenburg position for the irst day or two to help prevent swelling, unless contraindicated by patient’s condition or medical orders. (Patients in large casts may experience swelling in the legs, thighs, perineum, buttocks, and lower abdomen during the irst few days. Placing bed at an approximate 10-degree angle in Trendelenburg position will help prevent this swelling.) 9. Turn the patient at intervals so that all cast surfaces are exposed to the air to facilitate even drying and prevent skin pressure injuries. • When cast is still wet, turn patient hourly. • As cast dries, every 2 hours is suficient unless patient is uncomfortable. • Get adequate help when turning patient to prevent injury. • Use pillows to prop the patient at different angles as cast dries. (Air exposure allows moisture to evaporate.) 10. Instruct patient not to use sharp, pointed, or rigid items to scratch under the cast. (Skin under the cast Documentation Example Received from recovery room alert and stable. Fresh plaster cast encases right leg from mid-thigh to midtoes. Toes pink, warm, move well; sensation present; capillary reill less than 2 seconds. Edge of cast easily admits ingertip. Leg elevated on pillows. Rates pain as 3 out of 10. Advised to request pain medication if pain increases. (Nurse’s time-stamped electronic signature) Special Considerations • Provide full instructions for cast care for the patient discharged home with a cast. • Instruct to use a hair dryer only on the “cool” setting to help dry the cast or relieve itching. • Demonstrate how to wrap a cast in plastic for showering, if appropriate. • Demonstrate how to handle the extremity when repositioning, supporting the joints. Critical Thinking Questions 1. What would you do if you notice the edge of the cast is crumbling? 2. What would you tell a patient with a long leg cast who keeps slipping a ruler down in the cast to scratch the skin? 804 UNIT VIII Care of the Surgical and Immobile Patient Skill 39.2 Care of the Patient in Traction Skin traction is mostly used to decrease muscle spasm after a fracture or back muscle injury. Skin traction may be used on small children with a lower extremity fracture. SUPPLIES • Clean gloves (if needed) Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) Assessment (Data Collection) 1. Check the medical order for desired amount of weight for traction. (Ensures the correct amount of weight is applied.) 2. Assess boot, wrap, and traction appliance. Check that ropes and pulleys are working smoothly and weights are hanging free. (