BACHELOR OF NURSING

CHECKLIST
NUR 3915 Clinical Practice V 4(0+4)

Skin Traction

Ward/unit: Date:

Patient name: R/N:

Equipment
1. Bed with traction frame and trapeze 6. Elastic anti embolism stocking, as appropriate
2. Weights 7. Nonsterile gloves and/or other PPE, as indicated
3. Velcro straps or other straps 8. Skin cleansing supplies
4. Rope and pulleys
5. Boot with footplate

Nursing skill 4 3 2 1 0 Score

1 Review the medical record and the nursing plan of care to
determine the type of traction being used and care for the
affected body part.
2 Perform hand hygiene. Put on PPE, as indicated.
3 Identify the patient. Explain the procedure to the patient,
emphasizing the importance of maintaining counterbalance,
alignment, and position.
4 Perform a pain assessment and assess for muscle spasm.
Administer prescribed medications in sufficient time to allow for
the full effect of the analgesic and/or muscle relaxant.
5 Close curtains around bed and close the door to the room, if
possible. Place the bed at an appropriate and comfortable working
height.
6 Applying Skin Traction
7 Ensure the traction apparatus is attached securely to the bed.
Assess the traction setup.
8 Check that the ropes move freely through the pulleys. Check that
all knots are tight and are positioned away from the pulleys.
Pulleys should be free from the linens.
9 Place the patient in a supine position with the foot of the bed
elevated slightly. The patient's head should be near the head of
the bed and in alignment
10 Cleanse the affected area. Place the elastic stocking on the
affected limb, as appropriate
12 Place the traction boot over the patient's leg (Figure 1). Be sure
the patient's heel is in the heel ol the boot. Secure the boot with
the straps
13 Attach the traction cord to the footplate of the boot. Pass the rope
over the pulley fastened at the end of the bed. Attach the weight
to the hook on the rope, usually 5 to 10 pounds for an adult
(Figure 2). Gently let go of the weight. The weight should hang
freely, not touching the bed or the floor.
14 Check the patient's alignment with the traction.
15 Check the boot for placement and alignment. Make sure the line
of pull is parallel to the bed and not angled downward.
16 Place the bed in the lowest position that still allows the weight to
hang freely.
Remove PPE, if used. Perform hand hygiene.
17 Caring for a Patient With Skin Traction
18 16. Perform a skin-traction assessment per facility policy. This
assessment includes checking the traction equipment, examining
the affected body part, maintaining proper body alignment, and
performing skin and neurovascular assessments.
19 Remove the straps every 4 hours per the physician's order or
facility policy. Check bony prominences for skin breakdown,
abrasions, and pressure areas. Remove the boot, per physician's
order or facility policy, every 8 hours. Put on gloves and wash,
rinse, and thoroughly dry the skin.
20 Assess the extremity distal to the traction for edema, and assess
peripheral pulses (Figure 3). Assess the temperature, color, and
capillary refill (Figure 4), and compare with the unaffected limb.
Check for pain, inability to move body parts distal to the traction,
pallor, and abnormal sensations. Assess for indicators of deep-vein
thrombosis, including calf tenderness, and swelling.
21 Replace the traction and remove gloves and dispose of them
appropriately.
22 Check the boot for placement and alignment. Make sure the line
of pull is parallel to the bed and not angled downward.
23 Ensure the patient is positioned in the center of the bed, with the
affected leg aligned with the trunk of the patient's body.
24 Examine the weights and pulley system. Weights should hang
freely, off the floor and bed. Knots should be secure. Ropes should
move freely through the pulleys. The pulleys should not be
constrained by knots.
25 Perform range-of-motion exercises on all unaffected joint areas,
unless contraindicated. Encourage the patient to cough and deep
breathe every 2 hours.
26 Raise the side rails. Place the bed in the lowest position that still
allows the weight to hang freely.
27 Remove PPE, if used. Perform hand hygiene.
Total score /108
Comments:

Rubric for Skill Assessment

Excellent Good Fair Poor Not Done
4 3 2 1 0

Formula calculation: -

Total achieve score X 100 = ………………… %

Total score

Student name: Matric no.:

Examiner: Date: