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T31-1

Written: May, l985 Nursing Policy: T-31


Reviewed: 5/88; 5/89 LSUHSC-Shreveport, LA
Revised: 2/87; 5/90; 8/91; 5/92; 5/94; 3/96; 4/98; 10/00; 7/04; 5/06
3/09; 2/12
____________________________________________________________________________

SKIN TRACTION/NON-INVASIVE

PURPOSE:
To regain normal length and alignment of affected limb.
To immobilize a fractured extremity.
To lessen or eliminate muscle spasms.
To relieve pressure on nerves, especially spinal.
To prevent skeletal deformities or muscle contractures.

POLICY:
1. Physicians Order
The physician's order shall contain:
a. type of traction.
b. amount of weight to be applied (typically no more than 5 pounds)
c. discontinuation of traction
Skin traction may be contraindicated in the patient with an open or draining wound in the
affected limb, with a dermatologic condition or with a disease that predisposes the patient to
skin damage or poor healing e.g. diabetes.

2. Alignment
The affected extremity shall be maintained in proper alignment at all times with the
ropes unobstructed and weights hanging freely. Do not manipulate the extremity in the
patient who is preoperative or when the hip is not immobilized. A traction boot should
not be applied over an external pneumatic compression device that covers the calf.

3. Nurse Competency
The nurse who applies and/or removes the traction shall have documented competency to do
so.

4. Neurovascular Checks
The nurse shall perform neurovascular checks before traction applied and as ordered by
the physician or as dictated per unit policy, but no less than every four hours, reporting
abnormalities to the physician. Appropriate documentation shall be recorded on the
Neurovascular Flow Sheet including:
a. sensation
b. temperature
c. movement
d. distal perfusion
e. skin condition of the affected limb and of all tissue affected by immobility
f. signs/symptoms of compartment syndrome (numbness, tingling of the affected limb;
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decreased function; increased pain that is disproportionate to the injury and the analgesia
administered, especially with passive stretch; elevated temperature; edema or the sensation
of tightness or pressure; signs of decreased perfusion)

5. Additional
a. body alignment and correct position in the bed: shoulder, hips, legs; correct angle
of the joint
b. traction apparatus, the correct function of each component
c. engage the patient in active and passive movement; encourage deep breathing
d. details of any notification of the physician and other treatment team members

See Nursing Policy N-15 Neurovascular Assessment and Flowsheet

See Nursing Standards of Care: Care of the Patient with Neurovascular Impairment
Care of the Immobilized Patient

http://www.medcom.lsuhsc-s.edu/cfdocs/policies/Std_of_Care.cfm

6. Removal
Skin traction shall be removed by the RN/LPN at least every eight hours, to observe
the condition of the skin and to render skin care as needed, with appropriate
documentation in the Neurovascular Flowsheet.

7. Obtaining and Returning Equipment
Special equipment, (traction bars, pulleys, ropes and weights), for setting up
traction can be obtained from the Orthopedic Nursing Unit. All borrowed traction
equipment must be returned to the Orthopedic Unit for cleaning
following use. Vent-foam and batting can be obtained from the warehouse and ace
wraps from CMS. Vent- foam, batting, and ace wraps shall be discarded after single
patient use.

RESPONSIBLE PARTY ACTION

MD 1. Writes order for type of skin traction, amount of weight to be
applied, and site care.

RN, RN Applicant, LPN,
NA, Student Nurse
2. Assembles necessary equipment.

RN, RN Applicant,
LPN
3.

4.

Applies skin traction as per physicians order.

Observes traction for:
a.
b.
proper alignment, joints at appropriate angle
weights and pulley hanging free and functional

5. Performs neurovascular checks as ordered by the physician,
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RESPONSIBLE PARTY ACTION

but no less than every four hours.

6. Removes skin traction at least every eight hours and:
a.


b.
c.
d.

observes for skin breakdown; if skin integrity is
compromised; temporarily discontinues traction, and
notifies MD.
performs ROM to distal extremity if applicable.
performs skin care.
assesses for WOCN referral.

7. Documents Neurovascular Checks per this policy item 4.

MD 8. Writes order for discontinuation of traction.

MD, RN, RN Applicant,
LPN
9. Discontinues skin traction.
Unit Personnel 10. Returns borrowed equipment to the Orthopedic Unit for
cleaning following each patient use.
























References:

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El-Dahhakhny, A. Impact of educational program on nurses performance toward children in
thomas traction. International J ournal of Orthopedic and Trauma Nursing-Vol 14(4), Nov 2010.
Accessed 2/21/2012 http://www.nursingconsult.com/nursing/journals/1878-1241/full-
text?issn=18781241&full_text=html&spid=23757694&article_id=773395&article_author=&abs
tract=medline&start_pg=&end_pg=&parentpage=search&searchId=1270996268&searchTerm=s
kin+traction&page=1&search_type=allresults&sortBy=3&bestBetId=

Nursing Policy N-15 Neurovascular Assessment and Flow sheet
http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/N-14.pdf

Nursing Standards of Care: Care of the Patient with Neurovascular Impairment
http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/Stds_of_Care/Standar
d%202.pdf
Care of the Immobilized Patient
http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/Stds_of_Care/Standar
d%207.pdf
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____________________________________ _________________
J acqueline Robinson, BSN, RN Date
Director, Surgical Services




_____________________________________ _________________
J ean DiGrazia, MBA, RN Date
Assistant Hospital Administrator and CNO
Patient Care Services