The nurse is caring for a patient with a fractured femur in skin traction. Which action by the nurse is appropriate?

Deep tissue damage with visible blisters requires immediate intervention. It indicates that the skin is compromised, and the patient is at risk of developing pressure ulcers or skin breakdown. Prompt action is necessary to prevent further damage and ensure patient safety.

a. Slight redness at the site of the traction tape may be expected, and the nurse should monitor for any signs of worsening or discomfort. It does not require immediate intervention unless it progresses.

b. Minor irritation from the traction device can be managed by ensuring proper padding and positioning of the device. It is not a critical concern unless it worsens or leads to more severe skin issues.

c. Mild itching around the traction area may be common, but the nurse should assess for any signs of infection or allergic reaction. Immediate intervention is not typically required for mild itching.

Checking for signs of skin breakdown or pressure sores is essential to prevent complications associated with skin traction. The patient should inspect the skin around the traction site regularly and report any abnormalities to the healthcare provider.

a. Removing the traction weights without healthcare provider approval can lead to inadequate traction and compromise its effectiveness.

b. Avoiding movements that cause tension on the traction is essential to maintain proper alignment and prevent further injury.

c. Reapplying the traction tape daily is not necessary and may lead to skin irritation. Proper application by healthcare professionals is essential to maintain the appropriate tension.