Question

The nurse is assessing traction of a client with a fracture who is in skeletal traction. Assessment reveals a loosened pin on the bone. Which action is appropriate? A. Notify the physician B. Remove the weight to release the pressure on the pin C. Reposition the client to the supine position D. Try to remove the pin for examination

Short answer

Answer: The most appropriate action for the nurse to take in this situation is to notify the physician.

Step-by-step solution

The role of the nurse in patient care

The nurse is responsible for assessing, planning, implementing, and evaluating patient care. This includes recognizing potential problems and reporting them to the appropriate medical professional, such as a physician.

Evaluate each possible action

A. Notify the physician - The nurse should report potential issues they observe during patient care to the physician. This action allows the nurse to take the appropriate steps and ensure the patient receives the necessary care. B. Remove the weight to release the pressure on the pin - This action might seem appropriate, but it could also potentially lead to other complications. It is better to consult the physician before making any changes to the patient's traction. C. Reposition the client to the supine position - This action does not directly address the issue of the loosened pin. Additionally, some fractures might require specific patient positioning, and altering the patient's position without consultation could cause complications. D. Try to remove the pin for examination - This option is not within the scope of the nurse's responsibilities. Only a qualified medical professional, such as a physician, should perform actions that could potentially harm the patient.

Determine the appropriate action

Based on the evaluation of each possible action, the most appropriate action for the nurse to take in this situation is to notify the physician (option A). This option allows the nurse to report the potential issue while following standard medical procedures and ensuring the safety and well-being of the patient.

Key concepts

Nursing Responsibilities

Nurses play a critical role in ensuring patient safety and promoting healing. They are often the first to notice changes in a patient's condition. Their responsibilities are vast and often involve:

• Assessing and monitoring patients to identify any changes or complications.
• Implementing prescribed medical treatments and interventions.
• Communicating with other healthcare professionals, such as doctors, to address patient needs.
• Providing education and emotional support to patients and their families.

It's essential for nurses to understand their scope of practice. Tasks that require specialized training, like adjusting medical devices, should be left to professionals specifically trained to do so. By fulfilling these responsibilities, nurses can greatly contribute to a positive patient outcome.

Patient Care Assessment

Assessing patient care is one of a nurse's fundamental duties. It involves observing, identifying, and evaluating changes in a patient's health status. This process is multilayered:

• Nurses collect data by monitoring vital signs, checking wound sites, and assessing patient responses to treatments.
• They use their gathered data to recognize unfolding complications or symptoms needing immediate attention.
• Communication is key; nurses must notify physicians of any changes that require medical intervention.

Effective assessment ensures patient safety and facilitates timely intervention. Nurses analyze this information to decide on the best course of action, always prioritizing the patient's well-being.

Fracture Management

Fracture management focuses on immobilizing and supporting broken bones to heal properly. It requires a systematic approach to prevent complications. Important aspects include:

• Proper alignment and stabilization of the fractured bone.
• Monitoring for signs of infection, especially if surgical pins are involved.
• Ensuring the patient follows weight-bearing restrictions, if applicable.

Nurses must also be vigilant about the risk of delayed union or nonunion of bones. This responsibility involves meticulous care in managing the patient's environment and adhering to prescribed care protocols. By following these, the nurse plays a crucial part in the healing process and recovery.

Skeletal Traction

Skeletal traction is a method used to treat fractures and dislocations by applying continuous pulling force to extend and stabilize a bone. This treatment can be complex and has several critical components:

• Use of pins, wires, or screws to connect to bones and guide the traction force.
• Adjustment of weights and pulleys to maintain correct alignment and tension.
• Inspecting equipment regularly to ensure all parts are functioning and secure.

Nurses must observe for pin site infections, monitor pain levels, and check the traction settings carefully. They should collaborate closely with physicians when alterations are necessary. In cases of any complications, nurses' attentiveness can significantly impact patient outcomes and ensure effective treatment.