Question

The nurse is observing a student performing pin care on a client with skeletal traction. Which action by the student nurse requires intervention? A. Using a sterile cotton applicator to cleanse the pin site B. Administering ordered analgesic prior to the procedure C. Instructing the client that weights will be removed prior to pin care being performed D. Pouring hydrogen peroxide into a sterile container for cleansing per hospital protocol

Short answer

Answer: C. Instructing the client that weights will be removed prior to pin care being performed

Step-by-step solution

Analyze each option

Let's analyze each option: A. Using a sterile cotton applicator to cleanse the pin site: This is a correct practice, as pin care requires maintaining a sterile environment to avoid infection. B. Administering ordered analgesic prior to the procedure: This is also correct, as it manages the client's pain before the procedure. C. Instructing the client that weights will be removed prior to pin care being performed: This is incorrect. The weights are not usually removed during pin care, as it may alter the alignment of the bones and cause further discomfort. D. Pouring hydrogen peroxide into a sterile container for cleansing per hospital protocol: This is a correct practice. The solution used for cleansing follows the hospital's protocol.

Identify the incorrect practice

Among the given options, option C is the incorrect practice, as the nurse should not remove the weights during pin care. Removing the weights may cause improper alignment and additional discomfort.

Write the final answer

The action by the student nurse that requires intervention is: C. Instructing the client that weights will be removed prior to pin care being performed

Key concepts

Sterile Technique in Nursing

The practice of maintaining a sterile environment during medical procedures is a cornerstone of infection control in healthcare settings. Sterile technique involves the use of practices and procedures to prevent contamination from pathogens. This extends to the meticulous cleaning of the site where, for example, skeletal traction pins are inserted to alleviate the risk of infection.

During pin care, every item used, such as sterile cotton applicators, should only come into contact with sterile surfaces or the pin site itself. Any breach in this technique can introduce bacteria, leading to an increased risk of infection. The transfer of hydrogen peroxide into a sterile container, as per hospital protocol, is also part of this rigorous practice. The focus is to eliminate any potential for cross-contamination, ensuring that every step, from hand hygiene to the use of sterilized equipment, is carried out with the utmost care.

Pain Management in Clinical Settings

The anticipation and management of pain is a critical aspect of healthcare, particularly in procedures that might cause discomfort to the patient. Administering analgesics prior to a potentially painful procedure like pin care in skeletal traction is an example of proactive pain management.

It serves to minimize patient discomfort and can also improve the overall outcome of the procedure by reducing patient anxiety and allowing for better cooperation. The prescribed analgesic must be administered following the proper medication guidelines which include verifying the right patient, medicine, dose, time, and route. These measures are essential to maintain patient comfort and ensure their well-being, which is as crucial as the primary treatment they are receiving.

Skeletal Traction Maintenance

Maintaining skeletal traction involves constant monitoring and care to ensure the effective alignment and stabilization of bones. Proper maintenance includes regular assessments of the traction apparatus, ensuring the weights hang freely and are not resting on the floor, and monitoring the patient’s limb for signs of swelling, discoloration, or decreased sensation.

However, one aspect that requires clear understanding is that the weights used in skeletal traction should not be removed during routine pin care, as it may disrupt the bone alignment and lead to increased pain or other complications. Proper pin care requires meticulous cleaning of the pin insertion sites without disturbing the traction setup. If a healthcare professional suggests the removal of these weights during pin care, it is a clear indicator that an intervention is necessary to correct the process and provide education on proper skeletal traction maintenance.