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ATI Proctored Med Surg Focused Review
Safety & Infection Control: Care of client with Halo device for spinal injury:
Clients who have cervical fractures may be placed in a halo fixation device or cervical
tongs.
The purpose is to provide traction and/or immobilize the spinal column.
Screws are placed through a halo-type bar that encircles the head into the outer
table of the bone of the skull. This halo is attached to rods that are secured to a vest
worn by the client. Ensure that the wrench to release the rods is attached to the vest
when using halo traction in the event CPR is necessary.
Maintain body alignment and ensure cervical tong weights hang freely.
Monitor skin integrity by providing pin care and assessing the skin under the halo
fixation vest as appropriate.
Do not use the halo device to turn or move a client.
If the client goes home with a halo fixation device on, provide instruction on pin and
vest care.
Teach the client signs of infection and skin breakdown.
Basic Care & Comfort: Fractures & Immobilization devices: Maintaining proper
traction:
Types of Immobilization Devices:
Casts
Splints/immobilizers
Traction
External fixation
Internal fixation
*Traction uses a pulling force to promote and maintain alignment of the injured area.
Goals of traction include:
Prevent soft tissue injury.
Realign of bone fragments.
Decrease muscle spasms and pain.
Correct or prevent further deformities.
*Traction prescriptions should include the type of traction, amount of weight, and whether
traction can be removed for nursing care.
Classification of Traction:
Straight or running: The counter traction is provided by the client’s body by applying a
pulling force in a straight line. *Movement of the client’s body can alter the traction
provided.
Balanced suspension: The counter traction is produced by devices such as slings or splints
to support the fractured extremity while pulling with ropes and weights. *The client’s body
can be moved without altering the traction.
Types of Traction:
Manual: A pulling force is applied by the hands of the provider for temporary
immobilization, usually with sedation or anesthesia, in conjunction with the
application of an immobilizing device.
Skin: Primary purpose is to decrease muscle spasms and immobilize the extremity
prior to surgery. The pulling force is applied by weights that are attached by rope to
the client’s skin with tape, straps, boots, or cuffs. Examples include Bryant’s traction
(used for congenital hip dislocation in children) and Buck’s traction (used
preoperatively for hip fractures for immobilization in adult clients).
Buck's traction/skeletal: The pulling force is applied directly to the bone by weights
This study sourceattached by
was downloaded rope directly
by 100000831887191 toCourseHero.com
from a rod/screw placed
on 02-12-2022 through
05:58:15 the bone to promote bone
GMT -06:00
https://www.coursehero.com/file/18833448/ATI-proctored-med-surg-focused-review/
, alignment. Examples include skeletal tongs (Gardner-Wells) and femoral or tibial pins
(Steinmann pin). Weights 15 to 30 lb. can be applied as needed.
Prevention of skin breakdown:
Keep skin clean, dry, and intact. Provide a firm, wrinkle-free foundation with wrinkle-
free linens.
Use pressure-reducing surfaces and devices.
Inspect the client’s skin frequently and document the client’s risk using a tool such as
the Braden scale.
Clean the skin with a mild cleansing agent and pat it dry immediately following urine
or stool incontinence.
Bathe with tepid water (not hot) and minimal scrubbing.
Apply dimethicone-based moisture barrier creams or alcohol-free barrier films to the
skin of clients who are incontinent.
Do not use powder or cornstarch to prevent friction or repel moisture due to their
abrasive grit and aspiration potential.
Reposition the client in bed at least every 2 hr. and every 1 hr. in a chair. Document
position changes.
Keep the head of the bed at or below a 30° angle (or flat), unless contraindicated, to
relieve pressure on the sacrum, buttocks, and heels.
Use pressure-reducing devices (overlays; replacement mattresses; specialty beds;
kinetic therapy; foam, gel, or air cushions).
Keep clients from sliding down in bed, as this increases shearing forces that pull
tissue layers apart and cause damage.
Lift, rather than pull, clients up in bed or in a chair, because pulling creates friction
that can damage the outer layer of skin (epidermis).
Raise heels off of the bed to prevent pressure.
Ambulate clients as soon as possible and as often as possible.
Instruct clients who are mobile to shift their weight every 15 min when sitting.
Implement active and passive exercises for clients who are immobile.
Do not massage bony prominences.
Provide adequate hydration (2,000 to 3,000 mL/day) and meet protein and calorie
needs.
Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein puts
the client at greater risk for skin breakdown, slowed healing, and infection.
Provide nutritional support as indicated, such as vitamin and mineral supplements
(especially A, C, zinc, copper), nutritional supplements, and enteral and parenteral
nutrition.
Assessing implanted port:
Use a noncoring, non-barbed (Huber) needle. Noncoring needles have a deflected
point that helps avoid septal injury by slicing through the septum without coring out
a tiny piece of it each time the port is accessed. Most facilities policies allow access
to the implanted port with the same needle for 7 days.Hemodynamic status is
assessed with several parameters.
The most common site for implanted port placement is the anterior chest, just below
the clavicle. Other less common sites for implanted port placement include the upper
arm, the abdomen, and the back.
Total parental nutrition:
Is
This study source wasadownloaded
hypertonic intravenous
by 100000831887191 (IV) bolusonsolution.
from CourseHero.com The purpose
02-12-2022 05:58:15 GMT -06:00 of TPN administration is
https://www.coursehero.com/file/18833448/ATI-proctored-med-surg-focused-review/
ATI Proctored Med Surg Focused Review
Safety & Infection Control: Care of client with Halo device for spinal injury:
Clients who have cervical fractures may be placed in a halo fixation device or cervical
tongs.
The purpose is to provide traction and/or immobilize the spinal column.
Screws are placed through a halo-type bar that encircles the head into the outer
table of the bone of the skull. This halo is attached to rods that are secured to a vest
worn by the client. Ensure that the wrench to release the rods is attached to the vest
when using halo traction in the event CPR is necessary.
Maintain body alignment and ensure cervical tong weights hang freely.
Monitor skin integrity by providing pin care and assessing the skin under the halo
fixation vest as appropriate.
Do not use the halo device to turn or move a client.
If the client goes home with a halo fixation device on, provide instruction on pin and
vest care.
Teach the client signs of infection and skin breakdown.
Basic Care & Comfort: Fractures & Immobilization devices: Maintaining proper
traction:
Types of Immobilization Devices:
Casts
Splints/immobilizers
Traction
External fixation
Internal fixation
*Traction uses a pulling force to promote and maintain alignment of the injured area.
Goals of traction include:
Prevent soft tissue injury.
Realign of bone fragments.
Decrease muscle spasms and pain.
Correct or prevent further deformities.
*Traction prescriptions should include the type of traction, amount of weight, and whether
traction can be removed for nursing care.
Classification of Traction:
Straight or running: The counter traction is provided by the client’s body by applying a
pulling force in a straight line. *Movement of the client’s body can alter the traction
provided.
Balanced suspension: The counter traction is produced by devices such as slings or splints
to support the fractured extremity while pulling with ropes and weights. *The client’s body
can be moved without altering the traction.
Types of Traction:
Manual: A pulling force is applied by the hands of the provider for temporary
immobilization, usually with sedation or anesthesia, in conjunction with the
application of an immobilizing device.
Skin: Primary purpose is to decrease muscle spasms and immobilize the extremity
prior to surgery. The pulling force is applied by weights that are attached by rope to
the client’s skin with tape, straps, boots, or cuffs. Examples include Bryant’s traction
(used for congenital hip dislocation in children) and Buck’s traction (used
preoperatively for hip fractures for immobilization in adult clients).
Buck's traction/skeletal: The pulling force is applied directly to the bone by weights
This study sourceattached by
was downloaded rope directly
by 100000831887191 toCourseHero.com
from a rod/screw placed
on 02-12-2022 through
05:58:15 the bone to promote bone
GMT -06:00
https://www.coursehero.com/file/18833448/ATI-proctored-med-surg-focused-review/
, alignment. Examples include skeletal tongs (Gardner-Wells) and femoral or tibial pins
(Steinmann pin). Weights 15 to 30 lb. can be applied as needed.
Prevention of skin breakdown:
Keep skin clean, dry, and intact. Provide a firm, wrinkle-free foundation with wrinkle-
free linens.
Use pressure-reducing surfaces and devices.
Inspect the client’s skin frequently and document the client’s risk using a tool such as
the Braden scale.
Clean the skin with a mild cleansing agent and pat it dry immediately following urine
or stool incontinence.
Bathe with tepid water (not hot) and minimal scrubbing.
Apply dimethicone-based moisture barrier creams or alcohol-free barrier films to the
skin of clients who are incontinent.
Do not use powder or cornstarch to prevent friction or repel moisture due to their
abrasive grit and aspiration potential.
Reposition the client in bed at least every 2 hr. and every 1 hr. in a chair. Document
position changes.
Keep the head of the bed at or below a 30° angle (or flat), unless contraindicated, to
relieve pressure on the sacrum, buttocks, and heels.
Use pressure-reducing devices (overlays; replacement mattresses; specialty beds;
kinetic therapy; foam, gel, or air cushions).
Keep clients from sliding down in bed, as this increases shearing forces that pull
tissue layers apart and cause damage.
Lift, rather than pull, clients up in bed or in a chair, because pulling creates friction
that can damage the outer layer of skin (epidermis).
Raise heels off of the bed to prevent pressure.
Ambulate clients as soon as possible and as often as possible.
Instruct clients who are mobile to shift their weight every 15 min when sitting.
Implement active and passive exercises for clients who are immobile.
Do not massage bony prominences.
Provide adequate hydration (2,000 to 3,000 mL/day) and meet protein and calorie
needs.
Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein puts
the client at greater risk for skin breakdown, slowed healing, and infection.
Provide nutritional support as indicated, such as vitamin and mineral supplements
(especially A, C, zinc, copper), nutritional supplements, and enteral and parenteral
nutrition.
Assessing implanted port:
Use a noncoring, non-barbed (Huber) needle. Noncoring needles have a deflected
point that helps avoid septal injury by slicing through the septum without coring out
a tiny piece of it each time the port is accessed. Most facilities policies allow access
to the implanted port with the same needle for 7 days.Hemodynamic status is
assessed with several parameters.
The most common site for implanted port placement is the anterior chest, just below
the clavicle. Other less common sites for implanted port placement include the upper
arm, the abdomen, and the back.
Total parental nutrition:
Is
This study source wasadownloaded
hypertonic intravenous
by 100000831887191 (IV) bolusonsolution.
from CourseHero.com The purpose
02-12-2022 05:58:15 GMT -06:00 of TPN administration is
https://www.coursehero.com/file/18833448/ATI-proctored-med-surg-focused-review/
