The client is in Buck's traction for a fractured femur. Which does the nurse implement to prevent muscle spasms of the affected leg?

Question

1. Applies traction gradually, gently, and completely
2. Assesses the affected leg with the "five Ps" criterion
3. Eliminates potential pressure points from the traction
4. Ensures unobstructed countertraction to client's pelvis

Answer 1

1
1. Muscle spasms associated with a fracture occur because nerves are irritated by bone fragments and occur more frequently at the initiation of therapy. The nurse attaches weight to the traction slowly, gradually, and completely to help prevent and eliminate muscle spasms of the affected leg. The weight, hanging freely, usually creates enough pull on the muscle to release the spasm without increasing pain.
2. The nurse uses the "five Ps" criterion to assess client neurovascular status for early detection of neurovascular changes because assessment does not prevent a complica-tion. If the nurse observes clinical indicators of neurovascular impairment, the tissue already has the impairment, so it is not preventable; however, the client potentially benefits from early detection of a problem because most problems are smaller, easier to resolve, and potentially cause less damage than an advanced problem.
3. The nurse works to prevent pressure ulcers and nerve damage by removing or eli-minating sources of pressure and irritation before damage occurs because exposure to prolonged pressure causes tissue hypoxia and nerve irritation.
4. Countertraction to the pelvis is contraindicated in Buck's traction. Freely hanging weights are important to maintain the properly applied traction force and potentially prevent neurovascular impairment if the fracture involves bone fragments realigned by the traction.