Four-year-old David is placed in Buck's extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first?
a. Notify the practitioner of the changes noted.
b. Give the child medication to relieve the pain.
c. Reposition the child and notify the physician.
d. Chart the observations and check the extremity again in 15 minutes.
ANS: A
The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. Pain medication should be given after the practitioner is notified. This is an emergency condition; immediate reporting is indicated. The findings should be documented with ongoing assessment.
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