The client complains of a slight tingling in the toes of the affected leg 2 hours after application of Buck's traction with a foam boot with Velcro straps
Which nursing intervention is suitable to prevent potential complications related to the client complaint? 1. Apply warm blankets to the feet and reassess.
2. Check fit of the traction device near the knee.
3. Medicate client for pain with opioid analgesic.
4. Reassure client that this is a common complaint.
2
2. Tingling in tissue distal to a potential constriction indicates neurovascular impair-ment because tingling indicates potential nerve compression or irritation. This prompts the nurse to inspect the client knee area because this area is most likely to be affected by pressure from the traction device. Nursing intervention can prevent a potential complication of neurovascular impairment such as nerve damage by detecting the source of the pressure and eliminating the pressure.
1. The nurse applies warm blankets to the client's feet to increase regional tissue warmth and provide comfort because the client complaint of tingling is more likely related to nerve compression.
3. Although effective analgesic agents, opioids are ineffective therapy for tingling unless administered in excessive doses that alter the level of consciousness; besides, tingling is usually more annoying than it is painful.
4. The nurse avoids assuring the client that tingling is a common complaint because it potentially indicates neurovascular impairment.
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