The nurse is caring for the client in Russell's traction. Which should the nurse implement to assist the client with personal hygiene?
1. Remove traction, provide skin care under boot, and reapply boot.
2. Notify the provider about neurovascular deficits after the bathing.
3. Raise the head of the bed as tolerated while performing oral care.
4. Help the client to turn to the prone position with traction in place.
1
1. The nurse briefly removes the traction to provide skin care under the boot and then reapplies it to provide effective traction and to prevent skin breakdown. This provides the nurse with an opportunity to assess the skin and plan follow-up nursing care as indicated.
2. Bathing should not induce neurovascular impairment unless the client has cardi-ovascular or neurovascular disease; however, the nurse promptly reports neurovascular impairment under any circumstances.
3. The head of the bed must remain at 30 degrees or less for effective therapy. The nurse provides oral care to the client using basins, a straw in the glass of water, and by directing the client to turn to the side to prevent swallowing or gagging.
4. The prone position is contraindicated for clients in traction.
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