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Difficulty: Very hardBasic Care and Comfort

A nurse is managing the care of a 78-year-old client who is in balanced suspension skeletal traction following a comminuted right femur fracture. The client, who has a history of osteoarthritis, reports a new onset of dull, aching pain in the right heel and increasing stiffness in the lower back. Which of the following nursing actions is the most appropriate?

  1. Place a rolled towel under the right calf to suspend the heel off the bed and encourage the use of the overhead trapeze bar for repositioning.Answer
  2. B
    Elevate the head of the bed to 45 to 60 degrees to relieve the lower back stiffness and position a trochanter roll alongside the right hip.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to temporarily lift the traction weights to relieve tension while placing a foam pressure-relieving boot on the right foot.
  4. D
    Reassure the client that the discomfort is an expected age-related change exacerbated by bedrest, and gently massage the right heel to stimulate circulation.

Answer

The correct action is to place a rolled towel under the right calf to suspend the heel off the bed and encourage the use of the overhead trapeze bar for repositioning.
Placing a rolled towel under the calf successfully 'floats' the heel, entirely removing the pressure that is causing the ischemic ache. Additionally, utilizing the overhead trapeze bar allows the client to lift their upper body and buttocks off the mattress. This safely relieves pressure on the sacrum and lower back without changing the angle of the bed or disrupting the continuous pull of the traction weights.

Step-by-Step Solution

1
Assess the source and implication of the client's reported heel and lower back pain.
The nurse identifies the dull heel ache as an early sign of a pressure injury and the back stiffness as a complication of immobility.
Continuous pressure on bony prominences during bedrest leads to tissue ischemia, which presents as pain or aching before skin breakdown becomes visible.
2
Determine the constraints of providing comfort measures while maintaining balanced suspension skeletal traction.
The nurse recognizes that the head of the bed cannot be elevated above 20 to 30 degrees, and traction weights must never be removed, lifted, or supported.
Altering the bed angle significantly or relieving weight tension disrupts the continuous therapeutic pull required for proper fracture alignment and healing.
3
Select an appropriate intervention that relieves pressure without violating traction principles.
The nurse floats the heel using a rolled towel under the calf and instructs the client to independently shift their weight using the trapeze bar.
This provides effective basic care and comfort, safely relieving sacral and heel pressure while preserving the exact orthopedic alignment required.

Key Concept

Basic Care and Comfort in Skeletal Traction
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Topics

Basic Care and Comfort

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