Medical Surgical Spinal Cord Injury #5

Question

The nurse is providing discharge teaching to a client in halo traction along with their caregiver. Which statement by the caregiver reveals more teaching is indicated?

Answers

  1. “I need to cleanse the pin sites twice a day.”
    • Rationale:

      This answer is not correct since cleansing the pin sites is important to avoid infection. The client’s caregiver will examine the pin sites for crusting, drainage, redness, swelling, or tenderness and notify the doctor immediately if any signs of infection occur.

  2. “I will make sure he showers daily to help prevent infection.”
    • Rationale:

      This answer is correct since the client cannot get the vest wet. Clients in halo traction are at increased risk for skin breakdown. Keeping the skin clean and dry will promote healthy skin integrity. Sponge baths are advised by cleaning the skin under the halow vest with a slightly damp cloth.

  3. “I will inspect the skin under the vest daily using a flashlight”
    • Rationale:

      This answer is not correct since skin is our number one line of defense and because inspecting the skin daily will provide against infection. Utilizing a flashlight will help achieve full inspection under the vest.

  4. “I will provide a diet with foods high in protein and calcium.”
    • Rationale:

      This answer is not correct because a diet high in protein and calcium will facilitate skin and bone healing to the client in halo traction. Protein repairs muscle and skin and helps fight infection and calcium strengthens bones.

Overview

Halo traction is a static traction device used to immobilize and protect the spine after an injury. It consists of a headpiece with four pins inserted into the clients skull and a vest.

Explanation

Learning Outcomes

Halo traction is a static traction device used to immobilize and protect the spine after an injury. It consists of a headpiece with four pins inserted into the clients skull. The client will be at risk for infection at the pin sites. Examining and cleaning the pin sites daily will help prevent infection. Assessing the skin daily for skin maceration and moisture will help avoid fungal infections and help keep the skin intact. For this reason, showering is contraindicated for the client in halo traction. Protein repairs muscle and skin and helps fight infection and calcium strengthens bones.

Test Taking Tip

With halo traction, remember the skin is the first line of defense against infection.

Video Rationale