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See Figure 9.4[4] for an image of a client using an incentive spirometer. The skin underneath skin traction must be inspected on a regular and ongoing basis to prevent some of the possible complications associated with this type of traction including blistering, skin breakdown, compartment syndrome, circulatory impairment, neurological impairment, and areas of necrosis. Immobility can Complicate Life Muscular strength is classified on a scale of zero to five, as below. Traction is often set up by the nurse and, at times, a traction team may be used for the setup of the doctor's ordered traction. 1. People must be able to move to protect themselves from trauma and to meet their basic needs. Chapter 8: Body Mechanics and Patient Mobility Flashcards Use any of these techniques to place the stocking on the heel, and then check for proper placement of the heel marker before applying the rest of the stocking. As teenagers become adults, the nurse provides education about the effects of alcohol and other drugs on balance and safety while driving. Manual traction, which is applied with the hands, is done to properly align a bone after a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment. It is an essential part of living. Percussion is also performed by the nurse or the certified respiratory therapist. The depth of a wound is measured using a sterile cotton applicator which is then compared to the disposable rule for an accurate measurement. Some clients are prescribed compression stockings, also referred to as thrombo-embolic-deterrent hose (TED hose). Corn starch is NOT used. [3], There are several nursing diagnoses related to mobility. Coordination can be adversely affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis, flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of the bone. When working with school-age children, nurses provide education to prevent injury that can occur with activity, such as using helmets and knee pads to prevent injury while bicycling and skateboarding. 13.3 Applying the Nursing Process Nursing Fundamentals A commonly used NANDA-I nursing diagnosis is Impaired Physical Mobility. Nursing interventions promote a patients mobility and prevent effects of immobility. Some of these preventive techniques include: The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the most popular standardized screening tools that are used to screen and assess clients in order to determine if they are at risk for skin breakdown. This type of fracture occurs with depressed skull fractures. The treatment plan includes the removal of the cast and, at times, a fasciotomy or epimysiotomy are indicated. Coughing is expected, and clients should be encouraged to expel any mucus (not swallow it). The cone should not be forced into the fingers but placed gently. A transverse fracture is one that occurs straight across the fractured bone. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. When assisting a client with ROM activities, the nursing assistant must follow the plan of care established by the licensed therapist.