Traction is the application of a pulling force to a part of the body to promote and maintain alignment to an injured part of the body (Flynn, 2018, as cited in Hinkle et al., 2022, p. 1173). Skin traction is applied directly to the skin, exerting force over a large area of skin/soft tissue to transmit indirect pull/traction on the bone (Choudhry et al., 2020). The force may be applied using adhesive or nonadhesive traction tape or a boot, belt, or halter. It is used to stabilize a fracture leg, decrease muscle spasms and pain, and immobilize an area before surgery (Hinkle et al., 2022). Traction is primarily used as short-term intervention until other interventions, such as external or internal fixation, are possible (Hinkle et al., 2022). The use of skin traction has decreased, and its use is controversial, with conflicting evidence related to benefit and appropriateness of use (Biz et al., 2019; Brox et al., 2015; Choudhry et al., 2020; Etxebarría-Foronda & Caeiro-Rey, 2018). However, skin traction may still be prescribed for some patients and therefore nurses must be familiar with basic principles and guidelines for implementation.

Traction must be applied in the correct direction and magnitude to obtain the therapeutic effects desired. The affected body part is immobilized by pulling with equal force on each end of the injured area, mixing traction and countertraction. Weights provide the pulling force or traction. The use of additional weights or positioning of the patient's body weight against the traction pull provides the countertraction. See Box 9-2 Principles of Effective Traction.

Types of skin traction for adults include Buck's extension traction (lower leg), and the pelvic belt (Hinkle et al., 2022). Nursing care for skin traction includes setting the traction up, applying the traction, monitoring the application and patient response, and preventing complications from the therapy and immobility.

Assessment

Assess the patient's health record and the prescribed interventions to determine the type of traction, traction weight, and line of pull. Assess the traction equipment to ensure proper function, including inspecting the ropes for fraying and proper positioning. Assess the patient's body alignment. Perform skin and neurovascular assessments. Assess for complications of immobility, including alterations in respiratory function, skin integrity, urinary and bowel elimination, and muscle weakness, contractures, thrombophlebitis, pulmonary embolism, and fatigue.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Acute pain
• Risk for impaired peripheral neurovascular function
• ADL deficit

Outcome Identification and Planning

The expected outcomes to achieve when applying and caring for a patient in skin traction are that the traction is maintained with the appropriate counterbalance, and the patient maintains proper body alignment. Other outcomes that may be appropriate include that the patient reports an increased level of comfort, and the patient is free from injury.

Implementation

Action	Rationale
1. Review the health record and the plan of care to determine the type of traction being used and care for the affected body part.	Reviewing the health record and care plan validates the correct patient and correct procedure.
2. Perform hand hygiene. Put on PPE, as indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient. Explain the procedure to the patient, emphasizing the importance of maintaining counterbalance, alignment, and position.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
4. Perform a pain assessment and assess for muscle spasm. Administer prescribed medications in sufficient time to allow for the full effect of the analgesic and/or muscle relaxant.	Assessing pain and administering analgesics promote patient comfort.
5. Close the curtains around the bed and close the door to the room, if possible. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016).	Closing the door or curtains provides for privacy. Proper bed height prevents back and muscle strain.
Applying Skin Traction
6. Ensure the traction apparatus is attached securely to the bed. Assess the traction setup.	Assessment of traction setup and weights promotes safety.
7. Check that the ropes move freely through the pulleys. Check that all knots are tight and are positioned away from the pulleys. Pulleys should be free from the linens.	Checking ropes and pulleys ensures that weight is being applied correctly, promoting accurate counterbalance and traction function.
8. Place the patient in a supine position with the foot of the bed elevated slightly. The patient's head should be near the head of the bed and in alignment.	Proper patient positioning maintains proper counterbalance and promotes safety.
9. Assess the skin of the affected extremity for abrasions and circulatory status. Cleanse the affected area. Place the compression stocking on the affected limb, as appropriate.	The skin and circulation should not be compromised to avoid negative consequences related to use of skin traction (Hinkle et al., 2022). Skin care aids in preventing skin breakdown. Use of graduated compression stockings prevents edema and neurovascular complications.
10. Place the traction boot over the patient's leg (Figure 1). Be sure the patient's heel is in the heel of the boot. Secure the boot with the straps.	The boot provides a means for attaching traction; proper application ensures proper pull.
11. Attach the traction cord to the boot footplate. Pass the rope over the pulley fastened at the end of the bed. Attach the weight to the hook on the rope, usually 5 to 8 lb for an adult (Figure 2). Gently let go of the weight. The weight should hang freely, not touching the bed or the floor.	Weight attachment applies the pull for the traction. Gently releasing the weight prevents a quick pull on the extremity and possible injury and pain. Properly hanging weights and correct patient positioning ensure accurate counterbalance and traction function.
12. Check the patient's alignment with the traction in place.	Proper alignment is necessary for proper counterbalance and ensures patient safety.
13. Check the boot for placement and alignment. Make sure the line of pull is parallel to the bed and not angled downward.	Misalignment causes ineffective traction and may interfere with healing. A properly positioned boot prevents pressure on the heel.
14. Place the bed in the lowest position that still allows the weight to hang freely. Make sure the call bell and other essential items are within easy reach.	Proper bed positioning ensures effective application of traction without patient injury. Having the call bell and other items in easy reach contributes to patient safety.
15. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE decreases the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
Caring for a Patient With Skin Traction
16. Perform a skin-traction assessment per facility policy. This assessment includes checking the traction equipment, examining the affected body part, maintaining proper body alignment, and performing skin and neurovascular assessments.	Assessment provides information to determine proper application and alignment, thereby reducing the risk for injury. Misalignment causes ineffective traction and may interfere with healing.
17. Remove the straps every 4 hours per the prescribed interventions or facility policy. Check bony prominences for skin breakdown, abrasions, and pressure areas. Remove the boot, per prescribed interventions or facility policy, every 8 hours. Put on gloves and wash, rinse, and thoroughly dry the skin.	Removing the straps provides assessment information for early detection and prompt intervention of potential complications should they arise. Washing the area enhances circulation to skin; thorough drying prevents skin breakdown. Using gloves prevents transfer of microorganisms.
18. Assess the extremity distal to the traction for edema, and assess peripheral pulses (Figure 3). Assess the temperature, color, and capillary refill (Figure 4), and compare with the unaffected limb (Hinkle et al., 2022). Check for pain, inability to move body parts distal to the traction, pallor, and abnormal sensations. Assess for indicators of deep vein thrombosis, including calf tenderness and swelling.	Doing so helps detect signs of abnormal neurovascular function and allows for prompt intervention. Assessing neurovascular status determines the circulation and oxygenation of tissues. Pressure within the traction boot may increase with edema.
19. Replace the traction; remove gloves and dispose of them appropriately. Perform hand hygiene.	Replacing traction is necessary to provide immobilization and facilitate healing. Proper disposal of gloves prevents the transmission of microorganisms. Hand hygiene prevents the spread of microorganisms.
20. Check the boot for placement and alignment. Make sure the line of pull is parallel to the bed and not angled downward.	Misalignment causes ineffective traction and may interfere with healing. A properly positioned boot prevents pressure on the heel.
21. Ensure the patient is positioned in the center of the bed, with the affected leg aligned with the trunk of the patient's body. Check overall alignment of the patient's body.	Misalignment interferes with the effectiveness of traction and may lead to complications.
22. Examine the weights and pulley system. Weights should hang freely, off the floor and bed. Knots should be secure. Ropes should move freely through the pulleys. The pulleys should not be constrained by knots (Figure 5).	Checking the weights and pulley system ensures proper application and reduces the risk for patient injury from traction application.
23. Keep the bedsheets wrinkle free.	Wrinkles may create areas of increased pressure and contribute to alterations in skin integrity and patient discomfort.
24. Perform range-of-motion (ROM) exercises on all unaffected joint areas, unless contraindicated. Encourage the patient to cough and deep breathe every 2 hours.	ROM exercises maintain joint function. Coughing and deep breathing help to reduce the risk for respiratory complications related to immobility.
25. Raise the side rails. Place the bed in the lowest position that still allows the weight to hang freely. Make sure the call bell and other essential items are within easy reach.	Raising the side rails promotes patient safety. Proper bed positioning ensures effective application of traction without patient injury. Having the call bell and other items in easy reach contributes to patient safety.
26. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE decreases the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when traction has been maintained with the appropriate counterbalance, the patient has maintained proper body alignment, the patient has reported an increased level of comfort, and the patient has remained free from injury.