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An elderly female is admitted due to a change in her level of sensorium. During the evening shift, she attempts to get out of bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery.

Which intervention is most important for the nurse to include in this client's plan of care?

Answer :

Final answer:

The most crucial intervention is preventing immobility-related complications such as pressure sores, DVT, and pneumonia through regular repositioning, vigilant monitoring, and early mobilization.

Explanation:

The most important intervention to include in the client's plan of care, who is awaiting surgery for a broken left hip with Buck's skin traction applied, is the prevention of complications associated with immobility. Ensuring the patient is regularly repositioned to prevent pressure sores, monitoring for signs of deep vein thrombosis (DVT) and pulmonary embolism, and maintaining respiratory health to prevent pneumonia are critical.

Regular assessment is vital to detect early signs of infection, particularly around the site of the traction or potential urinary tract infections due to catheterization. The nurse should also ensure that the skin under the traction is monitored for irritation or breakdown, and the positioning of the traction apparatus should be checked for proper alignment to avoid additional stress on the hip.

It is imperative to collaborate with physical therapists to begin postoperative mobility exercises as soon as it is safe to do so, to decrease the risk of complications related to prolonged immobility. Education on the importance of these interventions should be communicated clearly to the patient and any caregivers to ensure ongoing vigilance during hospitalization and after discharge.

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