Upload
abby-filio-monge
View
224
Download
0
Embed Size (px)
Citation preview
8/3/2019 Applying a Two-Piece Cervical Collar
1/31
Applying a
Two-PieceCervical
Collar
8/3/2019 Applying a Two-Piece Cervical Collar
2/31
Overview
Pt suspected of having injuriesto the cervical spine must beimmobilized with a cervicalcollar to prevent furtherdamage to the spinal cord.
A cervical collar maintains the
neck in a straight line, with thechin slightly elevated andtucked in.
8/3/2019 Applying a Two-Piece Cervical Collar
3/31
Overview
Care must be taken whenapplying the collar not to
hyperflex or hyperextendthe patients neck.
8/3/2019 Applying a Two-Piece Cervical Collar
4/31
Equipment
Nonsterile gloves Tape measure
Cervical collar of appropriatesize Washcloth
Soap Towel
8/3/2019 Applying a Two-Piece Cervical Collar
5/31
Assessment
Assess for a patentairway. If airway is occluded, tryrepositioning using the jaw
thrust-chin lift method,
which helps open the airwaywithout moving the patientsneck.
8/3/2019 Applying a Two-Piece Cervical Collar
6/31
Assessment
8/3/2019 Applying a Two-Piece Cervical Collar
7/31
Assessment
8/3/2019 Applying a Two-Piece Cervical Collar
8/31
Assessment
Inspect and palpate thecervical spine area fortenderness, swelling,deformities, or crepitus. Do not ask the patient to move
the neck if a cervical spinal cordinjury is suspected.
8/3/2019 Applying a Two-Piece Cervical Collar
9/31
Assessment
LOC and ability to followcommands --- to determine anyneurological dysfunction If the pt is able to followcommands, instruct him or her not
to move the head or neck. If another person is available to
help, have him or her stabilize thecervical spine by holding the ptshead firmly on either side of thehead directly above the ears.
8/3/2019 Applying a Two-Piece Cervical Collar
10/31
Nursing Diagnosis
Risk for Injury Acute Pain
Risk for Aspiration Ineffective BreathingPattern
8/3/2019 Applying a Two-Piece Cervical Collar
11/31
Outcome Identification
& Planning
Pts cervical spine isimmobilized, preventing
further injury to the spinalcord Pt maintains head and
neck without movement
8/3/2019 Applying a Two-Piece Cervical Collar
12/31
Outcome Identification
& Planning
Pt experiences minimal tono pain
Pt demonstrates anunderstanding about theneed for immobilization
8/3/2019 Applying a Two-Piece Cervical Collar
13/31
Implementation
Explain procedure to pt.Review physicians order. Rationale: Explanation relieves
anxiety and facilitates cooperation.
Checking the order ensures that the
proper intervention is beingimplemented.
8/3/2019 Applying a Two-Piece Cervical Collar
14/31
Implementation
Perform hand hygiene andput on nonsterile gloves. Rationale: Hand hygiene and
gloving deter the spread of
microorganisms.
8/3/2019 Applying a Two-Piece Cervical Collar
15/31
Implementation
Assess patient for anychanges in neurologicalstatus. Rationale: Pt with cervical spine
fractures are at risk for problemswith the neurological system.
8/3/2019 Applying a Two-Piece Cervical Collar
16/31
Implementation
Gently cleanse the faceand neck with a mild soapand water. If the pt hasexperienced trauma,inspect the area for brokenglass or other material thatcould cut the patient or thenurse. Pat the area dry.
8/3/2019 Applying a Two-Piece Cervical Collar
17/31
Implementation
Rationale: Blood, glass, leaves,
and twigs may be present on the
pts neck. The area should be
clean prior to placing thecervical collar to prevent skin
breakdown.
8/3/2019 Applying a Two-Piece Cervical Collar
18/31
Implementation
With a second person stabilizing thecervical spine, measure from the bottomof the chin to the top of the sternum, andmeasure around the neck. Match theseheight and circumference measurementsto the manufacturers recommended sizechart.
Rationale: To immobilize the cervical spineand to prevent skin breakdown under the
collar, the correct size of collar should be
placed.
8/3/2019 Applying a Two-Piece Cervical Collar
19/31
Implementation
Slide the flattened collar under thepatients head. The center of the collarshould line up with the center of thepatients neck. Do not allow the ptshead to move when passing the collarunder the head. Rationale: The person stabilizing the
cervical spine should prevent the head frommoving to prevent further damage to the
cervical spine. Placing the collar in the
center ensures that the neck is straight in
alignment.
8/3/2019 Applying a Two-Piece Cervical Collar
20/31
Implementation
Place the front of the collarcentered over the chin, whileensuring that the chin area fitssnugly in the recess. Be surethat the front half of the collaroverlaps the back half. SecureVelcro straps on both sides.
8/3/2019 Applying a Two-Piece Cervical Collar
21/31
Implementation
Rationale: The collar should fit
snugly to prevent the pt from
moving the neck and causing
further damage to the cervicalspine. Velcro will help hold the
collar securely in place.
8/3/2019 Applying a Two-Piece Cervical Collar
22/31
Implementation
Check the skin under thecervical collar at least every 4hours for any signs of skinbreakdown. Remove the tophalf of the collar daily andcleanse the skin under thecollar. When the collar isremoved, have a secondperson immobilize the cervicalspine.
8/3/2019 Applying a Two-Piece Cervical Collar
23/31
Implementation
Rationale: Skin breakdown may
occur under the cervical collar if
the skin is not inspected and
cleansed.
8/3/2019 Applying a Two-Piece Cervical Collar
24/31
Implementation
Remove gloves and performhand hygiene. Rationale: Hand hygiene deters
the spread of microorganisms.
8/3/2019 Applying a Two-Piece Cervical Collar
25/31
8/3/2019 Applying a Two-Piece Cervical Collar
26/31
Evaluation
The expected outcome aremet when the pts cervicalspine is immobilized without
further injury. The ptverbalizes minimal to no painand demonstrates an
understanding of therationale for cervical spineimmobilization.
8/3/2019 Applying a Two-Piece Cervical Collar
27/31
Unexpexted situations and
Associated Interventions
The height and neckcircumference measurementsare between two sizes. Start with the smaller size. If the
collar is too large, the neck maynot be immobilized.
8/3/2019 Applying a Two-Piece Cervical Collar
28/31
Unexpexted situations and
Associated Interventions
Skin breakdown is noted onthe shoulder, neck, or ear. Apply a protective dressing
over the area and continue toassess for further skinbreakdown.
8/3/2019 Applying a Two-Piece Cervical Collar
29/31
Unexpexted situations and
Associated Interventions
Patient complains that thecollar is choking him. If not contraindicated, place the
patient in the reverseTrendelenburg position to seeif this helps. Assess thetightness of the cervical collar,you should be able to slide atleast one finger under the collar.
8/3/2019 Applying a Two-Piece Cervical Collar
30/31
Unexpexted situations and
Associated Interventions
Patient is able to move headfrom side to side with cervicalcollar on.
Tighten the cervical collar ifpossible. If the collar is as tightas possible, apply a collar onesize smaller and evaluate for abetter fit.
8/3/2019 Applying a Two-Piece Cervical Collar
31/31
References:
Taylors Clinical Nursing
Skills: A Nursing Process
Approach by Pamela
Evans-Smith