applying a two-piece cervical collar

8/3/2019 Applying a Two-Piece Cervical Collar

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Applying a

Two-PieceCervical

Collar


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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.


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Overview

Care must be taken whenapplying the collar not to

hyperflex or hyperextendthe patients neck.


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Equipment

Nonsterile gloves Tape measure

Cervical collar of appropriatesize Washcloth

Soap Towel


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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.


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Assessment


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Assessment


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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.


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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.


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Nursing Diagnosis

Risk for Injury Acute Pain

Risk for Aspiration Ineffective BreathingPattern


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Outcome Identification

& Planning

Pts cervical spine isimmobilized, preventing

further injury to the spinalcord Pt maintains head and

neck without movement


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Outcome Identification

& Planning

Pt experiences minimal tono pain

Pt demonstrates anunderstanding about theneed for immobilization


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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.


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Implementation

Perform hand hygiene andput on nonsterile gloves. Rationale: Hand hygiene and

gloving deter the spread of

microorganisms.


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Implementation

Assess patient for anychanges in neurologicalstatus. Rationale: Pt with cervical spine

fractures are at risk for problemswith the neurological system.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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Implementation

Rationale: Skin breakdown may

occur under the cervical collar if

the skin is not inspected and

cleansed.


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Implementation

Remove gloves and performhand hygiene. Rationale: Hand hygiene deters

the spread of microorganisms.


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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.


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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.


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Skin breakdown is noted onthe shoulder, neck, or ear. Apply a protective dressing

over the area and continue toassess for further skinbreakdown.


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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.


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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.


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References:

Taylors Clinical Nursing

Skills: A Nursing Process

Approach by Pamela

Evans-Smith

applying a two-piece cervical collar

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