Applying a Two-Piece Cervical Collar

Overview
Pt suspected of having injuries to the cervical spine must be immobilized with a cervical collar to prevent further damage to the spinal cord. A cervical collar maintains the neck in a straight line, with the chin slightly elevated and tucked in.

Overview
Care must be taken when applying the collar not to hyperflex or hyperextend the patients neck.

Equipment
Nonsterile gloves Tape measure Cervical collar of appropriate size Washcloth Soap Towel

Assessment
Assess for a patent airway.

If airway is occluded, try repositioning using the jaw thrust-chin lift method, which helps open the airway without moving the patients neck.

Assessment

Assessment

Assessment
Inspect and palpate the cervical spine area for tenderness, swelling, deformities, or crepitus.

Do not ask the patient to move the neck if a cervical spinal cord injury is suspected.

Assessment
LOC and ability to follow commands --- to determine any neurological dysfunction

If the pt is able to follow commands, instruct him or her not to move the head or neck. If another person is available to help, have him or her stabilize the cervical spine by holding the pts head firmly on either side of the head directly above the ears.

Nursing Diagnosis
Risk for Injury Acute Pain Risk for Aspiration Ineffective Breathing Pattern

Outcome Identification & Planning

Pts cervical spine is immobilized, preventing further injury to the spinal cord Pt maintains head and neck without movement

Outcome Identification & Planning

Pt experiences minimal to no pain Pt demonstrates an understanding about the need for immobilization

Implementation
Explain procedure to pt. Review physicians order.
Rationale: Explanation relieves anxiety and facilitates cooperation. Checking the order ensures that the proper intervention is being implemented.

Implementation
Perform hand hygiene and put on nonsterile gloves.
Rationale: Hand hygiene and gloving deter the spread of microorganisms.

Implementation
Assess patient for any changes in neurological status.
Rationale: Pt with cervical spine fractures are at risk for problems with the neurological system.

Implementation
Gently cleanse the face and neck with a mild soap and water. If the pt has experienced trauma, inspect the area for broken glass or other material that could cut the patient or the nurse. Pat the area dry.

Implementation
Rationale: Blood, glass, leaves, and twigs may be present on the pts neck. The area should be clean prior to placing the cervical collar to prevent skin breakdown.

Implementation
With a second person stabilizing the cervical spine, measure from the bottom of the chin to the top of the sternum, and measure around the neck. Match these height and circumference measurements to the manufacturers recommended size chart. Rationale: To immobilize the cervical spine and to prevent skin breakdown under the collar, the correct size of collar should be placed.

Implementation
Slide the flattened collar under the patients head. The center of the collar

should line up with the center of the patients neck. Do not allow the pts head to move when passing the collar under the head.

Rationale: The person stabilizing the cervical spine should prevent the head from moving to prevent further damage to the cervical spine. Placing the collar in the center ensures that the neck is straight in alignment.

Implementation
Place the front of the collar centered over the chin, while ensuring that the chin area fits snugly in the recess. Be sure that the front half of the collar overlaps the back half. Secure Velcro straps on both sides.

Implementation
Rationale: The collar should fit snugly to prevent the pt from moving the neck and causing further damage to the cervical spine. Velcro will help hold the collar securely in place.

Implementation
Check the skin under the cervical collar at least every 4 hours for any signs of skin breakdown. Remove the top half of the collar daily and cleanse the skin under the collar. When the collar is removed, have a second person immobilize the cervical spine.

Implementation
Rationale: Skin breakdown may occur under the cervical collar if the skin is not inspected and cleansed.

Implementation
Remove gloves and perform hand hygiene. Rationale: Hand hygiene deters the spread of microorganisms.

Implementation
Document condition of skin under the cervical collar, patients LOC, and patients pain level. Rationale: Documentation ensures continuity of care and provides an ongoing assessment record.

Evaluation
The expected outcome are met when the pts cervical spine is immobilized without further injury. The pt verbalizes minimal to no pain and demonstrates an understanding of the rationale for cervical spine immobilization.

Unexpexted situations and Associated Interventions

The height and neck circumference measurements are between two sizes.

Start with the smaller size. If the collar is too large, the neck may not be immobilized.

Unexpexted situations and Associated Interventions

Skin breakdown is noted on the shoulder, neck, or ear.
Apply a protective dressing over the area and continue to assess for further skin breakdown.

Unexpexted situations and Associated Interventions

Patient complains that the collar is choking him.

If not contraindicated, place the patient in the reverse Trendelenburg position to see if this helps. Assess the tightness of the cervical collar, you should be able to slide at least one finger under the collar.

Unexpexted situations and Associated Interventions

Patient is able to move head from side to side with cervical collar on.

Tighten the cervical collar if possible. If the collar is as tight as possible, apply a collar one size smaller and evaluate for a better fit.

References: Taylors Clinical Nursing Skills: A Nursing Process Approach by Pamela Evans-Smith