Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 17-2

Applying a Two-Piece Cervical Collar

Goal:The patient’s cervical spine is immobilized, preventing

further injury to the spinal cord. Comments

1. Review the medical record and nursing plan of care to
   determine need for placement of a cervical collar. Identify
   any movement limitations.


2. Gather the necessary supplies and bring to the bedside
   stand or overbed table.


3. Perform hand hygiene and put on PPE, if indicated.


4. Identify the patient.


5. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do and why you
   are going to do it to the patient.


6. Assess patient for any changes in neurologic status.
   (See Chapter 2 for assessment details.)


7. Place the bed at an appropriate and comfortable working
   height, usually elbow height of the caregiver (VISN 8
   Patient Safety Center, 2009). Lower the side rails as
   necessary.


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


9. Have a second caregiver in position to hold the patient’s
   head firmly on either side above the ears. Measure from
   the bottom of the chin to the top of the sternum, and
   measure around the neck. Match these height and circum-
   ference measurements to the manufacturer’s recommended
   size chart.


10. Slide the flattened back portion of the collar under the
    patient’s head. The center of the collar should line up with
    the center of the patient’s neck. Do not allow the patient’s
    head to move when passing the collar under the head.


11. 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. Check to see that at least
    one finger can be inserted between collar and patient’s neck.

ExcellentSatisfactoryNeeds Practice