The following is a sample nursing policy for c-spine immobilization.
To outline the procedure for applying immobilizing the upper spine, including application of a cervical collar and “boarding” the patient.
Application of a cervical collar and placing the patient on a backboard may be indicated for trauma patients with mechanisms of injury that place the patient at risk for spinal injury. This will not be necessary for patients with all of the following:
- no posterior midline cervical tenderness
- no evidence of intoxication
- normal level of alertness (GCS 15)
- no focal neurological deficit
- no painful distracting injuries
- The MD or RN will maintain manual stabilization of the cervical spine until cervical collar is applied and patient is placed on backboard.
* talk to the patient and tell them what you are doing- and not to move their head and neck
- Place hands on both sides of patient’s head with thumbs along mandible and fingers holding back of head.
- Assistants will help with the rest of the application of the cervical collar and backboard.
- Perform a baseline CMS assessment of the extremities.
- Remove jewelry from the neck and ears.
- Choose an appropriately sized collar by measuring the distance (with fingers) between the top of the shoulder where the collar will rest and the chin. This same number of fingers will fit between the fastener on the collar and the bottom edge of the rigid plastic of the collar.
- Cervical collar is assembled by snapping the fastener into the hole on the side of the collar
- Adjustable rigid cervical collars are measured from the bottom edge of the rigid plastic to the red circle denoting the size of the collar (red circle will move up or down as size of the collar is adjusted)
- Slide the back of the collar behind the right side of the neck until the Velcro tab is visible on the left side of the neck.
- Slide the chin portion up the chest until the chin fits in the collar.
- Secure the Velcro when the collar is on straight (nose, circle on chin portion of collar, and umbilicus are in alignment).
- Place the patient on a slide board with all team members working in a smooth fashion which moves the patient’s spine as little as possible. Patients already in bed will be log rolled and slider board inserted.
* Do not obtain a rectal temperature while the patient is turned unless the MD specifically requests this.
- Recheck CMS.
- The MD or RN can now remove hands from head.
- Document both CMS checks and procedure in patient’s record.