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I.D. Number: To ensure consistent and safe patient care for patients being treated with a halo vest.

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Plicies & Prcedures Title: HALO TRACTION PIN SITE & VEST CARE I.D. Number: 1052 Authrizatin [x] SHR Nursing Practice Cmmittee Surce: Nursing Date Revised: Date Effective: September 2012 Date Reaffirmed:
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Plicies & Prcedures Title: HALO TRACTION PIN SITE & VEST CARE I.D. Number: 1052 Authrizatin [x] SHR Nursing Practice Cmmittee Surce: Nursing Date Revised: Date Effective: September 2012 Date Reaffirmed: Scpe: SHR, Affiliates and CBOs Any PRINTED versin f this dcument is nly accurate up t the date f printing. Saskatn Health Regin (SHR) cannt guarantee the currency r accuracy f any printed prcedure. Always refer t the apprpriate website fr the mst current versins f dcuments in effect. SHR accepts n respnsibility fr use f this material by any persn r rganizatin nt assciated with SHR. N part f this dcument may be reprduced in any frm fr publicatin withut permissin f SHR. DEFINITIONS: Hal vest A hal vest includes a hal ring r hal crwn that is secured t the skull with skull pins and a rigid, fleece-lined vest. The vest is attached t the hal ring with adjustable metal rds r struts. Tgether the apparatus prvides stability t the cervical clumn while allwing the patient t be mbile. A hal vest can be used as primary treatment t stabilize cervical fractures r used as extra supprt after surgery. It may be applied t patients with r withut spinal crd injury e.g. patient may be a quadriplegic r have n deficits. - Sme hal rings and vests are MRI cmpatible, Check with MRI department if test required. Autnmic dysreflexia When spinal crd lesins prevent messages f painful stimuli (i.e. distended bladder, cnstipatin) frm reaching the brain an autnmic nervus system reactin is initiated. This is mst cmmn in injuries abve T 5 and present as episdes f high bld pressure, thrbbing headaches, prfuse sweating, flushing f the skin (abve the level f the spinal lesin), nasal stuffiness, apprehensin and anxiety. - It is a medical emergency, s recgnizing and treating the earliest signs and symptms efficiently is crucial. 1. PURPOSE 1.1 T ensure cnsistent and safe patient care fr patients being treated with a hal vest. 1.2 T ensure cervical stability is maintained t prevent further neurlgic injury. 1.3 T ensure skin integrity is maintained under the vest. 2. POLICY 2.1 Registered Nurses (RN s), Graduate Nurses (GN s), Registered Psychiatric Nurses (RPN s), Licensed Practical Nurses (LPN s) and Graduate Practical Nurses (GPN s) will prvide hal vest care. Page 1 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D. # PROCEDURE 3.1 Prir t hal vest applicatin (if able) Prvide patient/family educatin regarding hal vest device and what t expect Ensure adequate anxiety and pain-relieving medicatins are given as per Physician rders If supprting patient during applicatin f hal, suggest patient lk dwn t avid patient s eyebrws being lcked in a lifted psitin by the pins. 3.2 Pin Sites Pin sites need t be assessed nce per shift and PRN fr: signs and symptms f infectin pain r discmfrt lsening ften reprted by patients as nticing a clicking sund Nte: If patient falls, ensure pin sites are assessed by physician fr migratin r disldgement Pin site care will be perfrmed nce per shift and PRN Sterile technique is used in hspital. Patients may use clean technique at hme Wet sterile cttn applicatr with sterile nrmal saline Gently clean arund each pin. Use new applicatr fr each pin site. Wrk in a circular pattern and d nt g back ver the areas with the same applicatr When cleaning, apply gentle pressure t mve the skin at each pin t prevent skin frm grwing up the pin Dried secretins (crusts) shuld be gently remved. If difficult t remve r excess crusting present, wrap pin site with saline saked gauze. Attempt t remve the crusts with a sterile applicatr fllwing. Avid causing irritatin by vigrus cleansing D nt use any intments r antiseptics n the pin sites unless prescribed by the physician Clip hair when it grws arund the pin sites 3.3 Vests Vest, straps/buckles and blt integrity will be assessed nce each shift and PRN. Lse blts r wrn straps shuld be reprted t the physician as this may reduce fracture stability. Buckles shuld nt be released except fr skin care r vest maintenance (as utlined in 3.4 Skin/Vest Care) The sheepskin shuld be kept dry at all times. If siled r wet, ntify the physician, rthpedic technician r alternate trained in hal vest applicatin t have it changed. If edges are nly slightly damp, expse t air and reassess D nt add any padding under the vest fr cmfrt. If the vest des nt fit prperly ntify the physician, rthpedic technician r alternate trained in hal vest applicatin t assess and adjust accrdingly. Page 2 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D. # D nt use any supprts under the head Assess patient s swallwing. If a persn is having difficulties swallwing, a swallwing evaluatin shuld be cmpleted by a speech-language pathlgist A 7/16 wrench shuld be attached (i.e. t a rd r frnt vest plate, see Appendix A) at all times in case emergency vest remval is required Weight change (lss r gain) may affect vest fit. The physician shuld be ntified if vest fit changes s they can assess and refit if needed. If there are cncerns regarding nutritinal intake, cnsult a dietician and mnitr weight changes mre clsely. 3.4 Skin/Vest Care Patients wearing a hal vest are at increased risk fr skin breakdwn and shuld be assessed fr pressure areas a minimum f every shift with special attentin t bny prminences Patients withut neurlgic deficits will be able t self-reprt pressure areas, hwever, patients with neurlgic deficits may nt be aware f pressure areas and require increased visual inspectins. Nte: A prly fitting hal vest may trigger autnmic dysreflexia If patient is nn-cmpliant, at least tw staff must be present t perfrm vest/skin care. (One persn supprts the patient while the ther perfrms care.) Psitin patient flat n their side in gd alignment. PATIENT MUST NOT MOVE Und ne side strap f the vest. (One side shuld always be securely buckled). Nte: if the buckle psitin n the straps has nt been marked, mark them befre yu und them. (See Appendix A) Inspect skin integrity Place an incntinent pad/twel against the sheepskin t prevent the sheepskin frm getting wet then, with a damp washclth, wash the trs Dry the skin thrughly. D nt apply ltins r pwders under the vest Recnnect the strap t the prper ntch, then turn patient t the ther side and repeat the prcedure. Nte If it is very difficult t pass a twel between the vest and skin the physician, rthpedic technician r alternate trained in hal vest applicatin shuld be ntified t reassess fit Avid scratching under the vest. Ding s can disrupt skin integrity. 3.5 Repsitining & Mbility Nte: Never use the metal hal ring r struts/rds t lift, turn, r repsitin a patient Turn and repsitin the immbile patient every 2 hurs t prvide pressure relief Patient must be assisted the first time they ambulate and until safe independently as the vest alters their sense f balance. If patient als has altered sensatin they may require nging assistance. Page 3 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D. # Assess patient ability using TLR Transferring, Lifting and Repsitining principles and ensure yu have adequate assistance. Lgrll patient nt their side and place yur hands under the vest s the buckles d nt catch n the bedding. Assist patient as needed t sitting psitin. Allw patient time t adjust t altered balance befre standing. Initially a walker is ften helpful fr balance even if nt needed fr leg weakness. Nte: If patient requires a mechanical lift, ensure the vest des nt get caught n the sling r n the chair/bed when lifting r lwering Cnsult with physitherapy as needed. 3.6 Dcumentatin and Reprting Dcument n the nurse s prgress recrd what care was given, any bservatins nted and patient s tlerance Reprt any alteratins r adverse findings t the physician. 3.7 Chking/Cardiac Arrest (See Appendix B) If effective abdminal/chest cmpressins cannt be achieved with the vest intact: Lay the patient flat n a hard surface. (They will be lying n the back prtin f the vest) Release the straps n each side f the frnt prtin f the vest Lsen the blts n the hrizntal rds n the frnt vest plate Raise the frnt vest plate up (swiveling n the rd) t expse the chest Utilize the jaw thrust methd t pen the airway. Nte: The wrench fr the blts shuld be attached t the vest The patient shuld be kept flat and still until the Hal vest is reattached. 3.8 Prir t Discharge Hme 4. REFERENCES Prvide educatin regarding all the tpics listed abve. The Hal Vest Discharge Handut (Appendix C) may be used (Frm # pending). Ballert Orthpaedic. (n.d.). The hal system Part II: Prblems with & slutins t hal fixatin. Bernardni, G. Retrieved April 2011, frm Bremer Medical, Inc. (1993). Expsing the chest fr CPR and life supprt. Flrida, USA: Bremer Medical, Inc. Olsn, R. (1996). Hal skeletal tractin pin site care: Tward develping a standard f care. Rehabilitatin Nursing 21(5), pp Ryal Prince Alfred Hspital Intensive Care Unit. (2004). Intensive Care Service Nursing Plicy & Prcedures, Spinal Crd Injury (SCI). Page 4 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D. #1052 Sarr, A., Anthny, T., Magtt, R., & Mauceri, J. (2010). Develping a standard f care fr hal vest and pin site care including the patient and family educatin: A cllabrative apprach amng three greater Trnt area teaching hspitals. American Assciatin f Neurscience Nurses, 42 (3), pp Saskatn Health Regin. (2009). ICU guidelines fr hal vest care. Department f Adult Critical Care, RUH ICU, Saskatn, Saskatchewan Neurscience Unit. (1997). Patient infrmatin: Guide t wearing the hal vest. Ryal University Hspital, Saskatn, Saskatchewan. Page 5 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D. #1052 Appendix A 1 skull pin n hal ring 2 strut / rd 3 blt 4 wrench (7/16 ) 5 strap/buckle Alternate wrench placement (i.e. fr cnfused patients Nte marking n strap indicating crrect buckle placement. Sheepskin liner is wrn under the vest t prtect the skin. Page 6 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D. #1052 Appendix B Page 7 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D. #1052 Appendix C Saskatn Health Regin Addressgraph Discharge Careplan Patient Instructins Fr Hal Thracic Vest Vest Care Pin Care Yur Guide t Wearing a Hal Vest includes: Activity Clthing Sleep Shamping Sexual Activity Hal Remval Vest Care Befre discharge, be sure the vest fits cmfrtably. D nt lsen r adjust yur vest by yurself. Try t avid extremes f weight lss r gain which will affect the fit f the brace. If this ccurs, the brace will need t be refitted. Yu may nt be as active but a lt f calries may be burned just carrying the Hal Vest arund. Yu can stay n yur regular diet, but mnitr the fit f yur vest and adjust accrdingly. Have a daily spnge bath and use a wrung-ut face clth t clean the skin areas near the brace. D nt put pwders r ltins under the vest and never scratch under the brace. The sheepskin liner must be kept dry. If it accidentally gets wet, dry it with a hair dryer at lw temperature settings (as the brace and pins will cnduct heat readily). Inspect visible skin daily fr pressure areas r irritatins and reprt these t yur physician immediately The sheepskin liner will be changed as needed at yur return appintments. NOTE: the sheepskin is synthetic material which is highly flammable. Be aware f this danger if yu smke. Pin Care Pin care shuld be perfrmed at least twice a day. Assistance may be needed. Dip a Q-tip int nrmal saline Wrk gently arund the pin remving all crusting. Discard the Q-tip Use a clean Q-tip fr each pin site. Mve the skin as taught t instructed during yur hspitalizatin. Observe pin sites fr redness, swelling, drainage r increasing discmfrt r pain. Reprt these changes t yur dctr. D nt use any intments r antiseptics n the pin sites unless prescribed by a dctr. Pulling r turning by the Hal frame r supprting rds MUST BE AVOIDED. All mvement is transmitted t the pins and this may cause them t lsen. These pins will be checked and tightened as needed at yur fllw-up appintments. A clicking sensatin at the pin site is a sign f a lse pin and needs prmpt fllwup by a dctr. D nt fr any reasn adjust r remve these pins. The steel readily cnducts heat and cld. Wear warm head cvering when yu g ut in cld weather, use hair dryer n lw setting, etc. Page 8 f 10 Activity Yu will be very tp-heavy and yur balance will be impaired. This will imprve as yur bdy accmmdates t the new weight distributin but falling dwn culd be very dangerus. D nt cnsume alchl. Yur field f visin is als limited and yu will nt be able t see yur feet r the grund directly in frnt f yu, therefre yu must be very careful n stairs, uneven grund, r slippery surfaces (e.g., bathrms, thrw rugs, winter sidewalks, etc). Try t maintain nrmal scial activities but d nt engage in activities invlving heavy lifting, jumping r running. Getting int vehicles may be difficult. The easiest way is t back in, buttcks first, and slide until yur head is cleared. It is imprtant that smene helps t guide yur clearance, because bumping yur Hal culd lsen yur pins. D NOT drive as yu cannt turn yur head. Public transprtatin can be mre difficult as they ften shake a bit and yu are nt always guaranteed a seat. The vibratin will travel thrugh yur bdy t the pins and will be transmitted t yur skull if yu have t sit r lean against a hard surface. If it is necessary t use public transprtatin, try t avid crwds. Reading may be difficult as yu cannt tilt yur head. Prism glasses can be used fr this r try a music stand r easel t hld yur reading material. Sleep Yu may need mre sleep than yu usually did. Yur bdy uses mre energy even ding simple things because yu are wearing a brace. Lie in the middle f the bed. If yu are clse t the edge, yu may turn and tpple ver the edge. Prtect yur bed linen and mattress frm wear and tear by lying n an ld sheet r thin blanket. (Als be aware f this prblem when yu sit n uphlstered furniture.) Yu will nt be accustmed t having yur head suspended. Putting a rlled twel r pillwcase between yur head and the back f yur neck r cheek may help yu feel mre nrmal. It is imprtant, hwever, that the twel r pillwcase nt apply any pressure. Slightly elevating the head f the bed r mattress may als make yu feel mre cmfrtable. When getting ut f bed, it is imprtant NOT t try t sit straight up, bending frm the waist. This puts great stress n yur frnt pins. Get up by rlling nt yur side near the edge f the bed and while drpping yur legs ff the edge, push sideways with yur elbw and hand t bring yurself t a sitting psitin. Clthing Lse T-shirts r smcks ne r tw sizes larger than nrmal usually fit ver the brace. Lse jackets with frnt zippers and scarves r capes wrk quite well in cler weather. Remember t prtect the steel frm cld (r heat). Ftwear shuld be sturdy, lw heeled and have gd tractin. D nt wear high heels at anytime because they change yur balance and increase the risk f falls. Sme clthing may be altered with Velcr r snap clsures t accmmdate the hal frame. Mre infrmatin n this is available frm the Occupatinal Therapy Department. Page 9 f 10 Plicies & Prcedures: Hal Tractin Pin Site & Vest Care I.D.# 1052 Shamping Hair shuld be shamped regularly. Yu will need an assistant. Prtect the shulders f the vest with plastic. Tuck the plastic int the plates f the brace s that if frms a large cape. Drape the lse end f the plastic ver the edge f the tub r sink and the water will run away prtecting the sheepskin. Kneel ver the bathtub r sink and bed frward until yur head is lwer than yur shulders. Have yur assistant d the shamping and rinsing. D nt use any tints, dyes, sprays, gels r cnditiner n yur hair while pins are in. Dandruff under the ring is nt an uncmmn prblem. Sexual Activity Hal vest shuld nt stp sexual activity but it will prbably have t be mdified. The Hal apparatus was nt designed fr clse cntact, even hugging. When kissing, bth must be careful nt t bump the Hal ring r pins. It is easy t misjudge distances between an bject and yur Hal ring until yu have becme accustmed t wearing it. Sme psitins are safer fr yur partner than thers. A side-lying psitin is prbably mst cmfrtable fr bth. If ther psitins are used yu might find that putting a small pillw between yu will keep the rds frm injuring yur partner. Experiment within reasn but yu bth must be careful, gentle and tlerant. If yur neck injury has been particularly difficult t realign r hld in psitin, yur dctr may recmmend that yu abstain frm sexual activity until the six r eight week mark is reached. What t Reprt t Yur Dctr Swelling, discharge, r unusual redness at the pinsite Pain r clicking sensatin at a pinsite (with r withut redness) Feeling that yu can mve yur neck r rattling sunds frm the brace. Sreness r redness f the skin under the brace. Fall r injury. When Yur Hal is Remved Hal vest is usually wrn fr 12 weeks and is remved by the physician nce x-rays have cnfirmed that yur neck is healed. T reduce scarring, massage the pin sites abve yur eyebrws t break the adhesins which have frmed between the skin and the bne. This prcedure is dne t reduce the scarring n yur frehead after healing. Yu shuld cntinue t mve the skin ver the pin hles fr several days t avid reattachment f the adhesins. When the Hal is remved all the weight f yur head is n yur neck again. The muscles in yur neck have nt dne any wrk fr many weeks, therefre yur head will feel very heavy and yur neck very wbbly. Yu will be fit with a cllar t wear fr the next several weeks. When the cllar cmes ff yur dctr may recmmend physitherapy sessins t strengthen yur neck muscles. Yu shuld cntinue t restrict yur activities during this time but yu will ntice gradual imprvements every day. Yur dctr will advise yu when it is safe t return t mre strenuus activities. Frm # This material was adapted frm the 6300 Neurscience Educatin Cmmittee handut, April 1997 fr the sle use f patients and staff f the Saskatn Health Regin. Last mdified August Page 10 f 10
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