Page 2556 - Saunders Comprehensive Review For NCLEX-RN

▪ Sudden onset, severe throbbing headache

▪ Severe hypertension and bradycardia
▪ Flushing above the level of the injury
▪ Pale extremities below the level of the injury
▪ Nasal stuffiness
▪ Nausea
▪ Dilated pupils or blurred vision
▪ Sweating
▪ Piloerection (goose bumps)
▪ Restlessness and a feeling of apprehension

Box 69-24

Client Education for a Halo Fixation Device

▪ Notify the primary health care provider (PHCP) if the halo vest (jacket) or ring
bolts loosen.
▪ Use fleece or foam inserts to relieve pressure points.
▪ Keep the vest lining dry.
▪ Clean the pin site daily.
▪ Notify the PHCP if redness, swelling, drainage, open areas, pain, tenderness, or
a clicking sound occurs from the pin site.
▪ A sponge bath or tub bath is allowed; showers are not allowed.
▪ Assess the skin under the vest daily for breakdown, using a flashlight.
▪ Do not use any products other than shampoo on the hair.
▪ When shampooing the hair, cover the vest with plastic.
▪ When getting out of bed, roll onto the side and push on the mattress with the
arms.
▪ Never use the metal frame for turning or lifting.
▪ Use a rolled towel or pillowcase between the back of the neck and bed or next to
the cheek when lying on the side, and raise the head of the bed to increase sleep
comfort.
▪ Adapt clothing to fit over the halo device.
▪ Eat foods high in protein and calcium to promote bone healing.
▪ Have the correct-sized wrench available at all times for an emergency (tape the
wrench to the vest).
▪ If cardiopulmonary resuscitation is required, the anterior portion of the vest will
be loosened and the posterior portion will remain in place to provide stability.

Box 69-25

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