A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first?
A. Assess full ROM to determine extent of injuries.
B. Call for an immediate chest x-ray.
C. Immobilize the client’s head and neck.
D. Open the airway with the head-tilt-chin-lift maneuver.
Correct Answer: C. Immobilize the client’s head and neck.
All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn’t need to be opened since the client appears alert and not in respiratory distress. The management of patients with head trauma should always consider C-spine motion restriction. Hold the neck immobile in line with the body, apply a rigid or semi rigid cervical collar, and (unless the patient is very restless) secure the head to the trolley with sandbags and tape.
Option A: ROM would be contraindicated at this time. Cervical spine injury can be difficult to diagnose in the unconscious patient and should be assumed to be present until it can confidently be excluded. The patient should be positioned properly with the neck in neutral position and the head end of the bed elevated to 30°. This facilitates cerebral venous drainage.
Option B: There is no indication that the client needs a chest x-ray. A tension pneumothorax is a life-threatening emergency which should be diagnosed clinically and treated promptly. An indwelling arterial cannula allows serial blood gas measurement and continuous recording of BP. Pulse oximetry is valuable for indirect measurement of how well the patient is being oxygenated.
Option D: In addition, the head-tilt-chin-lift maneuver wouldn’t be used until the cervical spine injury is ruled out. The priority in TBI must always be to secure, maintain, and protect a clear airway. Remove secretions and foreign bodies by manual extraction or suction, giving oxygen by mask (10–12 1/min).
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