The nurse is caring for a patient with a halo device and vest. Which of the following must be included in this patient's plan of care?
1. use the vest to reposition the patient
2. tape a halo vest wrench to the front of the vest
3. assess motor and sensory function every 8 hours
4. expect skin breakdown around the vest edges
2
Rationale: A halo vest wrench is to be taped to the front of the vest to be able to remove the vest in the event the patient needs to receive cardiopulmonary resuscitation. The vest should not be used to move or reposition the patient. Motor and sensory function should be assessed every 2 to 4 hours. Efforts should be undertaken to avoid skin breakdown at the vest edges and do not expect skin breakdown.
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