After initial stabilization, every patient requires regular assessments. Document results on a PFC flowsheet (Appendix A) and monitor trends to identify signs of decompensation. Initiate nursing interventions early to prevent further harm.

  • Minimum: Manual blood pressure (BP) cuff, stethoscope, thermometer, pulse oximeter, glucometer, urinary catheter, flashlight, watch
  • Better: Digital, wrist BP cuff
  • Best: Portable monitor providing continuous vital signs display and capnography capability, glucometer

Vital Signs

  • Obtain BP, heart rate, respiratory rate, temperature, oxygen saturation, end-tidal CO2 (when available), Glasgow Coma Scale score, pain score, and peripheral pulses.
  • Inspect and Monitor Tubes
  • Examine all tubes (e.g., endotracheal tube [ETT] or cricothyroid tube, nasogastric [NG] tube, intravenous [IV] line, chest tube, urinary catheter) for correct placement and appropriate function, and ensure they are secured properly.
  • High-volume burn resuscitation results in global edema and ETT/cricothyroid tube position must be closely monitored. Securing tubes with circumferential ties is required when burned skin weeps fluid.

Caution: NG tubes should only be placed when radiographic or intraoperative confirmation is available, or when the benefit outweighs the risk. Routine NG placement for unconscious or intubated patients is not recommended in austere environments.

Monitor Input and Output

  • Check IV drip rate or give oral fluids as needed.
  • Ensure adult patients void an average of 30–50mL/h, or 100–200mL/h if exhibiting signs of rhabdomyolysis.
  • Check drainage from wounds and tubes.

Inspect Skin and Splints

Examine skin, including nares and mouth, for changes and ensure splints are fitted properly and pulses are present below splint. Monitor for allergic reactions to tape, developing erythema, excessive dryness, pressure indenting the skin, cracking, or breakdown.

Nursing Interventions

Applicable nursing interventions are identified and adjusted after every assessment is completed. Interventions are individualized on the basis of each patient’s illness or injury. Different interventions may be required depending on a patient’s level of consciousness, and a previously conscious patient may become unconscious. Positioning a patient in a comfortable position with head and injured extremities elevated is a basic and important intervention; one positioning method is to use a trifold lawn chair, or similar improvised support, to maintain elevation of the patient’s head and legs as needed.

The PFC nursing care plan (Appendix B) is a chart of nursing interventions with recommended intervals that the primary medical professional can fill out for the team to continue caring for a patient while the primary medical professional rests. Before deployment, medical professionals can use this tool to train teammates on nursing interventions so they can assist with patient care. Appendix C is an example of a completed chart with instructions.