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.
Vital Signs
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
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.