NURSING INTERVENTIONS

Applicable nursing interventions are identified and adjusted after every assessment is completed. Interventions are individualized based on each casualty’s illness or injury. Different interventions may be required depending on a casualty’s level of consciousness, noting that a previously conscious casualty may become unconscious.1 Positioning a casualty 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 casualty’s head and legs as needed.

The PCC nursing care tracker (Appendix B) is a recommended chart of scheduled nursing interventions with suggested intervals that should be used by the primary medical professional to build a care plan. This will allow for work/rest cycle management of the care team. Before deployment, medical professionals should use this tool to train teammates on nursing interventions so they can actively assist with casualty care.2

HYDRATION AND NUTRITION

Nutrition and hydration are critical for the outcome and survival of trauma patients. Adequate nutrition and hydration are necessary to modulate the catabolic and inflammatory response associated with trauma and critical illness. Early nutrition intervention provides exogenous fuel to support the preservation of lean body mass and attenuate the body’s stress response.3

For reference, the average weight and height of military members are 187 pounds (85 kilograms (kg)) and 69 inches (175 centimeters) for men and 152 pounds (69 kg) and 64 inches (163 centimeters) for women.3 We use these reference weights throughout this section for ease of calculations.

Non-medical Responders

Oral hydration should be provided to any non-intubated casualty that can tolerate it. For reference, the minimum fluid needs for the average male Service Member is 2.6L/day and 2.1 L/day for female Service Members, respectively – approximately 100-125 cc per hour at rest. Injured casualties, including those with burns, wounds, diarrhea, and patients in extreme climates, may require more. As a general rule, if a casualty complains of being thirsty, they are likely dehydrated, and fluid intake should be regularly encouraged.

Hydration by mouth

- Minimum: Potable water as tolerated.
- Better: Potable water + improvised oral rehydration solution (in 1 liter of potable water: ½ tsp of table salt + 5-6 tsp of table/granulated sugar)
- Best: Potable water + commercially available balanced oral rehydration solution. If a commercial oral rehydration solution is not available, the following recipe is optimal:1L Water + 9 tsp sugar + 1 tsp salt + 1 tsp baking soda + ¼ tsp potassium chloride (per Nutrition and Diet Therapy Branch, U.S. Army Medical Center of Excellence)

Nutrition

- Minimum: If casualty is alert, encourage food intake, protein shake, or oral nutrition supplement (ONS) every 4-6 hours
- Better: Casualty consumes 50-70% of meals by mouth. Encourage the use of oral nutrition supplements and high protein food items to help meet their needs. Small, frequent (5-6) meals throughout the day are often better tolerated than three regular meals.
- Best: Casualty consumes at least 75% of their meals by mouth. If casualty cannot consume regular-sized meals, encourage small meals throughout the day. Recommend the use of ONS to supplement intake in order to meet increased nutritional demands.

Medical Responders

Adequacy of hydration should be judged by the amount of urine the casualty is making. Adult casualties’ urinary output should be approximately 0.5 ml/kg/hr.4,5

Hydration via IV or IO

Casualties who are intubated and/or sedated should receive fluids via IV or IO to meet their estimated fluid needs. These fluid needs are in addition to fluids provided for resuscitation. It is recommended to replete the volume of urine output to maintain euvolemic status. If urine output decreases, fluid provided by IV/IO may need to be adjusted/restricted to prevent fluid overload, though it is important to consider fluid losses from other sources including diarrhea, emesis, burns, wound vacs, sweat, etc. Urine color may not be an accurate indicator of hydration status in this population.

- Minimum: Normal saline maintenance infusion, typically around 100-150 mL/hr depending on goal urine output
- Better: Lactated Ringer’s maintenance infusion, typically around 100-150 mL/hr depending on goal urine output
- Best: Plasma-lyte A maintenance infusion, typically around 100-150 mL/hr depending on goal urine output

Nutrition

- Minimum: If casualty is alert, encourage food intake or protein (oral nutrition supplement) shake every 4-6 hours.
- Better: Casualty consumes 50-70% of the meals by mouth. Encourage the use of oral nutrition supplements and high protein food items to help meet their needs. Small, frequent (5-6) meals throughout the day are often better tolerated than three regular meals.
- Best: Casualty consumes at least 75% of their meals by mouth. If casualty cannot consume regular-size meals, encourage small meals throughout the day. Recommend the use of ONS to supplement intake in order to meet their increased nutritional needs.

For casualties who are intubated, please refer to Considerations for Prolonged Field Care section.

REPOSITION AND CHECK PADDING

Non-medical and Medical Responders

Identify casualties who cannot reposition themselves or have difficulty doing so. Reposition the casualty and check padding at least every 2 hours.6 If laying on a harder surface, they may need to be repositioned as frequently as every 1 hour to prevent skin breakdown. To prevent ischemic tissue injury and the formation of pressure sores, frequent movement of the casualty is necessary. Relieving pressure from superficial capillaries allows the skin to recover from the temporary ischemia.7 Some of the most vulnerable areas to pressure include the back of the head, elbows, heels, and sacrum. Casualties who can reposition themselves should be encouraged to do so every 2 hours. If possible, ensure the casualty’s head of bed is elevated to about 30 degrees. This is especially important for unconscious patients, as it helps to reduce the risk of pneumonia.

Unconscious Casualties

- Minimum: Use extra clothing, blankets, and other soft items to pad bony prominences and create a wedge under the casualty, rolling them to one side every 1-2 hours. Use extra blankets to safely raise the casualty’s head 30 degrees.
- Best: Use pillows and wedges to achieve pressure relief and turn the casualty every 1-2 hours. Use a wedge to raise their head 30 degrees.

** Maintain spinal/log roll precautions during reposition if there is concern for spinal injuries, but the patient should still be repositioned carefully despite spinal injury concerns

Guide for changing linen and repositioning

- First, ensure there is enough slack on any lines (IV, foley, etc.) or wires/cords prior to rolling.
- Carefully remove pillows, blankets, or soft items being used for positioning.
- With two personnel, if possible, roll the casualty onto one side (if concerned about spine injury, carefully log roll while maintaining spine stabilization).
- Roll the old linen inward to the middle of the bed (long ways). Place new linen down and tuck under the old linen roll.
- Gently roll casualty in the opposite direction. Pull out the old linen and pull through the new linen.
- Place pillows, blankets, or soft items under casualty for positioning.
- Ensure the casualty’s ankles, knees, and elbows are not resting on top of each other and arms are not resting on the abdomen, by placing padding between them.
- Ensure the casualty’s head and neck are in line with the spine.
- Use additional padding items to relieve pressure from boney prominences. For example, pillows or other soft items can be placed underneath the casualty’s calves to prevent pressure on heels.
- Ensure creases and bumps in clothing, sheets, and blankets are smoothed out under the casualty.
- If any areas of non-blanchable erythema are noted, outline area with marker and prevent placing casualty on the affected area until it recovers or add additional padding if that is not possible.
- Burned and injured extremities should be slightly elevated and slightly flexed to optimize venous return and maintain adequate peripheral pulses.

ORAL CARE

Non-medical and Medical Responders

Good oral hygiene reduces oropharyngeal colonization which is associated pneumonia. Pneumonia can be acquired regardless of whether or not the casualty is intubated. Casualties who are conscious should brush their teeth a minimum of every 12 hours. For unconscious casualties, perform oral care at least every 4 hours.7 Ensure some type of suction is available (e.g., manual suction device, syringe with IV tubing).

Supplies

- Minimum: Gloves, lip moisturizer (i.e., petroleum jelly), tongue depressor, tape, self-made suction (60 mL syringe with tubing attached), gauze, and water
- Better: Gloves, gauze, lip moisturizer, tongue depressor, tape, hand-held suction, toothbrush, and toothpaste (use sparingly)
- Best: Gloves, gauze, lip moisturizer, tongue depressor, tape, commercial oral cleansing and suction system, and wall suction or suction machine

Guide for oral care using gauze

- To keep the casualty’s mouth open, make a padded tongue depressor by wrapping gauze around one end of it and securing with tape. Use foam tape, if available, for additional padding. Ensure depressor is only inserted just past the casualty’s teeth/gums.
- Wrap a gauze around a gloved finger and hold firmly with the rest of hand.
- Moisten the gauze with mouthwash or water (ensuring not to oversaturate) and gently clean the teeth and mouth cavity. The gums, hard palate, and tongue should also be cleaned.
- Clean teeth and oral cavity for approximately 1 minute. Multiple gauze swabs may be needed depending on the level of contamination in the mouth.
- Use suction as needed to clear secretions.
- Apply lip moisturizer.

SKIN CARE

Non-medical and Medical Responders

A bath should occur at least once every 24 hours with spot cleaning as necessary. Unconscious patients should be checked every 2 hours in case of involuntary bowel or bladder emptying. Cleaning the skin is an opportunity to evaluate additional injuries and visualize any new areas of erythema or skin breakdown. This includes a complete wipe down on all non-injured areas using the minimum, better, best method as stated below.8 Conscious patients should actively assist with baths and may use a shower if available. In the event that a shower is used, care should be taken to prevent introduction of water into dressings or invasive lines. Plastic covering and tape may be used to protect these areas.

Unconscious or bedbound casualties:

- Minimum: Use rinsed “baby” wipes*. Be sure to cleanse skin folds, armpits, and groin.
- Best: Full bath with soap, gauze or washcloths, and warm water, followed by changing linen, applying pads to bony areas, applying compression stockings, using pillows to elevate extremities, and providing padding around the casualty.

Guide for bed bath:

- Remove any additional pillows or wedges being used to position casualty.
- Wash face first and genitalia last. (Cleaning genitalia is detailed under Foley care.)
- Prepare a basin or bowl with warm water and a small amount of soap.
- Obtain multiple 4×4 gauze pads or clean washcloths and place in water.
- Expose body part to be washed, keeping the rest of the casualty covered, and place absorbent pad or towel under the area to absorb water.
- Take one gauze or washcloth out of the basin and wring out excess water. Wash small areas of skin at a time starting with the face. Gently wipe the casualty’s face, being sure to clean the eyelids, nose, mouth, and ears. Work your way down the rest of the body.
- Throw away dirty gauze and replace washcloths as you progress to different areas of the body or once contaminated. DO NOT place contaminated gauze or washcloths back into basin or bowl. If supplies are limited, different areas of the washcloth can be used to clean once one section is dirty.
- Alternate cleaning option: Wash/clean the casualty using two-gauge bandage rolls. Dip both rolls into clean water. Dip the second roll into soapy water and wrap around gloved hand. Keep unrolling the cleaned gauge bandage roll while using the opposite hand to clean the skin until the casualty is clean. Use the same method to rinse the casualty.
- Note skin condition, especially areas of reddening or skin breakdown. These areas will need to be checked frequently, and pressure should be relieved from these areas if possible. Document these areas and include size and characteristics.
- Dry skin after cleaning each area, taking extra care to ensure skin folds are dry.
- Comb casualty’s hair. Female hair should be braided on the side to prevent excessive tangling. Braids should not be placed down the back of the head (such as a single French braid) since this can lead to pressure spots.
- Consider changing out old tape and EKG leads every 24 hours, taking available resources into consideration.
- Ensure the skin is dry and apply lotion.
- Replace any pillows or wedges being used to position casualty.

*Caution: If baby wipes or skin wipes are used to wash the skin, the wipes should be thoroughly rinsed with water first, because most contain alcohol and residues that can irritate the skin.

MOBILIZATION AND AMBULATION

Early ambulation of critically ill casualties has been shown to decrease acquired weakness, increase functional capacity, and increase the number of ventilator-free days in Intensive Care Unit (ICU) patients.9 Mobilization exercises, such as active and passive range of motion exercises or even as simple as sitting on the side of the bed/cot have also proven to be beneficial in decreasing muscle weakness.10 The tolerance and appropriateness of mobilization and walking will differ depending on the casualty’s condition.

Non-medical and Medical Responders

The following recommendations for conscious casualties are dependent on their ability to sit and walk safely. Medical responders should decide what each casualty can tolerate based on their condition.

- Minimum: Help casualty to sit on the edge of the bed/cot 2-3 times a day.
- Better: Have casualty sit in a chair during the day, taking care to rotate pressure spots if they are not able to self-adjust.
- Best: Have casualty sit in a chair during the day and walk 2-3 times a day with assistance.

DEEP VEIN THROMBOSIS PREVENTION

The most common locations for deep vein thrombosis (DVT) include the lower leg, thigh, and pelvis. Recognition and treatment of a DVT require specific medical training and can only be accomplished by a medical responder. However, the prevention of DVTs is not a medical task and should be performed by any available Service Member. If available, compression stockings, or elastic bandages (wrapped starting from the toes upward) should be placed on immobile or unconscious casualties, ensuring toes remain exposed for capillary refill assessment. Casualties who are conscious and able may perform the following exercises, completing 10 repetitions of each exercise every hour while awake. This may be done in burned extremities or in the presence of open wounds but should be avoided when fractures or severe extremity injuries are present.7,11

Signs and Symptoms of DVT

- Swelling
- Pain or tenderness
- Cramping, aching, or increased warmth
- Red or discolored skin

Non-medical and Medical Responders

Conscious Casualties: 10x every 2 hours, while awake

- Foot pumps. Have the casualty stretch toes up and back, flexing feet, and hold for a few seconds. Then point toes and hold before repeating.
- Ankle circles. Have casualty raise both feet and trace a circle or each letter of the alphabet with their toes.
- Leg raises. With left leg straight, have the casualty raise foot off the bed/cot or floor, then lower. Repeat with right leg. Alternatively, slowly have casualty lift left knee up to chest, then bring foot back to the bed/cot or floor; repeat with right leg.
- Hamstring stretches. While casualty is lying on their back with straight legs, have them raise one leg to 90°. Instruct casualty to pull the leg gently toward the head and hold for up to 30 seconds. Slowly bring the leg back down to a flat position and repeat with the other leg.
- Shoulder rolls. Although developing a clot in the upper body is less likely, venous stasis should be avoided. Have the casualty raise shoulders and circle them back and down five times. Then reverse direction for five more repetitions.

Unconscious Casualties: 10x every two hours

- Ankle plantarflexion-dorsiflexion. Hold the ankle and heel of one foot and alternately bend the foot forward into plantarflexion and then push the foot upward into dorsiflexion. Hold each position for 5–10 seconds.
- Lower extremity massage. Using both hands and starting at the ankle, apply consistent pressure, massaging the leg in an upward motion through the thigh. (Items such as a plastic bottle may be used to roll the skin toward the head.) Ensure deep pressure is avoided when massaging behind the knee or over bony prominences. Alternate legs (to simulate walking) for five times on each leg.

RANGE OF MOTION EXERCISES

Non-medical and Medical Responders

At least every 8 hours, perform a range of motion exercise on all movable joints such as ankles, knees, hips, wrists, fingers, elbows, and shoulders, except where joint mobility is restricted by injury. Perform 5 to 10 repetitions of moving the joint through a full range of motion and have the casualty perform the movement unassisted when possible.

COUGH, DEEP BREATHE

To help prevent pneumonia, conscious casualties should be encouraged to take deep breaths every hour while awake. Sustained maximal inspiration helps to maintain inflation of the alveoli and is as effective as using an incentive spirometer.12 If the casualties have increased secretions, they should also be encouraged to cough and clear their airway hourly.

Non-medical and Medical Responders

Guide for deep breathing instruction:

- Instruct the casualty to breathe in deeply and slowly through their nose, expanding lower rib cage, and letting abdomen move forward.
- Hold for a count of 3 to 5 seconds.
- Instruct casualty to breathe out slowly and completely through pursed lips.
- Have casualty rest and repeat 10 times every hour.

INSPECT AND MONITOR TUBES

Medical Responders

Examine all tubes (e.g., endotracheal tube [ETT] or cricothyroid tube, orogastric or nasogastric [OG/NG] tube, intravenous [IV] line, chest tube, urinary catheter) for correct placement and appropriate function, and ensure they are secured properly and labeled.

LINE MAINTENANCE

Vascular access devices, such as IVs and IOs, should be assessed for patency (i.e., flushed) prior to each infusion to assess catheter function and prevent complications. They are flushed after each medication administration with sufficient volume and appropriate rate to complete the medication administration and to reduce the risk of contact between incompatible medications.

- Minimum: Flush access site with Normal Saline (NS) every 8 hours. Use a minimum volume equal to twice the internal volume of the catheter system (e.g., catheter plus add- on devices), typically 5 mLs for peripheral IVs.13
- Best: Flush access site with NS every 4 hours.

If only half of a prefilled NS syringe is used and saved for later, it should be labeled with the time and date first used and only used on one casualty. It should be discarded after 24 hours. Ensure the syringe is capped in between uses to prevent contamination and infection.

If prefilled NS syringes are unavailable, draw up NS into an unused, empty syringe from a bag of NS using the needle access port. Ensure the needle access port on the NS bag is cleaned using alcohol prior to access.

Procedure to flush peripheral line

- Gather equipment.
- Using aseptic technique, clean the access port with an alcohol prep pad.
- Take prefilled 10mL syringe of NS and needle (if applicable) or attach syringe to port.
- With constant pressure, inject NS into the port to flush the catheter to ensure the line remains open.
- If resistance is met, gently use pulsating pressure on the end of the syringe until NS flows freely.
- Carefully observe the IV site and discontinue any IV line that causes swelling, pain, or redness.
- Detach syringe and dispose; place needle in sharps container (if applicable).

SUCTION ORAL AIRWAY

Perform oral airway suction when needed to clear secretions from the mouth. Casualties should also be encouraged to cough up and spit out secretions, if possible.

- Minimum: Manual suction device or improvised suction device, such as a 25cm length portion of IV tubing connected to a 60mL syringe
- Best: Rigid suction tube, suction machine, or wall suction

Guide for oral suctioning

- Gather necessary equipment.
- Ensure casualty’s head is elevated.
- Perform hand hygiene.
- Place a clean towel under casualty’s chin.
- Don additional Personal Protective Equipment (PPE) based on the casualty’s need for isolation precautions or risk of exposure to bodily fluids.
- Introduce the suction device into the casualty’s mouth along the gumline to the pharynx.
- If using manual suction, apply suction while withdrawing the device slowly, working from the back to the front of the mouth. If using a suction machine, use the lowest setting appropriate for the thickness of secretions.
- If needed, clear the suction device with sterile water or 0.9% NS, if available.
- Repeat as needed, paying attention to casualty tolerance and oxygen saturation.

CHANGE INTRAVENOUS LINE, BAG, AND TUBING

Access sites, tubing, and bags may need to be changed to prevent infection; however, a PCC situation may not allow unnecessary expenditure of limited medical resources. Consider basic PCC principles regarding supplies, number of casualties, and potential evacuation time when deciding on frequency while using new supplies.

- Peripheral intravenous access: Do not replace unless there is evidence of infection, blockage, or infiltration.14
- Intraosseous access: Discontinue after 24 hours, a maximum of 48 hours if difficulty obtaining IV access.13
- Primary continuous infusion tubing: Change every 7 days (i.e., administering Lactated Ringers continuously for IV hydration).
- Primary intermittent infusion tubing: Change every 24 hours (i.e., administering an IV antibiotic intermittently).
- Secondary infusion tubing: Change every 24 hours (i.e., administering an IV antibiotic via a secondary line connected to primary tubing).
- Blood tubing: Change after every 4 units of products.
- Propofol: Change tubing every 12 hours due to lipid base.