ASSESSMENT AND DOCUMENTATION

ASSESSMENT

After initial stabilization, every casualty requires regular head-to-toe reassessments. Regular assessments allow providers to gain an understanding of the casualty’s baseline, changes to that baseline, and help to dictate treatment and the plan of care.

Non-medical Responders

- Reassess all interventions completed previously during the MARCH-PAWS assessment at the responder’s level of training.
- Become familiar with the PCC Flowsheet (Appendix A).
- Assist the medical responder as needed.

Medical Responders

- Minimum:
  - If appropriate, receive verbal reports from TCCC non-medical or other medical personnel on all interventions completed on the casualty.
  - Briefly review any casualty documentation provided( verbal or handwritten and note method conveyed).
  - Assess any interventions for appropriateness and effectiveness using the MARCH-PAWS sequence in accordance with PCC Guidelines:
    - Massive Hemorrhage - Assess all interventions for continued hemorrhage control.
    - Airway - Assess the airway for patency and check any adjuncts for proper placement and securement.
    - Respiration - Assess any interventions for tension pneumothorax, assess breathing for rate and depth, and check pulse oximetry if available.
    - Circulation - Assess pelvic compression device, if present. Check tourniquets, if present, and determine if conversion is indicated, check all dressings for effectiveness, and check pulses.
    - Hypothermia/Head Injury – Assess any interventions for hypothermia for ongoing necessity and effectiveness. Assess reported head injury for change in casualty’s status.
    - Pain - Reassess pain control - note the last time pain medications were administered and determine based on pain score if the casualty needs to be redosed.
    - Antibiotics - Reassess the need for antibiotics, either initial or repeat doses.
    - Wounds - Reassess and treat additional wounds.
    - Splints - Check any splints for proper fit and assess pulses distal to the splint.
- Better: Perform periodic re-assessment rounds. Include the following observations in ongoing clinical decision-making:
  - Is the casualty sick or not sick? (acutely ill, decompensating, or experiencing a serious medical/surgical condition requiring ongoing management?)
  - Is the casualty stable or unstable?
  - Is the casualty getting better or getting worse?
  - How is that assessment different from the last assessment?
- Best: Complete head-to-toe primary and secondary assessment. Perform comprehensive physical exam and detailed history with problem list and care plan. As soon as it is feasible, perform teleconsultation.

DOCUMENTATION

Document the casualty assessment and monitor trends to identify signs of decompensation. Quantity and severity of casualties may restrict the level of documentation the responder is able to complete.

Non-medical Responders

- Minimum: DD 1380 , SF 600
- Best: If trained by medical responder, assist in completion of more thorough documentation, such as the PCC flowsheet (Appendix A) and PCC nursing care tracker (Appendix B).

Medical Responders

- Minimum: DD 1380, SF 600
- Better: PCC flowsheet
- Best: PCC flowsheet, PCC nursing care tracker

VITAL SIGNS

Obtaining vital signs and trending them via documentation helps the medical responder to adequately assess casualty’s condition, assess treatment effectiveness, and determine future care needed. Frequency of vital signs is determined by the severity of the casualty's condition.

Frequency

- Non-critical casualty: Obtain vital signs every 12 hours.
- Stable but serious: Obtain vital signs every 4 hours.
- Critical Casualty: Obtain vital signs every 15-30 minutes with ongoing resuscitation until stability is established.

Non-medical Responders

- Minimum: Heart rate via pulse check, manual respiratory rate, pain scale, and checking color, condition, and temperature of skin. Mental status – alert or not alert.

Medical Responders

- Minimum: Systolic blood pressure (BP) estimation using presence of pulses, mental status (perform Glasgow Coma Scale [GCS] for any abnormality noted), heart rate via pulse check, pain scale, respiratory rate, and checking color, condition, and temperature of skin. Trend and document all vital signs in the PCC Flowsheet in Appendix A.
- Better: Above + temperature and manual BP.
- Best: Portable monitor providing ongoing or automatic periodic vital signs display, end-tidal carbon dioxide (ETCO2) monitoring (when appropriate), consider internal temperature monitors depending on patient condition, necessity, and supplies.

INTAKE AND OUTPUT

Recording fluid intake and output is an important clinical care process that helps the medical responder determine the progress of the disease and the effects of the treatment. Recording of intake and output helps to ensure that the casualty has a proper intake of fluid. Recording of output helps to determine whether there is an adequate output of urine and normal defecation. Correct recording of fluid balance helps ensure safe and effective nursing care to identify abnormalities in casualty conditions, proper resuscitation response, and fluid maintenance requirements over time. Critical casualties will typically have a Foley catheter (in-dwelling catheter,[IDC]) placed and may be getting hourly fluids or blood, which need to be monitored on a more frequent basis. Input and output is typically recorded in cubic centimeters (cc) or milliliters (mL). If trying to estimate input or output without measuring tools, think of common items to help estimate fluid volumes. For example, a standard soda can contains about 350 cc.

Intake

- Oral, intravenous (IV), intraosseous (IO), via nasogastric (NG) or orogastric (OG) tube

Output

- Drainage from wounds, urine, and bowel movements

Frequency

- Non-critical casualties: Monitor and document throughout the day as intake and output occurs, totaling after 24 hours. (Non-medical and medical responders)
- Critical casualties: Monitor and document every 1-2 hours, making changes to IV fluids as needed. Total after 24 hours to determine overall fluid status. (Medical responders)

Equipment

- Minimum: Collect urine output in available container, such as an empty water bottle.
- Better: Graduated cylinder such as an empty IV fluid bag, fluid collection pan, urinary collection bottle, Nalgene bottle or similar container
- Best: Urinary catheter (if indicated based on casualty condition)