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
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
Nutrition
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.
Nutrition
For casualties who are intubated, please refer to Considerations for Prolonged Field Care section.
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
** 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
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
Guide for oral care using gauze
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:
Guide for bed bath:
*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.
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.
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
Non-medical and Medical Responders
Conscious Casualties: 10x every 2 hours, while awake
Unconscious Casualties: 10x every two hours
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.
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:
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.
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.
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
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.
Guide for oral suctioning
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.