Page 73 - ATP-P 11th Ed

Table 17 Cont.
PCC Role-based Guidelines for Nursing Care and Wound Management
T T Intervention Frequency Paradigm
C C Deep Vein Thrombosis Every 1–2 • Minimum: Massage lower extremities SECTION 1
C C Prevention hours • Better: As above; add application of
C C **Pay attention to any compression stockings or elastic bandages to
- - wounds to the affected improve venous return.
C C limb** • Best: As above; add application of
M P commercial mechanical compression
C P stockings.
Head Injury • Minimum: Assess pupillary response, GCS
(Serial Neuro Exams) and level of consciousness/orientation, every
8–12 hours; MACE Exam x 1.
• Better: Neuro exam (as above) every
4 hours; MACE exam every 24 hours.
• Best: Neuro exam (as above) every 1 hour,
MACE exam every 24 hours.
Hyperthermia • Minimum: Expose skin to air.
Prevention/Treatment • Better: Place cold, wet cloths to groin, neck,
armpits (ice packs may cause hypothermia).
• Best: Use of cooled, forced air and infusion
of cooled fluids using commercially available
devices.
Administer Antibiotics • Minimum: Provide oral or intramuscular
injection of antibiotics per CPG.
• Better: Administer intravenous infusion of
broad-spectrum antibiotics, per CPG.
• Best: Administer wound- or mechanism-
specific antibiotics via intravenous infusion,
as directed by provider oversight.
Pain Control • Minimum: Intermittent dosing of analgesics
given oral/intramuscular/intravenous/
subcutaneous
• Better: Continuous infusion of analgesics
• Best: Regional nerve blocks
• Ensure above nursing interventions are completed by non-medical TCCC ASM and CLS
personnel.
• Conduct inventory of all resources.
• Document all pertinent information on PCC Flowsheet (attached).
• Additional interventions include:
Suction Advanced Every hour • Minimum: Manual suction device or
Airway improvised suction device, such as a 25cm
length portion of IV tubing connected to a
60mL syringe
• Better: Open suction tube, suction machine
• Best: Closed inline suction tube, suction
machine
(continues)

62 SECTION 1 TACTICAL TRAUMA PROTOCOLS (TTPs) ATP-P Handbook 11th Edition 63