Page 126 - JSOM Summer 2018

Auscultate Chest and Abdomen Suction Advanced Airway
Listen for changes in all lung fields and abdomen. • Minimum: Manual suction device or improvised suction
device, such as a 25cm length portion of IV tubing con-
Monitor Input and Output nected to a 60mL syringe
Check IV drip rate or give oral fluids as needed. Ensure adult • Better: Open suction tube, suction machine
patients void an average of 30–50mL/h, or 100–200mL/h if • Best: Closed in-line suction tube, suction machine
exhibiting signs of rhabdomyolysis. Check drainage from
wounds and tubes. Perform airway suction only when needed, using sterile tech-
nique for advanced airways or clean technique for the mouth
Inspect Skin and Splints and throat. Humidify the air using a humidifier, moist gauze,
Examine skin, including nares and mouth, for changes and or by boiling a pot of water.
ensure splints are fitted properly and pulses are present below 1. Gather necessary equipment.
splint. Monitor for allergic reactions to tape, developing ery- 2. Ensure patient’s head is elevated.
thema, excessive dryness, pressure indenting the skin, crack- 3. Perform hand hygiene.
ing, or breakdown. 4. Place a clean towel under patient’s chin.
5. Don eye protection.
6. Hyperventilate patient for 10 seconds.
Nursing Interventions
7. Perform appropriate suctioning with available equipment
Applicable nursing interventions are identified and adjusted (ensuring suction is performed while withdrawing the cath-
after every assessment is completed. Interventions are individ- eter for no longer than 10 seconds at a time).
ualized on the basis of each patient’s illness or injury. Different 8. Allow at least 30 seconds before repeating suctioning, if
interventions may be required depending on a patient’s level of needed.
consciousness, and a previously conscious patient may become 9. Perform oral care as needed but at least every 4 hours.
unconscious. Positioning a patient in a comfortable position
with head and injured extremities elevated is a basic and im- Reposition and Check Padding
portant intervention; one positioning method is to use a trifold • Minimum: Extra clothing, soft items
lawn chair, or similar improvised support, to maintain eleva- • Best: Pillows, blankets, towels
tion of the patient’s head and legs as needed.
Identify patients who cannot reposition themselves. Repo-
The PFC nursing care plan (Appendix B) is a chart of nursing in- sition patient and check padding at least every 2 hours. To
terventions with recommended intervals that the primary medical prevent ischemic tissue injury and the formation of pressure
professional can fill out for the team to continue caring for a pa- sores, frequent movement of the patient is necessary. Relieving
tient while the primary medical professional rests. Before deploy- pressure from superficial capillaries allows the skin to recover
ment, medical professionals can use this tool to train teammates from the temporary ischemia.
on nursing interventions so they can assist with patient care. Ap- 1. Roll the patient onto one side (if concerned about spine in-
pendix C is an example of a completed chart with instructions. jury, carefully log roll while maintaining spine stabilization).
2. Have an assistant remove pillows, blankets, or soft items
Plan and Document Nursing Interventions being used for positioning and gently guide the patient
• Minimum: Nursing care checklist portion of the PFC down onto their back.
flowsheet (Appendix A) 3. Using the same procedure, have assistant gently roll pa-
• Best: PFC nursing care plan (Appendix B) tient in the opposite direction.
4. Place pillows, blankets, or soft items under patient for
Flush Saline Locks positioning and have assistant guide patient back down.
• Minimum: Empty 10mL syringe, needle, bag of normal 5. Ensure the patient’s ankles, knees, and elbows are not
saline (NS), alcohol pads resting on top of each other and arms are not resting on
• Best: Prefilled 10mL NS syringes, needle (if applicable), the abdomen, by placing padding between them.
alcohol pads 6. Ensure the patient’s head and neck are in line with the
spine.
At least every 8 hours, flush saline locks with 10mL of NS. 7. Use additional padding items for bony prominences on
1. Gather equipment. hard surfaces.
2. Clean access port with alcohol pad. 8. Ensure creases and bumps in clothing, sheets, and blan-
3. Take prefilled 10mL syringe of NS and needle (if applica- kets are smoothed out under the patient.
ble) or attach syringe to port. 9. Be aware of the location of external equipment such as
4. With constant pressure, inject NS into port to flush catheter Foley catheter, IV tubing, ventilator tubing to prevent dis-
to ensure line remains open. lodging during repositioning.
5. If resistance is met, gently use pulsating pressure on end of 10. If any areas of nonblanchable erythema are noted, outline
syringe until NS flows freely. area with marker and prevent placing patient on the af-
6. Carefully observe the IV site for swelling or pain. Start a fected area until it recovers.
new IV if swelling or pain occurs. 11. Burned and injured extremities should be slightly elevated
7. Detach syringe and dispose; place needle in sharps con- and slightly flexed to optimize venous return and main-
tainer (if applicable). tain adequate peripheral pulses.

If prefilled syringes are unavailable, draw up NS into unused, Oral Care
empty syringe from a bag of NS, then follow steps above. • Minimum: Gloves, gauze, lip moisturizer

124 | JSOM Volume 18, Edition 2/Summer 2018