Page 36 - 2022 Spring JSOM

TABLE 17 PCC Role-based Guidelines for Nursing Care and Wound Management
PCC Role-based Guidelines for Nursing Care and Wound Management
TCCC - TCCC - TCCC - TCCC - Intervention Frequency Paradigm
ASM CLS CMC CPP *All Personnel - Complete Basic TCCC Management Plan for Nursing/Wound Management then:
• Many “nursing” interventions are actually basic soldier skills that need to be performed on those
casualties who cannot perform them on themselves.
• Therefore, many traditional non-medical tasks are listed at the Tier 1 level since they can essentially
be performed by anyone, but the activity can be overseen by medical personnel.
Lip care Every hour • Minimum: Commercial lip balm
• Better: Moisturizing lotion
• Best: Petroleum jelly
Oral/Nasal Care 24 hr • Minimum: Rotate site around mouth/nares, as feasible.
• Better: Rotate site and suction.
• Best: Rotate and suction with commercial device.
Oral/Dental Care Every 12 hr • Minimum: Brush with gauze, water and gloved finger
• Better: Brush with tooth brush with toothpaste.
• Best: Use tooth brush with Chlorhexidine rinse.
Cough/Deep Every hour • Minimum: Encourage deep breathing/forced cough x 10.
Breathing • Better: Sit up. Encourage deep breathing/forced cough x 10.
• Best: Sit up, turn, and encourage deep breathing with incentive spirometer/
forced cough x 10.
Repositioning/ Every 2 hr • Minimum: Turn to opposite side, pad with clothing or textiles.
Check Padding • Better: Turn to opposite side, pad with pillows or blankets.
• Best: Turn to opposite side, pad with pillows to all bony prominences and
between legs.
Splint Care Every 2 hr • Minimum: Use improvised splints (i.e., wood fence, plank).
• Better: Use commercial splinting device (e.g., SAM splint).
• Best: Use ortho-fiberglass splint with fluffing and elastic wrap.
**Re-check all pulses after splint placement.
Hypothermia Continuous • Minimum: Wrap patient in dry clothes or blankets.
Prevention • Better: Wrap patient in commercially available hypothermia prevention kit,
using air-activated heating element.
• Best: As above, add use of warmed, forced air and infusion of warmed fluids
using commercially available devices.
Head Injury Continuous • Elevate head of bed 30 degrees and then:
• Minimum: Lay patient against ruck sack/backpack
• Better: Pillows or blankets
• Best: NATO litter back rest
Non-medical Every hour • Minimum: Distract the patient and perform guided imagery.
Interventions • Better: Splint wounds, pad boney prominences, provide ice packs to injured/
swollen areas (or, alternate with warm packs).
• Best: As above, combine both elements.
Psycho-social Continuous • Minimum: Speak in calm tone, addressing casualty concerns, to reduce fear
Needs and anxiety.
• Better: Support with caring touch, listening to fears/concerns; explain all
procedures.
• Best: Institute rest/sleep cycle system to minimize delirium.
Nutrition Every 4–6 hr • Minimum: If patient is alert, encourage oral food/water intake.
• Better: As above, use MRE protein powder mixed with water.
• Best: As above, use commercially available tube feeding products or protein
shakes.
Hygiene Every 24 hr • Minimum: Rinse face, armpits, and groin with warm water, soap, and gauze roll.
• Better: As above, use baby wipes or wash cloth.
• Best: As above, use chlorhexidine-impregnated cleansing wipes.
Bowel As required • Minimum: Cleanse soiled skin as described for bath; reapply new dressings/
Management hypothermia management as appropriate.
• Better: As above, add a cloth/linen/plastic barrier to protect wounds/
hypothermia management kit from future soiling.
• Best: As above, add barrier cream to skin for protection against breakdown.
• Perform all recommended interventions from guidelines for above Tier level.
• Additional interventions include:
IV/IO Site Care • Minimum: Flush intravenous catheter every 12 hr; change intravenous infusion
tubing every 96 hr.
• Better: Flush intravenous catheter every 8 hr; change intravenous infusion
tubing every 72 hr.
• Best: Flush intravenous catheter every 4 hr. Change intravenous infusion
tubing every 48 hr.
• For IO: monitor the site closely for skin compromise (underneath the hub of
the IO); if possible, convert to an IV within 24 hr.
Wound Irrigation Every 24 hr • Minimum: Irrigate wound with potable water (cooled before use if boiled)
poured across wound
• Better: As above, use 10mL syringe and 18-gauge angio-catheter.
• Best: As above, using sterile saline or sterile water or appropriate antimicrobial
cleaning solution (i.e., Dankins).
Dressing Change • Minimum: Reinforce dressings.
• Better: Replace when soiled.
• Best: Change every 24 hr.
(continues)

34 | JSOM Volume 22, Edition 1 / Sping 2022