Hello, my name is Christy Hertel, and I am an advanced practice provider with the Trauma and Surgical Critical Care Department at ECU Health Medical Center in Greenville, North Carolina. Today, I am presenting Nursing Care During Humanitarian Crisis. I have no financial disclosures to present to you. Our objectives during this session is to discuss nursing concerns during prolonged field care and principles of appropriate documentation. During a humanitarian crisis, nurses can be utilized in a variety of roles, including assisting with obtaining initial evaluations from patients, maternal child care, assisting in the operating room, assisting with decontamination, and giving emotional support to patients. With limited resources, nurses may need to alter the way in which normal nursing care is provided. Joint Trauma System has provided a clinical practice guideline for nursing care during prolonged field care. We will delve into these nursing interventions and alterations to the care depending on resources available. The Joint Trauma System provides a minimum better best approach to nursing care. Vital signs that should be obtained are blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, end tidal CO2 when available, finger stick blood glucose levels, Glasgow Coma Scale scores, and pain scores, along with checking peripheral pulses. For vital signs, the basic equipment needed is a blood pressure cuff with stethoscope, thermometer, watch, pulse oximetry, and flashlight. A digital wrist blood pressure cuff is a better option, and the best scenario is if a portable monitor is available for continuous assessment of vital signs. If a glucometer is available, finger stick blood sugars should be monitored at least every 8 hours, and hypoglycemia treated with oral or IV glucose. Intake and output needs to be monitored to ensure adequate resuscitation. Oral fluids are allowed to conscious patients who are able to consume them. If intravenous fluids are administered, then drip rate should be checked. Manual count is the minimum, with the use of an in-line device for flow adjustment as a better option, and the best practice is the use of an infusion pump. Monitoring urine output closely to ensure that perfusion is adequate. Adults should maintain 0.5 to 1 milliliter per kilogram per hour of urine output. For a 70-kilogram patient, this is 35 milliliters per hour minimum. If rhabdomyolysis is suspected, then urine output should be 100 to 200 milliliters per hour to ensure adequate flushing of the kidneys to prevent acute kidney injury from build-up of myoglobin. The output from nasogastric tubes should be monitored and calculated into the total output as patients with large nasogastric tube outputs can have increased fluid needs, as well as electrolyte abnormalities. Nasotube drainage should be monitored to ensure ongoing thoracic bleeding is not present. Burn patients have high output from wounds, and dressing should be checked and changed as indicated by the level of saturation. Skin and splint inspection. Skin should be examined for indications of infections, such as urethema and warmth around a wound. Nares and mouth should be inspected for dryness or cracking that could indicate dehydration. Surgeries with tape should be examined for indications of allergic reaction, and tape should be changed daily to prevent skin breakdown. Splints should be assessed for tightness that could lead to skin breakdown or decreased circulation to the extremity, and pulses should be examined in a splinted extremity and monitored. Foley oral and skin care. Foley care should be performed daily with warm water and a non-irritating soap. The area of insertion should be thoroughly cleaned and dried. For males, this includes retraction of the foreskin to clean at the insertion site and under the foreskin. Oral care in conscious patients should include teeth brushing with toothpaste every 12 hours. For unconscious patients and intubated patients, oral care should be completed every 4 hours. For unconscious patients, the minimum is using lip moisturizer. Better is having access to mouthwash and a mouth moisturizer. The best care is if an oral cleansing and suction system is available. Skin care, including washing and moisturizing, should occur at least daily and more frequently if soiling occurs. Minimum is washing with prepackaged wipes. Better is having water with a mild soap and lotion available. Best is the use of disposable washcloths. Positioning and range of motion. Repositioning of patients that cannot move themselves should occur every 2 hours to prevent skin breakdown. Use of clothing or available soft materials is the minimum. The best is if blanket rolls and pillows are available. In addition to moving patients off their sacrum, attention should be paid to reducing pressure on heels and other joints. These areas should be assessed for signs of breakdown when repositioning occurs. Range of motion is completed every 8 hours. Passive range of motion in unconscious patients should include all major joints, including shoulders, elbows, wrists, hips, knees, and ankles. DVT prevention. Chemical prophylaxis for deep vein thrombosis prevention may not be available during prolonged field care. Compression stockings or ace dressings wrapped around lower extremities to add compression should be placed. Conscious patients should complete foot pumps, ankle circles, leg raises, and thigh stretches every hour. For unconscious patients, nurses should perform ankle plantar flexion, dorsiflexion exercises every 2 hours, along with lower extremity massage. Airway management. Patients without an advanced airway in place should be encouraged to turn, cough, and deep breathe every hour to prevent atelectasis. In unconscious patients without an advanced airway in place, oral suctioning and suctioning of the posterior pharynx should occur. Humidity should be provided with a humidifier, wet gauze, or steam from boiled water. If an advanced airway is in place, suctioning should be completed to remove secretions and allow for adequate oxygenation and ventilation. The minimum is the use of a syringe suction device. An open suction tube with a machine is better, and the best is a closed inline suction with machine. Following interventions, documentation needs to occur. Documentation tells the story of the patient's care along the continuum. Lack of documentation leaves a patient vulnerable to interventions not necessitated or deletion of essential care. Accurate documentation provides health care workers with trends. Monitoring trends allows for faster identification and changes in a patient's condition, leading to decreased morbidity and mortality. Documentation should be completed in real time. It should be legible for all health care workers to read. The documentation should be accurate. At minimum, vital signs assessment, medications, intake and output, and interventions should be documented. This is the prolonged field care flow sheet that is utilized for documentation as provided in the clinical guidelines by the Joint Trauma System. This initial page outlines a patient's injuries along with any telecommunication support that has been given. It is easy to follow a trend with this documentation with the patient's vital signs, intake output, Glasgow Coma Scale, and medications all listed on the same page. On the right-hand side of the page is a checklist for a reminder for nursing interventions that need to be completed. Nursing interventions and prolonged field care are documented on a flow sheet with initials when a task is completed. Along with the expected interventions, the frequency of interventions is listed in red as reminders. Recently, nurses have been exposed to other humanitarian crisis. A humanitarian crisis is defined as a singular event or a series of events that are threatening in terms of health, safety, or well-being of a community or large group of people. We are familiar with military operational environments and natural disasters being sites of a humanitarian crisis, but remember that your local rural hospital can easily become overwhelmed and resource limited. This was never more apparent than during the COVID-19 pandemic. During COVID-19, nurses showed their resilience and creativity with the development of several innovations to assist with patient care. This included development of ways to decrease entry into patients' rooms by bringing IV infusion pumps, dialysis machines, monitors, and ventilator control panels outside the patient's room. In addition, innovations that reduced the use of PPE, increased patient safety and readiness, and reduced foot traffic were all developed during the COVID pandemic. Nurses are often called the jack of all trades. Nurses possess many qualities that allow this to be accomplished. They are the constant at the bedside and thus the constant in a patient's journey. They provide continuity of care and do it with compassion and caring. Nurses are a vital part of any health care team. Thank you for your time and attention during this presentation.

nursing care

humanitarian crises

limited resources

resilience

COVID-19 pandemic