Care of critically ill patients Flashcards
Kirby`s Rule of 20.
First 10 are?
- Fluid balance
- Oxygenation/ventilation
- Blood pressure
- Heart rate, rhythm
- Glucose
- Temperature
- Albumin
- Electrolytes
- Mentation/attitude
- RBC
Kirby`s Rule of 20.
What are 11-20?
- GI motility and mucosal integrity
- Nutrition
- Renal function
- Coagulation
- Immune system/antibiotic dosage
- Drug dosages
- Pain control
- Nursing care and patient mobilization
- Wound care and bandage change
- Tender Loving Care
How to assess hydration? (5)
- Mucous membranes
- Skin turgor
- Body weight
- Evidence of edema or effusion
- Continuing losses (vomit, blood, diarrhea)
How to assess oxygenation/ventilation? (3)
- Auscultation of lungs (both hemithorax)
- Monitor respiratory rate and effort
- Use oximetry
Consider:
* Respiratory distress
* Risk for aspiration pneumonia
How to assess Blood pressure? (3)
- Check pulse (femoral & metatarsal)
- Capillary refill time
- Blood pressure machine
How to assess heart rate and rhythm? (2)
- Auscultation of the heart
- ECG
How to assess glucose and how often?
Normal level
* 80 to 120 mg/dL or
* 3.3 mmol/L to 6.2 mmol/L
(multiply or divide by factor of 18)
- Check once a day
- Depending on underlying problem (DM (hypergly) vs parvovirosis (hypogly))
4 categories of hypertension
I minimal risk: systolic <150
II mild risk: sys 150-159
III moderate risk: sys 160-179
IV severe risk: sys >180
(mainly for dogs)
Temp. assessment in critically ill patients?
minimum once a day
accelerated idioventricular arrhythmia or AIV
is a ventricular rhythm with a rate of between 40 and 120 beats per minute with ectopic rhythm of >3 consecutive premature beats.
common in splenic torsions and poorly controlled pain
VPCs must be differentiated from this
Some causes of hypoglycemia. (6)
xylitol intoxication,
insulin overdose,
insulinoma,
neonates,
Addison’s,
sepsis
Some causes of hyperglycemia. (5)
diabetes mellitus
ketoacidosis
stress
Cushings
iatrogenic
memory trick for simplying glu percentage calc.
2.5% = 0.05 ml/1ml of fluid
5% = 0.1 ml/1ml of fluid
note: over 5% glu can be irritating to blood vessels
Critical ill patients and albumin considerations. (3)
- Main plasma protein
- Osmotic pressure
- Effusions, edema
e.g. burns especially
consider plasma transfusions
Critical ill patients and electrolyte considerations.
- Nr 1. electrolyte it Potassium
- Electrolytes to be checked at
least once a day
hypokalemia fairly common
hyperkalemia commonly due to lower urinary tract obstruction or Addison’s
Critical ill patients and mentation considerations. (3)
- Monitoring changes in your patient’s mentation
- A declining level of consciousness is a poor prognostic indicator
- Pain?
Critical ill patients and RBC considerations. (2)
PCV and TS (total solids) check at least once a day
Critical ill patients and GI motility and
mucosal integrity considerations. (6)
Critically ill patients are at higher risk for:
* Gastric ulcers
* Ileus
* Gastritis
* Other GI disturbances
- Is your patient eating?
- Any vomiting or diarrhea?
Critical ill patients and Nutrition considerations.
Goal of nutritional support is to treat and prevent malnutrition.
Starvation leads to neg. nitrogen balance and accelerated catabolic state which in turn leads to villous atrophy, suppressed crypt cell prolif., loss of GILT, increased permeability etc.
When to start feeding the animal?
* Anorexia or decreased food intake for 3 days
* Loss of 10% of body mass not related to hydration status
* Hypoalbuminemia
* Recent trauma/surgery
* Etc., etc., etc.
Even fat animals need feeding!
Muscle condition scoring.
Scale of 0-3
The higher the number the better.
Body condition scoring for cats.
Body condition scoring for dogs.
Explain RER.
- Resting energy requirement
- Amount of calories necessary for a non-stressed animal in the postprandial state in a calm, thermoneutral environment.
Animals less than 2kg:
* RER=70*(body weight^0,75)
Animals over 2kg:
* RER= 30*(body weight)+70
* Bodyweight in kg
- Usually started with 1/4 -1/3 of RER, increased daily, if tolerated well.
In stressful conditions, caloric needs are actually higher but our goal is to meet the minimum.
Critical ill patients and feeding options. (4)
- Syringe feeding
- Tube feeding
- Parenteral feeding
- Microenteral feeding (used seldomly, orally, in working dogs in severe/stressful environments who work long hours)
Describe Feeding tubes
- Measured in unit: French (Fr)
- 1 French = 0,33mm
Usually start with 1/4- 1/3 of daily RER
* Nasoesophageal (-gastric) tube
* Oesophagostomy tube (Pharyngostomy tube)
* Gastrostomy tube
* Jejunostomy tube
Describe Nasoesophageal (-gastric) tube
- 3,5-8 Fr
- Easy to place; requires local anaesthetic only
- Generally well tolerated
- Short term (up to 14 days)
- Liquid diet only
- Contraindications: facial trauma, coagulopathy, respiratory disease
- Always verify correct placement with x-ray!
- Complications: sneezing, aspiration pneumonia, vomiting, tube migration, esophageal irritation, inflammation and scarring, tube clogging, epistaxis.
How to place a naso-esophageal tube?
Describe Oesophagostomy tubes.
- 12—22 Fr (cat vs large breed dog)
- Animals tolerate well
- Can be used for long period (weeks, months)
- Wider selection of diets (larger lumen)
- Works In patients with facial/oral diseases
- Requires general anesthesia to place
- Verify the correct placement by x-ray!
Animals can even eat independently while tube is placed (at that point you can consider removing the tube if they have recovered).
Esophageal placement may be favored to avoid irritating the gastroesophageal sphincter.
- Complications: cellulitis or infection of placement site, displacement during vomiting or regurgitation, clogging of
the tube. - More severe complications: pneumothorax, pneumomediastinum, damage to vascular structures or nerves in cervical region (rare).
Describe Refeeding syndrome
medical complications that result from fluid and electrolyte shifts as a result of aggressive nutritional rehabilitation.
- More common In tube-fed cats (reported also in dogs), not super common in general but does happen.
- Hypokalemia
- Hypophosphatemia
- Hyperglycemia
- +/- hypomagnesemia
Clinical signs: vomiting, lethargy, muscle
weakness, pale mucous membranes, bleeding, arrhythmias, impaired mental status, seizures, cardiac arrest.
Daily monitoring: clinical signs, monitoring K, Phos, Glu
First step is to decrease feeding. Supplement minerals/electrolytes as required.
Critical ill patients and renal function.
- Monitor Urine production
- ideally place Urinary catheters
- Record urine production as well
- Normal cats produce 18-28 ml/kg/day of urine (5-60 ml/kg/day in kittens)
- Polyuria has a urine volume of more than 40 ml/kg/day
- Normal dogs produce 20-100 ml/kg/day of urine
Critical ill patients and coagulation.
- Watch for Petechiae and ecchymosis
- make notes of More bleeding after venipuncture
DIC - disseminated intravascular coagulation
* characterized by systemic activation of blood coagulation
- which results in generation and deposition of fibrin
- leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome (MODS)
- Consumption of clotting factors and platelets in DIC can result in life-threatening hemorrhage.
Prognosis is very poor.
MODS
multiple organ dysfunction syndrome
is altered organ function in an acutely ill patient requiring immediate medical intervention. associated with the failure of one or more organ systems.
Critical ill patients and Immune system/antibiotic dosage. (4)
- Decreased immune function
- Wear gloves
- Try to minimize the risk of infections, asepsis!
- When needed, administer antibiotics
Critical ill patients and drug dosages. (3)
Appropriate documentation
* Treatment sheets/plans
* Drug interaction
* What and when is given
Appropriate dosages
Weighing the animal regularly and adjusting dosages.
Critical ill patients and pain control.
- Monitor and assess animal posture/behavior
- Multimodal analgesia
Consider if infiltration or regional analgesia might be required.
Critical ill patients and Nursing care and
patient mobilization (4)
Turning patients (soft bedding too)
Passive range of motion; physical therapy or joint massage
Keeping the patient free of urine scald and bed sores
Bathing, cleaning, clipping
Critical ill patients and Wound care and bandage change (3)
- Clean bandages
- Changing interval
- Appropriate local treatment
Critical ill patients and Tender Loving Care
Kindness and love
* Talk to them
* Take your time
- Playtime
- Walking
- Owner visits
- Recognize that mental health of your patient plays a direct role in their recovery.
Happiness helps with healing!
