Rule of 20 Flashcards
1
Q
What is the “Rule of 20” (3)
A
- Is a set of parameters that veterinarians are taught to address in every emergency/critical care patient.
- If these parameters are monitored and cared for diligently, the patient is likely to do well.
- Or if a patient isn’t doing well, systematically go through each parameter to be certain something hasn’t been missed.
2
Q
List the 20 parameters of the rule of 20. Be able to describe & explain them:
(Do your best)
(FYI: Know 12/20 - FINAL)
A
- Fluid Balance
- Oncotic pull
- Glucose
- Electrolytes and blood pH
- Oxgenation and ventilation
- Mentation
- Blood pressure
- HR/rhythm
- Albumin
- Coagulation
- PCV
- Kidney function
- Immune status (WBC)
- GI motility/function
- Drug dosages/metabolism
- Nutrition
- Pain Control
- Nursing care (catheters, PT,
hypothermia) - Wound care/bandage care
- TLC (patient emotional support)
3
Q
Describe & explain:
Fluid balance
A
- Inappropriate replacement and maintenance of intravascular and interstitial volume is the number one cause of patient decompensation and death in this author’s experience.
- Animals with systemic inflammatory response syndromes (SIRS) or large third body fluid spaces will have massive loss of fluids from the intravascular compartment into the interstitial and third body fluid spaces.
- Dehydration and poor perfusion are different problems, requiring different therapeutic strategies. Perfusion deficits are due to a loss of intravascular fluid volume (though heart failure must be ruled out as the cause).
- Replacement of these deficits should occur rapidly and involves giving enough solution to expand and maintain the intravascular space.
- Dehydration is an extravascular (primarily interstitial) volume deficit.
- This must be replaced with crystalloids, such as lactated ringers, Plasmalyte® or Normosol-R.
4
Q
Describe & explain:
Oncotic pull
A
- The administration of colloids with crystalloids during resuscitation and
maintenance fluid therapy will restore and maintain intravascular oncotic pull and intravascular fluid volume while minimizing interstitial fluid accumulation. - Choices of colloids that can be utilized include whole blood, fresh frozen plasma, gelatins, dextran, hydroxyethyl starch (hetastarch) and stroma free hemoglobin.
5
Q
Describe & explain:
Glucose
A
- The stress response in the cat frequently results in a transient hyperglycemia,
requiring recheck to rule out diabetes mellitus. The blood glucose should be maintained between 100-200mg/dl. - Hypotensive animals should be monitored closely for hypoglycemia.
6
Q
Describe & explain:
- Electrolytes (Calcium, sodium, chloride, potassium, magnesium)
- Acid-base balance
A
- Alterations in potassium concentrations are to be expected in critical animals, especially cats, although ventroflexion of the neck and generalized weakness can occur with hyokalemia in the cat, these signs are rare. This requires that serum potassium levels be monitored, and maintenance intravenous fluids supplemented (5-20 mEq/250ml of fluids).
- Cats with chronic renal disease can
have profound potassium wasting and require oral long-term supplementation.
7
Q
Describe & explain:
Oxygenation & Ventilation
A
- Arterial blood gases should be evaluated to show any evidence of hypoxemia, hypercarbia, or hyperventilation.
- This is important for early detection of pulmonary edema or acute respiratory distress syndrome (ARDS) common to animals with SIRS diseases.
- Oxygen supplementation is needed if there are perfusion or breathing problems.
- Oxygen is supplied best by nasal cannula or hood.
- Observation of the breathing pattern of the cat can determine the location of the problem and allow intervention without stressful diagnostics.
- Administration of a mild sedative (butorphanol0.2-0.4mg/kg IV) may be required while giving oxygen support.
8
Q
Describe & explain:
Level of Consciousness & Mentation
A
- A decline in the level of consciousness or
mentation of the animal warrants immediate investigation for hypotension, hypoglycemia and hyperammonemia. - Hypoxia, hypocarbia, hypercarbia, hypernatremia, hyponatremia, hyperglycemia, hypoglycemia, hepatic encephalopathy, hyperosmolality, severe fever, severe dehydration, shock, overwhelming sepsis, hypokalemia, hyperkalemia, tachyarrhythmias,
bradyarrhythmia’s, and thiamin deficiency must be considered in the list of etiologies for
changing consciousness. - Depressed mentation or level of consciousness requires that precautions
be taken to protect the airway from aspiration of gastric or esophageal contents and the animal monitored for vasovagal reflex.
9
Q
Describe & explain:
Blood pressure
A
- Systolic pressure must be maintained above 90 mmHg, and more importantly,
the mean arterial pressure is maintained above 60 mmHg. - A comparison of indirect blood pressure measurement techniques in the cat has found the doppler to provide the most accurate information (McLeish, 1977). Hypertension is suspected in the cat when systolic/diastolic blood pressures are > 160/100 mmHg.
- Pulse quality is not a reliable indicator (Kobayashi, 1990).
- Significant hypertension can lead to poor peripheral perfusion, retinal hemorrhage and detachment, renal damage, and myocardial wall thickening.
10
Q
Describe & explain:
Heart rate, rhythm, & contractility
A
- Careful auscultation of the heart and palpation of the pulse is required to detect murmurs, gallop rhythms or pulse deficits suggestive of underlying cardiac disease.
- This would be further evaluated and monitored by electrocardiography (ECG) as clinically indicated.
11
Q
Describe & explain:
Albumin (BUN)
A
- Serum albumin concentration should be maintained above 2.0 g/dl in the acutely ill
animal. - Hypoalbuminemia can result from increased membrane permeability, glomerular or intestinal loss, or liver failure.
- Serum albumin is necessary to maintain adequate intravascular oncotic pressure and for transport of cations and hormones.
12
Q
Describe & explain:
Coagulation
A
Disseminated intravascular coagulation (DIC) is a hypercoagulable condition that is to be anticipated in any animal that has:
- Capillary abnormalities or stasis
- Severe hypotension
- Massive tissue damage
- Red blood cell hemolysis
- Pansystemic disease
13
Q
Describe & explain:
Red blood cell/hemoglobin concentration
A
- Hemoglobin is the most significant factor
responsible for oxygen concentration of the blood. - When the red blood concentration is too low, hemoglobin is low, and oxygen delivery is compromised.
- However, when the red blood concentration is too high, the viscosity of the blood is
increased, compromising blood flow and tissue oxygen delivery. - The PCV should be maintained above 20%, and ideally between 30-45%.
14
Q
Describe & explain:
Renal function
A
- Shock, severe dehydration, hypotension, hypoxia, and nephrotoxic drugs can each contribute to renal dysfunction or failure.
- Baseline BUN, creatinine, and urinalysis are
obtained prior to fluid resuscitation when possible. - Creatinine and/or blood urea nitrogen will elevate as glomerular filtration is reduced.
- Urine output is assessed on an ongoing basis as a reflection of renal function, blood pressure and fluid balance.
15
Q
Describe & explain
Immune status, antibiotic dosage and selection, WBC count
A
- The ability of the body to
fight infection is assessed through white blood cell count and differential, fever response, and globulin levels. - Immunocompromise can be the result of the underlying disease, FeLV, FIV, Parvo or Distemper viral infection, or the therapy.
- Animals that are on immunosuppressive drugs or have neutropenia require isolation and strict aseptic procedures and minimal invasive monitoring and therapeutic techniques.
16
Q
Describe & explain:
GI motility and mucosal integrity
A
- Critical illness is frequently complicated by gastric paresis, ileus and gastric ulceration.
- Stress gastric ulcerations may be subclinical but predispose the patient to bacterial translocation, gastric paresis and blood and fluid loss.
- Any patient that is postanesthetic, post-operative (especially abdominal surgery - and particularly gastrointestinal), hypokalemic, suffering from gastrointestinal, reticuloendothelial, or neuromuscular diseases, or on narcotic analgesics has a probability of having gastrointestinal paresis.
- Ileus predisposes the patient to bacterial and endotoxin translocation, poor intestinal nutrient digestion and absorption,
gastrointestinal ulceration and vomiting.
17
Q
Describe & explain:
Drug dosages and metabolism
A
- When administering any drug, the proper dosage, route of administration, and dosing interval should be confirmed.
- In addition, based on the route of elimination, dosage and dosing intervals must be altered in animals with renal or hepatic disease.
18
Q
Describe & explain:
Nutrition
A
- The nutritional requirements of the critically ill animal should be addressed early to minimize tissue catabolism and development of hepatic lipidosis.
- Meat-based diets should be selected that provide a good quality protein, vitamin A, thiamin and niacin for carnivores.
- The diet should be adequately supplemented with taurine and arginine for cats.
- When the food is warmed prior to feeding or highly aromatic foods are fed, the palatability of the food offered to stressed and ill animals is often increased.
19
Q
Describe & explain:
Pain control
A
- Pain can manifest in animals by mental depression, tachycardia (in the dog and
rarely in the cat), restlessness, and/or and irritable attitude. - It is vital to the maintenance of cardiovascular function and the mental well-being of the patient to provide pain control.
- In the critically ill animal, it is best to titrate analgesics and sedatives to effect, as responses are variable and can be affected by underlying renal and hepatic dysfunction.
20
Q
Describe & explain:
Nursing care & patient mobilization
A
- The veterinarian is only as good as the nursing staff.
- A complete description of all nursing concerns in the critical animal is worthy of a textbook.
- Time should be taken to teach the nurses how and what to monitor and how to perform therapeutic procedures.
- The nursing staff should speak kindly and softly when working with these animals, using minimal restraint to accomplish any task.
- The animal must be removed from the cage and thoroughly examined at least twice daily.
Changes in their physical condition, even
pulmonary function, may be very subtle and occur rapidly.
21
Q
Nursing care & patient mobilization:
Catheter sites
A
- Catheter sites must be checked daily and each catheter labeled appropriately to avoid
confusion of lines and misuse of the tubes. - When catheters are removed, the tips should be saved for culture and sensitivity.
- The paw distal to the peripheral catheter must be checked multiple times during the day for evidence of paw edema, requiring re bandaging of the catheter.
- Elizabethan collars are often necessary for catheter security as well as an aid in handling
aggressive animals.
22
Q
Nursing care & patient mobilization:
Hypothermia
A
- This is a component of most critical cat and small dog diseases.
- The pet is initially warmed passively. Warm fluids are administered, and the cat can be wrapped in towels and blankets.
- Once intravascular volume has been replaced, warm water circulating blankets can be used, making sure the pet can move off of the heating blanket if it desires.
23
Q
Describe & explain:
Wound care/bandage change
A
- When the patient’s underlying disease requires wound debridement or surgical correction, the incision site or wound should be examined daily to ensure that appropriate healing is occurring.
- Anytime a bandage is moist, it must be changed.
- Any subcutaneous distal limb edema associated with fasciitis is controlled and reduced by compression bandages.
- These wraps are removed and the subcutaneous sites examined daily.
24
Q
Describe & explain:
Tender Loving Care
A
- The mental health of the patient is often as important as the physical health.
- It must be remembered that these animals are pampered pets. Visits by the owners are to be encouraged when it benefits the pet and having familiar items in their cage will make the owner feel better, if not the animal.
- It is important for house cats to have fresh litter and a place for their food away from their litter box. Blankets or bedding makes them more comfortable.
- Providing a box for the cat to hide in or using other techniques of obstructing their view of
strange animals, when their condition allows, reduces their level of fear and stress. - The animal’s biorhythms become disturbed when the ICU lights are on 24 hours per day. When possible, it is good to turn down the lights to stimulate night and promote sleep.
25
Nursing care & patient mobilization:
Recumbant patient's
- Recumbent patient's must be turned every 4 hours or maintained sternal when possible.
- Physical therapy will assist in maintaining muscle tone and blood flow to the limbs.
- Urine scalding and fecal soiling is prevented by providing absorbent bedding and cleaning the animal immediately.
- Results of monitoring procedures, treatments and observations should be carefully recorded.
- The nurse must feel confident and comfortable about reporting observed changes to the veterinarian.
- The staff must anticipate complications and be prepared for immediate intervention.
26
Nursing care & patient mobilization:
Severe Respiratory Distress
- Animals in severe respiratory distress should have an endotracheal tube and laryngoscope available by the cage.
- Diazepam or pentobarbital doses should be predetermined and available for the patient with cluster seizure activity.
