U2 O2 - Nursing the critical patient Flashcards
What is a Hospital Acquired
Infection (HAI) /
Nosocomial infection?
Infection acquired whilst the patient is in hospital.
Hospital acquired infection (HAI) rather than
community acquired (CAI). Some now use the
term hospital acquired in place of nosocomial
What is RER?
Resting energy requirement. Calories required
by an animal when at rest.
What is enteral nutrition?
Providing nutrients directly into the gastrointestinal (GIT) tract
What is parenteral nutrition?
Providing nutrients directly into the blood stream,
bypassing the gastro-intestinal tract
What is an enterocyte?
The cells that line the gastro-intestinal tract.
What are the 4 steps in a nursing care plan?
The nursing process is cyclical, consisting of four stages – assessment, planning,implementation (or intervention) and evaluation. Each of these stages will be considered in turn
What type of information is needed to gather a history for a patient to help create a nursing care plan?
• Age, sex and neutering status of the patient
• The nature of the problem
• When the problem started
• The reason for hospitalisation
• The type of assistance the patient might require
• The patient’s normal lifestyle- working dog, housecat etc.
• Normal diet and fluid intake- food type and preparation, frequency and types
of dishes used.
• Current nutritional status and current food/ fluid intake
• Normal exercise schedule
• Ability to exercise currently
• Usual location and substrate for urination and defaecation or commands used
etc.
• Other medical conditions and treatments
• Current medication and how administered
• Temperament and how it gets on with other animals/people
• Pain score and last analgesia administration
• TPR
• Any other relevant information e.g. afraid of men, white coats etc
What type of things should be considered during the planning stage of a patient care plan?
The following includes examples of things to consider during the planning stage N.B.
they may not ALL be relevant, at this stage, for each patient:
• What is the patient’s RER?
• What will the patient be fed?
• How often will they be fed?
• How much food will be given?
• How often will the amount of food eaten be monitored?
• How will the patient be fed?
• What type of accommodation will the patient be given?
• What bedding/ hides should be provided?
• What medication is required?
• How often will this be given?
• How will this patient manage to urinate and defaecate?
• What are the actual problems for this patient e.g. recumbency?
• What are the potential problems for this patient e.g. depression, decubitus
ulcers, aspiration pneumonia?
• How much pain is the patient feeling and what are its analgesic needs? N.B.
This should be assessed by using a validated pain scoring system. Whether
any medication is required, which medication to use, what dose and what
route should all be decided by the veterinary surgeon, but their decision is
likely to be affected by the results of nursing observations, interventions and
monitoring. There are many non-medical nursing interventions that could be
considered in the planning stage that would be important in pain management
e.g. deep bedding/ memory foam bedding and ensuring the patient is in a
quiet area. Other considerations may be added or removed as appropriate.
For example, although a patient with osteo- arthritis may have limited mobility,
it is likely to benefit from short gentle exercise on a very regular basis to
maintain blood flow and reduce stiffness.
Why do call orders need to be agreed with the veterinarian when planning a care plan for patient?
Call orders need to be agreed with the veterinary surgeon, especially in the ECC setting. For example, what heart rate will prompt the nurse to immediately inform the veterinary surgeon of a change in patient status? The nursing plan also needs to include contingency planning for if things going wrong- such as the animal developing other problems, not responding to treatment or developing side effects from the current treatment. Thus, the nursing plan is not fixed but is dynamic – it will change from day to day or even hour to hour, especially in the ECC setting. It is also important that the nursing plan fits in with the veterinary surgeon’s treatment plan.
Effective communication between the veterinary nurse and veterinary surgeon is vital.
What does the implementation of a care plan involve?
As the name suggests this is the nursing care that is delivered to the patient- giving medication, offering fluid, hand-feeding the inappetent patient, wound management, grooming, exercise, tender loving care (TLC) etc. All the medications administered, nursing care and the timing should be documented along with the patient response.
During the implementation phase it may be that further findings are reported to veterinary surgeon, that may then influence the ongoing treatment plan for the patient.
Examples of this type of situation include-
➢ noting signs suggestive of nausea when offering food to the patient
➢ repeating a pain score following administration of an analgesic and finding
that the patient’s level of pain relief is inadequate.
What does the evaluation stage of a nursing care plan involve?
This is the stage when the effectiveness/outcome of the nursing care is examined.
This is a particularly important stage - ideally the nursing goals have been achieved and the patient is responding well. If not, then the plan will need to be reviewed - the original plan may have been effective, but the patient may have developed new problems in the meantime. Or the original plan, or more likely aspects of it, were not suitable and need to be reviewed to meet the patient’s ongoing needs.
How often should evaluation of a nursing care plan take place?
Evaluation will often take place at the same time
as implementation- something has worked well or not; evaluation will also take place at least once daily when ‘ward rounds’ are being carried out; or when there is staff handover.
What different nursing care plan models are most commonly used in the veterinary setting?
Various versions of theoretical nursing models have been used in human nursing to develop nursing plans. The two versions which were initially applied to veterinary nursing are the Roper, Logan and Tierney model and the Orem model. Since 2007, the Orpet and Jeffery Ability Model has been increasingly used in the nursing of
veterinary patients
What is the basis of the roper, logan and tierney nursing model?
The basis of this model is to relate the nursing care of the patient to the normal activities of daily living
What do the authors of the roper, logan and tierney nursing model considered the twelve activities of human daily living?
The authors described twelve activities of human daily living that they considered normal- • A safe environment • Communication • Breathing • Eating / drinking • Eliminating waste Grooming • Controlling body temperature • Movement • Work / play • Expressing sexuality • Sleeping • Dying
An assessment of how well the patient can carry out each of these is made and how they affect the nursing care that will be required.
What is the Orem nursing care model focussed on?
Orem’s model also follows the basic concepts of assessment, planning, implementation and evaluation, but the nursing care is focussed on the ability of the
patient to care for themselves (Orem, 2001). The role of the veterinary nurse therefore is to make up any deficit between what the animal should do to care for
themselves and what they are able to do. For example, if the patient is not able to groom themselves, then the veterinary nurse will need to carry this out.
What are the 8 self care requisites that are considered in the Orem nursing care plan model?
Orem listed eight self-care requisites for humans which can also be applied to animals
• Provision of air
• Provision of water
• Provision of food
• Elimination of waste
• A balance between activity and rest
• A balance between solitude and social interaction
• Prevention of hazards
• To feel normal in relation to other- N.B. this can be particularly challenging to
assess in veterinary patients. There are many questions over how developed
their emotions are and how to assess what is “normal” for the species.
What is the basis of the orpet and Jeffrey ability nursing care plan model?
This is the first veterinary care model based on • Assessment • Care Plan • Evaluation • Influencing factors
The rationale behind this model is eliciting information from the owner on the patient’s usual routine against the ten ‘abilities’ from the model. The patient’s ability
to perform these, along with potential and actual problems are considered. All the information is then used to create a care plan for the period of hospitalisation
What are the 10 abilities that should be considered in the Orpet and Jeffrey ability nursing care plan model?
Is the animal able to - • eat adequate amounts? • drink adequate amounts? • urinate normally? • defaecate normally? • breath normally? • maintain body temperature? • groom and clean itself? • mobilise adequately? • sleep & rest adequately? • express normal behaviour?
What would be considered to be a nursing process?
➢ assess ALL the patient’s needs
➢ plan the nursing care
➢ fully implement nursing to meet the patient’s needs and support its recovery
➢ evaluate the nursing care.
What will the frequency of how often a patients nursing care plan is evaluated depend on ?
The frequency with which all of this is done will depend entirely on the patient’s underlying problem. With critical patients there will be very frequent assessments and the plan may be altered often. It is crucial with ECC patients not to overlook or
be distracted from the nursing process during the case management. With ECC patients, it is essential to consider all the patient’s current needs and the nursing
care appropriate to its current condition. However, as this is a dynamic situation, the patient’s needs and nursing care requirements may change rapidly and frequently. It is also important to consider the whole patient and not just focus on the disease/
injury in relation to the patient’s needs and care. For example, detailed wound care may be planned and implemented in a trauma patient, but if appropriate nutrition is not provided, the patient’s wound is not likely to heal well.
What is a catabolic process?
Without adequate nutrition, the patient must
rely on its own body stores for production of glucose for energy - this results in a catabolic process leading to break down of fats, carbohydrates and, most significantly, because of sympathetic nervous system stimulation, proteins.
Why does the breakdown of proteins occur particularly in critical care patients?
occurs, particularly in critical care patients, to provide amino acids for immunoglobulin and acute phase protein production - the two mainstays of the
body’s defence system.
What happens to the metabolic rate in ill patients?
The metabolic rate of animals in starvation normally
decreases but in ill patients, it increases meaning the patient’s energy requirements
increase.
What cells in the gastrointestinal tract require nutrients for survival?
An additional important consideration is that the enterocytes of the functioning gastrointestinal tract need a direct supply of nutrients to aid their survival.
What will happen if enterocytes in the gastrointestinal tract do not receive any nutrition?
Enterocytes are one of the most rapidly dividing cells in the animal’s body and need a constant source of energy delivered directly to the intestinal lumen to maintain gastrointestinal health. The lack of delivery of a continuous supply of energy to the enterocytes results in damage and atrophy of their villi. Ongoing lack of adequate nutrition leads to death of enterocytes and inability to replace them.
How cam a lack of continuous supply of energy to the enterocytes result in ileus?
The lack of delivery of a continuous supply of energy to the enterocytes results in damage and atrophy of their villi. Ongoing lack of adequate nutrition leads to death of enterocytes and inability to replace them.This creates a weakness in the intestinal barrier which makes it more likely that bacteria and
endotoxins will gain access to the systemic circulation. With a lack of enterocytes, fluid and food matter stagnates in the GI tract which can lead to the patient
developing ileus and other complications
Why is enteral nutrition preferred over parenteral?
This explains why considering the nutritional needs of the patient is essential and why enteral feeding is preferred where possible rather than parenteral nutrition (Devey, 2008). Enteral nutrition is easier to safely deliver than parenteral nutrition in
veterinary patients; and provides more balanced nutrition, with less risk of sepsis. It
is also significantly cheaper. However, its main drawback is where there is significant
gastrointestinal (GI) tract damage
What is microenteral feeding?
Micro-enteral feeding is the delivery of very small amounts of easily absorbed
nutrients (glucose, amino acids and small peptides), electrolytes and water directly to
the gastrointestinal tract. The aim of micro-enteral feeding is to feed the enterocytes
rather than meeting the patient’s entire nutritional requirements.
Micro-enteral nutrition delivers minimal calories and so does not provide all the energy requirements for the patient. It is purely a supportive means of
attempting to main GI health until full enteral nutrition can begin. It also supports the function of gut-associated lymphoid tissue (GALT)
What is the calculation for micro-enteral nutrition?
Micro-enteral nutrition is administered slowly (e.g. 0.25 – 0.5ml/kg/hour) or 1-4 ml/kg bolus every 2-3 hours - in this way the GI tract is not stressed. Providing nutrition to the enterocytes has been shown to decrease recovery time in dogs suffering from
diseases such as parvovirus
What are the aims of nutritional support in the veterinary patient?
The aim of nutritional support for the veterinary patient is to provide sufficient nutrients (energy, protein, essential fatty acids and micronutrients) to - • meet the daily requirements • minimise abnormal metabolism • minimise protein breakdown • support the immune system • support wound healing and repair • avoid overfeeding
What are the three different energy calculations for RER?
Energy calculations for patients at rest (RER or resting energy requirement) include:
➢ RER (kcal) = 70 (bodyweight (Wt.[kg]) 0.75
➢ RER (kcal) = 30 x (Wt. [kg]) +70
➢ RER (kcal) = (40 or 50) x (Wt. [kg])
The guidance varies as to which should be used (see personal communication)
Why are the protein requirements likely to be elevated in sick patients?
In diseased states, stress starvation develops where protein breakdown, proteolysis, is accelerated – in contrast to fasting in the healthy patient where fat stores are preferentially broken down. The inflammatory response, associated with illness and injury, leads to altered cytokines and stress hormone levels which changes metabolism, promoting a catabolic state, especially protein catabolism (Chan, 2013).
Thus, the protein requirements are likely to be elevated in sick or debilitated patients proteins and amino-acids are needed to provide inflammatory proteins, repair tissues
and produce antibodies etc
What percentage of protein content should be provided in the total energy provision?
The protein content should provide 20-30% of the total energy provision for patients
receiving enteral nutrition.
How many g/kg of protein should be provided to dogs to provide their total energy requirements?
This equates roughly to 2-3g/kg bodyweight in dogs
How many g/kg of protein should be provided to cat to provide their total energy requirements?
> 3g/kg bodyweight (>30% total energy provision) in cats
What patients would not be able to tolerate higher levels of protein?
Protein intake may have to be reduced in patients that cannot tolerate higher levels of protein such as those with renal failure.
What basis is the nutrient content of foods evaluated on?
When the nutrient content of foods is evaluated, it is mainly done on a “dry matter” basis. This is a better reflection of the amount of individual nutrients present
in each food.
What nutrient has twice the number of calories per gram as carbohydrates and protein?
Energy dense diets such as Hills a/d® have a high fat content - fat has twice
the number of calories per gram as carbohydrate or protein.
Is dietary fat related to pancreatitis in cats?
In feline patients, the amount of dietary fat is not thought to be a causative factor for
the development of pancreatitis
Why is it important to provide dietary glucose?
In critical patients, glucose is an immediate energy source especially for the central nervous system. Glycogen stores are often rapidly depleted meaning that if dietary glucose is not provided, new glucose must be obtained by gluconeogenesis via the
breakdown of body proteins especially muscle, as discussed above.
What are some tips to avoid causing food aversion?
Tips to avoid causing food aversion include-
• If the patient is showing signs of nausea or discomfort when the food bowl is presented, immediately remove it from the kennel and patient’s view
• If a patient declines one food type, remove it from the kennel and wait for a
period (~1-2hrs) before offering another food type. Food should not be left in the kennel unless it is clear the patient is not nauseous.
• Multiple bowls of different types of food should not be left with any patient
• Food should be offered in small amounts initially until the patient is eating reliably by themselves.
It is also important when nursing patients to recognise clinical signs that may suggest nausea e.g. salivation or dysphagia, moving away from the bowl, turning the
head away or growling and hissing.
Why should patients not be force fed?
In addition, canine and feline patients should not be force fed, including syringe feeding, as this can cause aspiration, induce more stress, and lead to food
aversions; however, assisted feeding may be appropriate as long as performed with care
What can encourage voluntary eating?
Spending time with a critical care patient, managing the environment (e.g. decreasing noise and providing a hide) and providing appropriate tender, loving care may be sufficient to encourage voluntary eating in some patients, especially if factors such as using a similar bowl to home are considered
What are the two main options for the delivery of nutrition?
There are two main options for delivery of nutrition to a patient- enteral and parenteral routes
What route of nutrition delivery should always be used if possible?
The enteral route should always be used if possible. It supports enterocyte function and replication; it also supports the function of gut associated lymphoid tissue (GALT). Parenteral delivery of nutrition should be considered as a last resort and a short-term provision.
How is parenteral nutrition administered and why?
It requires placement and management of a central line due to the high osmolarity of
parenteral nutritional products
What problem is there a higher risk of getting with parenteral nutrition?
There is a risk of sepsis declining gastro-intestinal
health with longer periods of parenteral feeding.
Why should appetite stimulants only be used short term?
Whilst appetite stimulants may be a consideration in some veterinary patients they are ideally only used as a short-term ‘kick-start’ (Michel, 2018), on veterinary direction. Of more importance, however, with the anorexic patient is identification of
why they are not eating and how the condition can be managed. Anorexia may be pain, nausea or even stress, anxiety or fear related in the hospitalised patient - all possible causes need to be reviewed
What is the most widely used appetite stimulant in the veterinary hospital?
The most widely used appetite stimulant is the serotonin antagonist (anti-emetic) - mirtazapine. Mirtazapine and cyproheptadine are considered less likely to cause side-effects than diazepam, especially in cats (Michel, 2018) but there are possible side-effects with all these appetite stimulants. Appetite stimulants tend to have a short period of action and stop working after a period, so if the underlying issue is not identified the patient may return to the practice again with anorexia.
What material is best used for a feeding tube and why?
Polyurethane or silicone tubes are preferred for longer term tube feeding - being soft
and flexible, they are less likely than polyvinylchloride or red rubber tubes to cause
patient injury and discomfort or be affected by stomach acid
What type of patients is orogastic tubes used most commonly in?
Orogastric tubes (stomach tubes) tend to be used to provide nutrition to neonates
when they are too weak to suckle from their mother or take a bottle; they might also
be used in other species e.g. birds or chelonians.
What are the risks involved with using a orogastric tube?
Introducing the tube repeatedly can be stressful and could cause oesophageal damage. In neonates, particularly kittens and puppies, incorrect placement of these tubes must be avoided as it leads to fluid or
food being delivered directly to the lungs and can cause drowning. Naso-enteric tubes are generally preferred to orogastric tubes.
If the animal regurgitates, there is a risk of aspiration which could result in aspiration pneumonia; if the tube is incorrectly placed, food or fluid will be introduced into the respiratory tract- a very serious occurrence; additionally the patient may bite through and swallow the tube. In adult patients orogastric tube placement is not appropriate for assisted feeding. An orogastric tube may be used for gastric lavage or in a patient
with gastric dilatation. However, in these situations, the patient should be sedated or under anaesthesia.
What is the insertion technique for an orogastric tube?
A flexible feeding tube of 8-12 French Gauge (FG) for cats and dogs <8kg; and 12- 24 French Gauge (FG) for dogs >8kg is required. The tube is premeasured from the rostral part of the jaw to the level of the ninth intercostal space (level of the stomach); a mark is made on the tube so that the handler knows when the tube has been inserted to its correct depth. If being used repeatedly for feeding a neonate then a
tape marker can be used. The tube is suitably lubricated with KY gel or another non-toxic water-based lubricant; the patient’s mouth is opened and the tube is passed over the tongue until a swallow reflex is elicited. Once this occurs, the tube should be advanced slowly, with the swallow, to allow entry to the proximal oesophagus. The tube is then inserted to the level of the mark, signifying it has entered the stomach. If the patient coughs this suggests the tube has entered the trachea. If the patient can vocalise around the tube, this usually indicates that it is correctly placed in the stomach. To confirm the orogastric tube has been introduced as far as the stomach, suction should be applied to the tube. If fluid is aspirated, the tube is likely to be in the stomach; if the tube is in the oesophagus, aspiration (1-2ml) will rapidly cause negative pressure as the oesophagus collapses around the end of the feeding tube. Prior to administering food through the tube, a small volume of water should be flushed through to ensure the tube is in the correct place and that it is not blocked.
The liquid feeding formula may then be administered, the tube flushed again with water and then withdrawn.
How long can a nasogastric tube be in place for?
These methods of feeding are suitable for a short-term period (< 7 days)- this is preferable to repeated orogastric intubation
What is the main disadvantage of a naso- oesophageal or gastric tube?
As NO and NG tubes are relatively very narrow, their main disadvantage is that only truly liquid formulae can be used
What conditions would be unsuitable for a naso-oesophageal or nasogastric tube and why?
NO and NG tubes are not appropriate for patients with oesophagitis, megaoesophagus, nasal injuries, epistaxis or (repeated) vomiting; if there is a risk of increased intracranial pressure, they are not appropriate due to the risk of sneezing. They are also not appropriate for unconscious patients, those lacking a gag reflex or patients with pharyngeal or laryngeal issues Due to the narrow bore, there is a chance of these tubes blocking; there is also the
potential for tube removal by the patient.
What should be considered when using an NO or NG tube?
When considering whether to use a NO or NG tube, the following can be considered-
• does the patient have a condition such as parvovirus enteritis where access to the stomach is required to remove the build-up of air or fluid? in many patients, a naso-gastric tube can be useful to carry out gastric decompression
by removing fluid or air, as indicated by the patient’s status and illness.
• in a patient who is ‘simply’ anorexic and there is no concern over fluid/ air build- up or ileus, then naso-oesophageal tube placement, terminating in the
distal third of the oesophagus, is suitable for providing nutrition.
N.B. Whilst there has been discussion (Michel, 2018) about a potential increased risk
of gastro-oesophageal reflux if the tube is positioned in the stomach, the current
evidence does not support this.
What is the insertion technique for a naso-oesophageal or naso-gastric tube?
Insertion technique
Polyurethane or silicone tubes are preferred, particularly if entering the stomach as neither of these two materials will harden with exposure to acid (unlike polyvinyl tubes). The size of tube selected will be dependent on the patient size e.g. ~ 3 French Gauge (FG) for neonates; ~ 5 French Gauge (FG) for cats and dogs <8kg; and ~ 8 French Gauge (FG) for dogs >8kg. Before placement, it is important to confirm that the tube to be used is a suitable length for the patient it is to be placed in. Naso-oesophageal and nasogastric tubes are placed in a similar manner- the main
difference being that the nasogastric tube ends in the stomach and the nasooesophageal tube ends in the distal oesophagus. Both tubes are inserted, as their
name suggests, via the nasal passages
Local anaesthetic is drawn up into a 1ml syringe with a 23-gauge catheter attached; and is then sprayed into the nasal passage of the dog/cat. The time required for the local anaesthetic agent to work should be recorded and the patient returned to the kennel until this time has elapsed. Additionally, a drop of lidocaine can be introduced into the conjunctival sac, on the selected side, which will travel to the nasal cavity via
the nasolacrimal duct. By increasing patient comfort, this can facilitate placement of the tube. The measured and marked tube is lubricated with a water-soluble gel. The end is then directed ventromedially into the nasal passage (aim toward the base of
the opposite ear); and gently threaded to the depth of the mark. The patient’s head should be kept at a normal angle to encourage swallowing of the tube rather than its passage into the trachea.
Once correct placement has been confirmed, the tube is fixed in place either by suturing it to the skin/fur in these locations or stapling with butterfly tapes on the
tube:
• immediately as it exits the nasal cavity laterally
• on the dorsum of the frontal bone area
• on the top of the head
What equipment is required for placement of a naso-oesophageal or naso-gastric tube?
The equipment required for placement is -
1. local anaesthetic
2. naso-oesophageal / nasogastric tube (pre-measured from nose to seventh
intercostal space (naso-oesophageal) or ninth intercostal space (nasogastric) and marked with indelible ink or tape)
3. suture material and tissue glue; or butterfly tabs on the tube and suture material/ a stapler
How can you ensure correct positioning for a naso-oesophageal or gastric tube placement?
Correct positioning should be confirmed radiographically using two orthogonal views.
Radiography is the only way to be certain of correct placement of the tube and should be performed prior to starting to tube-feed the patient.
Additional placement checks could be performed by checking for negative pressure (by attaching a syringe and applying suction); and instillation of a small volume of sterile water/ 0.9% saline into the tube. For a NO tube, an end-tidal CO2 monitor, with adaptor, can be attached to the tube to check placement in the oesophagus. The oesophagus will have negligible low/ zero levels of CO2.
What could indicate that a NO or NG has passed in to the airway?
Coughing would suggest that the tube had passed into the airway, however, in critically ill patients the cough reflex is often suppressed and so this is an unreliable
way of confirming correct placement.
Where should an NO or NG tube be secured once it has been placed?
Once correct placement has been confirmed, the tube is fixed in place either by suturing it to the skin/fur in these locations or stapling with butterfly tapes on the
tube:
• immediately as it exits the nasal cavity laterally
• on the dorsum of the frontal bone area
• on the top of the head
Why is it important not to secure an NO or NG tube along the side of the face in a cat?
It is particularly important, in a cat, not to secure the tube along the side of the face as it is an extremely sensitive area and the whiskers can be irritated. It is, however, acceptable to secure the tube along the side of the face in dogs if required.
Why is it best not to use super glue to secure an NO or NG tube?
Historically tissue or super glue has been used. However, when the tube is removed the hair in that area will be pulled out with the glue and quite often does not grow back so this should be avoided if possible and other options are available.
An Elizabethan collar is then placed to prevent removal by the patient; and the tube should be capped.
How do you use and maintain an NO or NG tube?
Feeding can start immediately after placement, as required. Daily feeding amounts are usually calculated and then divided into 4-6 small volumes; or administered continuously via a syringe driver. Before and after every feed, the tube should be flushed through with some sterile saline/ water to ensure patency and that it has not become displaced. After feeding and further flushing, the tube should be capped, to prevent air from being sucked into the stomach/oesophagus. The external nares
should be kept clean. N.B. Sterile saline or water is used in case the tube has been dislodged and the patient is at risk of aspiration. Bearing in mind the cough reflex may be suppressed, assessing for dislodgement this way may be challenging and is
a relatively unreliable method. The patient must be watched carefully during administration of liquid for any signs of agitation/ distress that might suggest fluid is
entering the lower respiratory tract. If aspiration has occurred it is likely to affect the patient’s respiratory function so the patient’s breathing (rate, pattern, noises) should be carefully monitored at each check.
The tube should be assessed regularly to ensure it has not moved- thus, the requirement for marking the correct insertion depth on the tube prior to placement.
Care should be taken to monitor patients that have vomited, as the tube could be expelled, damaged or aspirated, if a section has been regurgitated into the mouth and then bitten off. To prevent removal by the patient, an Elizabethan collar should be used. The tube can be easily removed when it is no longer required- the sutures/staples are removed and the tube can then be taken out.
What are the most common problems with NO or NG tubes and delivery of nutrition?
The most common problem is removal of the tube by the patient. Gastrointestinal upsets can sometimes occur with the reintroduction of feeding, especially in patients who have had longer periods of anorexia - with diarrhoea, vomiting and /or regurgitation; aspiration pneumonia is a serious potential problem if the tube is incorrectly placed or is dislodged. Aspiration pneumonia may also occur secondary
to vomiting or regurgitation. Erosion of the oesophagus with a naso-oesophageal cat is a possibility and so careful monitoring of the patient’s response to supportive feeding is essential
What is the main advantage of using an oesophageal feeding tube?
These are particularly useful in patients that require assisted feeding for several days to weeks; and in individuals who have facial trauma / injuries. They are preferred by many for use in feline patients as they are far better tolerated than the tubes placed
via the nares. Patients can be sent home with an oesophagostomy tube in place for feeding at home. They might also be used where a NG/NO tube would not be an option e.g. nasal cavity injury. nasogastric ones and so semi-solid foods may be used. Oesophagostomy tubes used are generally larger bore than naso-oesophageal or nasogastric ones and so semi-solid foods may be used. These tubes are used in preference to pharyngostomy tubes which are not now recommended due to the risk
of complications
What are the disadvantages of an oesphageal feeding tube?
Oesophagostomy tubes are placed surgically and therefore the patient needs to be anaesthetised. They are quite easy to place, and easily maintained- although close monitoring for infection at the insertion site is essential
What is the insertion technique for oesophageal feeding tube placement?
Oesophagostomy tube placement requires anaesthesia of the patient. The patient is placed in lateral recumbency and the lateral neck is clipped and aseptically prepared.
The patient is anaesthetised and intubated. An area of skin on the (left) lateral neck is clipped (mandibular ramus to thoracic inlet) and surgically prepared. A pair of long handled curved forceps is introduced into the mouth and inserted into the proximal oesophagus to a point halfway down the neck. The end of the forceps is pushed outwards to tent the skin overlying the oesophagus. The surgeon makes a stab incision over the end of the haemostats, allowing them to poke through the wound.
The distal end of the feeding tube is grasped and pulled through the wound and out through the mouth, to the premeasured mark on the tube (previously measured from the cervical region to the 7th-8th intercostal space). The end of the tube is then turned
around and fed back into the oesophagus. The tube is positioned so that the marked section of tube sits at the oesophagostomy wound site. The tube is sutured in place using a Roman sandal suture technique. Radiography should be performed to confirm correct positioning. A sterile dressing should be placed over the oesophagostomy site before taping/bandaging it in place. As the tube has been secured with an anchoring suture the dressing is to protect the insertion site more than to hold the tube in place. The tube can be flushed with sterile saline/ water and
‘bunged’. An Elizabethan collar can be used to prevent the patient from biting at the area and dislodging the catheter. Kitty Collars™ are also extremely useful for longer term use as they are lightweight and specifically developed for protecting oesophageal tubes.
What equipment is needed for an oesophageal feeding tube placement?
The following equipment is required1. All material for general anaesthesia and aseptic skin preparation
2. Surgical kit including scalpel blade and handle, curved forceps e.g. Carmalt
haemostats
3. Large bore feeding tube, premeasured and marked from the surgical insertion site to the seventh/ eighth intercostal space (i.e. the distal end of the oesophagus). Approximate tube size: cats-small dogs 6-10 French Gauge (FG); medium/large/giant dogs ≥ 12→ 18 →30 FG. As with NO/NG tubes, polyurethane and silicone tubes are better for longer term placement.
Commercial kits are available often with accompanying placement instructions (e.g. Vygon Vet, 2015; Mila International (2015))
4. Suture material
5. Bandages/sterile dressings/ Kitty Collars™
6. Bung for the tube
How do you maintain and use an oesophageal feeding tube?
Daily maintenance involves checking the wound site and ensuring the tube has not become displaced. The stoma site should be managed aseptically- any evidence of patient distress or discomfort; pyrexia, wound swelling, reddening, discharge or
abnormal smell should be noted and reported to the veterinary surgeon. The dressing should be changed daily, or when soiled, and replaced.
The tube can be used as soon as the patient recovers from anaesthesia (Brown, 2013); although others recommend waiting a period before using (Aldridge and O’Dwyer, 2013). The feeding plan will be dictated by the patient’s underlying condition, reason for placement and prior length of starvation etc. 30-50 % of the RER should be fed on the first day of feeding; this should be increased to 100% over
the next 1-2 days. The meals should be split into several (4-6) small meals daily. Before and after each feed the tube should be flushed with sterile saline/ water. If the patient coughs or becomes distressed, no food should be administered until the
placement has been confirmed. Some authors (Aldridge and O’Dwyer, 2013) advocate aspirating from the tube prior to flushing and feeding. This is a feeding tube that relies on gravity so once food is introduced into the tube it should slide down the oesophagus into the stomach. If food or water is being aspirated from the tube, then this might indicate a problem with either the tube or the patient. Aspiration of these tubes is useful for a quick check of placement prior to feeding- as the oesophagus is air filled, when a syringe is used to aspirate the tube, negative pressure will be rapidly apparent (1-2 ml) indicating correct placement
What are the possible problems involved in the placement of oesophageal feeding tubes?
Important structures e.g. the jugular vein may be damaged during placement. The tube may become dislodged into the mouth and then chewed with pieces being swallowed or aspirated. Aspiration pneumonia, patient removal of the tube and tube blockage are further potential complications. Infection at the insertion site is also relatively common.
Oesophagostomy tubes should not be used in unconscious patients; those with repeated vomiting or oesophageal disorders.
When would a gastrostomy tube be indicated?
When there is disease, infection or injury to the upper alimentary tract and a need for long-term nutritional support (>3 days), placement of a gastrostomy tube may be considered
How long can gastrostomy tubes be kept in place?
These are the widest bore tubes and can be left in place relatively long-term if well-maintained (1-6 months) (Aldridge and O’Dwyer, 2013); up
to one year (Michel, 2018) or permanently
What would placement of a gastrostomy tube not be appropriate for?
A gastrostomy tube would not be appropriate for a patient with persistent vomiting
What two methods of placement can gastrostomy tubes be placed?
Gastrostomy tubes can be placed either surgically or endoscopically.
How are gastrostomy tubes placed surgically?
Gastrostomy tubes can be placed surgically - this method is usually undertaken when a laparotomy is already being performed. The incision through the flank and into the stomach is made separately from the laparotomy incision. The tube is placed through the body wall into the stomach- a purse string suture is placed around it to secure it tightly. In addition, the tube can be ‘pexied’ into place with sutures placed around the incisions between the stomach wall and the abdominal wall to create adhesions; the omentum can also be used to seal the wound and prevent leakage (
What equipment is required for endoscopic assisted placement of a gastrostomy tube?
The following equipment is required:
1. clippers and skin preparation
2. surgical kit and drapes
3. non-absorbable, monofilament suture material
4. flexible endoscope
5. peg mushroom tipped tube (various companies produce commercial kits and
describe the placement technique e.g. Vygon Vet (2015, (a)); Mila (2015, (a))
6. hypodermic needle/ intravenous catheter
7. dressing and bandage material
8. Elizabethan collar
What is the technique for a endoscopic assisted placement of a gastrostomy tube?
➢ The patient is positioned in right lateral recumbency; clipped over the left
caudal ribcage and cranial abdomen and the skin is surgically prepared.
➢ The endoscope is passed down the oesophagus into the stomach. Air is then
insufflated into the stomach allowing the fundus to be identified easily from the
outside.
➢ A hypodermic needle/ intravenous catheter is introduced aseptically through a
2-4 mm skin incision into the fundus of the stomach; or the trochar is inserted
through the abdominal wall if a commercial kit is being used.
➢ Suture material is threaded through the needle/catheter and grasped by the
forceps on the endoscope; or, if using a commercial kit, a guide wire is
introduced via the trochar and grasped by the endoscope. The end of the
suture material/guidewire is left protruding from the abdominal wall wound.
➢ The other end of the suture material/ guidewire (in the stomach) is then pulled
up the oesophagus. Upon exiting the mouth, the suture material/guidewire is
then secured to the distal end of the PEG tube.
➢ If a needle/catheter was used this is now removed leaving the suture material
protruding from the abdominal wall entry wound.
➢ The suture material/guidewire is now pulled from the entry wound on the
abdominal wall - this pulls the PEG tube down the oesophagus and into the
stomach. The PEG tube (which has a narrowed cap on its distal end to ease
extraction) is then pulled up to the abdominal wall entry wound; as it starts to
exit the skin, it is grasped with a pair of haemostats/forceps to pull it out
further.
➢ The tube is pulled through the wound until the mushroom tip comes to lie up
against the wall of the stomach.
➢ A Roman sandal suture is used to secure the tube to the body wall; before
applying a sterile, primary dressing to the exit wound. A full body bandage is
placed over the tube and around the body; with an Elizabethan collar
generally being required to prevent patient interference
When should feeding through a gastrostomy tube start and why?
In both cases feeding should not start, ideally, until 24 hours post placement to allow a good seal to develop between the stomach and inner abdominal wall and minimise the chance of leakage and peritonitis
What are the feeding considerations when using a gastrostomy tube?
In both cases feeding should not start, ideally, until 24 hours post placement to allow a good seal to develop between the stomach and inner abdominal wall and minimise the chance of leakage and peritonitis. Some authors state that feeding can start after 12 hours if a PEG tube has been placed (Aldridge and O’Dwyer, 2013). Initially, for ~12 hours, small volumes of sterile water (~5ml/kg) may be flushed through the tube.
After this 30-50% of the daily energy requirement (RER) can be fed in multiple small meals of ~20-30ml, 5-6 times a day. A liquid formula, warmed to body temperature prior to use, should be slowly administered. A slurry can be made by diluting various
foodstuffs with water- although, as previously discussed, the amount of energy in the volume delivered must be known. It is important to attempt to aspirate some of the liquid/food from the tube and the stomach prior to administering the next feed- this
ensures that old food is not present in the tube and that the stomach is emptying properly. If the stomach is not emptying properly, the next feed should be delayed, and the veterinary surgeon should be informed. Gastric motility enhancers may be
required.
The tube should always be flushed with sterile saline/ water before and after feeding, to ensure no blockages occur. This is more of a consideration with a gastrostomy tube as thicker preparations of food are administered through this type of tube.
By the second or third day of feeding, the volume administered can be increased to supply the patient’s daily energy requirements (RER).
What is a serious potential complication for a gastrostomy tube placement?
The patient should be monitored closely for any signs suggestive of sepsis/ peritonitis e.g. pyrexia. N.B.
Septic peritonitis is a serious potential complication if the gastrostomy tube is dislodged or removed before adhesions have formed between the stomach and body
wall.
How frequently can changing of the bandage for a gastrostomy tube occur after it has been placed for a while?
Once the tube has been in place for a while, the frequency of bandage changing can be decreased to every 2-3 days- correct positioning of the tube and absence of signs of infection should be ascertained. To protect the tube from patient interference, a body stocking (Michel, 2018) or a medical pet suit can be placed over the dressing and bandage.
What is the minimum amount of time a gastrostomy tube can be in place for?
Gastrostomy tubes must be left in place for a minimum of 10-14 days before removal. This allows sufficient adhesions to form between the stomach and the body
wall to prevent peritonitis when the tube is removed.
What possible problem may occur with the placement of a gastrostomy tube placement?
Possible problems
Poor sealing of the stomach to the inside of the body wall can lead to seepage with
the risk of localised or generalised peritonitis. The patient should be monitored
closely for signs suggesting peritonitis. Other potential complications include:
• damage to other organs e.g. spleen during blind placement
• infection/ cellulitis at the tube entry site
• blockage of the tube due to poor maintenance or kinking
• patient removal of the tube causing peritonitis
• premature removal of the tube causing peritonitis
• overfeeding (Hill, 2015)
What is the indication for a enterostomy tube?
These types of feeding tubes can be used where food cannot be delivered into the stomach e.g. diffuse gastric disease, protracted vomiting or delayed gastric emptying (Michel. 2018). They can also be useful in patients with pancreatitis or duodenal disease or injury. Due to the requirement for constant infusion of nutrients, this method requires the patient to be an in-patient.
What is the insertion technique for an enterostomy tube?
Insertion of these tubes is generally performed surgically- although a duodenostomy tube can be placed endoscopically, as with the gastrostomy tube. In addition, nasojejunal feeding tubes have been placed in dogs with endoscopic guidance and interventional radiography (Papa et al., 2009). If placed via laparotomy the ventral abdomen and, usually, the left flank is clipped and surgically prepared. The tube is introduced through an incision into the jejunum, which is closed around the tube, using a purse string suture. The tube exits the abdominal wall via a flank incision. A piece of bowel is sutured to the inside of the body wall encouraging adhesions to form, minimising the risk of peritonitis. The tube is secured to the external body wall using a Roman sandal suture. The tube should be covered with a sterile dressing and then bandaged to the body wall with a body bandage. An Elizabethan collar should be used.
How must food be delivered through an enterostomy tube?
Continuous infusion of the feeding formula is essential, as the volume which may be administered at any one time is limited by the tube size (5-8 FG) - the jejunum is not a storage organ. The tube should be flushed through with sterile saline/ water 3-4 times daily to prevent blockages which are a common complication (Aldridge and O’Dwyer, 2013). As the liquid diet must be concentrated to supply sufficient calories, there is a risk of osmotic diarrhoea.
What is the minimal time an enterostomy tube can be placed?
The tube must be left in place for a minimum of 14 days before removal to allow adequate adhesions to form between the enterostomy site and the body wall. This decreases the chance of peritonitis developing following tube removal.
How do you maintain an enterostomy tube?
The insertion site should be checked regularly for signs of infection, leakage or tube
dislodgement; with body bandage dressings being changed every 2-3 days.
Specific elemental diets produced for jejunal feeding are necessary.
What are the potentially problems that could occur when delivering food through an enterostomy tube?
Osmotic diarrhoea, due to the concentrated nature of the foods offered, is a common
problem.
Other problems include kinking and blockage of the tube and the potential for
peritonitis to develop.
What is parenteral nutrition?
This is providing nutrition by any means other than enteral route- nutrients are supplied directly into the blood stream avoiding use of the GI tract altogether.
What are the potential reasons for administering parenteral nutrition?
Potential reasons for administering parenteral nutrition include-
➢ if the patient has a non-functioning GI tract e.g. protracted vomiting, severe
malabsorption, prolonged ileus
➢ if insufficient nutrition can be provided via the enteral route
➢ if the patient is unconscious (relatively prolonged)
➢ If the patient is at a high risk of aspiration
➢ If the patient has severe neurological deficits that may increase its chances of
developing aspiration pneumonia.
What is total parenteral nutrition and partial parenteral nutrition?
Parenteral nutrition can either be described as Total (TPN) where all the nutrition
administered to the patient is given parenterally or Partial (PPN) where 40-70% of
the nutrition is given parenterally.
Ideally how should total parenteral nutrition be administered?
Ideally TPN should be administered as a constant rate infusion and will therefore require an infusion pump.
The special solutions used for intravenous administration must be stored, made-up
and administered in a sterile manner (Michel, 2018). Close monitoring is required
during hospitalisation for any evidence of complications e.g. infection at the catheter
What route and site is parenteral nutrition usually administered and why?
Catheterisation of a central vein e.g. jugular vein is generally required for
administering total (central) parenteral nutrition because peripheral veins are prone
to thrombophlebitis due to the high osmolality (~ 550mOsm/L) of the parenteral
nutrients.
Preparations used in partial parenteral nutrition, however, are more dilute and
therefore can be administered via a peripheral vein (peripheral parenteral nutrition)
What are parenteral liquid formulas usually made up of?
The liquid formulas used for parenteral nutrition, in the cat and dog, contain a source
of protein (amino acids), carbohydrate (as dextrose) and lipid emulsion. Trace
minerals and water-soluble vitamins, such as the B vitamins, may be added to thisalthough other fat-soluble vitamins are better administered separately, if required
(Michel, 2018). Solutions can occasionally be purchased from a local hospital and
should be made up fresh each day
How long do patients usually receive parenteral nutrition and what needs to be considered if it is longer than this?
Most veterinary patients receive TPN for no more than a week- if it must be used for a longer period, supplementing other nutrients e.g. folate may be required
What is a serious complication that can occur with parenteral nutrition?
Sepsis is the most common and serious complication due to the nutrients for administration being the ideal breeding ground for bacteria and fungi. In addition,
thrombophlebitis is a potential problem especially if peripheral vessels are used.
How should food be prepared prior to delivering it through a feeding tube?
For tube feeding, the food should be well-blended to ensure it is smooth and warmed to body temperature before administration. The patient should be given the
opportunity to eat voluntarily first, if appropriate.
Prior to administering the food through a feeding tube, the tube should be aspirated, what would you expect to happen? and what should you do if this doesn’t happen?
As previously mentioned, prior to administering the feed, the tube should be aspirated and negative pressure confirmed; unless it is a tube placed into the
stomach where gastric secretions will be aspirated. If a large volume of food (more than half the previous feed) is aspirated from a patient with a gastrostomy tube, the next feed should be delayed and the vet should be informed (Teft, 2015) – prokinetic
treatment may be needed.
What rate should tube feeding be carried out?
Tube feeding should be administered slowly initially (~ 1 ml/ minute)
If there are no issues, feeding should be continued at a gradually increasing rate, with the entire feed lasting 10-20 minutes
What should the patient be observed for when administering food down a feeding tube?
the patient should be observed closely for any adverse signs suggesting nausea e.g. swallowing
in excess, hypersalivation, vomiting or discomfort (e.g. unsettled or vocalising) (
What can be done if a feeding tube is blocked?
Following feeding the tube should be flushed. If the tube become blocked, it may need to be X-rayed to confirm that is it not kinked. If there is an obstruction from previously administered food, various solutions can be used to try to unblock it e.g. cola, pancreatic enzyme powder mixed with sodium bicarbonate (Michel, 2018). If this is unsuccessful, the tube will need to be removed and replaced.
What monitoring should be carried out when a patient has a feeding tube?
Careful monitoring of patients receiving assisted feeding is essential. In addition to normal monitoring (demeanour, TPR etc.), twice daily weighing and assessment of hydration status should be performed (Michel, 2018). Assessing the following from
blood samples can be of value in monitoring the progress of the patient receiving assisted feeding - blood glucose, total protein, albumin, PCV, urea and electrolytes.
Lipaemic plasma should be noted
After placement of a feeding tube how much of the patients RER should be delivered?
The aim is to provide 33-50% of the RER of the patient on day one and 66-100% on
day two - the full RER should be given by day three
What percentage of a dog and cats RER should be made up of protein?
proteins (15-25% of RER for dogs and 25-35% of RER for cats)
What percentage of a dog and cats RER should be made up of lipids?
lipids (35-40% of RER for dogs and 50% for cats)
What percentage of a dog and cats RER should be made up of dextrose?
dextrose (35-40% of RER for dogs and 20% for cats).
What are the main problems associated with feeding tubes?
The main problems associated with feeding tubes, as previously stated, are tube
blockage, dislodgment and wound site infection.
What is refeeding syndrome and what potentially life threatening problem could this lead to?
Refeeding syndrome is also a consideration in a patient that has been anorexic prior starting to starting assisted feeding (Wortinger, 2011). Since the patient has been in a starvation/catabolic state, the transition to a positive energy balance, with hyperglycaemia, can lead to a large release of insulin. This can cause potentially fatal hypophosphataemia, hypokalaemia and other electrolyte disorders.
Why should trickle feeding occur alongside parenteral nutrition?
The enterocytes of the alimentary tract normally receive their nutrients through the gut and, as discussed previously, this is important for their function and replication.
As such, additional small amounts of enteral nutrition (trickle feeding) should be given, if tolerated, to patients receiving parenteral nutrition. This has been shown to decrease hospitalisation and improve outcome in people
What are the two different types of sources of infection for nosocomial infections?
The source of the infection may be endogenous (patient source) or exogenous (external)
What are the different ways in which infections can be mitigated?
Avoidance of infection is essential- as with all patients this is aided by scrupulous attention to personal hygiene e.g. short nails, hair tied back etc.; appropriate attire e.g. PPE; frequent handwashing following the WHO method and aseptic management of patient interventions. In addition, thorough cleaning and disinfection of kennels, equipment, theatre and wards is essential, along with infection monitoring. A strict protocol must be followed for patients requiring barrier/isolation nursing. HAI/ nosocomial infections may arise in the following situations, especially.
What are nosocomial blood stream infections most associated with in hospital patients?
HAI/ nosocomial blood stream infections are most associated with indwelling vascular catheters Septicaemia associated with an indwelling intravenous catheter is called ‘catheter-related blood stream infection (
Where can infection originate from a catheter related blood stream infection?
Infection can originate from various sources e.g. migration of skin organisms contaminating the tip of the catheter or guidewire during placement; during connection of the administration set to the
catheter hub or if a contaminated infusion is administered
How can a catheter-related blood stream infection be confirmed?
Infection can be confirmed by
removing the catheter and culturing the tip
What does treatment of a catheter-related blood stream infection involve?
Treatment involves removal of the indwelling catheter and administering antibiosis based on culture and sensitivity results (Smarick and Edwards, 2015). N.B. If a patient is in an intensive care unit (ICU) and
has multiple lines and catheters in place, it is important to consider carefully which might be causing the problem.
The most likely cause are central lines and urinary
catheters. If a patient develops pyrexia, for no apparent reason, after placement of
one of these, removal would be indicated followed by culture.
Why are indwelling urinary catheters frequently placed in veterinary patients?
Indwelling urinary catheters are frequently placed in veterinary patients
• to improve nursing care e.g. recumbent/unconscious
• to monitor urine output
• to facilitate bladder emptying in patients that are unable to urinate normally
e.g. FLUTD/ neurological or spinal disorders
• following corrective surgery e.g. repair of a urethral tear
What type of nosocomial urinary infection is most common in hospital patients and why?
Extraluminal contamination is the most common cause and arises because of bacteria ascending the outside of the urinary catheter along the biofilm that has formed
How does an intraluminal urinary infection arise?
Intraluminal infection arises when bacteria colonise the bladder through the inside of the urinary catheter. This may be associated with an open in-dwelling catheter; or a poorly managed closed collection system, especially where contaminated urine is allowed to reflux back into the bladder from the collection bag. Breaking sterility during urinary catheter placement; and perineal and peri-urethral faecal contamination are likely to increase the risk of an ascending urinary tract infection, particularly in cats and female dogs who have a short urethra.
What is a biofilm on a urinary catheter?
A biofilm can form at the catheter tip which can provide a protective barrier allowing a population of bacteria to persist. Local pH can be altered by the biofilm population
and lead to mineral deposition and potential catheter occlusion.
What are the risk factors for catheter associated urinary tract infections?
Risk factors include female gender, duration of catheterisation, length of ICU stay and the use of
antimicrobial therapy
How can you avoid a catheter associated urinary tract infection?
Avoidance of CAUTI involves-
• strict attention to aseptic technique during catheter placement and
management
• use of a closed collection system
• allowing continued, unobstructed urine flow
• keeping the collection system lower than the patient
• NOT flushing an in-dwelling catheter unless essential (and not via the
collection bag)
• removing of the urinary catheter as soon as possible
Are antibiotics indicated for patients with an indwelling urinary catheter?
Prophylactic administration of antibiotics is NOT indicated in a patient with an
indwelling urinary catheter. The focus should be on aseptic placement and
management of the catheter and collection bag, as well as appropriate patient care
and management
What should happen if a catheter associated urinary tract infection is diagnosed?
If CAUTI is diagnosed, the urinary catheter needs to be removed. This will often cause the UTI to resolve.
If asymptomatic or ongoing UTI is a consideration, urinalysis and urine culture should be performed 24-48 hours following removal of the catheter. The urine to be cultured should be obtained by cystocentesis
What type of patients are at risk of pneumonia?
Patients that are recumbent for long periods can
develop atelectasis of the dependant lung which can make them more susceptible to infection. Animals that regurgitate and vomit (e.g. post-surgery) have an increased risk of aspiration if they are recumbent. Patients that have been vomiting excessively
prior to presentation may have aspirated before admission. Endotracheal tubes and naso-oesophageal/nasogastric and tracheostomy tubes provide a route of entry into the respiratory tract for bacteria. It is therefore essential to ensure these are
scrupulously clean before placement (ET tube) and appropriately managed (NO and NG tube).
How often should recumbent patients be turned?
Prevention is important. Recumbent patients should be turned regularly (every 1-2 hours) - patients should be turned from left lateral to sternal to right lateral
recumbency Going straight from left lateral to right lateral means that both lung fields may be collapsed and could lead to deterioration in the patient’s respiratory function
What signs might be indicative of a development of aspiration pneumonia?
Great care should be taken to avoid and monitor a patient for development of aspiration pneumonia. All patients should be monitored closely for signs suggestive of pneumonia e.g. unexplained fever, tachypnoea, cough etc. In hospitalised human
patients that develop pneumonia, the mortality rate is high
What can surgical site infections be classified as and when must an infection occur for it to be considered as associated with surgery?
Surgical site infections (SSIs) can be classified as superficial, deep or organ/space; and, to be associated with surgery, must occur within 30 days of the surgical
procedure
What are the risk factors for incisional infection?
Risk factors for the development of postoperative infections have also been identified in veterinary
patients (Brown, 2012). Length of anaesthesia, duration of surgery, duration of hospitalisation, increased number of persons in the surgery room, intact males and concurrent endocrinopathies have all been identified as risk factors for the development of a SSI (Brown, 2012). Use of immune-suppressive medications and pre-existing infection are also factors.
What is the appropriate patient nursing to prevent surgical site infections?
Appropriate patient nursing is essential to prevent a SSI e.g. aseptic management of
drains and incision sites post-surgery, avoidance of hypothermia and maintaining
patient hygiene
Should antibiotics be used to prevent infection in a surgical site?
There is much debate about the use of antibiotics in the peri-operative period due to the potential for antibiotic resistance - there are many factors to consider. Antibiosis should never be a substitute for aseptic technique in patient management (Brown,
2015). The aim of administration of parenteral prophylactic antibiotics in the perioperative period is to reduce the intraoperative bacterial population below the critical level required to induce an infection. Pre- and intraoperative antibiosis will therefore generally be administered for all clean-contaminated procedures; and certain clean procedures e.g. those that involve the placement of an implant (e.g. orthopaedic or intravascular prosthesis). If the wound is already infected, ‘dirty’, the choice of antibiotic should be based on culture and sensitivity
What output of a drain would removal be considered?
The drain should be removed when the volume decreases to < 5-10 ml/kg/24 hours
Why might physiotherapy be employed for patients?
Physiotherapy may be employed • to improve circulation • allow muscle and tendon relaxation • to aid pain management • to reduce of inflammation • to promote recovery.
What patients might benefit from physiotherapy?
Physiotherapy may be of benefit in the following situations because ECC patients can be susceptible to – • build-up of pulmonary secretions • pressure sores/ decubitus ulcers • muscle contraction and spasm • muscular weakness • joint stiffness • swelling • pain • depression • boredom • stress
What situations would physiotherapy be contraindicated?
Physiotherapy would be contraindicated/ not appropriate in the following situations -
• unstable critical patients
• unstable limb fractures or spinal injuries
• head trauma
• surgical emergencies (e.g. gastric dilatation etc.)
• blood disorders
What different physiotherapy techniques can be employed for patients?
Techniques that can be employed include effleurage, petrissage, coupage and respiratory physiotherapy. Thermotherapy e.g. heat and cold therapy may be
appropriate in the management of some ECC cases e.g. orthopaedic (Van Dyke, 2010). Thermotherapy can also be useful to maintain comfort levels in the
management of patients with osteo-arthritis, that are hospitalised for another reason.
what are the benefits of positional physiotherapy?
Positional physiotherapy can be recommended by the veterinary surgeon to promote an increase in lung volume; to improve patient ability to clear secretions and reduce the risk of hypostatic pneumonia. It is the simplest and most important form of physiotherapy used to reduce the risk of, and treat, atelectasis (incomplete expansion of part or all the lung).
How do you carry out positional therapy?
Patients should be turned from right lateral to sternal to left lateral recumbency, ideally every 1-2 hours, and certainly every 4 hours, whilst also allowing for rest
periods. Additional positional techniques include supported sternal recumbency or assisted standing
How long should supporyed sternal recumbency or assisted standing be carried out in a debilitated patient?
Additional positional techniques include supported sternal recumbency or assisted standing. Short times should be used in each of these positions (<15 mins)
as it can be distressing for the debilitated patient. It is important to closely monitor the patient for any sign of distress or deterioration in respiratory function. As with all physiotherapy build up gradually to 15 minutes - starting with shorter times 3 - 4 times daily. The patient should be supported comfortably in each position.
What are the benefits of assisted standing?
Assisted standing encourages the patient to take breaths- increasing lung capacity
and expansion; with improved tidal volumes stretching the airway and encouraging
coughing.
What is postural drainage?
Postural drainage should be used with the patient in lateral recumbency, with the lung to be treated uppermost and the patient’s head lowered. Gravity is used to assist drainage of fluid. Postural drainage positions should be used in the short
treatment times suggested above.
What is nebulisation and what is the benefit of it?
Prior to chest physiotherapy, the veterinary surgeon may recommend nebulisation where aerosolised droplets of sterile water are delivered into the respiratory tract.
This is intended to hydrate the tissues and moisten secretions making them easier to mobilise and cough up
What is the benefit of coupage and vibrations?
Coupage and vibrations are techniques which can be used to encourage the movement of fluid within the airways by loosening secretions. The patient should be
in a postural drainage position. It is useful in patients who are recumbent for long periods as they are in danger of developing atelectasis and dependant lung oedema; it may also be used in some patients with chest infections e.g. pneumonia, bronchiectasis, bronchitis etc.
What is coupage?
Coupage involves the rhythmical percussion of the wall of the thorax with cupped hands and loose wrists.
What are vibrations?
Vibrations involves placing the hands on the wall of the
thorax and moving them quickly from side to side: this helps to dislodge mucous and fluid from the alveoli into the larger airways to be ultimately coughed up.
When would coupage or vibrations not be appropriate?
They would not be appropriate if the patient had rib fractures, marked pain or indwelling chest drains etc.
How long should coupage and vibrations be performed?
Both techniques should only be performed over 4-6 respiratory cycles at a time.
What are the general physiological effects of chest physiotherapy?
General physiological effects of chest physiotherapy -
• encourages movement of fluid and mucous out of the lungs
• reduces the microbial load of infection in the lungs
• improves lung capacity
• reduces or prevents pressure sores
• increases feeling of well being
How can coughing be encouraged?
With all chest physiotherapy, promotion of coughing of the secretions is important.
This can be encouraged by extending the neck or gentle airway compression.
Aseptic suction techniques may be required in debilitated patients.
What are the contraindications for respiratory physiotherapy?
Contraindications for respiratory physiotherapy -
• recent trauma or surgery
• patients with obvious chest injuries
• flail chest
• fractured ribs
• bleeding disorders
• certain medical conditions affecting the lungs e.g. neoplasia
What can exercise and massage therapy assist in prevention of and promote recovery for?
Exercise and massage therapy stimulate the patient, can assist in prevention of and promotes recovery for – • pressure sores/decubitus ulcers • muscle contraction and spasm • muscular weakness • joint stiffness • swelling • pain • depression
What are the contraindications for exercise and massage therapy?
Contraindications for exercise and massage therapy include –
• joint trauma or disease
• unstable fractured limbs or spinal injuries
• head trauma
• neoplasia
• bleeding disorders
• limb or spinal injuries
What is effleurage?
Effleurage: This is where the palms of the hands are used to lightly skim over the
body surface. It is used first to stimulate blood supply to the skin and is used to
promote both lymphatic and blood flow. It should be performed in the direction of the
heart. It can vary from light stroking to more vigorous firm massage towards the
patient’s heart.
What are the general physiological effects of effleurage?
General physiological effects of effleurage –
• warms skin, subcutaneous and muscle tissue (mechanical effect of pushing,
friction from rubbing and vacuum from pressure)
• promotes well-being
• promotes venous and lymphatic flow
• speeds removal of waste and supply of nutrients
What is pretissage?
Petrissage: This is more of a kneading, compressive massage effect and is useful for
decreasing/relaxing muscle tone after the initial warming provided by effleurage. As
this is more forceful, it can cause pain, so patients should be careful monitored
during this treatment.
What are the general physiological effects of pettrissage?
General physiological effects of petrissage –
• warms the skin, dermal layers and muscle
• reduction of subcutaneous lipids
• stretches some muscles and mimics normal muscle function
• increases cell permeability
• promotes blood supply and wound healing
• promotes relaxation and reduces pain
What is tapotement?
Tapotement This involves tapping the tissue rather than stroking or kneading. It may be incorporated in coupage. It can be an adjunct to pain management in some patients, although is less likely to be tolerated by cats.
What conditions should effleurage, petrissage and tapotement not be performed with?
Effleurage, petrissage and tapotement should NOT be performed in patients with fever, hypovolaemic shock; or over wounds, fracture or tumour sites
What is passive range of movement?
Passive exercise/ Passive range of Movement- this is where limbs are manipulated
whilst the animal is unable or unwilling to move itself.
What are the benefits of passive range of movement?>
It allows exercise of muscles
and joints to improve blood flow and venous return; it helps to maintain joint mobility
with no patient effort and stimulates the nervous system decreasing the likelihood of
muscle atrophy
What are the indications for passive range of movement?
Indications
• Patients who are unable to move due to debility or coma.
What are the general physiological effects of passive exercise?
General physiological effects of passive exercise
• stretches muscles and tendons
• exercises joints but minimises concussive effects
• encourages peripheral circulation
• encourages lymphatic return
• decrease risk of thrombus formation
What is active assisted exercise?
Active assisted exercise - when the patient is more able and, following assisted standing, it can advance to active assisted walking – where support is required e.g. a blanket or towel under the abdomen to enable the patient to start moving and regain
balance.
What is active exercise?
Active exercise - this is where the patient is encouraged to move around with controlled but regular activity. Simply taking the animal for a walk on a lead is the least stressful method and is easy to perform. Patients may be able to stand but are weak so must practise walking to regain balance and increase muscle tone. Its disadvantages are that many critically ill patients cannot perform such exercise. The
patient may need to be supported with a harness etc. It is essential to prevent damage
What are the general physiological effects of assisted active and active exercise?
General physiological effects of assisted active and active exercise - • promotes lung expansion • stretches muscles and tendons • exercises joints • encourages peripheral circulation • exercises the animal in as natural a way as possible • stimulates GI tract • increases patient well-being
The four stages of the basic nursing care plan are
(N.B. it is important to be aware of the ability model for designing and implementing a care plan for a veterinary patient)
Select one:
a. Analysis, planning, interaction and evaluation
b. Assessment, planning, implementation and evaluation
c. Amendment, provision, inspection and evaluation
d. Analysis, provision, implementation and assessment
The correct answer is: Assessment, planning, implementation and evaluation
Which of the following is assessed for the patient when using the Roper, Logan & Tierney model of nursing to create a nursing care plan? (Useful source) Select one: a. The activities of living b. The disease process c. Universal self-care requisites d. The ability to look after itself
The correct answer is: The activities of living
Orem's model of nursing care focuses on Select one: a. Age of patient b. Self care c. The activities of living d. Specific illness
The correct answer is: Self care
A 20 kg dog has been admitted with a fractured mandible. As part of the treatment plan, the veterinary surgeon has decided that a feeding tube should be placed to provide assisted feeding.
a) calculate the resting energy requirements of this patient
b) consider three problems that could be encountered if this patient was over-fed
(N.B. Please consider what feeding tubes could be used in this patient. Consider the advantages and disadvantages of each choice)
a) RER = (30 x bodyweight in kg) + 70
= (30 x 20) + 70
= 670 kcal
OR
RER = 70 (bodyweight (Wt.[kg]) 0.75
= 70 (20 x 20 x 20 / square root twice)
= 70 ( 9.46)
= 662 kcal
Gastrointestinal upset - vomiting, diarrhoea. Hepatic dysfunction. Hyperglycaemia. Electrolyte imbalances Respiratory distress Others
Which of the following drugs is an appetite stimulant?
Select one:
a. Ketamine
b. Amoxicillin
c. Acepromazine
d. Mirtazapine
The correct answer is: Mirtazapine
When inserting a naso-oesophageal tube in a cat:
a) state what equipment is required to place the tube
b) state the aftercare and monitoring that should be provided to the patient after tube placement
c) name 2 possible problems that could be encountered
a) local anaesthetic, lubrication tube, suture material & tissue glue, buster collar
b) the tube should be regularly assessed to ensure it has not moved. Monitor the patient to ensure that they have not vomited, biten through the tube, or moved / removed the tube. Before and after every feed the tube should be flushed through with some sterile saline to ensure patency and that it has not become displace. After feeding and flushing the tube should be bunged to prevent air from being sucked into the stomach / oesophagus.
c) aspiration pneumonia and oesophagitis
State one advantage and one disadvantage for two of the following tubes:
Naso-oesophageal Oesophagostomy Gastrotomy - PEG Gastrotomy - surgical Jejunostomy
(N.B. Please ensure you are aware of indications for use, nursing care and advantages/ disadvantages of all)
Tube Advantages Disadvantages
Naso-oesophageal
Relatively cheap and easy to place
Can be placed without a general anaesthetic
Can only give a very liquid diet
Patients may not tolerate tube
Oesophagostomy
Relatively cheap and easy to place
Can give denser diet
Need anaesthesia to put in place
Gastrotomy - PEG
Relative easy to place
Can give denser diet
Need anaesthesia & endoscope to place
Gastrotomy - Surgical Can give denser diet Need anaesthesia and laparotomy to place
Jejunostomy Can use in patients suffering from pancreatitis Need anaesthesia and laparotomy to place
a) Name 3 sites where nosocomial infections can occur
b) State 4 actions that should be taken to reduce the likelihood of an animal developing a nosocomial infection
Nosocomial infections:
blood stream infections (catheter related)
skin infections
urinary tract infections
lung infections (pneuomia)
surgical site infections
Reducing likelihood of animal developing a nosocomial infection
monitor patient carefully for development of nosocomial infections
antibacterial therapy only when appropriate
use of personal protective equipment when handling patients e.g. gloves
minimise handling of the patient
meticulous hygeine e.g hand washing etc
minimise the number of indwelling catheters and drains
Physiotherapy has been prescribed by the veterinary surgeon for a recumbent patient - describe the techniques that could be used to promote increased lung capacity
Positional physiotherapy and postural drainage, assisted standing if appropriate to increase lung expansion. Short sessions starting at 5 minutes at a time building up to a maximum of 15 minute sessions 3-4 times daily. Support well and comfortably and reduce stress. Lateral recumbancy at other times turning every 2-4 hours. however it is also important that the patient is allowed a good period of complete rest if possible.
Coupage and vibrations can also be used to reduce the chance of hypostatic pneumonia and atelectasis and to mobilise secretions. Nebulisation may be advised prior to coupage and vibration therapy. Aseptic suction techniques may be applied to remove excess secretions is a patient is unable to mobilise by coughing them up.
