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.
