Nursing Care of the Critically Ill Patient
Harold Davis, BA, RVT, VTS (Emergency & Critical Care)
Providing nursing care for the critically ill patient can be a challenging endeavor. Each case the technician encounters is different and has its own nuances. To provide high quality care, the veterinary technician is challenged to draw from their knowledge and experiences, remain flexible and be creative. The veterinary technician must have a sufficient knowledge and skill base and the ability to think critically. The knowledge base must encompass basic concepts of anatomy and physiology as well as a basic understanding of common disease processes, diagnostic, and therapeutic procedures. Technicians should also be familiar with potential complications or risk factors associated with these diseases, and procedures.
Traditionally, technicians have been trained in a task-based fashion. It will be helpful to include a goal-oriented approach for caring for the critically ill patient. Nursing goals should be directed at identifying and working towards desired out comes, and identifying and minimizing patient risk. For example, the doctor has diagnosed severe dehydration. The goal is to correct fluid volume deficits. The patient will need to be placed on IV fluids. The patient is now at risk for the development of 1. Cathter related infection, 2. Other catheter related complications (phlebitis, thrombosis, infiltration, etc.) and 3. Fluid overload. The technician should be prepared to take action to minimize these risks, recognize them if they occur and take appropriate action to correct the problem. This discussion will address various nursing care procedures and include desired goals or outcomes along with potential risk factors. Figure 1 will form the foundation for this discussion.
Figure 1 Patient Care Checklist
Upon receiving responsibility for the care of a patient the veterinary technician should assess the patient. The assessment includes becoming familiar with the patient's history, and performing a physical examination.
The history may be obtained from the client or may be passed on between technicians during rounds. Rounds are an excellent forum for communication. Information (Figure 2) should be provided as to the significant changes in the patient's status. The technician should become skilled at performing physical examinations; it defines the patient's responses to the disease process. The physical exam helps establish a baseline for comparison in evaluating ongoing nursing or medical interventions. At minimum, a temperature, pulse, and respiration should be checked; in addition mentation should be noted, chest auscultated and the bladder palpated. The patient's hydration status should be determined. A quick assessment should be made of all catheters. Following the nursing assessment and a review of the doctor's orders, plans should be formulated for the nursing care of the patient.
Figure 2 Topics to be addressed during rounds
Planning Patient Care
Planning patient care involves developing plans to meet the needs identified in the assessment phase. Planning helps the technician become organized, set priorities, and contemplate actual and potential problems or risk factors. The technician should be capable of recognizing those risks and have a plan for dealing with them. A part of the planning process includes the development of nursing care plans. Nursing care plans should include monitoring ins and outs, nutritional support, meeting comfort needs including assessing for pain. Measures should be taken to minimize the risk of nosocomial infections. Bandage and wound care should be performed. Non-ambulatory patients will require recumbent patient care. Catheter care will need to be performed.
Implementation of the Nursing Care Plans
Monitoring Ins and Outs
The nursing goal of monitoring "ins and outs" is to ensure maintenance of fluid balance and nutritional intake. "Ins and outs" provide valuable information about fluid balance and nutritional intake. The patient's entire intake and output is monitored and documented. "Ins and outs" are monitored at regular intervals throughout the day. Intake includes all fluids (water, IV fluids including blood products, and liquid diets). Output includes, urine feces, vomiting and third space losses (fluid loss into body cavities). The total volume of fluids "in" should be compared to "outs", the two volumes should be just about equal. If "ins" exceeds outs the patient is at risk for fluid overload. If "outs" exceed "ins" then the patient is at risk for dehydration. Assessing body weight is another way of determining fluid balance. Acute changes in body weight are usually a reflection of acute fluid gains or losses.
When documenting food intake it is better to document the number of kcal's eaten rather than the number of cans or jars eaten. Usually the cans of food state the caloric density of the diet. By recording kcal's eaten, the technician will have a better idea as to whether or not the patient is meeting it's energy requirements.
The nursing goal is to ensure that the patient is meeting its energy requirements. There are serious negative consequences of acute malnutrition including: decreased immune response, loss of function of tissues and organs and delayed wound healing. A patient's history may be helpful in determining if nutritional support is needed. If it has been three or more days since the patient ate, nutritional support may be indicated. The physical exam might reveal acute loss of lean body mass, fat, muscle wasting, or edema. Hypoalbuminemia and lymphopenia may indicate poor nutritional status. Once it is decided to initiate nutritional support the technician will need to calculate the patient's energy requirements.
Most hospitalized veterinary patients can be fed at their calculated resting energy requirement (RER), realizing their actual energy requirements may change over the course of the disease process and recovery. 1 RER can be calculated using either one of the following formulas. The allometric formula (RER (in kcal/day) = 70(BWkg0.75)) is used in dogs and cats of all weights or the linear formula (RER (in kcal/day) = (30 x BW kg)+70) may be used in patients that weigh at least 2 kg.
Once the daily caloric requirement (kcal/day) is determined and the diet has been selected, the volume of food to feed is calculated. Divide the daily caloric requirement by the caloric density (kcal/can, kcal/ml etc), to determine the total daily volume of diet to feed.
Patient Comfort Needs
The nursing goal for meeting the patient's comfort needs depends on what comfort need the technician is addressing. Comfort needs includes keeping the patient clean and dry, seeing to the patients mental well being, assessing the patient for pain
The nursing goal is to prevent urine scald and skin break down. This goal is accomplished by keeping the patient clean and dry. Should it urinate or defecate on itself, the patient should be washed with a mild soap and water. Care should be taken to remove all the soap. Finally, the patient is dried.
It is important to consider the patient's mental well-being. Prior to treating a patient (poking, sticking and prodding) take the time to make friends with the patient; this may set the tone for further encounters with the patient It is helpful to talk and pet them when treatments aren't due, so they don't assume that every time you open the cage door it means poking and prodding. Taking a patient out on a walk can do a lot to lift it's spirits. Since many dogs don't like to urinate in their cage this will give them the opportunity. With cats consider positioning their cage near a window so they can get a little sun, this may be beneficial in lifting their spirits. It is important for a patient to have time to rest; try and group treatments together so that the patient has some time to rest.
It is important to take a proactive role in addressing pain management. One should assume that if the procedure is painful for a human, it is likely to be so for an animal. Waiting for a patient to show signs of pain is a poor approach to pain management. In this instance a higher dose of analgesia may be required to relive the pain compared to taking the proactive or pre-emptive approach.
It is imperative that the technician be observant of signs (Figure 3) associated with pain. Individually these signs do not indicate pain, but collectively and given the patient=s recent history an assessment regarding pain should be rendered.
Figure 3 Clinical signs suggestive of pain (considered collectively)
Nosocomial infections are hospital-acquired infections: the patient did not enter the hospital with the infection. Factors that predispose a patient to a hospital-acquired infection include age (geriatric or neonate), immunosuppressed patients, diagnostic and therapeutic invasive procedures, antimicrobial therapy and long-term hospitalization. Nosocomial infections are perhaps more common in large hospitals and referral centers. Common causes of nosocomial infections include Escherichia coli, Klebsiella, Salmonella, canine parvovirus and feline panleukopenia. The nursing goal is to minimize the risk of nosocomial infections (Figure 4)
Figure 4 Steps to be taken to reduce risk of nosocomial
Bandage / Incision or Wound Care
Bandages are placed to protect lacerations and surgical incisions and provide minimal support. They should remain dry and clean. The veterinary technician should look for signs that an appendage bandage is too tight or is irritating to the patient. The exposed toes at the end of the bandage should be warm and not swollen. The bandage should be free of abnormal odors. The skin above the bandage should be checked for local irritation. The bandage should be evaluated if the patient is licking or chewing the bandage.
A patient's surgical incision should be evaluated several times a day. A surgical incision may be expected to produce mild redness and swelling with no drainage from the incision site. Extensive surgical manipulation, infectious contamination, or self-mutilation (licking, scratching), cause swelling, redness, bruising, drainage and an area that is hot to the touch.
Localized swelling, which is fluid filled, may be due to a seroma (serum pocket) or hematoma (hemorrhage) formation. Swelling that occurs several days postoperatively and is hot to the touch, may be due to an abscess or cellulitis.
Dehiscence is the separation of all layers of an incision or a wound. Dehiscence of an abdominal wound may result in evisceration of abdominal organs.
If a patient is aggressively licking or pawing the incision site, appropriate action should be taken to prevent this.
All wound/incision checks should be documented in the medical record. Any abnormal findings are brought to the attention of the clinician.
Recumbent Patient Care
Patients suffering neurological, orthopedic, or traumatic problems can be recumbent for prolonged periods of time. Care of the recumbent patient can be very challenging. Primary nursing goals are to minimize or prevent decubital ulcers and lung atelectasis. Decubital ulcers develop over bony prominences as a result of continuous pressure and damage to the skin. Other factors that contribute to decubital ulcer formation include inadequate nutrition, moist skin, decreased sensory perception, and friction or shearing forces. Only the bottoms of the feet are made to withstand the continuous pressure of the body's weight. It stands to reason that patients in lateral recumbency for extended periods of time are at risk for the development of decubital ulcers. Adequate nutrition is important for maintaining skin integrity. Moistness can contribute to skin breakdown. Friction and shearing forces may occur if a patient is dragged or pulled across a floor leading to disruption in skin integrity.
Atelectasis is the collapse and consolidation of regional small airways. This is a result of one lung being on the down side to long without adequate expansion.
To achieve the nursing goals the veterinary technicians can provide pressure relief, insure appropriate nutritional support, keep the patient clean and dry, and enhance or maintain circulation. Bedding is an important factor in the prevention of decubital ulcers. Fleece pads and blankets work well to aid in pressure relief. Air and water mattresses have also been advocated for use in the prevention or decubital ulcers. It is also helpful to place the patient on padded grates, to prevent the patient from lying in urine soaked fleece pads. If a patient becomes urine soaked it should be bathed immediately, this will prevent urine scalding. Disposable diapers are excellent for absorbing urine and keeping the patient dry. The recumbent patient should be turned every 2-4 hour if they aren't sternal. Avoid pulling or dragging the patient across the floor, rather lift and turn. Turning the patient not only prevents the formation of decubital ulcers it aids in the prevention of atelectasis of the lungs. If exercise is not contraindicated passive exercise and massage should be instituted. Passive exercise involves moving the limbs back and forth and flexing the joints. The passive exercise helps to improve muscle tone and promotes circulation. If peripheral edema is present, massage may be helpful in reducing the edema.
The veterinary technician is charged with the care of a variety of types of catheters. In general, the nursing goals for catheters include: minimizing the risk of infection, insuring functionality, and prevention of complications, which are specific to the type of catheter in use.
It is important to be familiar with the mechanism of catheter related infections. Sources of infection include: care giver hands, autoinfection, migration of organism along the catheter (internal and external), and contaminated disinfectants.
IV catheter care should be performed every 48 hours or on an as needed basis. The catheter dressing should be removed and the site inspected. You should look for signs of phlebitis, infection, and or thrombosis. Signs of phlebitis may include erythema, swelling, tenderness upon palpation, and an apparent increase in skin temperature over the vein. The signs of infection are phlebitis and a purulent discharge. Signs of thrombosis include a vein that stands up without being held off and a thick cord like feeling to the vein. When signs of phlebitis or thrombosis are apparent, the catheter should be removed and a new one placed at a different site. While flushing the catheter with heparinized saline, the insertion site should be observed for leaking of fluid at the insertion site and pain upon injection. If either one is observed, the catheter should be removed and replaced with a new one. If any portion of the catheter is exposed, it should be noted. If the catheter site looks good then the site should be cleaned with an iodophor or chlorhexidine solution. When the catheter site is dry, apply a small amount of Betadine or triple antibiotic ointment to a sterile 2x2 gauze pad and cover the insertion site with the sterile 2x2. Then re-bandage the catheter. Traditionally it has been recommended not to leave a catheter in place any longer than 72 hours. These recommendations come from human medicine. It has been shown that the likelihood of complications increases the longer catheters are left in place. 2 , 3 It has been our experience that as long as routine catheter care is performed, and the catheter removed when problems are first noticed, one can often exceed the 72 hour rule. A study looking at peripheral and jugular venous catheter contamination in dogs and cats 4 supports our experiences.
IV catheters should be observed several times a day. If the catheter bandage is found to be wet, then the reason should be identified and the bandage should be changed. Swelling distal to the catheter is usually indicative of a tight bandage. Swelling proximal to the catheter may be due to infiltration.
Urinary Catheter Care
Urinary catheter care is performed every 8 hours. It entails cleaning the prepuce or vulva and its surrounding area with Betadine scrub and water rinse. The sheath or vestibule is then flushed with a dilute Betadine solution. Apply Betadine ointment with Q- tips to the sheath or vulvar opening. The urinary catheter itself should be kept clean especially in the female patient where the vulva is in close proximity to the rectum.
The urinary catheter should be attached to a collection system. By maintaining a closed collection system you decrease the chance of a urinary tract infection (UTI). Do not disconnect the urinary catheter from the collection system. Drain the system every 2-4 hours rather than hourly. Urinary collection bags may be obtained commercially or you can use an empty sterile IV bag. The addition of 3% Hydrogen peroxide to the urinary collection system has been shown to decrease the incidence of UTI. 5 Five to ten milliliters of hydrogen peroxide is added to the urinary collection system.
Chest Drain / Gastrostomy Tube Care
The procedure for chest drain and gastrostomy tube care is much like IV catheter care. The bandage is removed and the insertion site is inspected every 24 hours. The site is cleaned and re-bandaged.
As part of nursing care, technicians should constantly evaluate the patient's condition. The technician should be looking to see if the therapy is improving the patient's condition. In addition, evaluation of the nursing care plans should be considered. Evaluation may be inherent in many of the nursing care procedures discussed such as catheter or bandage care. The technician should ask him or herself if risk factors are turning into complications. It is important to remember, "If you don't look, you won't see".