Advanced Nursing Care

Advanced Nursing Care
Danielle Mierau RVT, VTS (ECC)

Taking time to think about the case while you are doing treatments is the biggest step to becoming a great nurse. If you are just going around from patient to patient getting treatments done and not thinking about the case, you are only doing half the job. The other half of the job is knowing signalment, presenting complaint, clinical signs to watch for, drugs the patient is on and any potential drug interactions and side effects, if drugs need to be given on an empty stomach, etc. As nurses we need to take our time with each patient so we can think through the case and give it our full attention.

When I am doing treatments I always want to know how old the animal is. I can usually tell what breed they are, so I then try to think of what disorders are prevalent in that breed. What was their presenting complaint; in other words why are they here? Do they have any underlying conditions; are they a diabetic? I take all of this information and think about the patient as a whole while I am doing their treatments. If I am administering drugs I make sure the amount makes sense; we usually give 0.05-0.1 mg/kg hydro cefazolin is usually 22mg/kg, etc. If a dose or an amount sounds funny, I double check it with the primary clinician. The way you ask the clinician about the dose is important. Your tone shouldn’t be accusatory or aggressive; it should be calm and non-confrontational. We are asking because we want to make sure the drug dose is correct not because we want to point out that the doctor is wrong. You should never give a drug if you aren’t aware of why it is being used, how to give it and what the potential side effects are of giving it.

As ICU techs we should be aware of the treatment plan for our patients. If the clinician hasn’t given us this information we should find them and ask what their plan is for the patient so we know what the end goals are. Communication between techs and doctors is very important. If we aren’t communicating, then we aren’t doing our job as well as we can. We need to be able to talk to the clinicians about the patients. They are trusting us to care for their patients because they can’t sit with them 24 hours a day; that’s our job. If you are concerned about a patient you need to communicate that concern to the clinician and why it bothers you. If you are going to talk to the clinician about a concern make sure you have all of the patient’s vitals. Monitoring a patients vitals more than the doctor deems necessary is never a bad idea unless it stresses the patient out. A clinician may ask you what the patient’s SpO2 is if you are worried about their respiration rate or effort. Anticipating what they may ask and being prepared for that may help the vet to fully understand what is going on with their patient if they are unavailable to come and evaluate it themselves.

If I think a patient looks “dumpy” I always check its blood pressure. When taking oscillometric blood pressure readings always make sure that the heart rate shown on the machine is within 10% of the heart rate you have taken manually. If you are getting readings that are inconsistent or don’t make sense, double check the pressure with a Doppler. Make sure your cuff is the appropriate size; the width of the cuff should be 30-40% the circumference of the limb where you are putting the cuff on.

Primary Survey

Taking a step back from the patient and observing them for a minute gives you an opportunity to observe them in an “unstressed” state. When looking at them, be sure to note their mentation, respiratory effort, mucous membrane color, etc. A primary survey helps us to assess the animal without recording numbers..... at this point we don’t care what the respiratory rate is, we are assessing if the patient is having difficulty breathing, we want to know if their mucous membranes are anything but normal because if they are, we need to address that NOW, not after we get a heart rate and a temperature. If they have an altered mental state we have to be sure not to occlude jugular veins because this can increase intracranial pressure which is very undesirable, especially in head trauma patients. Patients with head trauma should have their heads elevated 30 degrees from their body; but be sure not to elevate just the head at the neck because this can kink off jugular veins and tracheas if the animal is debilitated enough to not correct that on their own.

If you are concerned about respiratory rate or effort, it should be addressed immediately. Oxygen is the cheapest first line drug we can give, so provide the patient with oxygen via flow-by method, oxygen hood, oxygen cage, etc. Deliver oxygen in the least stressful way possible. Patients with dyspnea should always be dealt with carefully. Dyspneic patients can be stressed to death so make sure to go step by step with them and make sure they are receiving oxygen at all times. It is important to prioritize treatments especially with these patients as you may have to do one thing at a time to avoid stressing them out too much.

Patients who are icteric, even slightly, can have liver damage, and patients with liver damage can have coagulation issues. So when taking blood from icteric patients try to stay away from jugular veins as they can and will bleed more from this vein than from a peripheral vein. At least with a peripheral vein you can put a tight bandage on it for a short time.

Feeling pulses is another way to help determine how critical your patient is during the primary survey. You should be able to feel pulses, especially femoral pulses, quite easily. If you are unfamiliar with feeling pulses practice on healthy patients so you know how they should feel before trying to find them on unhealthy patients which can be difficult. It’s a good idea to feel them upon the presentation of the patient but it is also a good idea to feel them through out the patient’s treatment to determine differences in them. As a rough guide, if you can feel a femoral pulse, the patient’s systolic blood pressure is over 60mm Hg. If you can feel a pedal pulse their systolic blood pressure is over 80mm Hg. If you have a patient with a weak, thready or bounding pulse it needs to be addressed immediately. If they need fluids, remember that the bigger the catheter, the faster the fluids are delivered. Placing large bore catheters is a good idea, even in stable patients as this gives you practice placing them in healthy veins. If you can place them in hydrated patients well, your chances are better at being able to place them in dehydrated patients. You don’t want to try placing them for the first time in patients who have less than desirable veins.... you are just setting yourself up for failure.
Increased heart rates can only be maintained for so long by the heart. If you have a large dog come in with a heart rate over 160 bpm they need to be seen immediately. They can be tachycardic for more than few reasons but the two most common are pain and hypovolemia. Pain can be treated with opioids and hypovolemia can be treated with fluids; either way the patient should be addressed asap.

Critical Care Nursing

If your patient is critical, or they will be in the hospital for a while and will require multiple blood collections sampling, catheters are a good idea. It is more invasive for the patient, but it is also more comfortable than being poked multiple times in various veins. Sampling catheters also help with decreasing the amount of people required to collect blood and they are especially helpful in fractious cats. Patients with coagulation disorders should have sampling catheters placed in peripheral veins rather than jugular veins as they will bleed less and can be wrapped tight for a short period of time to help decrease the amount of blood loss.

Urinary catheters should always be considered for patients who are recumbent and or have wounds on the back end. While urinary catheters can introduce bacteria if not cared for aseptically it is sometimes worth the risk. It is undesirable to have a patient lying in their urine especially if they have open wounds. If you need to measure ins and outs; like in patients with renal failure; having a urinary catheter allows you to do that more accurately. Sterile urinary catheter care is extremely important as it will cut down on the chance or severity of infection.

When dealing with patients who have open wounds ,be sure to wear gloves so you don’t transfer bacteria from your hands to their wounds. This will decrease the chance of infection.

Be aware of when medications need to be given on an empty stomach (sucralfate, zentonil, etc.) or to be given with food (meloxicam, etc.). Sometimes the doctors are filing out their treatment sheets in a hurry and may miss that. We, as technicians, are their double-check or back up system. Remember, we need to be careful how we ask them about these kinds of mistakes.

One of the biggest things for patients in the ICU is making sure they are comfortable. Pain medications are one of the nicest things we can provide for them while they are under our care. Be sure you know how to differentiate pain from dysphoria. You can use a pain score to help you determine this like the Glasgow Pain Score. When an animal is in pain they are still responsive and react to painful stimuli. Some sources say that elevated heart rate and/or blood pressure can indicate pain while some sources say this isn’t a good indicator. If patients are dysphoric they usually won’t react to painful stimuli and may not be responsive to environmental stimuli.

Another way to make the patient comfortable is by spending time with them. Sometimes they just need to be reassured with your presence or by you petting them. Giving TLC to the patients is necessary as it helps them mentally while they are healing physically. I am more than happy to spend my time petting a patient to get them to sleep or by talking to them and hand feeding them so they eat. We need to make sure that not every interaction with them is a negative one. This will make them more comfortable and may make our job nursing them easier.