5 quick and easy skills to use with your GI patients
This won’t come as a surprise to you, but… gastrointestinal diseases are some of the most common conditions we’ll face in practice.
From acute gastroenteritis to inflammatory bowel disease, pancreatitis to parvo, the veterinary nurse is heavily involved in the care and monitoring of our gastrointestinal patients.
And in today’s post, which is the first in a brand new 5-part series, I’m going to be sharing 5 practical tips, hacks and nursing skills you can use to nurse your GI patients more effectively.
Ready for something new this month?
I’m so excited to be bringing a brand new challenge to the blog, social media and email - introducing the Up Your Medial Nursing Skills challenge! Throughout all of October, we’ll be coming together to share 25 top tips and nursing hacks to perform with your medical patients, along with case studies, mini-trainings and more!
There are also prizes for being involved… so to get the mini trainings and case studies sent straight to your inbox and make sure you don’t miss out, make sure you’re on the VIP email list!
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So this week, for week one of our challenge, it’s the turn of our GI patients. Let’s get stuck into our first skill…
#1: Calculating and administering fluid therapy to dehydrated patients
Fluid losses are something we see SO commonly in our GI patients. Hyporexia or anorexia, regurgitation and/or vomiting, and diarrhoea are common findings in both acute and chronic GI disease, and with these, dehydration isn’t far behind.
This means that being able to assess fluid balance in our patients, quantify their fluid losses, and know how to accurately replace these is a vital GI nursing skill.
So let’s talk dehydration…
Dehydration is the loss of fluid from the interstitial/intracellular space (the fluid around +/- in our cells). This differs from hypovolaemia, which is the loss of circulating (intravascular) volume.
In GI patients, we typically see dehydration first - though severe dehydration can also lead to hypovolaemia, so patients can present with both!
Dehydration causes clinical signs such as:
Tacky or dry mucous membranes
Sunken eyes
Skin tenting (loss in skin elasticity)
Acute weight loss
The severity of these signs is used to estimate the patient’s percentage of dehydration:
Up to 4%: No obvious clinical signs
4-6%: Tacky mucous membranes
6-8%: Skin tenting, dry mucous membranes
8-10%: More marked skin tenting, dry mucous membranes and sunken eyes
10-12%: Persistent skin tenting, dry mucous membranes, sunken eyes and dull corneas; progressive signs of hypovolemia
Once you’ve got your patient’s percentage dehydration, it’s time to calculate their fluid deficit.
Calculating fluid requirements
Every 1% dehydration equates to a fluid loss of around 10ml/kg body weight.
This means that we can use the patient’s percentage dehydration to work out their fluid deficit using the following formula:
10 x body weight (kg) x percentage dehydration = total fluid deficit (ml)
We’ll then determine how quickly we’re going to correct this dehydration (usually it is over 6-24 hours, depending on the individual patient), and divide the fluid deficit by the number of hours to get the patient’s fluid rate in ml/hour.
Remember, though - this doesn’t include their maintenance fluid requirements, only the volume they’ve lost! So we need to factor this in too.
On top of this, we know that our GI patients often have further vomiting and diarrhoea in the hospital. This means their fluid requirements often change throughout hospitalisation, and one of our roles when nursing these patients is to continually assess their fluid requirements, and adjust rates as directed.
#2: How to set up and use your endoscope
If the first thought that’s just entered your head is ‘Don’t break the scope!!!’ then keep reading.
Yes, quite a lot of us have been ‘brought up’ scared of scopes, believing they are delicate, fragile and very expensive bits of equipment. And all of that IS true.
But they are also not something to be scared of - the reality is our vets put them through far more stress and strain using them than we do setting up and cleaning them!
So, handle your scopes carefully - but don’t be put off of getting hands-on with them. If you’re seeing lots of GI patients, chances are you’ll need to use your gastroscope a fair bit!
Setting up
Here is a super quick guide to setting up your scope quickly and easily - without risking damage!
Check over the outside of your endoscope for any abnormalities or damage, paying close attention to the tip of the insertion tube, relief cones, tubing and controls.
Avoid handling the endoscope by relief cones - these are there to protect weaker areas of the endoscope where components join together.
Leak test your scope before use. When doing this, gently move the angulation dials up, down, left and right - sometimes, small leaks can only be seen when the end of the scope is bent.
Deflate your scope once the leak test has passed.
Plug your endoscope into your light source and air pump on your tower (these are usually together in one unit).
Attach the water bottle, filled with distilled water, to the endoscope.
Attach the suction tubing to the endoscope and the other end to the suction unit.
Attach the camera head, or camera connection cable (depending on the type of scope you have) to the endoscope and tower.
Attach the air/water and suction buttons to the endoscope.
Test the air, water and suction functions to make sure everything is working.
Turn on the light source and camera, and white balance your endoscope.
Enter the patient details on your tower, and securely hang the scope with the insertion tip protected ready for use.
And when you’re nursing these patients during endoscopy? Keep a close eye on their ventilation, end-tidal CO2 levels and blood pressure especially. Often, as the stomach is inflated with air during the procedure, it puts pressure on the diaphragm causing hypo- or hyperventilation.
#3: How to select an appropriate diet for your GI patient
Now I’ll caveat this by saying that I am NOT a nutritionist/nutrition VTS, but diet is something that every veterinary nurse should know about when it comes to GI patients.
There are a lot of different diets out there for patients with gastrointestinal disease, because we see a wide variety of different gastrointestinal diseases - each with their own dietary requirements!
I’ve popped a quick list of some of the main ones together for you below. This is by no means an exhaustive list, and of course, the exact requirements will vary between individuals, but in general:
Vomiting patients
Vomiting patients often benefit from lower-fat, low-residue diets, since fat and fibre can delay gastric emptying. We ideally want to feed smaller, more frequent meals to avoid overdistending the stomach.
Chronic enteropathy patients (e.g. IBD)
These patients often require a hypoallergenic diet - either a novel protein (one to which the patient has never been exposed before) or a hydrolysed protein (one where the protein source has been broken down into smaller components) diet.
The theory behind using novel protein or hydrolysed protein diets in patients with inflammatory or food-responsive enteropathies is that they reduce antigenic stimulation within the immune system.
Many of these patients also benefit from a low-residue diet, and small, frequent meals.
Protein-losing enteropathy (PLE) patients
Patients with PLE have a combination of chronic enteropathy and lymphangiectasia, where fats and proteins leak from damaged lymphatic tissue in the intestines.
These patients require a low-fat diet. Specifically, we want to avoid long-chain triglycerides as these promote lymph flow and protein leakage through the GI tract.
We also want this diet to be low-residue and either hydrolysed or novel protein, since many of these patients have a concurrent IBD.
Short bowel syndrome patients
Patients with short bowel syndrome have had large portions of their intestinal tract removed, e.g. following foreign body ingestion. This causes malabsorption, weight loss and many vitamin deficiencies.
We manage these patients with a moderate-to-high fat, energy-dense diet with low-to-moderate fibre content. We often need to supplement these patients with pancreatic enzymes, fat-soluble vitamins and vitamin B12, too.
Dysbiosis patients
Patients with dysbiosis have abnormalities in their bacterial flora within the GI tract. These patients often benefit from either a low-residue or fibre-enhanced diet, depending on the individual. Patients with severe bacterial overgrowth may require antimicrobials, and patients often require prebiotics/probiotics.
Pancreatic disease patients
Patients with pancreatitis often require a low-fat diet. The exact degree of fat restriction (moderate, low or ultra-low fat content) will depend on the individual patient. Cats, for example, do not require significant fat restriction as they have naturally higher fat requirements than dogs.
#4: How to place and manage an oesophagostomy feeding tube
Patients with GI disease often require assisted feeding - and in most cases, we’ll be delivering this via an oesophagostomy tube.
These provide short-to-medium-term nutritional support and have the major benefit that your patient can be discharged with the tube in place, so our clients can continue feeding and administering medications easily at home.
So let’s talk about placement
Here’s how to place one:
Place your patient in right lateral recumbency and clip and prepare the left side of the neck.
Insert a large, curved pair of artery forceps through the mouth into the oesophagus, and push on them so the tip is tenting the skin upwards.
Adjust the tip so it is correctly positioned and away from major vessels.
The vet makes an incision over the forceps, whilst the nurse pushes the forceps up and through the incision.
The vet then takes their (pre-measured to the 9-10th rib) O tube and inserts this into the tip of the forceps.
The nurse grasps the forceps firmly and pulls them, pulling the O tube through the incision and out of the patient’s mouth.
The nurse then discards the forceps, takes the end of tube O tube in their hand, and turns this, pushing it down the patient’s oesophagus.
The vet gradually pulls on the O tube to remove the kink created by pushing the tube. Eventually, the tube will ‘flip’ and move into the correct position.
The position of the tube is checked with X-ray and adjusted as needed, before being sutured in.
The tube is covered with a dressing.
And then it’s time to manage your tube…
The main things to think about when managing O tubes are:
Aseptic handling and management of the tube: though these tubes are not sterile once in place, tube site infection is something we see commonly. We always want to wear gloves when handling the tube and ensure the site is regularly checked, cleaned with antimicrobial solution, and a new dressing applied at least every 12-24 hours.
Tube site checks: before using the tube it should be checked to ensure it remains correctly positioned. If any concerns about the tube exist, it’s safer to double-check the position with a quick X-ray before using it.
#5: How to create a feeding plan
So you’ve just placed your tube, and now it’s time to think about how you’ll meet your patient’s nutritional needs.
The first thing to do is a nutritional assessment - there are some great tools out there to help you do this, such as the WSAVA nutritional assessment guidelines.
Once you’ve assessed your patient’s nutritional needs, it’s time to create their feeding plan:
Calculate their resting energy requirement (or maintenance energy requirement depending on the individual).
Adjust this as required based on their duration of anorexia/hyporexia. As a general rule, I like to increase them to full RER over the same number of days they’ve been anorexic/hyporexic for. For example, if they’ve not eaten for 3 days, we generally start at 1/3rd of their RER.
Divide their required calories by the calorie density of the food (kcal/g or kcal/ml) to get the volume required that day.
Determine how often you want to feed your patient - we tend to feed around every 4-6 hours, since this is similar to gastric emptying time. However, patients with delayed gastric emptying may require smaller volumes, or even continuous trickle feeding depending on the individual.
Divide the volume of food required per day by the number of meals due to get the volume needed per feed.
What if they’re eating a little bit?
If it’s appropriate to offer food to your patient alongside their feeds, I like to do the following:
Offer them the same number of calories they’d be due at their tube feed.
Measure the volume consumed and calculate the number of calories eaten.
Adjust the tube feed volume by this amount, topping up with the tube feed to meet the patient’s requirements.
So there you have it! 5 quick and easy skills you can use when caring for patients with gastrointestinal disease. If you want to know about any of these in more detail, there are full blog posts on many of these topics which I’ll link here for you.
Want to take this further? Later this week I’ll be sharing a case study as part of the challenge, so you can put all of these skills into practice! To get it sent straight to your inbox, make sure you’re on the VIP list by signing up here.
