Ever felt like your VN qualification has limited what you can do with your patients?

Me too.

It’s all too easy to feel like we’re limited in what we can do to nurse our patients as veterinary nurses. And whilst there are some skills that can legally only be performed by vets, the reality is there is still a lot more we can be doing as nurses.

And our medical patients are a great example of where we could do more.

When I think back to my pre-medicine nurse days, I really didn’t know much about medicine. I thought everything that didn’t need surgery was a medical patient - and that my role was soley to nurse them in the hospital. And boy, was I wrong.

Fast forward a good few years and medical nursing has shown me more and more how much we can offer these patients, and how much job satisfaction we can get from our role in their care.

In this post, I’m going to share 3 simple things you can do to start thinking about your medical patients differently, so you can use more practical skills, have collaborative discussions with your vets about these patients, and feel comfortable suggesting changes to their treatment plans.

Don’t forget - if you want to learn more about just how much is possible with your medical patients, I’m running a free workshop in one week’s time! To grab your spot for the Medical Nursing Masterclass on November 14th, visit this link.

1: Consider both the individual patient AND their disease process

In nursing school I was taught ‘don’t think of the patient as a disease, think of them as an individual’. And whilst that’s absolutely true, the reality is we need to do both to nurse them successfully.

We need to be thinking about their disease.

We need to think about how it impacts them in order to plan our care.

• What signs are we likely to see?

• What deterioration could be possible and why?

• What does this mean we need to look out for, and what emergency interventions do we need to prepare?

• What might this mean for the patient when they go home, and what will we ask our client to do at home in order to care for them?

One really simple question to ask yourself when you are caring for medical patients is this:

What can I do, as a nurse, to minimise the effect of this disease on my patient?

That might be measuring fluid output and intake in a patient with renal disease, or writing that patient up to be weighed more regularly since they’re at risk of fluid overload. It might be planning a certain diet for a patient to meet the needs of their condition and minimise complications like refeeding syndrome. It might be preparing for emergency intervention in a respiratory patient.

Whatever it is, we want to ensure we are looking at the disease and the impact of it on our patients, as well as their individual needs - and tailoring our care appropriately.

We can make sure we’re also meeting the needs of our individual patients by using things like “getting to know you” questionnaires, looking for notes from previous visits about things like fear and behaviour, and looking back at previous hospital sheets to see what worked well last time they were in.

2: Don’t think that Schedule 3 = Surgery

Our medical patients often need a lot of interventions. This means lots of opportunities for us to use our skills - or develop new ones!

Schedule 3 procedures are not limited to minor surgeries. There are a lot of different procedures our medical patients benefit from - and lots of these can be performed by us under the direction of the vet.

In fact - we’re often the best people to do these, since they are often ‘wards’ procedures and part of our inpatient care considerations. By getting the nurses doing these, our vet team can continue focussing on their operating list or consultation block, safe in the knowledge that their nursing team are getting on with these tasks and delivering amazing care to their patients.

Here are just a few things we can (and should!) be doing:

• Placing naso-oesophageal and/or nasogastric feeding tubes

• Placing sampling lines for repeated blood sampling

• Placing urinary catheters (cats, dogs, males and females!)

• Placing faecal foley catheters

• Calculating and preparing constant rate infusions

• Calculating and preparing supplemented fluid therapy

• Calculating, preparing and administering blood products

• Placing arterial lines

• Collecting arterial blood samples

Where appropriate to do so, and based on the individual patient’s needs!

Here’s an overview of how to do my two most commonly-performed procedures in that list - NO/NG tube placement and sampling catheter placement.

How to place a nasal feeding tube

You will need:

• Feeding tube of appropriate size

• Topical ocular local anaesthetic drops

• Sterile water-based lubricant

• Permanent marker

• 1.25cm x 2cm tape strips (x2) and glue or skin staples, OR

• 23g x ⅝” needle and 3-0 non-absorbable suture material

• Elizabethan collar

• 5ml syringe

Here’s how to do it:

• Measure the tube from the 8-10th rib (for a NO tube) or the last rib (for a NG tube) to the nostril and mark with a permanent marker.

• Apply topical local anaesthetic drops into the nostril and eye.

• Lubricate the tube.

• With the patient’s head pointing slightly upwards, insert the tube into the nostril and advance in a ventromedial direction until the marked point.

• Attach the 5ml syringe to the tube and aspirate:

  • Air: Increases suspicion for incorrect placement (trachea).

  • Negative pressure: Likely correct placement in the oesophagus (suction against the oesophageal wall).

  • Gastric contents: Placement in the stomach.

• Secure the tube either with butterfly tape strips and glue, or using a finger-trap suture near the nose, but out of the patient’s eyeline.

• Place a second tape strip or suture on the top or side of the head to secure the tube away from the patient’s face.

• Confirm correct tube placement with radiography, then place an Elizabethan collar to prevent interference.

How to place a sampling catheter

You will need:

• Clippers and antimicrobial skin scrub

• Sterile gloves

• Sterile fenestrated drape

• Sampling catheter (Drum/PICC) kit

• Suture material

• Y or T connector

• Needle-free injection valves

• Sterile saline

• Dressing material

Here’s how to do it:

• Clip and aseptically prepare the site (usually the medial or lateral saphenous vein is used).

• Apply sterile gloves and aseptically prepare your kit.

• Insert an over-the-needle catheter into the vein.

• If using a drum kit:

  • Attach the drum introducer device to the catheter and feed the sampling catheter through it.

  • Remove the stylet and attach the sampling catheter to the over-the-needle catheter.

  • Attach a T or Y connector to the sampling catheter, and attach needle-free injection valves to this.

  • Secure the catheter in place with tape and bandage.

• If using a PICC kit:

  • Feed the guidewire through the over-the-needle catheter.

  • Remove the catheter, leaving the guidewire in the vein.

  • Feed the sampling catheter over the guidewire and into the vein.

  • Attach a T or Y connector and needle-free injection valves.

  • Suture the catheter in place and cover with a sterile dressing and bandage material

• Clearly label the line as a sampling line, with the date placed.

By performing these advanced nursing skills, we get to develop practically whilst also delivering better care to our patients!

3: Nurse these patients OUT of the hospital as well as when they’re an inpatient

There is a lot more we can do when it comes to nursing these patients. And this includes when they’re at home, too!

Think about it. The vast majority of our medical patients have some kind of lifelong (or very long-term), progressive condition. In some cases these will be terminal.

If we’re only nursing these patients for the 1-14 days they’re in the hospital, they’re only getting nursing care for a very short part of their disease!

There is a lot more we can do to support these patients at home - not just through things like nursing appointments, but also through remote support, follow-up emails, phone calls or video calls, reviewing information clients are sending in to us, and evaluating the patient’s at-home nursing needs.

We can work with clients to identify interventions the pet may need at home, and teach our clients how to do those, or work with them to adjust their environment if needed. For example, we can:

• Formulate an illness management plan to identify potential and actual problems at home, then make an action plan with our clients

• Help make changes to the home, for example to reduce stress in a multicat household, or reduce allergens in a respiratory disease patient

• Teach clients physiotherapy techniques their pet will benefit from

• Teach clients how to gradually introduce inhaled medications, use nebulisers and other respiratory support devices

• Teach clients how to administer injectable medications or subcutaneous fluids

• Show clients how to collect ear-prick blood samples and perform at-home glucose testing

• Teach clients how to express bladders and support patients who are unable to urinate at home

• Teach clients how to use and care for oesophagostomy feeding tubes at home

And this is only a short list - the reality is there is so much more we can do, it just takes some out-of-the-box thinking and a good discussion with your vet team to see how you can help!

By thinking about how we can minimise the impact of our patient’s disease during hospitalisation, using practical schedule 3 nursing skills, and incorporating at-home nursing care, we’ll significantly improve patient care, help the rest of our team, and increase our own job satisfaction. So if you want to do more with your medical patients, I’d really recommend implementing these steps! You’ll also get to know your patient better, and your clients will really see how vital you are in the care of their pet.

Don’t forget, if you want to learn more about how you can apply this to your patients, in just a week’s time I’ll be hosting a free workshop showing you how to do that. Together we’ll work through 4 patients with different medical disorders, planning their care and developing new skills. Save your spot at www.veterinaryinternalmedicinenursing.com/nurse - I can’t wait to see you there!