How to apply your medical knowledge and plan amazing nursing care: part 1
I’ve said it before and I’ll say it again - there are near-endless opportunities to develop your nursing skills (and brain!) when caring for medical patients.
And in the next 2 posts we’re going to look at how to do exactly that!
I’m going to introduce you to 2 patients with different medical disorders, and together, we’ll work to plan their care. Today, we’ll meet our first one, Buddy, a Westie with aspiration pneumonia.
Imagine you’re nursing these patients in your hospital. You’re on duty when they arrive, you’re monitoring them during procedures, you’re working with the veterinary surgeon to implement their treatment plan, you’re running their nursing care.
What would you do if you were in charge of this patient’s nursing care? What skills would you use to improve their experience in the hospital?
Take the prompts I’ve left for you below each case, and make your own notes on how you’d nurse these patients… then compare those with mine below!
Make sure you DM me with your thoughts on Instagram, too - I can’t wait to see what you come up with!
PS. Want more information on how to plan and deliver nursing care for different diseases, and to learn the step-by-step practical skills you need to nurse these patients? The updated pocket guide range has everything you need to know inside. You can grab your copy here.
Introducing Buddy
Buddy is a 6-year-old, male neutered West Highland White Terrier weighing 7kg. He has presented as an emergency with a history of regurgitation and progressive lethargy, anorexia and coughing. This morning, his family have noticed he is tachypnoeic with increased respiratory effort.
Triage
You collect Buddy from reception and begin to perform a triage examination, focussing initially on the cardiovascular, respiratory and neurological systems. You note the following:
Heart rate 160 beats/minute
Slightly weak pulses, synchronous with heartbeat
Respiratory rate 60 breaths/minute, shallow, with increased inspiratory effort
Mucous membranes pale pink and slightly tacky
Capillary refill time 1-2 seconds
Neurologically normal, alert, but quiet
Stressed on assessment
Oxygen saturation 91% on lip fold with good quality plethysmograph trace
Crackles audible on thoracic auscultation, especially over the cranial lung fields bilaterally
What steps would you take after your assessment?
My next steps would be to provide oxygen supplementation, discuss my triage findings with the veterinary surgeon as soon as possible, then secure IV access (if appropriate to do so with Buddy’s stress levels and respiratory function) and obtain blood samples as needed under veterinary direction. If appropriate, I would administer an anxiolytic agent such as butorphanol if requested by the veterinary surgeon, depending on the degree of stress and the effect this is having on Buddy’s breathing.
Diagnostics
The veterinary surgeon asks you to perform a thoracic point-of-care ultrasound and acquire images for them to interpret. They also ask you to obtain venous access and run a venous blood gas initially. These tests reveal:
Increased B-lines on thoracic POCUS and normal glide sign
A mild respiratory alkalosis (pH 7.47, PvCO2 31mmHg)
You settle Buddy into an oxygen kennel (FiO2 approximately 40%) and begin intravenous fluid therapy with lactated Ringer’s solution at 4ml/kg/hour, as requested by the veterinary surgeon. Butorphanol (0.2mg/kg IV) is continued as needed, up to every 6-8 hours.
After Buddy settles, the veterinary surgeon asks you to obtain 3-view thoracic radiographs under mild sedation with butorphanol only. These show evidence of oesophageal dilation, increasing the vet’s suspicion for a megaoesophagus. In addition to this, you note Buddy has had some generalised weakness in hospital, leading the vet to suspect myasthenia gravis, leading to a megaoesophagus and subsequent regurgitation and aspiration pneumonia. You collect samples for acetylcholine receptor antibody testing to confirm this diagnosis, and submit these to the external laboratory.
Treatment
In the meantime, the vet asks you to carry out the following treatment plan:
Amoxicillin-clavulanic acid (20mg/kg IV every 8 hours)
Ongoing IVFT at an appropriate rate depending on hydration/perfusion status
Maropitant (1mg/kg IV every 24 hours)
Metoclopramide constant rate infusion (2mg/kg/day, running alongside intravenous fluid therapy at a rate of 1ml/hour)
Continued oxygen therapy via O2 kennel
Pyridostigmine (0.5mg/kg PO) is added once results return, confirming a diagnosis of myasthenia gravis.
How would you calculate and administer Buddy’s metoclopramide CRI?
Here’s what you need to know:
Rate: 2mg/kg/day
Concentration: 5mg/ml
Weight: 7kg
And here’s how to do it:
2mg/kg/day x 7kg = 14mg/day
14mg/day divided by 5mg/ml = 2.8ml/day of undiluted metoclopramide
24ml - 2.8ml of undiluted metoclopramide = 21.2ml of dilutent (e.g. 0.9% saline)
Mix 21.2ml saline and 2.8ml metoclopramide in a syringe to make 24ml total
Run at 1ml/hour via a syringe driver
Nursing Care
What would your nursing considerations be for Buddy? Have a think about the following areas:
Hydration
Nutrition
Monitoring
General care
Oxygenation and ventilation
Mobility
Venous access
Eliminations
(This is not an exhaustive list, and anything else you think of goes too!)
Here are my thoughts:
Hydration
Patients with pneumonia can easily have increased fluid losses. They are often tachypnoeic and oxygen-dependent, and oxygen itself can be very drying to mucous membranes. In addition to this, we want to promote the moistening and loosening of respiratory secretions. On top of all of this, Buddy is likely to have a reduced water intake (potentially due to a reduced willingness to drink, alongside his history of anorexia) and is at high risk of regurgitation when he does drink.
We know Buddy is currently receiving intravenous fluid therapy and we need to regularly assess his fluid status, and adjust the rate of his fluid therapy as appropriate (under veterinary direction).
Nutrition
We know Buddy has a history of anorexia and regurgitation. However, at least initially, we need to balance his nutritional status and his respiratory status - and respiratory stabilisation takes priority initially. Once Buddy is breathing more comfortably and able to adequately oxygenate and ventilate, we can make a plan for his nutrition. This may include tube feeding if he will not eat voluntarily; however, due to his oesophageal disease the most appropriate tube choice for him would likely be a PEG tube - and these require more intensive management than oesophagostomy tubes.
Once Buddy begins eating for himself, postural feeding is an important consideration due to his megaoesophagus. He will require propping up in a vertical position whilst he eats, and for at least 15-20 minutes after each meal, to minimise the risk of regurgitation.
Monitoring
There is a lot we need to be checking regularly in Buddy’s case. Parameters to regularly assess include:
Respiratory rate, pattern and effort
Body position (is there orthopnoea? Is his breathing worse in one particular position? Do we need to turn him?)
Oxygen saturation +/- arterial blood gas analysis
Lung sounds
Serial thoracic point-of-care ultrasound
Heart rate and pulse quality
Mucous membrane colour and capillary refill time
Temperature
Food and water intake
Eliminations
Blood pressure
Demeanour/neurological status
Evidence of ongoing regurgitation, coughing, nasal or oral discharge
Corneal drying/ulceration (due to oxygen therapy)
Stress levels
Bodyweight
Oxygen level, CO2 level, humidity and temperature in the O2 kennel
Evidence of medication side effects (pyridostigmine overdose, for example, can cause a cholinergic crisis).
The frequency of each of these should be adjusted as appropriate, based on Buddy’s progress.
Oxygenation and Ventilation
Managing Buddy’s oxygen therapy is a really important nursing consideration. Buddy’s oxygen requirements will change throughout hospitalisation - in addition to him (hopefully!) improving and his oxygen requirements lessening, he may also need to be delivered oxygen in a different way, or at a higher FiO2 if an oxygen kennel becomes less suitable for him.
For example, larger dogs or dogs in small oxygen kennels can eliminate a lot of CO2 into the environment, and if the oxygen kennel does not have a way to remove this, rebreathing will result. For this reason, many oxygen kennels have a soda lime canister incorporated within them to remove environmental CO2.
Oxygen kennels can also become very hot and humid quickly, if they do not have an inbuilt thermostat and/or humidity monitor. In these situations, an alternative method of administering oxygen may be more suitable.
The method by which we give oxygen will also affect the FiO2 (inspired oxygen fraction). In general, the more severe the respiratory compromise and hypoxaemia, the higher the FiO2 required. If the patient can’t effectively oxygenate, they will put more and more effort into breathing until respiratory fatigue results. If fatigue progresses, respiratory failure can result - for this reason, we need to carefully monitor oxygenation and respiratory function and adjust the way we give oxygen therapy if needed.
The best way to monitor oxygenation is by performing an arterial blood sample for gas analysis. This determines the arterial oxygen and carbon dioxide content, as well as giving us information on acid-base status.
If hypoxaemia (a PaO2 of less than 85-90mmHg on room air, or less than 5 times the FiO2) is present, we need to adjust the way we give oxygen.
In Buddy’s case, how could we do this?
We could consider placing nasal oxygen cannulas. These are placed in a similar way to NO feeding tubes, but do not advance all the way to the oesophagus - and if placed in both nostrils, we can achieve a FiO2 of around 60%. They’re well tolerated, can be placed quickly and easily in conscious patients - and can be placed by VNs, too!
General Care Considerations
In addition to everything we’ve discussed above, Buddy needs a lot of general nursing care. This will include managing his eliminations and mobility, respiratory physiotherapy and recumbency care, vascular access and providing an appropriate environemnt.
Environment
We want to make sure Buddy is housed in a quiet, calm and comfortable environment, yet one where he can be closely monitored in the event he deteriorates. We also want to ensure that his bedding is thick, padded and absorbent in the event he becomes recumbent, and in case he is unable to be moved outside to urinate/defecate (since he is oxygen-dependant).
Recumbency and Special Sense Care
Depending on Buddy’s mobility, regular turning may be required to prevent orthostatic pneumonia and ensure adequate lung inflation (preventing atelectasis). If this is the case, I would try and maintain his front end in sternal if possible, turning his hind limbs only - and if he is able to mobilise himself, I would skip this all together.
Whilst Buddy receives oxygen therapy, I would pay close attention to his ocular care - fluorescein staining his eyes to check for corneal ulceration daily, and applying ocular lubricant regularly under veterinary direction.
Eliminations
In terms of his eliminations, we have a couple of options:
Connect a portable oxygen cylinder to nasal oxygen cannulas and continue administering oxygen as he moves (if appropriate)
Avoid moving him at all, and manage any eliminations passed with regular bedding checks/changes and careful grooming to prevent soiling/scalding
Consider placing a catheter to manage his urination if he cannot be walked outside.
In reality, we need to weigh up the risks and benefits of all of these options against his clinical condition. A urinary catheter may not be appropriate if he will only be recumbent and oxygen-dependent for a short time, since it carries a risk of hospital-acquired infection. He may be able to mobilise without it significantly increasing his respiratory effort, and if that is the case, walking outside with a portable cylinder would be a good option for him. I would also minimise the amount of exercise he needs to do generally, so carry him to and form the garden and pop him on the floor to urinate/defecate only, or move him on a trolley, for example.
Mobility and Physiotherapy
We need to balance Buddy’s mobility and his respiratory status, only mobilising him as much/for as long as he is able to adequately ventilate/oxygenate.
Respiratory physiotherapy will be an important part of his nursing management, and regular nebulisation can help hydrate and loosen respiratory secretions. Ideally, we want to pair this with mobility to help him expel these loosened secretions - even walking around on the ward floor whilst attached to a portable oxygen source, for example.
Vascular Access
Maintaining vascular access is another important consideration, not just for administration of fluids and medications, but in the event of deterioration or respiratory distress requiring prompt intervention.
Buddy’s IV should be undressed, checked for evidence of local infection or thrombophlebitis and redressed at least twice daily, with regular flushing between this to check patency. If there are concerns regarding his catheter, it should be replaced.
What about after the hospital?
Buddy will need careful management at home, not just in the clinic. He will be going home with a megaoesophagus and this means he will be at risk of regurgitation and further aspiration episodes.
We need to teach his family how to minimise this, by using raised feeding chairs (‘Bailey chairs’) and offering water from a height, then maintaining him in an upright position afterwards.
Nurses are ideally placed to offer support to our clients with patients like Buddy, and to teach them about managing food, water and medications at home. Once we’ve done this, we can also check in regularly with them via phone or email, to ensure everything is ok at home, and answer any questions that might pop up.
Have you ever managed a patient like Buddy? Did you have the same considerations as me, or is there anything you’d have done differently? I’d love to know - so please drop me a DM on Instagram and let’s chat about it!
Don’t forget, if you want help planning care for patients like Buddy, the new pocket guide to respiratory disease contains everything you need to know about caring for these patients, including the practical skills you can perform with them! You can pick up a copy here.
