Medical nursing procedures



Medical nursing procedures


Jo Masters



INTRODUCTION


Much of the work of the veterinary nurse is concerned with nursing medical patients. These are the patients that are not hospitalized for any type of surgical procedure. Medical conditions can be divided into those that are caused by microorganisms and are infectious, e.g. cat flu or canine parvovirus, and those that develop as a result of an upset in the normal processes of the body, e.g. renal failure, diabetes mellitus or exocrine pancreatic insufficiency. Many patients may not require hospitalization and may be treated during a consultation or at home, but some will require further diagnostic tests and if critically ill will require observation and skilled nursing care. Those patients that have an infectious disease must be isolated to prevent the spread of infection and barrier nursing procedures must be instigated either at home or within the practice.


The aim of nursing the medical patient is to help the animal to return to a state of normal health as soon as possible. While in the hospital it must be kept warm and comfortable, free from pain and, remembering that this is an animal removed from its normal surroundings, free from fear and apprehension. Veterinary nurses play an extremely important part in the recovery process and the care that they give must be based on an understanding of the disease process and the aims of the treatment regime.


This chapter describes the general techniques used in medical nursing and relates them to some of the more common conditions seen in practice. It is important to understand that most of the techniques can be used in a range of conditions and examples of their use are listed before each procedure.





Procedure: General examination of the dog or cat



1. Action: Observe the patient in its kennel and record any abnormalities.


    Rationale: Handling the patient will involve some stress, which may influence clinical signs.


2. Action: Remove the patient and place in a comfortable position suited to a full examination.


    Rationale: If the patient feels comfortable it is less likely to try to escape. A cat or small dog should be examined on a table whereas a larger dog may be more suited to an examination on the floor.


3. Action: Ask an assistant to reassure and restrain the patient.


    Rationale: Reassuring the patient will help it to relax. An assistant should be ready to restrain the patient if it tries to escape or becomes aggressive during the examination.


4. Action: Examine the patient starting at the cranial end, identifying any abnormalities, including discharges, wounds, lumps and painful areas.


    Rationale: Examining a patient from head to tail as a routine will limit the likelihood of any area being excluded. Any abnormalities should be noted, however minor or unrelated to the treatment the patient is receiving.


5. Action: Temperature, pulse and respiration (TPR) parameters should be taken at this time.


    Rationale: TPR should be noted whenever the patient is examined as a measure of the patient’s progress.


6. Action: Record all findings on the patient’s hospital card.


    Rationale: All findings must be recorded on the hospital card to help identify any abnormalities and communicate the patient’s progress to all staff. Report any abnormalities to the veterinary surgeon.



Procedure: Barrier nursing – avoidance of cross-infection



1. Action: Staff should be allocated solely to the isolation facility and not allowed to nurse patients in the general ward.


    Rationale: Staff could transmit infection from the patient they are nursing to others of the same species or those susceptible to infection such as immunologically challenged patients and paediatric or geriatric patients.


2. Action: Personal protective clothing such as disposable gloves, aprons and foot covers should be worn. This should be placed in the clinical waste after use.


    Rationale: Protection from zoonotic disease is a high priority. The wearing of protective clothing will prevent disease being spread via staff clothing.


3. Action: Patients who are most likely to spread disease should be cleaned out and treated after all other patients in the isolation facility.


    Rationale: This will prevent disease being spread from the most infectious patient by the nursing staff.


4. Action: Each patient in the isolation facility should be allocated its own equipment, i.e. food bowl, water bowl, litter tray. This should be washed and disinfected, or sterilized separately from others. Bedding should all be disposable and should be placed in the clinical waste.


    Rationale: Infection can be spread from fomites such as kennel equipment. Allocation of equipment to specific kennels will limit this, as will cleaning the items separately. Keep track of equipment by numbering kennels and their applicable equipment. Most bedding cannot be sterilized satisfactorily and may pass infection on during the cleaning process.


5. Action: All findings must be recorded on the patient’s hospital sheet. Report all abnormalities to the veterinary surgeon. Barrier nursing notices should be displayed.


    Rationale: The veterinary surgeon should be made aware of the patient’s progress. Barrier nursing notices can prevent inadvertent cross-contamination – personnel entering the isolation area should be kept to a minimum.



Procedure: Application of an enema (dogs)




1. Action: Prepare all equipment – including enema solution at body temperature (and associated tubing, catheters, Higginson’s syringe as required), disposable gloves, aprons and absorbent tissue. Lubricant will also be required.


    Rationale: As with all procedures the preparation of the equipment before beginning the procedure is both an efficient and practical method of working. The solution should be warmed to prevent shock and promote tolerance.


2. Action: Restrain the patient in a suitable environment – near to an outside door. Two members of staff will be required for this procedure and should wear gloves and aprons to prevent contamination. Place the patient in a standing position.


    Rationale: Giving an enema is a messy procedure and faeces can pass on infection both to the staff and to other patients. The dog will need to evacuate its bowel soon after the application of the enema and will require an area that can be cleaned and disinfected effectively.


3. Action: The end of the tubing to be inserted into the rectum should be lubricated before insertion. The assistant should raise the patient’s tail and the anal area should be cleaned with some warm water to remove any faecal material or debris.


    Rationale: Lubricating the tube end will allow easy access and prevent damage to the rectal mucosa. The anal area should be cleaned to prevent infection being introduced from the external area.


4. Action: Place the end of the tubing in the patient’s anus and gently twist until it is in the rectum. The enema solution should be introduced slowly either by gravity or by pump depending on the method used. The solution may be administered until a back flow is seen.


    Rationale: Gently twisting the tube end will encourage the anal sphincter to relax and allow passage of the tube into the rectum. This is more difficult in cats. A back flow will indicate that the rectum is full of enema solution.


5. Action: Once the solution has been delivered, the dog should be allowed free access to a run area to evacuate its bowels.


    Rationale: If the solution has worked as required, bowel evacuation should commence shortly; if not, you may need to repeat the treatment.


6. Action: When bowel evacuation is complete, the patient should be cleaned appropriately and a note made of the amount and type of excreta passed.


    Rationale: The patient should be thoroughly clean, dry and comfortable before being put back into its kennel. The type of excreta passed may indicate the reason for a constipation problem, e.g. bones.



Procedure: Catheterization of the dog




1. Action: Prepare all the equipment, including sterile catheter and any application equipment, e.g. stylets to assist with introduction, lubricant, disposable gloves, apron, sterile sample container or collecting vessel such as a kidney dish, syringe, three-way tap or bung. If measurement of urine output and input is required, a urine collection bag will need to be prepared. Absorbent material such as swabs/tissue will be useful and suture material may be required for indwelling catheters.


    Rationale: As with any procedure, the preparation of the equipment before beginning the procedure is both an efficient and practical method of working. Ensure that you understand why the catheter is being introduced and any procedures that will be carried out after its introduction. This will enable all necessary equipment to be prepared. The catheter and collection bag should be sterile to prevent infection being introduced into the urinary tract.


2. Action: The assistant should restrain the patient on the examination table. Gloves and aprons should be put on. The preputial area should be cleaned and the penis extruded.


    Rationale: The patient may be standing or in lateral recumbency depending on personal preference. Protective clothing should be worn to prevent the spread of zoonoses and introduction of infection to the patient.


3. Action: Remove the catheter from its outer packaging and cut the end from the inner packaging, which is used as a feeder sleeve.


    Rationale: The use of a feeder sleeve allows the catheter to be fed into the urethra without having to touch the sterile tubing.


4. Action: The catheter tip should be lubricated, introduced into the urethra and then advanced using gentle pressure. Urine will flow back down the catheter when the bladder is reached and may require collection. The bladder may need flushing depending on the procedure to be carried out. Suturing or sticking the catheter to the prepuce will be required if the catheter is to be indwelling.


    Rationale: Gentle pressure should enable the catheter to pass the narrowing of the urethra at the ischial arch or around an enlarged prostate gland. If resistance is met the catheter size may need to be reassessed. The application of zinc oxide tape to the catheter enables it to be sutured to the preputial area.


5. Action: Remove the catheter slowly and dispose of it correctly. Clean and dry the patient before returning it to its kennel.


    Rationale: Removing the catheter slowly will help prevent tissue damage and urine splashes, which could be a zoonotic risk. All catheters and associated equipment should be disposed of in the clinical waste. Keeping the patient clean will prevent urine scalds.



Procedure: Catheterization of the bitch




1. Action: Prepare all the equipment, including sterile catheter and any application equipment (such as vaginal speculum and stylets to assist with introduction if required), lubricant, disposable gloves, apron, sterile sample container/collecting vessel (such as a kidney dish), three-way tap or bung. If measurement of urine output and input is required, a urine collection bag will need to be prepared.


    Rationale: As with all procedures, preparing the equipment before you begin is both an efficient and practical method of working. Ensure that you understand why the catheter is being introduced and any procedures that will be carried out after its introduction. This will enable all necessary equipment to be prepared. The catheter and collection bag should be sterile to prevent infection being introduced to the urinary tract. Foley catheters must not be reused as the balloon weakens after each use.


2. Action: Put on gloves and an apron. Ask the assistant to restrain the patient, either in lateral or dorsal recumbency, or in a standing position depending on the insertion method used. If the catheter is to be inserted using the digital method, sterile gloves should be worn by the person carrying out the procedure.


    Rationale: Protective clothing should be worn to prevent the spread of zoonoses and introduction of infection to the patient. For insertion in dorsal recumbency the patient should be in a straight position with the hind legs flexed and drawn cranially. For all methods the tail must be firmly restrained.


3. Action: The vulval area should be cleaned and free from debris.


    Rationale: Cleaning the area will prevent introduction of infection to the urogenital tract.


4. Action: The catheter should be removed from its outer wrapping, exposing the tip from the inner sleeve, and lubricated. Do not use petroleum-based lubricants on latex catheters. If using a Foley catheter the stylet should be placed and the balloon checked for easy inflation (Fig. 3.1).


    Rationale: Aseptic technique is necessary to prevent introduction of infection. Stylets aid the introduction and placement of the catheter and should be sterile. Most stylets are placed through the tubing but stylets used with Foley catheters should be laid alongside the tubing with the stylet placed in a drainage hole at the catheter’s tip.


5. Action: Place the speculum blades between the vulval lips. If working with the patient in dorsal recumbency, the blades should be inserted as far caudally as possible, then the speculum should be inserted vertically into the vestibule, turning the handles cranially. If working with the patient standing, the speculum should be inserted at a slight angle towards the spine, then horizontally.


    Rationale: In dorsal recumbency the blades should be inserted to avoid the clitoral fossa.


6. Action: Once the speculum is in place, open the blades and identify the urethral orifice.


    Rationale: The urethral orifice should be visible halfway between the vulva and the cervix. If the patient is standing, it will be on the floor of the vestibule; if in dorsal recumbency, it will be on the uppermost side.


7. Action: If using the sterile digital method, the first finger of one hand (usually the non-writing hand) should be lubricated and placed into the vestibule, feeling along the ventral surface for a raised area.


    Rationale: The urethral orifice is just cranial to this raised area and can be identified with the finger and the catheter guided in.


8. Action: The tip of the catheter should be inserted into the urethral orifice and gradually advanced until it reaches the bladder.


    Rationale: With the patient in dorsal recumbency the hind legs should now be extended caudally to allow straightening of the urethra for easier catheter introduction.


9. Action: If a Foley catheter is to be indwelling, the balloon should be inflated, the stylet removed and a collection bag attached. An Elizabethan collar may be used.


    Rationale: The inflated balloon keeps the catheter secure in the bladder without the need for suturing.


10. Action: When the appropriate procedure has been completed, remove the catheter slowly, having first deflated the balloon in the Foley catheter, and dispose of it correctly. Ensure that the patient is clean and dry before being returned to its kennel.


    Rationale: Removing the catheter slowly will prevent tissue damage and reduce the risk of urine splashes, which could carry a zoonotic disease. All catheters and associated equipment should be disposed of in the clinical waste. Keeping the patient clean will prevent urine scalds.



Procedure: Catheterization of the tomcat

This procedure is normally carried out under a general anaesthetic, as it may be painful and struggling may cause penetration of the urethra.




1. Action: Prepare all the equipment, including sterile catheter and any application equipment, e.g. stylets to assist with introduction if required, lubricant, disposable gloves, apron, sterile sample container or collecting vessel (such as a kidney dish), three-way tap or bung. If measurement of urine output is required, a urine collection bag will need to be prepared.


    Rationale: As with all procedures, preparing the equipment before you begin is both an efficient and practical method of working. Ensure that you understand why the catheter is being introduced and any procedures that will be carried out after its introduction. This will enable all necessary equipment to be prepared.


2. Action: Put on gloves and apron. Position the cat in lateral or dorsal recumbency, ensuring that the tail is out of the way.


    Rationale: In this position the perineal area and the penis can be easily accessed.


3. Action: Remove the catheter from its outer packaging and cut the end from the inner packaging, which is used as a feeder sleeve. Lubricate the tip of the catheter.


    Rationale: The use of a feeder sleeve allows the catheter to be fed into the urethra without touching the sterile tubing. Lubrication of the tip will ensure ease of introduction and will prevent tissue damage.


4. Action: Extrude the penis by applying gentle pressure on either side of the prepuce, and introduce the catheter into the urethra (Fig. 3.2). If a Jackson cat catheter is used, remove the metal stylet.


image
Figure 3.2 Catheterization of a tomcat.

    Rationale: Gentle preputial pressure should result in extrusion of the penis.


5. Action: Continue with the procedure – collection of sample, drainage of bladder, hydropropulsion, etc.


    Rationale: If an indwelling Jackson cat catheter is used, suture it to the prepuce. Attach a collection bag and use an Elizabethan collar.


6. Action: Remove the catheter slowly and dispose of it correctly. Return the cat to its kennel when it is clean and dry.


    Rationale: Removing the catheter slowly will prevent tissue damage and urine splashes, which could be a zoonotic risk. All catheters and associated equipment should be disposed of in the clinical waste. Keeping the cat clean and dry will prevent urine scalds.



Procedure: Catheterization of the queen




1. Action: Prepare all the equipment including sterile catheter and any application equipment, e.g. stylets to assist with introduction, lubricant, disposable gloves, apron, sterile sample container or collecting vessels such as a kidney dish, three-way tap or bung. If measurement of urine output is required, a urine collection bag will need to be prepared.


    Rationale: As with all procedures, preparing the equipment before you begin is both an efficient and practical method of working. Ensure that you understand why the catheter is being introduced and any procedures that will be carried out after its introduction. This will enable all necessary equipment to be prepared.


2. Action: Put on gloves and apron. Restrain the cat and ensure that the tail is also restrained.


    Rationale: Restrain the cat either in a standing position or in lateral recumbency.


3. Action: Remove the catheter from its outer packaging and cut the end from the inner packaging, which is used as a feeder sleeve. Lubricate the tip of the catheter.


    Rationale: The use of a feeder sleeve allows the catheter to be fed into the urethra without touching the sterile tubing. Lubrication of the tip will ensure ease of introduction and will prevent tissue damage.


4. Action: Place the catheter between the vulval lips and introduce into the urethra by angling the catheter ventrally, using gentle pressure until the catheter enters the urethral orifice.


    Rationale: The use of a vaginal speculum is not necessary for this procedure. Queen catheterization is not often performed, as blockages are rare.


5. Action: Continue with procedure – collection of sample, drainage of bladder, hydropropulsion, etc.


    Rationale: If an indwelling Jackson cat catheter has been used, suture it in place, attach a collection bag and use an Elizabethan collar.


6. Action: Remove the catheter slowly and dispose of it correctly. Return the cat to its kennel when it is clean and dry.


    Rationale: Slowly removing the catheter will prevent tissue damage and urine splashes, which could be a zoonotic risk. All catheters and associated equipment should be disposed of in the clinical waste. Keeping the cat clean and dry will prevent urine scalds.



Procedure: Manual expression of the bladder



Manual expression of the bladder may be required in recumbent patients or those suffering from bladder paralysis. Natural elimination of the bladder is preferable to urinary catheterization but it should not be attempted where there is any possibility of urethral obstruction.



1. Action: Put on gloves and apron and prepare urinary collection equipment (if required) and absorbent tissue.


    Rationale: Protection of staff from zoonotic diseases transmitted by urine is essential. Urinary collection equipment, such as a kidney dish, or a sterile sample pot may be required if the urine requires analysing.


2. Action: An assistant should restrain the patient in a standing position in a suitable area that is clean and easy to disinfect.


    Rationale: Restraining the patient in the standing position will ensure easy access to the bladder. The area in which the patient urinates should be easy to disinfect to prevent contamination. Dogs will often feel happier urinating outside.


3. Action: Isolate the bladder by palpation of the caudal abdomen and place one hand either side of it on the external abdominal wall.


    Rationale: A full bladder should be easy to palpate, as it will feel like a distended sac in the caudal abdomen. If there are difficulties in isolating the bladder, ask a veterinary surgeon to examine the patient for you.


4. Action: Apply gentle pressure to the abdominal wall on either side of the bladder to encourage urination. Urine should flow freely and be directed into a collection container (Fig. 3.3). Do not be tempted to squeeze the bladder – if there is any resistance and no urine flow, stop the procedure.


image
Figure 3.3 Manual expression of the bladder while supporting a recumbent patient. Reproduced, with permission, from Lane and Cooper (2003), Butterworth-Heinemann.

    Rationale: Gentle pressure either side of the bladder will mimic the action of the abdominal muscles and should produce a flow of urine. If there is an obstruction in either the bladder or the urethra, no urine will flow. A full bladder may rupture if pressure is put on it. Squeezing a bladder with an obstructed urethra may result in rupture or bruising of the bladder wall.


5. Action: When the flow ceases release the pressure. Measure the volume; note its colour, turbidity, smell and the time it was passed. Record your results on the patient’s hospital record.


    Rationale: Records should be kept of all procedures. Measuring fluid output is vital in patients on fluid therapy and a comparison of these details will enable accurate assessment of the patient’s progress.


6. Action: Ensure that the patient is clean and dry before replacing it in its kennel. All areas where urination has occurred should be cleaned and disinfected and disposable clothing placed in the clinical waste.


    Rationale: Ensuring that the patient is clean and dry will prevent urine scalds. Protection of staff and other patients from contamination is vital – disinfection should be a high priority.

Related posts:

  1. Measuring clinical parameters
  2. First aid procedures
  3. Anaesthetic procedures
  4. Diagnostic imaging

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Jan 8, 2017 | Posted by in NURSING & ANIMAL CARE | Comments Off on Medical nursing procedures

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