Clean, Dry, Safe, and Comfortable Housing

Veterinary professionals have a responsibility to act as advocates for animals when people bring their pets for care and treatment. Providing a clean, dry bed in an appropriate cage or enclosure is vital (Figure 16-1). In some veterinary hospital environments housing is limited to cages elevated above the ground or runs enclosed by fencing, thus creating a “step” in and out of the cage or run. These circumstances provide challenges for the preoperative/postoperative patient and those who care for them. It may seem elementary to consider but patients should be cared for as if they were our own pets and we should occasionally stop to consider, “If I were my patient, how would I feel? What would make me feel better?”

Bedding and Decubital Ulcers

Rubber mats may be used to provide appropriate footing in cages and kennel runs (Figure 16-2). An essential factor with any orthopedic or neurologic patient that is unable to walk is preventing decubital ulcers. Decubital ulcers develop over bony prominences such as the olecranon process, acromion process, greater trochanter, tuber ischium, and medial and lateral malleoluses. Prevention is crucial and begins with proper bedding. A helpful rule of thumb is that 1 inch of bedding should be used for every 40 pounds of body weight. Bedding should be changed daily and the cage or run cleaned daily as well. It has been well documented that frequent position changes and ample bedding decrease the incidence of pressure sores, edematous limbs, and joint and muscle stiffness.^1,2 Recumbent patients should be turned every 4 to 6 hours at a minimum.

Urine/Fecal Scald

Providing absorbent pads underneath the patient to facilitate the absorption of urine and feces of recumbent patients is essential to keep the patient and cage from becoming excessively soiled. Alternatively larger patients that are incontinent may be placed on fenestrated grates to allow excess urine and feces to drain away from the patient. Urine- or fecal-scalded skin typically appears red, irritated with or without serous exudate, and is caused by prolonged exposure to urine or feces (Figure 16-3). Proper nursing care should be initiated immediately if scalding occurs and consists of cleansing the area, drying thoroughly, applying creams such as Desitin (Johnson & Johnson, New Brunswick, NJ) or Skin Sake (Skin Sake, Hamburg, AR) (Figure 16-4) to help protect the skin and baby powder to the fur to absorb additional fluid. The importance of preventing the patient from licking its urine/perianal scald, wounds, and/or incisions is paramount. A no sting barrier film (Cavilon, 3M, St. Paul, MN) (Figure 16-5) also can be used to protect the skin.

Positioning of the Neurologic Patient

If the patient is unable to sit sternally, foam rolls, pads, wedges, or rolled-up towels can be placed beside the patient to help it maintain a sternal position and prevent it from falling over (Figure 16-6).

Elizabethan Collars

The Elizabethan collar, or e-collar, is very helpful to discourage patients from licking their incision. The art of a functioning e-collar lies in the sizing and fitting of the collar. Elizabethan collars are typically made of plastic, but softer cloth e-collars are also commercially available. When placed appropriately the brim of the e-collar should extend well past the patient’s nose (Figure 16-7). This ensures the patient cannot lick the incision. The collar should be comfortably snug around the patient’s neck. To check the tightness of the collar, two fingers are passed under the collar. If two fingers cannot be passed under the collar, it is too tight. If three or more fingers can be passed under the collar, it is too loose. Most commonly, e-collars are too loose and the patient has little trouble getting it off. Patients must become accustomed to daily tasks such as eating and drinking while wearing an e-collar. Food and water must be placed close enough to the patients for them to reach the bowls. Attention must be paid to the patient’s appetite and willingness to eat. Many patients have difficulty learning to eat while wearing an e-collar. In this case the e-collar can be removed, feeding should be supervised, and the collar promptly reapplied after eating or drinking. In addition many patients refuse to eat or drink during their stay at the hospital. Hand feeding or assisted syringe feeding using pureed canned food is recommended, but feeding should be slow enough to allow ample time for swallowing. Patients should wear the e-collar at all times in the hospital and at home until the sutures or staples are removed and any open wounds are adequately healed.

Medications

Although the decision regarding prescribed medications is ultimately the veterinarian’s decision, the adept veterinary technician must always be aware of the current medications for each patient. Unflavored medications are best administered disguised, if possible, in food or a treat before mealtimes. The technical staff often is responsible for medicating patients, and this can be facilitated with soft, treat-like dog medication devices (Greenies Pill Pockets, Nutro Products, Inc., Franklin, TN). The technical staff is in a position to make the veterinarian aware of any discrepancies regarding medication, such as a history of concurrent nonsteroidal antiinflammatory drugs (NSAIDs) and corticosteroids, or an abrupt switch from one NSAID to another without a washout time in between. The veterinary technician is also essential to identify side effects a patient may be experiencing, such as vomiting, diarrhea, or melena. These classic NSAID side effects usually occur 2 to 3 days after beginning NSAID administration but may take up to 2 weeks to develop. If such signs develop the veterinarian should be notified immediately and the NSAID discontinued.

It is important to realize that many owners may give their pets aspirin, but do not consider this as a medication because it is easily obtained over the counter. It is critical to take a thorough medication history to prevent serious side effects from drug interactions. Aspirin is a nonselective COX inhibitor and may increase gastrointestinal side effects when given with other NSAIDs or COXIB class medications.³

Understanding When, What, and How

Understanding when a patient is a candidate for surgery, what procedure is recommended, and how it is performed comes with years of experience of the veterinary surgeon. For canine rehabilitation practitioners it is beneficial to be aware of certain factors regarding the patient’s condition. For example if a patient has sustained a fracture several days before surgical repair, the injury will be more difficult to repair because of contracture of muscle, fibrosis, and early callus formation. This may make the initial rehabilitation period somewhat more challenging because of greater surgical trauma during fracture repair. It is also beneficial to know which fractures should be surgically repaired, and which may be managed successfully with external coaptation devices. Additionally knowledge of common orthopedic procedures is essential to the rehabilitation practitioner to fully understand postoperative considerations and the basic care of these cases.

For the neurologic patient with intervertebral disk disease or trauma, triage begins with the history. It is vital to collect information regarding the duration of clinical signs, the time elapsed since the patient became paretic/paralyzed, and any use of steroids or other antiinflammatory medication. After a patient has lost deep pain there is a 50% chance it will regain functional mobility if surgery is performed within 24 hours. In general every hour past 24 hours from the point when deep pain is lost decreases the prognosis for a full recovery exponentially.⁴ It is good to remember that the loss of deep pain does not definitively preclude a dog from regaining motor function. However, dogs that do not recover deep pain, rarely regain conscious voluntary motor function and their ambulation is not normal. It is also important to remember that any dog that has intact deep pain in its affected limbs has the potential to recover function.

Managing the Recumbent Patient

Some conditions require a lengthy recovery and animals may initially be recumbent. During this critical time, it is especially important to provide intensive nursing care to avoid serious complications.

Patients should be turned every 4 hours if they cannot turn themselves. They should be placed on a padded bed. An absorbent pad should be placed under the animal if incontinence is an issue. For patients that urinate frequently it may be necessary to have the animal on an elevated grate that will not allow urine to pool under the animal.

Animals that are recumbent for a very long time may be at risk for developing decubital ulcers. It may take as little as 1 hour of sustained pressure to develop a deep decubitus.⁷ In particular, animals with thin skin and prominent bony protuberances, such as greyhounds and whippets, are especially prone to developing decubital ulcers. Prevention of ulcers is far superior to treatment of ulcers. Therefore the skin should be assessed each day for redness of the skin or other evidence of skin breakdown. If redness or irritation of skin is noted, a “doughnut” may be made to help distribute pressure away from the area.

Care of the Incision

The adept practitioner should be familiar with the characteristics and appearance of “normal” incisions, in order to properly identify questionable or compromised incisions (Figure 16-8). It is important to note the location of the incision(s), the number of incisions, number of individual sutures, and the type of incision closure(s). Effort should be made to ensure the incision(s) is clean and dry. Following surgical closure of the incision in the operating room the skin around the incision is cleaned with either warm sterile saline or hydrogen peroxide and allowed to dry. Although hydrogen peroxide may recruit free radicals and cause oxidative injury to tissue, the use of hydrogen peroxide to clean blood and other fluids from the skin around the wound has minimal effects on healing if not directly applied to the incision. For standard orthopedic procedures a nonadherent pad is applied with triple antibiotic ointment and affixed over the incision with wide adhesive tape (Figure 16-9). This temporary dressing serves to protect the incision and may be removed when the incision is sealed after 2 to 3 days if there is no drainage. Often the postoperative orthopedic patient’s incision will have slight bloody or serosanguinous discharge the day of surgery and the day following surgery. This is considered to be normal and becomes less prominent as a fibrin seal is created approximately 24 to 72 hours⁸ after surgery (Figure 16-10). When allowable a cold compress can be applied immediately after surgery for 15 to 20 minutes to the operative site to provide analgesia, and to decrease inflammation and edema formation.^9,10 The patient’s incision should be monitored daily for any drainage or discharge, apposition of wound edges, excessive inflammation or swelling, and any missing staples or sutures (Figure 16-11). Before discharge the patient’s incision should be evaluated and cleaned again if needed. The patient should not be discharged with an actively draining or open incision (Figure 16-12). Patients with edema in a single limb should have this limb elevated to help prevent swelling by lying on the opposite side and using a rolled towel or pillow to elevate the edematous limb if tolerated.

Cold Compresses

Cold compresses may be applied to the operative site immediately following surgery. Common practice is to affix a nonadherent sterile pad with adherent tape over the incision, and apply the compress directly on or around the temporary dressing. Studies of human patients have indicated that it is not effective to apply a cold compress through a thick padded bandage.¹¹ Thus cryotherapy should be performed at the time of bandage changes if a bandage must remain on the patient. When applying a cold compress, a barrier such as a nonadherent sterile pad or very thin towel may be placed between the skin and the cold compress to maintain patient comfort (Figure 16-13). It is important to use a compress appropriately sized for the patient. For example in a small dog with a distal radius and ulnar fracture that has been repaired with a bone plate, an extra-small to small cold compress should be used. Likewise for a mastiff with a femur fracture repair, a large to extra-large cold compress would be best. For more information on types of cold compresses, the reader is referred to the chapter on superficial thermal modalities.

Warm Compresses

It is important to remember that if the tissues are inflamed from disease, injury, or surgery, application of heat is contraindicated. Warm compresses may begin after the acute postoperative inflammatory phase has ceased, usually around 72 hours postoperatively or postinjury. The application of heat results in increased blood flow to the area, and possibly decreased muscle spasms. When applying a warm compress when drainage is present, always provide a barrier, such as a nonadherent sterile pad or an absorbent pad with a plastic backing, between the skin and the compress to reduce disease transmission. It is important to always test the compress before application on the patient to be certain that it is not too hot. Several commercially made compresses are available. For more information regarding types of warm compresses, see Chapter 18, Superficial Thermal Modalities.

Massage

Soft tissue massage can be beneficial in reducing postoperative edema. The degree of limb edema can vary following orthopedic surgery depending on the size of the patient, the procedure performed and the severity of the injury. Ideally massage is performed following superficial thermal modalities and before assisted ambulation or controlled therapeutic exercises. It is important to begin the massage distally and work proximally to increase lymphatic and venous flow and thereby decrease edema (Figure 16-14). The edges of the incision should be avoided. The degree of pressure applied by the hand and fingers should be gentle but firm. Patients that have compromised incisions or skin grafts are not candidates for soft tissue massage. The reader is referring to the chapter on massage for more information regarding massage techniques.

Assisted Standing

Standing exercises focus on strengthening shoulder, elbow, hip and stifle extensors and reeducating muscles needed for balance and proprioception. Several approaches can be used to facilitate standing. Particularly when a patient is large, assistive devices such as slings, physio rolls, mobility carts, wheelchairs, or lifts may be used to maintain a patient in a standing position (Figure 16-15). In smaller patients, the therapist can manually support the patient to maintain a standing position (Figure 16-16, A). Two common variations of this exercise are static standing and sit-to-stand exercises. Static standing is typically performed three to five times daily for 2 to 5 minutes or until the patient fatigues. It is useful to support the patient under the ischiatic tuberosity and on the cranial aspect of the stifles to facilitate a normal standing angle of the hind limbs (Figure 16-16, B). Conversely one often will need two people to maintain limb position in a tetraparetic patient even with abdominal support from a physio roll or sling system. It is important to maintain normal foot position at all times during this exercise (prevent knuckling and encourage weight bearing). It is recommended that one should perform standing exercises at the time of eating or drinking, because standing often improves while the patient is distracted by the act of eating and drinking.

Assisted Ambulation

Assisted ambulation is paramount with orthopedic and neurologic patients. It is necessary to assist postoperative patients getting into and out of cages, and to help them up from a recumbent position, as well as while ambulating. The caregiver provides assistance when needed and also prevents the patient from falling or overloading tissues and surgical repairs (Figure 16-17). Caution should be taken if the patient is excessively painful or ill tempered. To best help these patients begin early ambulation, the patient must trust the caregiver. Therefore some time must be invested in allowing the patient to become accustomed to the assistive device and the procedures involved in placement and assisting ambulation. Numerous assisted ambulation devices such as slings and harnesses are commercially available. The practitioner should be familiar with the devices, how they work, and how to graduate a patient from one device to a more challenging device. For more on this topic see Chapter 17, Assistive Devices.

Everyday Activities as Rehabilitation Exercises

Encourage owners to make everyday activities a rehabilitation exercise in disguise. For example, while a postoperative patient is standing to eat from a food bowl, an opportunity is presented to do some standing and weight-shifting exercises. Not only will the dog probably be more interested in the food than the standing or weight-shifting exercise, but the behavior is tolerated and positively reinforced with the food (Figure 16-18).

Recognizing Signs of Infection

Monitoring for infection begins on day 1 postoperatively, with most infections occurring within 7 days after surgery. The classic signs of inflammation are heat, redness, swelling, pain, and loss of function; the cardinal signs of infection are often the same but they persist beyond the acute inflammatory period and may be accompanied by discharge from the incision, fever, lethargy, and poor to no appetite. However, local abnormalities are more commonly observed than signs of systemic illness with MRSI infections in orthopedic procedures. Often the patient is discharged, and the client calls with concerns a few days to 2 weeks after surgery. The most common clinical history is a sudden decrease in use of the surgical limb, or the limb may develop significant edema. The surgical limb may also have a seroma or active serosanguinous or purulent drainage from the surgical site. A seroma is a collection of serum in the body, producing a fluctuant to firm swelling. If clinical signs of a postoperative infection are noted by the client, the patient should be seen by the veterinarian as soon as possible.

A sample is obtained from the affected area and submitted for cytology, culture, and sensitivity. To aseptically drain a seroma, the site should be clipped and cleaned thoroughly with an aseptic scrub such as chlorhexidine. Wearing exam gloves or sterile gloves, a butterfly catheter or needle attached to a syringe is inserted into the seroma. The fluid is aspirated and collected into the proper tubes or material is placed on a culturette. A seroma does not necessarily indicate that an infection is present. The diagnosis of infection is based on cytology or culture results.

When patients have a postoperative infection, the area is often inflamed, edematous, warm to the touch, and painful on palpation. Postoperative infections may involve the joint, periarticular soft tissues, or the site of an implant such as a plate or pin. In any case, radiographs are indicated to help determine the extent of the infection. While the patient is sedated an arthrocentesis may be performed to determine if intraarticular infection is present. Septic arthritis is associated with greater postoperative morbidity and less favorable long-term outcomes.

To aseptically perform an arthrocentesis the site should be clipped and cleaned thoroughly with an aseptic scrub such as chlorhexidine. Wearing sterile gloves, a 20- or 22-gauge -inch needle is inserted into the joint, usually just medial to the patellar tendon. In the event that the joint is not infected, caution should be used to avoid affected skin and subcutaneous tissues while obtaining joint fluid to avoid carrying infection into the joint. Fluid is allowed to drip from the needle into a sterile collection vial. If fluid does not drain a syringe may be attached and fluid gently aspirated and collected into the proper tubes or culturettes. Normal joint fluid is clear and viscous. Abnormal joint fluid may be cloudy and red-tinged, indicating the presence of blood; or cloudy white or yellow, indicating the presence of purulent material.

The fluid should be cultured for both aerobic and anaerobic bacteria. It generally takes 72 hours to obtain culture and antibiotic susceptibility profiles of organism(s). In this case, the client is instructed to continue on an empirical antibiotic or perhaps no antibiotic, until the results are available. During this time it is imperative that the patient be prevented from licking the wound. After culture and susceptibility results are available the patient is placed on the appropriate antibiotic therapy for 3 to 6 weeks. In serious cases the patient may need to return every other day or daily or be hospitalized for bandage changes and wound debridement (Figure 16-19).