The art of patient care
NASHVILLE, TN – Veterinary medicine is a combination of science and art, using research evidence and data as a guide while relying on clinical experience, observation, patient or client feedback and the ability to interpret the patient’s state of mind. In the art of patient care, the patient’s behavioral response to treatment is the central focus, explained Erica Mattox, VTS (ECC) presenting at the International Veterinary Emergency and Critical Care Symposium.
Patient care is any interaction between the patient and the veterinary team in the clinic that promotes wellness or recovery from illness or injury, and addresses the patient’s physical and emotional well-being.
The best critical care technicians are proactive and able to diligently monitor their patient to observe subtle changes. Sometimes an emergency is obvious but sometimes it is not. Picking up on a new respiratory pattern or the slight agitation that the patient was not previously displaying may detect an emergency. Providing excellent patient care may be the difference between life and death.
Triage and physical exam of the patient
All patients in a potential emergency situation must be triaged. Assessment must be done accurately and rapidly. A visual exam should be done as stress-free as possible. One of the fastest and most effective ways to assess a patient is using a RAP system: respiration, alertness, and perfusion. If the patient is experiencing a life-threatening emergency, immediate treatment should be initiated. All staff should be trained to recognize an emergency and initiate CPR.
Once the patient has been triaged, the standard physical exam includes patient vitals such as temperature, heart rate, pulse rate, respiratory rate, mucous membrane color, capillary refill time and mentation. “It is important,” noted Ms. Mattox, “to remember that vitals are simply numbers to measure each systems functions and the physical exam must also include parameters evaluated by a technician’s knowledge of the patient. The assessment should consider any degree of change in prior parameters, anxiety or agitation, discomfort, and behaviours.” Monitoring changes in patient parameters and status is often referred to as recognizing trends. Trends help to recognize whether a patient’s status is improving or declining.
Stabilization and treatment of critical cases often requires hospitalized care for an extended period of time. It is important to create a care plan based on the unique needs of ach individual patient; the plan should cater to their physical, physiological, and psychological well-being. The plan should include realistic expectations for patient recovery and for the healthcare that the medical team can provide.
Monitoring the critical care patient
Critical condition patients often need advanced monitoring and patient care technicians are intimately involved. Ms. Mattox said that while critical patients need to be monitored continuously, stable patients should have a complete set of vitals and assessment done every 4 hours, and it is important for the technician to observe all patients constantly for decomposition and unplanned needs such as cage cleaning after soiling.
Critical patients require fluid therapy. Monitoring fluid therapy includes evaluation of patient hydration status, catheter site evaluation, and equipment evaluation. Fluid therapy and feeding tubes should be constantly monitored for patency and efficiency.
Urine output should also be monitored in critical patients; normal ranges are 1-2ml/kg/hr. This is not only important to evaluate fluid therapy but to indirectly monitor perfusion and kidney function. Placement of a urinary catheter and closed collection system allows for close monitoring of urine output but it can also be measured by weighing absorbable pads used to catch voided urine.
Patient care technicians should make ongoing pain assessments based on changes in patient behaviors in the hospital. Technicians normally spend the most time with the hospitalized patient and must be able to pick up on subtle cues associated with patients experiencing a change in pain status. To keep pain assessments more objective, the use of pain scores is important.
Test results – knowing when it is an emergency
Critical care technicians must understand normal versus abnormal test results and know what values constitute an emergency. (See Chart 1) It is also important to know what is normal for that particular patient before their treatment begins. “Being above or below textbook normal parameters does not always mean the veterinary patient is in crisis,” Ms. Mattox advised. “For example,” she said, “the normal temperature in small animals is often documented at 100-102.5F. However, temperatures do not concern most veterinarians unless they are below 99F or above 103F.
While a temperature of 104F is an indication of a potential disease process the increased temperature itself is not an emergency. It is more important to understand that a patient whose temperature has been 100F for 12 hours has increased to 104F, indicating a change in a trend that should be investigated to determine why the change occurred and if the treatment plan needs adjusting.”
Chart 1: Normal vs. emergency vitals
Vital |
Normal |
Emergency |
Temperature |
100-102.5F |
Hypothermia below 96F Hyperthermia above 106F |
Heart Rate *dogs |
60-120bpm |
Bradycardia under 60bpm Tachycardia over 160bpm |
Heart Rate *cats |
160-220bpm |
Bradycardia under 180bpm Tachycardia over 230bpm |
Pulse |
60-120bpm Easily palpable and strong |
Different than heart rate Weak or thready |
Respiratory Rate |
20-40bpm |
Tachypnea over 50bpm
|
Respiratory Effort |
Smooth and mechanical |
Any effort is abnormal |
Mucous Membranes |
Pink |
Not pink Blue – decreased oxygenation Dark Red – infection, inflammation Pale pink/White – anemia, decreased perfusion
|
Capillary Refill Time |
1-2 seconds |
Prolonged – poor perfusion |
Mentation |
Alert and Active |
Decreased level of consciousness |
Other patient care requirements
Since hospitalized patients are often on a number of different drug therapies, it is important for technicians to have a good working knowledge of commonly used drugs such as pharmacodynamics, pharmacokinetics, side effects and interactions with other drugs. It is also important to understand techniques involved in administering medications without causing unnecessary stress.
Monitoring and recommending nutritional intervention, and understanding the appropriate timing and technique to carry out the nutrition plan, are vital for the recovery of most hospitalized patients.
Care of recumbent patients can be challenging. Patient care technicians should prepare for adequate bedding, rotation, passive range of motion exercises, elimination management, and oral and ophthalmic care.
It is important that patients receive care that enhances their environment and ultimate comfort. This should include TLC (grooming, walking, petting), quiet time to rest, and social interaction with the patient care technician.
Thorough, legible records are essential to provide details on how a case is being managed, including the rationale for treatment decisions, as well as information on the patient’s progress and response to treatment. It is important to pass on information about the patient’s behavior and subtle changes noted during their care for the next patient care technician.
“Open communication with the veterinarian and other members of the health care team is necessary to discuss concerns about the patient’s status or current treatments,” said Ms. Mattox.
Critical care technicians should be knowledgeable and compassionate when speaking with owners of a pet in crisis. The technician often plays a vital role in client communication. In order for clients to make rational decisions regarding their pet’s care, it is important that time is spent explaining the nature of the animal’s problems, recommended treatment options, possible complications and expected prognosis. The owner should be made to feel at ease and to have confidence that their pet is being cared for in a professional and pleasant environment.
Conclusion
Patient care technicians who practice the art of patient care are a very vital part of the critical care medical team. CVT
