Medical Nursing for Veterinary Technician

Part 1 

Fluid therapy is a critical part of ensuring the correct administration of IV fluids in dehydrated animals. It is also essential to first decide the required fluids and their rates. The purpose of fluid administration is to replace the lost fluid, correct electrolyte abnormalities, maintain organ or tissue perfusion rate, and enhance kidney diuresis as the patient undergoes anesthesia. Fluids can be administered to replace losses due to vomiting that happens during or before surgery. The first step when dealing with dehydration is to determine the dehydration level of the patient through observing the clinical symptoms of dehydration and their corresponding body dehydration rates (Davis et al., 2013). For patients with a 5 to 6 percent dehydration rate, the clinical indication entails a subtle loss of skin elasticity. 6 to 8 percent dehydration rate is defined by delays in return of skin to normal position, skin turgor, eyes marginally sunken into orbits, and a small increase in capillary refill time. 10-12 percent dehydration rate is defined by potential shock signs, possible consciousness alteration, dull eyes, and eyes sunken into orbits, complete skin turgor loss, and dry mucous membranes. Shock signs define 12 to 15 percent dehydration rate and imminent death if not managed (Donohoe, 2012). 

After determining the hydration status of the patient, the next step is to calculate the fluid replacement volume and rate. The calculation entails using three values that include the maintenance requirement, ongoing losses, and the percent dehydration (Davis et al., 2013). 

The formula for percent dehydration (hydration deficit) entails: 

Bodyweight × percent dehydration (in decimal) ×1000= fluid deficit in ml 

Ongoing fluid loss involves both insensible and sensible losses. Insensible losses cannot be quantified and include lost fluids in feces and respiratory tract losses during panting, among others. These can be estimated and be incorporated into the total fluid rate. Sensible losses can be measured and include fluids lost through urine. Maintenance fluids entail the needed fluid volume daily to sustain balance without a change in total body water (Davis et al., 2013). Computing the required fluid therapy and fluid rate entails calculating maintenance requirements, an approximation of ongoing losses, and the computation of hydration deficit. 

Computing the fluid deficit involves multiplying the body weight by the dehydration percent (decimal). In turn, this result in the volume of fluid the patient requires to be rehydrated if ongoing losses are absent. The presence of continuous losses, such as through vomiting, means that the estimated losses should be added to the fluid deficit. The liquid rate of the patient is based on the computed hydration deficit, estimated ongoing losses, and maintenance rate. The replacement fluid volume entails the total of current losses and hydration deficit (Davis et al., 2013). 

For the feline patient in the case, there is no shock, ongoing losses are absent, the dehydration rate is 10 percent, and the patient weighs 8 lb. 

8lb= (8lb/2.2) kgs 

=3.6kgs 

Dehydration rate= 10 divide by 100 

=0.1% 

The hydration deficit for the cat = 3.6kgs ×0.1% × 1000mls 

= 360mls 

Maintenance fluid for the patient per hour 

The cat is 3.6kgs in weight, 

= (3.6kg) 3 = 46.656 

=2.6 

Maintenance fluid =2.6 multiplied by 80ml 

=208 mls 

Maintenance rate per hour=208/24hours= 8.67mls/hour 

The cat will require 15mls/hour + 8.67mls/hour for dehydration correction, 

= 23.67mls/hour 

The third phase of fluid therapy entails monitoring. Monitoring involves observing the forward perfusion parameters such as capillary refill time, heart rate, the color of the mucous membrane, mentation, respiratory rate, quality of the pulse, and color and temperature (Davis et al., 2013). Normal parameters indicate the effectiveness of fluid therapy. Monitoring also involves measuring packed cell volume/total protein (PCV/TP) and urine specific gravity (USG). Low values demonstrate a return to normal levels in the intravascular domain and overall hydration improvement. Dilute urine demonstrates the restoration of fluid balance (Donohoe, 2012). 

Multiple weight checks across the duration of the therapy can also be used to monitor fluid therapy. For instance, total body water (TBW) is 60 percent of the bodyweight of the patient. High fluid volume in any compartment results in a corresponding increase in the overall weight of the patient. A 10 or more improvement from baseline admission weight indicates over-hydration, and the need to stop the therapy (Davis et al., 2013). 

It is important to monitor fluid therapy to avoid issues such as fluid overload that can complicate the entire treatment and result in peripheral edema, ascites, and pulmonary edema with the possibility of developing compartment syndrome (Donohoe, 2012). 

Part 2 

Cardiopulmonary resuscitation (CPR) is the treatment for animals experiencing cardiopulmonary arrest. CPR provides adequate oxygen and blood flow to vital organs and sustains life (Clarke & Trim, 2013). CPR combines two techniques, chest compressions and rescue breathing, to ensure continued oxygen supply to the lungs and sustain blood circulation to move oxygen to other body parts, including the vital organs (Hassel, 2014). 

Advanced CPR is performed by a specialist in a veterinary clinic and involves various steps. The first step entails initiating basic life support where the CPR team starts chest compressions (C), followed by obtaining airway (A) and finalized by starting breathing (B) (CAB resuscitation). Chest compressions ensure pulmonary blood flow to enhance oxygen uptake, waste removal, and tissue perfusion for delivering oxygen to reinstate metabolic activity. The two CPR related theories include cardiac pump theory and thoracic pump theory (Hassel, 2014). Based on the cardiac pump theory, it is vital to directly compress the cardiac ventricles between the sternum and the spine for patients in dorsal recumbency or between the ribs for patients in lateral recumbency (Hassel, 2014). Based on the thoracic pump theory, chest compressions increase intrathoracic pressure by compressing the aorta while collapsing the vena cava, which results in blood flowing out of the thorax (Hassel, 2014). The scientific literature suggests that the thoracic conformation determines the mechanism to use even though thoracic pump theory is recommended for medium, large, and giant patients with rounded chests while the cardiac pump theory is recommended for patients with narrow and deep chests (Hassel, 2014). The CPR steps include first ensuring the presence of good lighting because this fosters vein visualization and endotracheal intubation. The second step is to identify cardiopulmonary arrest early to ensure effective patient resuscitation. Identifying cardiopulmonary arrest entails following the airway, breathing, and circulation checks quickly in apneic unresponsive patients. CPA evaluation occurs when the palpable pulse, effective ventilation (agonal breaths are ineffective breaths), or audible heart are absent. 

After a CPA diagnosis, basic life support (BLS) should follow immediately through the Circulation, Airway, and Breathing (CAB) idea. BLS involves handling circulation first due to the ineffectiveness of ventilation in the absence of cardiac output. Delaying to initiate chest compressions can worsen the outcomes since oxygen delivery to the brain and heart during CPR is restricted by the flow of blood instead of the content of arterial oxygen (O’Dwyer, 2014). Compressions are vital during the initial few resuscitation minutes than ventilations. The next step after diagnosing CPA entails chest compressions. The chest compression steps based on the cardiac pump theory include: 

Applying direct compression over the heart with the patient staying in lateral recumbency, 

Performing 100 to 120 compressions per minute, 

Performing 10 breaths per minute ventilation throughout the cycle, and 

Allowing sufficient chest recoil between compressions. 

The chest compressionsteps involved in thoracic pump theory entail: 

Placing the patient in lateral recumbency and applying compression at the widest thorax part between the seventh and eighth intercostal spaces, 

Depressing the thorax by a third, 

Using 100 to 120 compressions per minute, 

Performing ventilation at ten breaths per minute through the compression period, 

The compression-to-relaxation ration should be 1:1, and 

Sufficient chest recoil between compressions should be allowed. 

Airway and breathing follow after compression to enhance ventilation through intubation. Intubation can be initiated in lateral recumbency to reduce the requirement for stopping chest compressions when placing the endotracheal tube (Clarke & Trim, 2013). 

Mouth-to-snout ventilation can be used if the endotracheal tube is unavailable to enhance waste elimination and oxygenation. The process entails holding firmly the patient’s mouth closed with one hand and extending the neck to ensure the snout and the spine are in alignment (Hassel, 2014). 

Chest compressions should be performed simultaneously with ventilation. The ventilation should be performed at ten breaths per minute, including the inspiratory time of nearly one second. The tidal volume should be 10 ml per kg for each breath (Clarke & Trim, 2013). 

After initiating basic life support, advanced life support follows with a focus on electrical defibrillation and drug therapy. Drug therapy entails applying vasopressors, anticholinergics or antiarrhythmics, alkalinizing drugs, reversal agents, and intravenous fluids. It is recommended to place an intraosseous catheter or central intravenous or peripheral (Hassel, 2014). 

Vasopressors increases peripheral vasoconstriction and enhance cardiac output (Hassel, 2014). Anticholinergics are applied as parasympatholytic drugs, while antiarrhythmics manage pulseless ventricular tachycardia or ventricular fibrillation. Reversal agents are applied following the recent use of reversal anesthetic medications (Clarke & Trim, 2013). Intravenous fluids should not be administered in hypervolemic or euvolemic patients during CPR because high atrial pressure will lead to decreased heart and brain perfusion. The fluids can be used among hypovolemic patients to reinstate sufficient volume and increase chest compression efficacy through enhanced perfusion. Corticosteroids should not be used during CPR, while alkalinization therapy can be used in patients with prolonged CPA above 10 to 15 minutes. For patients with ventricular fibrillation or pulseless ventricular tachycardia, electrical defibrillation can be used (Hassel, 2014). 

The possibility of a veterinary emergency is inevitable, which emphasizes the importance of being ready (Hassel, 2014). It is vital to ensure that an emergency cart is available at the clinic. The cart should have things such as endotracheal tubes, ties, syringe for inflating cuff; laryngoscope; and syringes and needles. Others are IV catheters, tape, t-ports, flush, male adapter, emergency drugs (lidocaine, naloxone, atropine, and epinephrine), scalpel blades, Gauze, Thoracocentesis supplies, and gloves/sterile gloves (Clarke & Trim, 2013). 

Part 3 

Both patient and environmental factors can impede the healing of traumatic wounds in animals. The main patient factors that delay wound healing include age, body state, concurrent disease, and nutritional intake (Mickelson, Mans & Colopy, 2016). Traumatic wounds cause animals to shift to a metabolic state, which requires sufficient nutrition. Protein deficient diets and hypoproteinemia decrease the strength of wounds and delay healing. Existing illnesses such as uremia, hyperadrenocorticism, and diabetes mellitus delay the healing process. Besides, some drugs such as chemotherapeutic medications and corticosteroids impede the healing process by reducing the wound strength. By focusing on rapidly dividing cells, chemotherapeutic agents, adversely affect wound strength and fibroblast proliferation. 

Environmental factors that delay wound healing include mechanical factors such as wound debris, motion, and tension; the presence of seroma or hematoma, infection, tissue viability, tissue perfusion, and temperature (Mickelson et al., 2016). The availability of foreign materials such as devitalized tissue, hair, dirt, or debris causes inflammation that delays the repair stage by prolonging the inflammatory stage. Mechanical factors such as placing a tight bandage, high tension, and motion impair the supply of blood, which may lead to necrosis and tissue ischemia. The degree of temperature influences the tensile strength of a wound. 

Ensuring sufficient patient nutrition is a crucial aspect of wound healing in animals. The presence of wounds places animals in a metabolic condition that requires sufficient nutrition by increasing protein and calorie intake to meet nutritional needs. Negative nitrogen balance leads to slow wound healing. The main nutrients entail glucose and protein. The normal plasma protein level is 7.0 to 7.5 g/dl but levels less than or equal to 6.0g/dl contribute to slow healing whereas amounts less than 5.5 g/dl lead to the risk of healing failure by nearly 70 percent (Peycke, 2019). Protein helps the body by hindering edema while glucose offers energy to fibroblasts and leukocytes that significantly contribute to wound strength and collagen formation. The healing process necessitates the presence of adequate energy nutrients such as carbohydrates and fats for tissue rebuilding(Peycke, 2019). The absence of these nutrients compels the body to break down endogenous protein to address the body’s needs for rebuilding tissues to heal wounds 

Seroma or hematoma hinder fibroblast migration and promote infection through fluid accumulation in the wound bed, and result in wound ischemia, which delays strength formation and healing (Mickelson et al., 2016). Wound infection adversely affects the wound healing process by causing wound dehiscence. Bacteria release proteolytic enzymes and other particles that hinder wound healing (Tear, 2014). Seroma and hematoma also increase the pressure below the suture line, which increases the risk of interruption of the wound edges. 

The measures that can be taken to limit the impact of inadequate nutrition include implementing nutritional support to maintain body weight and avoid overfeeding. It is vital to first compute the energy requirements of the patient. For patients with normal protein tolerance, the protein intake should be 4 to 6 g per 100 kcal or 15 percent to 25 percent of the entire needed energy for dogs. For cats, the intake should be 6 g protein per 100 kcal or 25 percent to 35 percent of the entire energy. For animals with a severe wound such as degloving injuries or burn wounds, adjustments should be made to address the high protein requirements (Peycke, 2019). Enteral feeding should also be initiated when voluntary intake does not meet the nutritional needs to assist in maintaining intestinal health. This should be initiated in cases where the patient resists eating during the initial 2 to 3 days following the wound. Monitoring should follow through examining factors such as hydration status, tube placement, blood state, gastrointestinal signs, and body weight (Peycke, 2019). Parenteral nutrition can also be introduced for patients that cannot be fed enterally or orally. 

Improperly assessing and closing an unsuitable wound is the basis of seroma and hematoma. It is advisable to select the wound closure type based on the status of the patient, the approximated level of contamination in the wound, the level of damage to the soft tissue, and the amount of the available adjacent tissue for closure (Tear, 2014). Primary closure should be initiated after classifying the wound as clean-contaminated or clean. Delayed main closure should be carried out two to three days following the occurrence of the wound and before granulation tissue forms (Tear, 2014). In turn, this decreases the rate of wound infection in cases where it is challenging to eliminate contamination. 

Part 4 

A comprehensive oral examination for dental issues in animals is vital and it involves an extraoral examination and an intraoral assessment (Kressin, 2009). The extraoral examination starts with an evaluation of facial symmetry. Face palpation should be performed to identify fluctuant or firm masses. Salivary and lymphatic tissue palpation should follow to identify issues concerning the intraoral illness. The mouth of the patient should be opened and closed to identify clicking and popping sounds or crepitus in the temporomandibular joint. It is also important to palpate the right and left mandible to identify symphyseal instability or fractures. Another vital step is to perform dental radiographs to assess patients with missing teeth and to exclude embedded teeth that can cause oral cysts to form. Assessment for the chronic obstructive respiratory syndrome (CORS) should be performed without tongue retraction and before intubation to identify everted laryngeal saccules ad laryngeal collapse (Kressin, 2009) 

For intraoral evaluation, the initial step entails restraining the patient to close its mouth and avoid injury. Then, the evaluator views the lower and upper lips before separating them gently to examine oral mucosa, dental occlusion, and dentition. The examiner can also view the sides of the oral cavity to observe teeth surfaces. Tools such as cotton-tipped applicators can be used when examining oral anatomy to avoid personal injury. The examiner can then palpate the mandibular lymph nodes and neck before tilting the head of the patient back to point the nose up to relax the lower jaw and open the mouth to view the oral cavity. An assistant can help the examiner for large patients to secure the body and the head. Force should not be used to avoid injury and chemical restraint may be required for aggressive patients. The oral examination allows the examiner to view the gingiva, cheek mucosa, incisive papilla, alveolar mucosa, mouth floor, palate, tongue, and lips (Kressin, 2009). All observed issues are then noted each time they are viewed for further examination. Failure to examine animals to ensure their dental health may lead to diseases such as periodontal illness. 

Periodontal illness refers to an inflammation and infection of the periodontium (tissues surrounding and supporting the teeth) caused by plaque bacteria and the reaction of the patient to the bacterial infection (Reiter, n.d.). While animals suffer from gingivitis that causes gingiva inflammation in reaction to plaque bacteria, periodontal illness is a severe illness that entails alveolar bone and periodontal ligament inflammation, which then leads to attachment loss ( bone resorption, gingival recession, periodontal pocketing). The early stages of the illness entail normal alveolar margin architecture and height with the presence of gingivitis only. Early periodontitis then follows with less than 25 percent loss of attachment, the presence of stage one furcation in multi-rooted teeth. The second stage is represented by early radiographic periodontitis signs. The third early-stage entails moderate periodontitis that includes 25 percent to 50 percent loss of attachment or the presence of the second stage furcation in multi-rooted teeth (Reiter, n.d.). The pathogenesis of periodontal disease involves bacterial plaque on the tooth’s crown surface presenting antigen to the marginal gingiva, which stimulates an inflammatory reaction and leads to gingivitis (Reiter, n.d.). Periodontitis occurs when the host reacts to subgingival plaque in which the inflammatory mediators that the host produces directly lead to tissue and bone damage around the root (Reiter, n.d.). The metabolic products that the bacteria produce also lead to bone damage. Failure to manage the early stages of periodontal illness leads to the development of grade four periodontal disease that can only be managed through surgery. 

The surgical tools used in Grade 4 periodontal illness include scalpel blade, periodontal elevators, sharp curettes, tissue forceps, tissue scissors, small needle holders, and suture scissors (Gawor, 2015). Scissors are used for incisions to create periodontal flaps, which are necessary for visualizing the affected areas, ensure effective cleaning, reshaping affected tissue, and covering damaged places. A periosteal elevator also creates envelop flaps and full flaps. Envelope flaps reduce the possibility of dehiscence and lead to low suturing while full flaps ensure uninterrupted blood flow. A sharp curette is used to make flaps to allow the doctor to visualize the root surface to create a clean and smooth tooth surface for reattachment. It is also vital for clients to understand how to take care of the dental hygiene of their animals to hinder diseases such as periodontal illness (Gawor, 2015). 

Clients can use several prevention measures such as tooth brushing or wiping the teeth using a gauze pad to remove accumulated supragingival plaque, feeding animals using fibrous and firm items that penetrate the teeth to wipe plaque during chewing, and using products the prevent or slow pellicle attachment (Reiter, n.d.). 

It is also important for clients for learn about various ways of preventing periodontal disease by first identifying the complexity of preventing periodontitis. The vital information to understand is that regular oral hygiene to eliminate supragingival plaque helps in protecting the animals from developing subgingival plaque while reducing the number of bacteria in the mouth (Reiter, n.d.). It is also important to identify and remove predisposing factors. 

References 

Clarke, K. W., & Trim, C. M. (2013).  Veterinary Anaesthesia E-Book . Elsevier Health Sciences. 

Davis, H., Jensen, T., Johnson, A., Knowles, P., Meyer, R., Rucinsky, R., & Shafford, H. (2013). 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats.  Journal of the american animal hospital association ,  49 (3), 149-159. 

Top of Form 

Donohoe, C. (2012).  Fluid therapy for veterinary technicians and nurses . Chichester, West Sussex, UK: Wiley-Blackwell. 

Gawor, J. (2015). Periodontal Surgery: Selected Techniques - WSAVA 2015 Congress. Retrieved November 21, 2019, from https://www.vin.com/apputil/content/defaultadv1.aspx?id=7259185&pid=14365&print=1 

Hassel, D. M. (2014).  Emergency and Critical Care, An Issue of Veterinary Clinics of North America: Equine Practice, E-Book  (Vol. 30, No. 2). Elsevier Health Sciences. 

Kressin, D. (2009, February). Oral Examination of Cats and Dogs. Retrieved November 21, 2019, from https://www.vetfolio.com/learn/article/oral-examination-of-cats-and-dogs. 

Mickelson, M. A., Mans, C., & Colopy, S. A. (2016). Principles of wound management and wound healing in exotic pets.  Veterinary Clinics: Exotic Animal Practice ,  19 (1), 33-53. 

O’Dwyer, L. (2014, February 1). Preparation and techniques for cardiopulmonary resuscitation. PDF. London. 

Peycke, L. E. (2019, October 15). Nutrition and Wound Healing. Retrieved November 21, 2019, from https://todaysveterinarypractice.com/nutrition-and-wound-healing/ . 

Reiter, A. M. (n.d.). Periodontal Disease in Small Animals - Digestive System. Retrieved November 21, 2019, from https://www.merckvetmanual.com/digestive- system/dentistry/periodontal-disease-in-small-animals. 

Tear, M. (2014).  Small Animal Surgical Nursing-E-Book . Elsevier Health Sciences.