Printer Friendly

Chapter 3: Technician evaluations with suggested interventions.

[ILLUSTRATION OMITTED]

INTRODUCTION

This chapter contains a list of all technician evaluations with each evaluation defined and the desired resolution identified. Evaluations are followed by suggested or common interventions and rationales. However, the suggested interventions are not exhaustive; that is, in certain cases, the veterinarian or the veterinary technician may decide that additional interventions are appropriate. Likewise, the use of all suggested interventions may not be warranted in every case. Ultimately, the selection of appropriate interventions and plans of care reflect individual patient needs and the judgment of the medical team.

The various technician evaluations are printed alphabetically. However, for easy reference, they have been grouped according to the Needs Ladder (Figure 3-1) as well as by body system (Figure 3-2) and in alphabetical order (Figure 3-3).

ABNORMAL EATING BEHAVIOR

Definition/Characteristics

Abnormal eating behavior is consumption of food in a manner that is atypical of normal species behavior. Atypical behaviors can include rapid ingestion of food (wolfing), food regurgitation followed by repeated consumption, pica, grass eating, begging, and coprophagy. Secondary signs of abnormal eating patterns can include bloating, nausea and/or vomiting, and other signs of gastrointestinal (GI) distress such as anorexia, rolling, posturing, and restlessness.

Desired Resolution

Consumption of appropriate feeds in a manner that is acceptable to owners and minimizes adverse medically associated conditions.

Interventions with Rationale/Amplification

1. Assess the animal for signs of acute GI distress. Notify the veterinarian immediately if such signs are noted. All animals, but particularly large breeds of dogs such as Great Danes and English mastiffs, may suffer serious sequelae from bolting large meals. Pica (ingestion of aberrant food or garbage) can result in diarrhea and vomiting with resulting dehydration.

2. Collect samples and complete diagnostic tests as directed by the veterinarian. Disease processes can induce numerous eating abnormalities. Medical causes should be ruled out prior to initiating behavioral approaches to treatment.

3. Provide client education:

* Wolfing food. Divide daily ration into three or four small meals per day. Provide a quiet, stress-free location for consumption of food. Separate dog from other animals during mealtimes. Particular kibble shapes may help to encourage chewing and reduce this wolfing behavior.

* Pica. Treatment is often unrewarding; aversion therapy can be attempted. Most cases are treated using avoidance.

* Begging. Approximately 30 percent of dogs beg for food. Begging behaviors typically lead to excessive caloric intake and obesity. Treatment includes ignoring begging behavior and removing the animal from area during mealtimes and food preparation. Feed dog in separate area of home while owners are eating. Recommend using low-calorie snacks if owner insists on feeding the animal treats.

* Coprophagy. Treatment is often unrewarding. Avoidance techniques include application of For-Bid, fresh pineapple, or meat tenderizer (sprinkle over meals at 1 tsp/25 lb) to all meals. Covering cat litter box or immediately removing feces from yard is highly recommended. Free-choice feedings or diets high in fiber may have some beneficial effect. Routine prophylactic deworming is recommended for all coprophagic animals.

* Grass eating. This is considered normal behavior for dogs.

[FIGURE 3-1 OMITTED]

[FIGURE 3-2 OMITTED]
Figure 3-3: Technician Evaluations Listed in Alphabetical Order

Abnormal Eating Behavior
Acute Pain
Aggression
Altered Gas Diffusion
Altered Mentation
Altered Oral Health
Altered Sensory Perception
Altered Urinary Production
Altered Ventilation
Anxiety
Bowel Incontinence
Cardiac Insufficiency
Chronic Pain
Client Coping Deficit
Client Knowledge Deficit
Constipation
Decreased Perfusion
Diarrhea
Electrolyte Imbalance
Exercise Intolerance
Fear
Hyperthermia
Hypervolemia
Hypothermia
Hypovolemia
Impaired Tissue Integrity
Inappropriate Elimination
Ineffective Nursing
Noncompliant Owner
Obstructed Airway
Overweight
Postoperative Compliance
Preoperative Compliance
Reduced Mobility
Reproductive Dysfunction
Risk of Aspiration
Risk of Infection
Risk of Infection Transmission
Self-Care Deficit
Self-Inflicted Injury
Sleep Disturbance
Status Within Appropriate Limits
Underweight
Urinary Incontinence
Vomiting/Nausea


ACUTE PAIN

Definition/Characteristics

Acute pain is the sudden onset of an unpleasant sensory experience, the intensity of which can be mild to severe. Acute pain is associated with changes in behavior (aggression, fear, restlessness, withdrawal, and/or vocalizations), guarding and/or posturing, repetitive behavior (pacing and/or repeatedly lying down and arising), excessive grooming, anorexia, diaphoresis, pupillary dilation, and changes in vital signs (blood pressure [BP], heart rate, and respirations).

Desired Resolution

Absence of signs of acute pain; the animal appears comfortable; behavior has returned to normal or baseline.

Interventions with Rationale/Amplification

1. Rank pain response on a level of 0-5. Record findings and alert the veterinarian to the level of pain.

Pain may be quantified with the following scale:

* 0 = no pain

* 1 = mild intermittent discomfort

* 2 = mild pain

* 3 = moderate pain

* 4 = severe pain

* 5 = extreme pain

The pain response in animals is frequently identified through behavioral changes such as alteration in normal vocalization patterns (dogs will whine; cats may growl or purr), withdrawal (cats will attempt to hide; dogs will suddenly appear timid) or attention-seeking behaviors, aggression, excessive grooming or licking (or a sudden lack of any grooming), repetitive behaviors, fixed unresponsive staring, guarding of affected area, tendency to refuse to move, and anorexia. Physiological signs of pain can include increased BP, heart rate, and respiratory rate. Pale mucous membranes caused by peripheral vasoconstriction also are common.

Pain is most successfully treated via prevention (e.g., administering pain medication prior to surgical interventions) or early intervention. Once the pain response has been activated, a higher dose of medication is typically required to provide relief. Tolerance to pain is variable and individualistic; it is affected by factors such as species, gender, health, age, and breed. In general, younger animals exhibit more signs of pain than do geriatric animals. Prey species such as birds, rabbits, horses, and sheep take active measures to hide a pain response as long as possible.

Ranking pain response during each examination of the animal will assist the veterinarian in determining whether the animal has responded to treatment, as evidenced by progressively decreasing scores. Veterinarians should be notified if pain is unrelieved by treatment or appears to be increasing.

2. Monitor and record vital signs. Worsening vital signs may indicate that the animal is still experiencing pain. As pain resolves, these parameters will trend toward normal.

3. Use nonpharmacological approaches to control pain when appropriate. Application of heat (heating pads or hot packs), cold (ice packs or hydrotherapy), gentle stroking, or environmental modifications (deep bedding or soothing sounds) have been shown to decrease the pain response. If possible, position the animal to decrease sensation of pain. Occasionally, positioning can partially relieve acute pain. Although most animals instinctively assume the position that provides the most relief, some animals may be too weak to position themselves. Be very careful about positioning an animal who has suffered blunt trauma (e.g., was hit by automobile or fell) as spinal injury is possible and movement of the animal may exacerbate the initial injury.

4. Administer pain medications as directed by the veterinarian. Analgesics frequently used in veterinary facilities include the nonsteroidal anti-inflammatories (NSAIDs) or opioids (narcotics). Recent advances in identification and control of pain have led to increased use of preemptive and multimodal analgesia. In addition, local, transdermal, and topical modes of administration are becoming increasingly popular. Never apply topical heat (e.g., heating pads) over topical patches as this can increase rate of delivery of drug to toxic levels. Monitor for adverse side effects of any pain medications.

Adverse side effects noted with NSAID use include:

* Vomiting or changes in appetite

* Changes in bowel movements such as black, tarry, or bloody stool

* Changes in behavior

* Jaundice

* Changes in drinking or urination habits

* Changes in skin, such as redness, itching, or scabs

Adverse effects associated with narcotics include:

* Constipation

* Respiratory depression

* Weakness or ataxia

* Nausea

* Mania (cats)

* Skin reactions to topical patches

* Euphoria

* Changes in appetite

5. Ensure safety of owner and veterinary personnel through the use of appropriate restraint techniques. Animals in acute pain may become aggressive, particularly as they are being handled and examined by a stranger. Restraint and muzzling provides increased safety for the animal's caregivers. Use extreme caution when applying a muzzle to an animal that shows signs of respiratory compromise or shock, perhaps using alternative measures such as an E-collar, which won't interfere with respiratory efforts.

6. Educate owner about signs of pain as well as methods of administering prescribed analgesic medications, necessary precautions when administering medications, and side effects of medications. Instruct owner to call the veterinarian if pain reoccurs or appears to be unrelieved by treatment. Providing both verbal and written instruction facilitates client understanding and compliance. Since many animals do not vocalize pain, owners must be given specific instructions on what signs to look for regarding pain.

AGGRESSION

Definition/Characteristics

Aggression is defined as hostile behavior exhibited toward other animals and/or people. Aggression can be characterized by increased vocalizations (barking, growling, or hissing), raised hackles, baring of teeth, eye-to-eye contact, biting, kicking, and scratching.

Desired Resolution

Animal exhibits no hostility or challenging behavior toward other animals and/or people unless so instructed by handler.

Interventions with Rationale/Amplification

1. Restrain the animal using a technique that eliminates or minimizes potential of injury to the handler or animal. Aggressive animals pose a threat to caregivers and/or other animals. The type of equipment used for restraint varies with each species. Restraint can induce undesirable physiological changes in the animal.

2. Interview owner carefully to identify situations in which the animal exhibits aggression as well as the duration of the problem. Classify the type of aggression. Identification of triggers may enable the owner, veterinarian, and technician to develop proper management strategies. Although highly undesirable, most incidences of aggression are not considered abnormal. Aggressive behavior or actions are typically a normal species behavioral pattern that is incompatible with owner's lifestyle or needs. Aggression can be classified as follows:

--Dominance aggression: Usually males that attempt to dominate family members. Often become aggressive when approached while eating, disturbed in sleep, restrained, pulled, pushed or lifted, groomed, or medicated.

--Possessive aggression: Related to dominance aggression. Occurs when an object or food is withdrawn from the animal.

--Play aggression: Usually in young/juvenile dogs and involves growling and nipping that doesn't break the skin. Animals often simultaneously exhibit play behaviors such as bowing, wagging their tails, and running in circles.

--Fear-induced aggression: Occurs in either sex; animals often bite when reached for or cornered. Animals often simultaneously exhibit fearful body language.

--Pain-induced aggression: Occurs in either sex when humans attempts to medicate or examine a painful area.

--Territorial aggression: Occurs in either sex and usually involves strangers (animals or humans) approaching an area that dog perceives as its territory.

--Predatory aggression: Typical hunting behavior exhibited. Dog is attacking what he or she believes to be prey.

--Parental aggression: Occurs in females protecting offspring.

3. Discuss various coping techniques with owner to identify best options for the particular animal. Inform owners of dangers associated with animal aggression; address the need to protect vulnerable individuals such as children and visitors.

--Dominance aggression: Consider castration. Initiate behavior modification therapy and general obedience training. Long-term prognosis for this form of aggression is poor.

--Possessive aggression and territorial aggression: Physical separation such as kennels and fenced-in yard. Initiate behavioral modification therapy.

--Play aggression: Terminate inappropriate play (such as children running and playing tug-of-war). Use appropriate toys and decrease stimuli during play periods.

--Fear-induced aggression: Identify eliciting stimuli and initiate counterconditioning.

--Pain-induced aggression: If possible, identify source and eliminate pain. Initiate counterconditioning. Avoid punishment.

--Predatory aggression: Extremely difficult to eliminate; confinement is the only reliable method of control.

--Parental aggression: Limit number of humans interacting with female until weaning has occurred. Separate female when handling offspring.

4. Identify community resources that are available to owner. Training facilities, private trainers, therapists, and humane societies may be able to provide help to owner.

5. Check the animal's vaccination history to ensure that all vaccinations, especially rabies, are up to date. Vaccination of an aggressive animal provides protection to victims of aggression by decreasing the likelihood of disease transmission.

ALTERED GAS DIFFUSION

Definition/Characteristics

Altered gas diffusion is an imbalance in normal oxygen and carbon dioxide exchange at the alveolar level. Causes include changes in the alveoli (e.g., chronic obstructive pulmonary disease, pneumonia, and pulmonary edema), changes in blood flow (e.g., congestive heart failure and pulmonary embolism), and changes in oxygenation of the blood (e.g., oxygen deprivation, carbon monoxide poisoning, and hypoventilation). Altered gas diffusion is associated with dyspnea; tachycardia; cyanotic mucous membranes; altered arterial blood gases (ABGs) and oxygen saturation; and/or changes in behavior and LOC, including confusion, restlessness, lethargy, and coma.

Desired Resolution

Adequate oxygenation as demonstrated by improved breathing pattern, normal heart rate, pink mucous membranes, ABGs and oxygen saturation WNL and improved level of consciousness.

Interventions with Rationale/Amplification

1. Provide supplemental oxygen as ordered. Monitor and record oxygen saturation levels. In many cases, supplemental oxygen will increase oxygen saturation in the blood. Monitoring of oxygen saturation levels over time will indicate whether the animal is responding to treatment of underlying cause.

2. If possible, position the animal for maximum airway clearance. Extension of the head allows for maximum airflow.

3. Assemble all necessary emergency equipment, including endotracheal tubes, tracheotomy sets, and suction catheters. In emergency situations, easy access to emergency equipment improves delivery of care to the animal.

4. Monitor and record all signs and symptoms of respiratory distress. Notify the veterinarian immediately if signs and symptoms increase or do not improve following treatment. Acute respiratory distress can quickly escalate to an emergency situation. Failure to improve after treatment indicates other treatment options need to be considered.

5. Monitor pertinent lab values such as ABGs. Report all lab values to the veterinarian. Following successful treatment, laboratory values will normalize or return to patient baseline.

6. Provide fluids at rate and route ordered by the veterinarian. Adequate hydration allows the animal to mobilize and excrete secretions.

7. Administer medications as ordered by the veterinarian. Various medications such as broncodilators, diuretics, and corticosteroids may aid in increasing oxygenation. Antibiotics may be ordered to treat or prevent infection. Heparin or coumadin will aid in preventing emboli.

ALTERED MENTATION

Definition/Characteristics

Altered Mentation is a change in cognition, emotional state, and/or level of consciousness. Altered mentation may be of chronic or acute onset. It is characterized by changes in behavior (e.g., being withdrawn, displaying aggression, and walking in circles), regression in training (e.g., housebroken dog soiling in the house), confusion (e.g., not recognizing owner), decreased response to external and internal stimuli (e.g., decreased pain response), excessive sleeping, and/or coma. Altered mentation of a chronic nature may be caused by the aging process or by various neurological diseases. Changes in mentation with an acute onset may be caused by trauma, infection, electrolyte imbalances, or any physiological process that alters brain chemistry and oxygenation.

Desired Resolution

Return to baseline cognition, emotional state, and level of consciousness. (Chronic changes in mentation may be progressive and irreversible.)

Interventions with Rationale/Amplification

1. Obtain a complete history from owner regarding the animal's baseline level of mental functioning and any changes that have been observed. The veterinarian should be notified immediately of any animal that exhibits a decreased level of consciousness as this may indicate an emergency situation. A complete history will assist the veterinarian in determining whether the changes in mentation are chronic or acute and will provide information important in diagnosing the cause.

2. Obtain samples of urine and blood as ordered by the veterinarian; perform laboratory tests of samples. These tests may yield important information regarding the cause of changes in mentation. For example, altered liver function enzymes may indicate hepatic dysfunction, which can lead to portosystemic encephalopathy. Electrolyte imbalances and hypoglycemia also are possible causes of altered mentation.

3. Administer fluids and medication as ordered by the veterinarian. The use of fluids and choice of medications will be dependent upon the veterinarian's conclusions regarding the underlying cause of altered mentation. Note that any animal with a decreased level of consciousness should not be given anything by mouth unless it has been determined that the animal has an intact gag reflex.

ALTERED ORAL HEALTH

Definition/Characteristics

Altered oral health is a decline in the physical condition of the oral cavity that can be characterized by halitosis, gingivitis, periodontitis, glossitis, dental tartar, oral masses, dysphagia, anorexia, ulceration, drooling, dryness, and tooth loss.

Desired Resolution

Restoration of normal tooth, tongue, and gingival surfaces, accompanied by pain resolution. Initiation of appropriate oral prophylactic care program.

Interventions with Rationale/Amplification

1. Collect samples and perform diagnostic tests as directed by the veterinarian. A complete blood count (CBC) and chemistry profiles are frequently performed prior to a routine dental cleaning. Various tests such as cite tests for FeLV/FIV or biopsies can be performed when oral health reflects systemic or neoplastic disease.

2. Perform dental cleaning as directed under the supervision of the veterinarian. Dental cleaning requires the use of general anesthesia. Routine dental cleaning and prophylactic procedures should be performed by the technician. Numerous texts providing a step-by-step description of dental prophylaxis and cleaning are available.

3. Provide medication as directed by the veterinarian. The type of medication selected is determined by the underlying cause of oral disease. Antibiotics, anti-inflammatories (both nonsteroidal and steroidal), and occasionally immunosuppressive agents may be utilized.

4. Provide nutrition support as necessary. Animals suffering from oral masses, trauma, or severe dental disease may be unable to prehend, masticate, or swallow. Nutritional assistance in the form of altered diet texture (balanced, syringeable prepared critical care diets or gruels), pharyngostomy or JPEG tubes, or total parenteral nutrition (TPN) may be required.

5. Moisten oral cavity as necessary. Comatose animals and those unable to keep their tongue within the oral cavity will experience excessive drying of tongue and gingival surfaces. Application of a moistening agent such as glycerin is warranted.

6. Provide client education. Technician involvement is fundamental to establishing an appropriate preventative oral health care program. Technicians should educate/counsel clients on the following:

* Explain risk factors associated with oral disease. Liver, renal, and cardiovascular diseases have been linked to poor dental health. Numerous pamphlets, handouts, videos, and models are available for client education purposes.

* Explain the pet's current dental problems and treatments/procedures recommended by the veterinarian. Using the pet's dental chart when discussing problems is very helpful. Clients are more likely to treat their pet's medical condition when they fully understand the medical significance of the problem.

* Develop an individualized preventative home care plan that addresses plaque control. There are effectively three methods for accomplishing plaque control. These include mechanical (tooth brushing, dental diets, and chews), chemical (chlorhexidine solutions) and barrier (oravet) methods.

** Tooth brushing. This is the gold standard of plaque control. Human or pet toothbrushes that have soft bristles can be used. Toddler-size brushes are appropriate for small dogs and cats; compact head brushes can be used for larger animals. Brush length and curvature is a matter of preference. Do not use human toothpaste as it can cause emesis, gastric irritation, or fluoride intoxication. Flavored pet toothpaste is recommended. Recommended products should have the Veterinary Oral Health Council (VOHC) endorsement; this is the veterinary equivalent to the American Dental Association (ADA).

*** Instruct client to hold brush at a 45[degrees] angle to tooth surface. Using a circular motion, brush the buccal surface of the tooth. The lingual surface does not need to be brushed. Brush for 1 minute on each side. Ideally, the teeth should be brushed daily; however, clients should be encouraged to develop a frequency that will fit their schedule.

*** Problem animals can be acclimated to the procedure slowly through positive reinforcement. Owners can start by simply allowing the animal to lick the toothpaste from the brush. It is helpful initially to place dogs in a corner to prevent backing away. Minimal use of restraint is recommended on cats.

** Dental-specific diets. Most dental diets are formulated such that they "scrape" the tooth surface and remove plaque when the food is eaten or they employ a calcium chelating agent that makes calcium unavailable for inclusion in tartar (calculus). Dental-specific diets are available through Hill's, Royal Canin, Iams, Purina, and Eukanuba.

** Chews and toys. These items also remove plaque mechanically, although their importance is somewhat limited. Rawhide items should be avoided as they are choking hazards. Chew ropes or Kongs can be utilized.

** Chlorhexidine. Numerous types of solutions and gels are available to remove plaque chemically. Zinc-containing solutions also are used.

** Barriers. Inert polymers can be applied to the tooth surface weekly to prevent bacterial adherence, thereby minimizing tartar buildup.

ALTERED SENSORY PERCEPTION

Definition/Characteristics

Altered sensory perception is an impaired ability to assimilate environmental information. Alterations commonly involve ocular and auditory systems.

Desired Resolution

Restoration of sense/perception or patient's and owner's adjustment for long-term care.

Interventions with Rationale/Amplification

Visual

1. Provide a safe environment. Remove unnecessary items from kennel (toys and empty bowls) and secure water/food bowls to prevent tipping. Provide a quiet environment.

2. Always have larger animals on a leash/harness when outside the kennel. Be aware of potential obstacles for the patient. Maintaining slight pressure on the leash will provide the animal with a degree of guidance. Carry smaller animals.

3. Always alert the patient to your presence by speaking softly. Touch can be used as a reassuring measure if the animal is already aware of your presence. It is easy to frighten a visually impaired animal.

4. Monitor food and water consumption. Animals should be shown the location of food and water bowls. Bowls that are not secured should be removed after feeding.

5. Place animals on a PVC grate if needed. This will help keep the patient dry and clean from spilled food and waste.

6. Educate owners regarding safe home environments. Remove obstacles, allow the animal to become familiar with the environment, and provide an enclosed area for outside exercise. If needed, assist owners in locating trainers who work with impaired animals.

Auditory

1. Always place the patient on a leash/harness when outside the kennel. Animals with auditory impairment are less able to sense danger (e.g., an approaching car); leashing the animal provides safety.

2. Prior to touching the animal, make visual contact to ensure that the animal is cognizant of your presence. Animals with auditory impairment may be startled by a sudden touch and may react aggressively.

ALTERED URINARY PRODUCTION

Definition/Characteristics

Altered urinary production is a variance from normal levels of urinary elimination or a change in urine characteristics. Changes in urinary output may originate at the renal level (e.g., kidney failure and kidney infection) or in the ureters, bladder, or urethra (e.g., urethral obstruction). Altered urinary output may be characterized by anuria, oliguria, polyuria, dysuria, hematuria, or other changes in the color/consistency of urine (e.g., cloudy, presence of sediment, and foul odor).

Desired Resolution

Production and elimination of normal amounts of clear, yellow urine. No pain with urination.

Interventions with Rationale/Amplification

1. Obtain a detailed history from owner regarding the animal's normal urinary pattern as well as observed changes in urination. Other changes (e.g., behavior, eating, resting, and presence of pain) also should be noted. A good history provides the veterinarian with baseline data for the particular animal and aids in diagnosing the condition.

2. Monitor and record the animal's vital signs at intervals ordered by the veterinarian. Since the kidneys are intimately involved in regulating BP, renal abnormalities can impact vital signs. A drop in BP results in a decreased pulse pressure (weak pulse) but an increased rate. An increase in BP results in a pounding pulse and possibly vein distension.

3. Obtain a urine sample and perform urinalysis as ordered by the veterinarian. Note and record any deviations from normal in urine color/ characteristics. There are various methods for obtaining urine samples. Dogs may be taken outside on a leash and allowed to explore areas where other animals have urinated; this may prompt the animal to mark the area, and the urine can be captured. Urine can sometimes be expressed from cats; if expression is not possible, a urinary centesis may be performed. A urinalysis provides valuable information to the veterinarian and serves as an aid in diagnosing the condition.

4. Record the animal's urinary output every 8 hours or more frequently when ordered by the veterinarian. Notify the veterinarian when output is greater or less than normal for the species of animal. Prolonged anuria or oliguria can result in permanent damage to the kidneys; prompt intervention can save renal function. Urinary output is usually estimated; however, when a urinary catheter is in place, the amount can be measured exactly.

5. Administer fluids and medications as ordered by the veterinarian. Animals whose urinary output is low secondary to dehydration need to be rehydrated. Certain conditions (e.g., urethral obstruction) are treated with superhydration (hydration that exceeds the body's metabolic needs) to flush the renal system. When an animal is superhydrated, expect to see higher-than-normal levels of urine production. Certain medications such as diuretics, antibiotics, and analgesics may be ordered by the veterinarian.

6. Place urinary catheter when ordered by the veterinarian. Animals that are producing adequate amounts of urine but are unable to pass the urine risk bladder perforation. A catheter also may be placed if the veterinarian needs to know the exact amount of urinary production.

ALTERED VENTILATION

Definition/Characteristics

Altered ventilation is a change in inspiration/expiration that leads to abnormal oxygenation. This state is associated with dyspnea, orthopnea, adventitious lung sounds, use of accessory muscles for breathing, nasal flaring, mucous membrane cyanosis, decreased oxygen saturation, and altered ABGs.

Desired Resolution

Reestablish a normal pattern of respiration. Absence of signs of respiratory distress such as dyspnea, orthopnea, nasal flaring, use of accessory muscles, and cyanosis. Oxygen saturation and ABGs are normal or are returned to patient baseline.

Interventions with Rationale/Amplification

1. Provide supplemental oxygen as ordered for hypoventilation. Note and record patient's oxygen saturation level. Supplemental oxygen can help to increase oxygen saturation of the blood.

2. Monitor and record vital signs and signs of respiratory distress, including dyspnea, orthopnea, nasal flaring, and use of accessory muscles. Notify the veterinarian immediately if an increase in respiratory distress is noted. Trending of these signs over time will assist the veterinarian in determining whether treatment is effective. Acute/increased respiratory distress is a veterinary emergency.

3. Auscultate lungs for adventitious lung sounds, which may include rales, rhonchi, crackles, and/or wheezing. Record results. Adventitious lung sounds should dissipate with effective treatment.

4. Assemble all necessary emergency equipment, including endotracheal tubes, tracheotomy sets and suction catheters. In emergency situations, easy access to emergency equipment improves delivery of care to the patient.

ANXIETY

Definition/Characteristics

Anxiety is a distressing change in cognitive/sensory/emotional baseline characterized by purposeless or repetitive movements (pacing, constant lying down and arising, or walking in circles); heightened or decreased attention to external stimuli; panting and/or drooling; changes in facial expression; vocalizations; physiological changes such as increased BP, heart rate, and respiration; and dilated pupils. Anxiety is part of the fight-or-flight reaction; and it ranges from mild (as the animal perceives a possible threat) through moderate, severe, and panic (as the animal perceives imminent injury or death).

Desired Resolution

Absence of anxiety as evidenced by return to normal or baseline behavior; normal physiological parameters.

Interventions with Rationale/Amplification

1. If possible, identify and remove cause of the animal's anxiety. Owner information is especially critical in assessing anxiety as behavior that prompts a visit to the veterinarian may not be evident at the time of the visit.

2. If it is not possible to remove the cause of anxiety, discuss various coping strategies with owner. Strategies include removing the animal from source of distressing stimuli (e.g., bringing the animal inside during thunderstorms) and isolating (crating) the animal.

3. Administer/dispense medication as ordered by the veterinarian. Certain medications such as anxiolytics and tranquilizers may be used by owner on an as-needed basis.

4. Educate owner about medication, including time for onset, peak, and duration of effect. Discuss use of medication prior to anticipated anxiety-producing experience. Owners who can anticipate the animal's need may be able to prevent anxiety from occurring through proper use of medication and coping techniques.

BOWEL INCONTINENCE

Definition/Characteristics

Bowel incontinence is the inability to voluntarily control bowel elimination. Total incontinence is associated with unpredictable loss of stool or constant oozing of soft stool. The animal may exhibit red or excoriated skin in the anal area or fecal matter clinging to the coat in the anal area. Total incontinence may be an acute and short-lived phenomena (e.g., an animal suffering from acute diarrhea) or may be chronic and of long duration. Partial bowel incontinence is characterized by loss of stool at somewhat predictable times (e.g., following meals and during the overnight period when the animal is not taken outside for several hours).

Desired Resolution

Animal achieves voluntary control of bowel elimination or achieves a pattern of bowel elimination that is acceptable to owner.

Interventions with Rationale/Amplification

1. Obtain a complete history from owner, including times and amounts of bowel movements, length of time problem has been occurring, and circumstances surrounding incontinence. A complete history will assist the veterinarian in selecting appropriate diagnostic tests, possible treatments, and management techniques.

2. Carefully inspect the skin for signs of irritation or scald caused by repeated exposure to feces. Animals that have diarrhea are particularly prone to fecal scald in the perianal area. Application of protective barriers such as petroleum jelly may be warranted. Clipping the perianal area can help to minimize fecal/hair matting.

3. Provide appropriate environmental modifications. Placing animals on a PVC-coated cage grate/floor assists in keeping them clean and dry, especially in cases associated with diarrhea. Always remove the collar when an animal is placed on the grate. Check bedding throughout the day for fecal contamination.

4. Collect samples and run diagnostic tests as directed by the veterinarian. Fecal samples are frequently examined in animals suffering from acute incontinence secondary to diarrhea. Other diagnostic tests can include CBCs and serum chemistry profiles.

5. Administer medications and diets as ordered by the veterinarian. Certain medications such as antibiotics/antimicrobials and antihelmentics may be ordered by the veterinarian to treat causes of diarrhea. Topical ointments may be ordered to treat skin irritation. Feeding a low-residue diet can decrease amount of stool produced. Several low-residue diets are on the market, including Hill's i/d, Royal Canin DIGESTIVE LOW FAT LF, and Eukanuba Low-Residue. When inflammatory bowel disease (IBD) is the diagnosis, a limited-antigen diet may be the veterinarian's choice. Limited ingredient diets are produced by Royal Canin, Hill's, Purina, and Iams. Some cases may be fiber-responsive and necessitate the use of a high-fiber diet such as Royal Canin CALORIE CONTROL CC HIGH FIBER and Hill's w/d or r/d.

6. Discuss possible management techniques with owner. New onset incontinence may resolve quickly when underlying causes are treated. Partial incontinence (short- or long-term) may be treated by toileting the animal more frequently and more regularly, particularly immediately following meals. Total incontinence presents more of a management problem, with confinement, crating, or outdoor living being the only viable alternative for the animal. The use of pet diapers helps to minimize soiling of the living areas but increases the frequency of perianal scald. Unfortunately, because of the associated management problems, many owners elect to euthanize animals that have become totally incontinent.

It is important to clarify with the owner that inappropriate elimination or house soiling is not always synonymous with incontinence and previously house-trained animals may exhibit sudden onset of incontinence for a variety of medical reasons.

CARDIAC INSUFFICIENCY

Definition/Characteristics

Cardiac insufficiency is the inability of the heart to provide adequate blood flow to meet metabolic requirements. Cardiac output may be altered by reduced preload, increased afterload, reduced contractility, or alterations in heart rate and/or rhythm; signs and symptoms may vary according to the cause. Signs of reduced preload include jugular vein distention (JVD), peripheral edema, weight gain, fatigue, and dyspnea. Signs of increased afterload include increased BP, shortness of breath, mucous membrane cyanosis, increased capillary refill time (CRT), and/or skin temperature changes. Signs of reduced contractility include generalized, peripheral and/or dependent edema, sudden weight gain, shortness of breath and dyspnea, adventitious lung sounds, and cough. Signs of altered heart rate/ rhythm include electrocardiogram (ECG) changes, respiratory distress, fatigue, and anxiety. Reduced urine output may be present whenever cardiac output is decreased as the kidneys are not properly perfused.

Desired Resolution

Normal or stable ECG; vital signs within normal limits; no signs/ symptoms of respiratory distress; absence of edema; return to baseline weight; animal is able to return to normal or baseline activity level.

Interventions with Rationale/Amplification

1. Provide supplemental oxygen as ordered. Supplemental oxygen increases available oxygen.

2. Weigh patient daily. One kilogram (2.2 lb) of weight increase indicates a liter of retained fluid. Trending of this parameter over time will indicate whether the animal's condition is stable, improving, or deteriorating.

3. Monitor and record vital signs, oxygen saturation, and CRT every 4 hours or more frequently as ordered by the veterinarian. Generally, more critical patients receive more frequent monitoring. Trending of these parameters will assist the veterinarian in determining whether treatment is effective.

4. Provide or limit fluids as ordered by the veterinarian. Hemodynamic status is negatively impacted by decreased cardiac output. Excess fluids may contribute to massive edema; conversely, since fluid that has third-spaced is not available for intravascular use, adequate fluids must be provided to maintain blood volume.

5. Monitor and record ECG results. Trending of this parameter over time will assist the veterinarian in determining whether treatment is effective.

6. Administer medications and therapeutic diets as ordered by the veterinarian. Monitor and record the animal's response to treatment. Various medications such as diuretics, vasodilators, anti-hypertensives, antidysrhythmics, antibiotics, and inotropics may be ordered. Diets that may be selected include Royal Canin EARLY CARDIAC EC, Hill's k/d, Hill's h/d, and Purina CV Cardiovascular.

CHRONIC PAIN

Definition/Characteristics

Chronic pain is a distressing sensory experience that has existed for more than 1 or 2 months. Onset may be gradual (e.g., osteoarthritis) or sudden (e.g., tendon injury). Chronic pain is associated with changes in behavior (e.g., withdrawal, vocalization, and guarding), decreased appetite, general appearance of unthriftiness, "dull" facial expression, and/or musculoskeletal changes (e.g., limping and muscle atrophy). Vital signs are often normal as the animal's body has acclimated to the presence of pain.

Desired Resolution

Absence of signs of chronic pain; animal appears comfortable; behavior has returned to normal or baseline.

Interventions with Rationale/Amplification

1. Restrain and muzzle the animal if necessary. Animals in pain may become aggressive, particularly when being handled and examined by a stranger. Restraint and/or muzzling provides increased safety for the animal's caregivers.

2. Observe the animal for signs of chronic pain; record results. Question owner regarding onset, duration, and patterns of chronic pain; record results. This information will aid the veterinarian in determining the cause of pain.

3. Administer/dispense medications as ordered by the veterinarian. Certain medications such as analgesics, corticosteroids, and muscle relaxants may be ordered to reduce the animal's pain.

4. Educate owner regarding signs of continued pain. Instruct owner to call the veterinarian if pain is unrelieved by treatment. Since many animals do not vocalize pain, owners must be instructed about methods for assessing pain in the animal.

CLIENT COPING DEFICIT

Definition/Characteristics

Client coping deficit is the inability of the client to cope with, understand, or accept a pet's medical condition. Coping deficits are frequently accompanied by feelings of fear, anxiety, anger, denial, apathy, frustration, or grief. Responses can be directed at self, pet, or medical staff.

Desired Resolution

Client adapts to, accepts, and appropriately responds to the pet's medical needs.

Interventions with Rationale/Amplification

1. Provide an appropriate environment for the client to receive potentially disturbing information. Busy reception areas and noisy treatment rooms are inappropriate sites for giving clients medical information. Clients should be brought into an examination or consultation room to minimize distractions and to ensure privacy during medical discussions.

Remove potentially interruptive items such as cell phones and pagers from the room. As pets can be distracting when moving around, whining, or seeking comfort from their owner, technicians are advised to discuss medical issues prior to bringing the pet to the client.

2. Provide client education regarding the diagnosis and treatment of the identified medical condition. Clients often require detailed information to understand and accept a pet's medical condition. Information can be supplied in the form of demonstrations, printed materials, videos, Web sites, or verbal instruction. Remember that written information should supplement, not substitute for, verbal communication.

Comparison to similar human medical conditions, such as diabetes, can be made when discussing long-term care issues. However, care must be taken to avoid anthropomorphisizing, or placing human emotions on an animal. For example, dogs would be unlikely to suffer the same emotional distress that humans would experience when informed of a limb amputation.

3. Provide support. Clients may require emotional support when making medical or end-of-life decisions regarding a pet. Nonverbal communication is a very important component of emotional support. The use of attending behaviors is recommended. These can include direct eye contact, nonjudgmental expressions, open body postures, and speech directed to the client at eye-to-eye level.

It is very important to listen actively and avoid the tendency to interrupt. Ultimately, the goal of the veterinary medical team is to facilitate and support the client during the interaction, not to make the medical decisions for the client.

4. Provide client education regarding euthanasia if warranted. Humane euthanasia is a stressful yet sometimes necessary procedure. Technicians must recognize the grief and difficulties associated with euthanasia and strive to provide the compassion and tact warranted. The following are general recommendations regarding client education/involvement in humane euthanasia:

* Schedule euthanasia appointments for more quiet times of the day.

* Schedule a quiet room if the client elects to be present for the euthanasia.

* Complete all paperwork, including consent forms and body disposal options, prior to admitting the animal. Ideally, these details are arranged the day prior to the euthanasia.

* If the client wants to know, describe the drugs used and protocol for euthanasia. Provide educational materials such as pamphlets if needed.

* If the client elects to be present during the procedure, prepare the client for what he or she might see during and after death. Be sure to inform the client that the procedure is painless.

* If the client is present during the euthanasia, medical personnel should "pronounce the pet dead." Clients may wrongly believe that the animal is still alive if the eyes are open.

* Allow the client quiet time with the pet after the euthanasia. Assist the client in clipping a lock of fur, removing a collar, or performing any other symbolic ritual that is meaningful to him or her.

* Prepare the body appropriately if the client wants to take the animal home for burial. (Note that some areas do not allow home burial of euthanized animals.) Carry the body to the client's car (use a side or back door if possible) and ensure that the client is able to drive.

* Update the patient chart as deceased.

* Send a condolence card.

* Refer client to appropriate support groups if warranted. (Most veterinary colleges have hotlines and support groups.)

CLIENT KNOWLEDGE DEFICIT

Definition/Characteristics

Client knowledge deficit is a lack of information or understanding by the owner regarding the animal's diagnosis/prognosis, recommended procedures, or at-home care. Owners may or may not verbalize a need for education.

Desired Resolution

Owner verbalizes understanding of all aspects of the animal's condition, including instructions for at-home care. Owner is able to demonstrate any procedures (e.g., medication administration) required for at-home care.

Interventions with Rationale Amplification

1. Assess client's current level of knowledge. Owners vary greatly in their familiarity with animals. A first-time owner requires more education than a long-time pet owner.

2. Educate owner regarding all aspects of the animal's condition, including but not limited to diagnosis, prognosis, care provided or to be provided by veterinary team, and care to be provided at home. An educated owner is more likely to follow discharge instructions and provide proper care for the animal.

3. Demonstrate any procedures that client will need to perform at home (e.g., medication administration, ear cleaning, and wound care). If necessary, before leaving the hospital, have owner demonstrate procedure to ensure proper technique. Many owners are unfamiliar with certain aspects of the aftercare required by the animal.

4. Provide written discharge instructions to owner; if available, provide written information regarding the animal's diagnosis/condition. Owners picking up an animal may feel stressed by the thought of assuming care for the animal. Generally, an individual's ability to learn and process new information is decreased by stress. Providing written information gives the owner an opportunity to absorb new material in the nonstressful environment of his or her home.

5. Inform owner that the staff is available to answer any questions about the animal's condition and care after discharge. Emphasizing availability will decrease the owner's anxiety.

CONSTIPATION

Definition/Characteristics

Constipation is the inability to pass feces or infrequent passage of small, hard feces. Signs of constipation include tenesmus, anorexia, hypoactive bowel sounds, abdominal bloating, abdominal tenderness, and the animal's dragging the anal area on the ground. Severe cases of constipation can develop into a bowel obstruction.

Desired Resolution

Passage of normal amount of softly formed stool with no signs of abdominal distress.

Interventions with Rationale/Amplification

1. Obtain a complete history from owner, including description of normal bowel habits, regular diet, signs of constipation, and date of onset. A complete history will aid the veterinarian in diagnosing the underlying cause.

2. Monitor and record frequency, volume, and consistency of any bowel movements. Note the presence of blood, mucus, or foreign material. Monitoring fecal output will help to assess the degree of constipation and will influence the need for and type of interventions.

3. Assess the animal for signs of dehydration, including dry mucous membranes and poor skin turgor ("tenting"). Administer fluids at rate and route ordered by the veterinarian. As an animal becomes dehydrated, the body pulls fluid from the gut, leading to hard, dry stools. Proper hydration is an important consideration in relieving and preventing constipation.

4. Record fluid intake and output volumes. Constipation is commonly associated with dehydration.

5. Monitor and record signs of tenesmus or abdominal distress, including abdominal bloating/tenderness, anorexia, and abnormal bowel sounds. Specifically note whether tenesmus occurs before or after defecation. Tenesmus prior to defecation suggests that constipation may be the major problem. Postdefecation tenesmus can be suggestive of colitis or prostate problems. Signs tend to dissipate as successful treatment progresses.

6. Administer medications and treatments as ordered by the veterinarian. Rectal suppositories and/or enemas may aid the animal in passing hard stool. Digital disimpaction may be possible in a larger animal. Laxatives and stool softeners may be administered orally.

7. Alter diet as directed by the veterinarian. A high-fiber, high-moisture diet may be recommended for animals that are prone to constipation. High-fiber diets include Royal Canin CC HIGH FIBER, Hill's w/d and r/d, and Purina DCO Diabetes Colitis and OM Overweight Management.

8. When hospitalized, allow ample opportunity for the animal to defecate. Some animals require longer and more frequent opportunities to defecate. Most animals are hesitant to defecate in front of strangers. Some cats require one litter box for defecation and one litter box for urination.

9. Encourage physical activity if appropriate. Activity helps to stimulate defecation. Animals that are physically able should be encouraged to exercise. This movement stimulates GI blood flow and motility.

10. Educate owner regarding proper diet and exercise program for the animal. An educated owner is more likely to comply with the suggested treatment program.

DECREASED PERFUSION

Definition/Characteristics

Decreased perfusion is a reduction of blood flow through the capillaries causing insufficient oxygenation of cells and tissues. Any system in the body may be subject to altered tissue perfusion; the affected system should be referenced. Most commonly, reference is made to cerebral, cardiopulmonary, renal, GI, or peripheral perfusion. Defining characteristics vary depending on which body system is affected.

* Altered cerebral perfusion may result in changes in behavior and/ or LOC; changes in vital signs, reflexes, and pupillary reaction; and changes in motor skills.

* Altered cardiopulmonary perfusion may result in dyspnea, dysrhythmias, increased CRT, and changes in behavior (anxiety and restlessness).

* Altered renal perfusion may result in oliguria, anuria, and/or hematuria; increased specific gravity (i.e., increased concentration) of urine; increases in BUN and creatinine (Cr); and changes in BP.

* Altered GI perfusion may result in anorexia, nausea and/or vomiting, abdominal distention, pain/tenderness in the affected area, melena, and altered bowel sounds.

* Altered peripheral circulation may result in localized erythema, changes in skin temperature, tenderness/pain in the affected extremity, edema, changes in pulses, and necrosis.

Desired Resolution

Reestablish adequate oxygenation at the cellular level.

* Cerebral perfusion: return to normal or baseline behavior and LOC; normal vital signs, reflexes, and pupillary reactions; return of normal or baseline motor skills.

* Cardiopulmonary perfusion: vital signs normal; respirations unlabored; CRT < 2 seconds; return to baseline behavior.

* Renal perfusion: normal volume of clear, yellow urine; normal lab values; normal BP.

* GI perfusion: appetite normal with no signs of GI upset; stool normal volume, color, and consistency; normal bowel sounds.

* Peripheral perfusion: skin normal color and temperature; absence of pain and edema; normal pulses.

Interventions with Rationale/Amplification

Cerebral Perfusion

1. Provide supplemental oxygen as ordered. Monitor and record oxygen saturation levels.

2. Monitor and record patient's vital signs every 4 hours or more frequently as ordered by the veterinarian. Notify the veterinarian immediately if vital signs deteriorate. Inadequate perfusion to cerebral tissues can affect all body systems.

3. Monitor and record patient's behavior, LOC, reflexes, pupillary reactions, and motor skill levels. Notify the veterinarian immediately of any sudden change in status. Trending of these parameters over time will assist the veterinarian in determining whether the patient is responding to therapy.

4. Administer medications and fluids as ordered by the veterinarian. Various medications such as corticosteroids and embolytics may increase cerebral perfusion. Animals with decreased cerebral perfusion may be unable to self-hydrate due to changes in LOC.

Cardiopulmonary Perfusion

1. Provide supplemental oxygen as ordered. Supplemental oxygen can increase oxygen saturation of the blood, providing optimum oxygenation to the heart and lungs.

2. Monitor and record vital signs, including CRT and oxygen saturation, every 4 hours or more frequently as needed. Notify the veterinarian immediately if vital signs deteriorate. Inadequate perfusion to the heart or lung tissue may induce changes in vital signs.

3. Note and record signs of respiratory distress, including flaring nares, use of accessory muscles, orthopnea, and hemoptysis. Notify the veterinarian immediately of signs of increased respiratory distress. Hemoptysis signifies an extreme emergency. Inadequate perfusion to the lungs often results in signs of respiratory distress.

4. Observe and record patient's behavior every 4 hours or more frequently as ordered by the veterinarian. Patients experiencing decreased cardiopulmonary perfusion often exhibit marked restlessness and anxiety.

5. Administer medications and fluids as ordered by the veterinarian. Medications such as nitroglycerin, beta blockers, ACE inhibitors, and antiarrhythmics may increase cardiac perfusion. Antiembolytics and diuretics may be used to increase pulmonary perfusion.

Renal Perfusion

1. Monitor and record patient's intake and output every 8 hours or more often as directed by the veterinarian. Also note color and clarity of urine. Volumes less than 0.27 mL/kg/h are suggestive of oliguria. Normal urine production volumes are as follows: cat, 10-20 mL/kg/day; dog, 20-80 mL/kg/day.

2. Monitor and record patient's vital signs every 4 hours. Decreased kidney perfusion can result in significant alterations in BP, which in turn impacts heart rate and respiratory rate.

3. Monitor lab values daily. High BUN and Creatinine indicate current or impending renal failure. As perfusion increases, these values should trend toward normal.

4. Administer medications and fluids as ordered by the veterinarian. Medications that increase cardiac output may result in a concurrent increase in renal perfusion. Diuretics also may be ordered to increase urine production. Fluid volume is regulated to provide maximum renal perfusion.

GI Perfusion

1. Monitor and record patient's stool output every 8 hours. Also note color and consistency of stool. Decreased volume of stool, melena, constipation/ diarrhea, and alterations in frequency of bowel movements can be signs of decreased GI tissue perfusion.

2. Monitor for and record signs of abdominal distress, including change in eating habits, abdominal distention, or pain in the affected area. These are all signs of decreased GI perfusion.

3. Monitor and record patient's bowel sounds every 8 hours. Decreased GI tissue perfusion may result in hypoactive or absent bowel sounds.

4. Administer medications and fluids as ordered by the veterinarian. Various medications such as stool softeners and laxatives may aid in reestablishment of normal bowel activity. Antibiotics and analgesics also may be considered. Adequate hydration is necessary for normal stool consistency.

Peripheral Perfusion

1. Monitor and record skin color and temperature, edema, pulse strength, and tenderness/pain in the extremities.

Edema may be quantified using the following scale:

* 0 = no edema

* 1 = mild

* 2 = moderate

* 3 = severe

Pulse strength may be quantified using the following scale:

* 0 = no pulse

* 1 = weak pulse

* 2 = normal pulse

* 3 = pounding pulse

* D = pulse present but determined by Doppler

Pain may be quantified with the following scale:

* 0 = no pain

* 1 = mild, intermittent discomfort

* 2 = mild pain

* 3 = moderate pain

* 4 = severe pain

* 5 = extreme pain

2. Administer medications as ordered by the veterinarian. Analgesics may be ordered for pain in the affected extremities.

DIARRHEA

Definition/Characteristics

Diarrhea is the presence of loose, unformed stool. It is characterized by abdominal pain, bloating, increased defecation frequency and urgency, foul fecal odor, abnormal color of feces, and changes in behavior. Bowel sounds may be hypo- or hyperactive. Frequent passage of small amounts of stool is common, and previously continent animals may exhibit bowel incontinence during episodes of diarrhea. Causes of diarrhea are numerous and can include microorganisms, parasites, irritation to the digestive tract (e.g., certain medications, chronic inflammatory processes, and sudden change in diet), or stress. Diarrhea may be accompanied by dehydration, electrolyte imbalances, and metabolic acidosis.

Desired Resolution

Production of a normal amount of softly formed stool, free from abnormal odors, mucus, or blood. Animal is continent of stool.

Interventions with Rationale/Amplification

1. Monitor and record the animal's vital signs, including heart rate, respiratory rate, CRT, mucous membrane color, skin turgor, and temperature. Frequency of vital monitoring will depend on the severity of the diarrhea. Dehydration may result in decreased BP, increased heart rate, and increased respiratory rate. Metabolic acidosis may result in increased respiratory rate as the body attempts to compensate by "blowing off" excess carbon dioxide. The animal may have an increased temperature when diarrhea is caused by an infectious microorganism.

2. Monitor and record frequency, volume, and consistency of diarrhea. Specifically note the presence of blood, mucus, or foreign materials. Characteristics associated with small intestine diarrhea can include watery, profuse stool and presence of melena. Characteristics associated more with large intestine diarrhea include hematochezia, mucus, and increased frequency of defecation.

3. Monitor and record presence of tenesmus. Straining to defecate is typically associated with large intestine issues.

4. Observe for signs of electrolyte imbalances. Sodium and potassium loss occurs secondary to severe diarrhea. Clinical signs can include weakness or dysrhythmias.

5. Weigh the animal daily. Severe diarrhea can result in rapid fluid loss and dehydration. A 500 cc fluid loss is equivalent to a 1 lb loss of body weight.

6. Examine perianal area for evidence of fecal scalding or irritation at least 2 times per day. Frequent defecation or diarrhea can irritate the perianal tissues. Always keep the perianal area clean and free from feces. Appropriate cleaning and protection of perianal tissues is imperative. (Apply petroleum jelly or another scald barrier.)

7. Administer fluids as directed. Record rate, route, and volume of fluids administered. Fluids can be administered orally, subcutaneously, or intravenously. The route is influenced by the degree of dehydration and presence of vomiting. Diarrheas can be associated with increased fluid loss and dehydration. Dehydration secondary to prolonged or severe diarrhea is especially dangerous for very young or elderly animals.

8. Obtain laboratory specimens for diagnostics tests as ordered by the veterinarian. Commonly performed tests include fecal floatation, direct smears, parvovirus cite test, and bacterial cultures of fecal specimens. Blood samples for CBCs, electrolyte levels, and serum chemistries also may be warranted. Hemoglobin and hematocrit (H&H) may be increased due to concentration of blood; WBC may be elevated if microorganisms are present.

9. Administer medications as ordered by the veterinarian. Various medications may be ordered depending on the cause of the diarrhea. Diarrhea caused by microorganisms may be treated with antibiotics/antimicrobials. Parasite infestation may be treated with antihelmentics. Inflammatory processes may be treated with corticosteroids. Pancreatic enzyme supplementation may be used in cases of maldigestion. Diarrhea of any origin may be treated with antidiarrheals.

10. Provide appropriate diet. Animals experiencing diarrhea may initially have food withheld to rest the GI tract. Vomiting animals should be placed on an n.p.o. status. Appropriate diets for diarrheal conditions are bland and contain highly digestible protein, low fiber, and relatively low fat. Examples of suitable commercial diets include Hill's i/d, Purina EN, and Royal Canin DIGESTIVE LOW FAT LF. Food should be provided in small, frequent meals with no restriction on water. The animal's normal diet can be gradually reintroduced 2-3 days after the diarrhea has resolved.

11. Use appropriate precautions to prevent spread of infectious or zoonotic diarrheas. Hands should be thoroughly washed between contact with all veterinary patients. Use of designated laboratory coats or other garments in cases of suspected infectious diarrhea is highly recommended. Housing areas and bedding should be meticulously disinfected between patients. Dogs brought outside to defecate should be restricted to designated areas away from healthy animals.

12. During patient admission, carefully question owner regarding onset, duration, and frequency of bowel movements and changes in the animal's diet, routine, or environment. This information will aid the veterinarian in determining the cause of the diarrhea.

13. Educate owner regarding medications dispensed, diet, and follow-up care. Ensure that owner understands all instructions. Providing both written and oral instructions will increase the likelihood of owner compliance.

ELECTROLYTE IMBALANCE

Definition/Characteristics

Electrolyte imbalance is an alteration in normal electrolyte values. Imbalances can result from an increase or decrease in an electrolyte level.

Desired Resolution

Electrolyte values within normal limits.

Interventions with Rationale/Amplification

1. Collect samples and conduct tests as directed by the veterinarian to monitor electrolyte levels. Notify the veterinarian of results and document in the patient chart. Many conditions warrant electrolyte sampling every 8 hours. Conditions frequently associated with electrolyte changes include the following:

--Hyponatremia: diarrhea, heart failure, and vomiting

--Hypernatremia: renal failure and diarrhea

--Hyperkalemia: decreased urine production, renal failure, urinary obstruction, and Cushing's disease

--Hypokalemia: anorexia, administration of fluids low in potassium, vomiting, diarrhea, renal disease, diuresis post urinary obstruction

--Hyperphosphatemia: diabetes, insulin therapy, and parenteral nutrition

--Hypomagnesemia: administration of fluids low in magnesium and diarrhea

2. Monitor for, record, and report any clinical signs associated with electrolyte abnormalities. Clinical signs can include the following:

--Hypernatremia: anorexia, apparent thirst, vomiting, muscular weakness, behavioral changes, and seizures or coma

--Hyponatremia: lethargy, nausea, and weight changes

--Hyperkalemia: muscle weakness, ECG changes (peaked narrowed T waves, shortened QT interval, and widened QRS interval), and arrythmias

--Hypokalemia: muscle weakness, ventroflexion of head, forelimb hypermetria, arrythmias, and PU/PD

--Hypocalcemia: muscle twitching, face rubbing, stiff gate, behavioral changes, ataxia, and seizures

3. Administer medications as directed by the veterinarian and record in patient chart. Treatments ordered by the veterinarian can include the following:

--Hypophosphatemia: intravenous (IV) potassium chloride

--Hypernatremia: IV glucose solutions, sodium bicarbonate, calcium gluconate, and diuretics

--Hyponatremia: isotonic or hypertonic (extreme cases) saline

--Hypocalcemia: calcium gluconate and vitamin D

EXERCISE INTOLERANCE

Definition/Characteristics

Exercise intolerance is the physical inability to engage in normal or desired activities. Exercise intolerance is characterized by changes in vital signs (increased heart rate, respiratory rate, and BP) and shortness of breath with exertion, fatigue, muscle weakness, and/or changes in daily behavior (e.g., increased sleeping/resting and decreased play).

Desired Resolution

Animal exhibits sufficient physical energy to engage in normal or baseline activity.

Interventions with Rationale/Amplification

1. Obtain complete history of exercise intolerance from owner, including onset (sudden versus progressive), duration, and symptoms noticed by owner. Also confirm heartworm status (i.e., whether the animal is on a preventative program). This information will aid the veterinarian in making a medical diagnosis regarding the underlying cause of exercise intolerance.

2. Monitor and record the animal's vital signs. This information will assist the veterinarian in developing a treatment plan for the animal.

3. Provide supplemental oxygen as ordered by the veterinarian. Supplemental oxygen may increase oxygen saturation in the blood, thus decreasing shortness of breath.

4. Administer medications as ordered by the veterinarian. Depending on the cause of activity intolerance, many different medications may be ordered by the veterinarian.

5. Educate owner regarding the animal's physical limitations. Explain exercise plan to owner. An owner who is educated about the daily treatment plan is more likely to be compliant.

FEAR

Definition/Characteristics

Fear is a distressing emotional response to a threat. The threat may be real (e.g., a predator) or imagined (e.g., blowing paper). Fear response may be innate, such as fear of a predator, or may be a learned response, such as fear of a veterinarian. Fearful animals can exhibit changes in facial expression, decreased response to environmental stimuli other than the threat, and heightened response to all stimuli associated with the threat. The fight-or-flight response to fear induces physiological changes that include increased heart rate, respiratory rate, and BP; dilated pupils; panting; diaphoresis; and/or nausea/vomiting.

Desired Resolution

Animal controls fear response to the extent that physiological changes are minimized and attending personnel are not harmed.

Interventions with Rationale/Amplification

1. Identify and remove the source of fear if possible. Common inciters of fear within the veterinary facility include loud equipment such as clippers and vacuums, unfamiliar people, and barking or noisy animals. The following techniques can be used to minimize these issues.

* Board or house cats separate from dogs. Separate birds from all other species.

* Use the animal's name whenever possible to establish rapport/familiarity with the animal.

* Wait an appropriate length of time for the drug to take effect if a premedication or sedative is used.

* Allow animals to visualize and hear loud vibrating equipment such as clippers prior to applying to the animal.

* Work slowly and deliberately around the animal. Do not attempt to rush the animal into the procedure.

* Limit the animal's exposure to high-traffic, noisy areas of the clinic.

* Some animals may benefit from "nonmedical treat trips" to the clinic. Puppies and kittens in particular can benefit from friendly, nonthreatening trips as a means of lessening the incidence of conditioned fear responses.

2. Note in the animal's medical record any extremely fearful responses. Fear can artificially alter laboratory values such as blood glucose and BP. If an animal is very distressed during blood draws or other procedures, that fact should be noted as it may affect the interpretation of test values. Medical notation also is important for purposes of alerting staff to modify future procedures or protocols, thus ensuring staff safety when an animal responds with fear-induced aggression.

3. Use appropriate restraint techniques. Safety of owner and personnel is of utmost concern. Fear-induced aggression is frequently manifested by biting and scratching. The restraint technique selected should be based on the animal's behavior. Many animals respond to a calm, reassuring voice, while others may require being muzzled, placed in a cat bag, wrapped in a towel, or restrained using another measure. Animals that become highly aggressive due to fear may require tranquilization or sedation.

4. Discuss long- and short-term management options with owner. Some animals may require intervention to minimize the disruption of fear-based behaviors. Learned fear responses can sometimes be unlearned with proper training and relearning. Innate fear responses are more difficult to eradicate but may be lessened with training. Frequently cited causes include thunderstorms, fireworks, car rides, and certain family members or strangers. Treatment options include one or more of the following: avoidance, behavior modification therapy, or medication. Owners electing to pursue behavioral modifications should be referred to a qualified animal trainer/behaviorist.

5. Administer medications as ordered by the veterinarian. Certain medications such as sedatives, tranquilizers, and anxiolytics may reduce fear response.

HYPERTHERMIA

Definition/Characteristics

Hyperthermia is an increase in normal body temperature. Hyperthermia may be associated with increased respiratory rate, tachycardia, panting, warm skin, dry mucous membranes, altered laboratory values (electrolyte imbalance, increased PCV due to dehydration, or metabolic acidosis), seizures/convulsions, and changes in LOC. Hyperthermia can range from a low-grade fever to a life-threatening condition. (Fever is an increase in body temperature in response to infection, an immune-mediated disease, drug reactions, or adverse environmental conditions.)

Desired Resolution

Body temperature within normal range.

Interventions with Rationale/Amplification

1. Monitor and record temperature, pulse rate and character, respiratory rate and character, CRT, mucous membrane color, and LOC. The frequency of monitoring will be ordered by the veterinarian and is dependent upon the severity of the hyperthermia. Trending of these parameters over time will indicate whether the animal is responding to treatment. Normal temperature values ([degrees]F): dogs, 99.5-102; cats, 100-102; ferrets, 100-102; horses, 99-101; cattle, 101-102. Animals exhibiting a change in LOC or seizures should be under constant supervision.

Extreme hyperthermia is a veterinary emergency; the veterinarian should be notified immediately if the animal's temperature is above 104[degrees]F.

2. Provide a cool environment for the animal; use fans to increase air circulation and bathe the animal in tepid or slightly cool (never cold) water. If bathing is not possible; apply ice packs or cold water to the groin, base of neck, and foot pads. Cold water and/or ice should never be applied to the entire body of the animal as this may result in constriction of surface blood vessels, which causes an increase in body temperature. Tepid/cool rinses prevent vasoconstriction while promoting cooling. Ice packs and cold water may be applied only to areas of high blood flow and areas of cooling, such the groin (between the hind legs), base of neck, and foot pads.

In cases of life-threatening hyperthermia, a cool water enema can be administered to decrease core body temperature. However, this procedure will prevent further use of rectal thermometers for obtaining the animal's temperature.

Measures should be continued until the temperature is less than 103[degrees]F (all species).

3. Monitor fluid intake and provide fluids at rate and route ordered by the veterinarian. Hyperthermia is often accompanied by dehydration.

4. Provide supplemental oxygen as ordered by the veterinarian. Increased respiratory rate results in increased oxygen demand. Animals requiring more than 1/2 hour of oxygen therapy should receive humidified oxygen.

5. Monitor fluid loss, noting color of urine. Hyperthermia may cause dehydration, which results in anuria or oliguria. Animals suffering from dehydration often have concentrated, very dark urine or may not produce urine for a few hours.

6. Obtain laboratory samples as requested by the veterinarian. Common tests performed to assess causes and effects of hyperthermia include CBC, urinalysis, chemistry profiles, electrolyte levels, urinalysis, and serum titers. As the cause of hyperthermia resolves, these values should trend toward normal.

7. Administer medications as ordered by the veterinarian. Common medications used to treat hyperthermia include antipyretics, corticosteroids (prednisone), electrolytes, and antibiotics. Antibiotic response fevers should drop within 48 hours of administration of medication.

HYPERVOLEMIA

Definition/Characteristics

Hypervolemia is an increase in intravascular, interstitial, or intracellular fluid. It is associated with dyspnea, increased respiratory rate, coughing, nasal discharge, adventitious lung sounds (crackles or rales), edema, rapid weight gain, JVD, abdominal distention, and/or increased BP (pounding pulse). Laboratory values show a decrease in urinary concentration (i.e., a decrease in specific gravity), and PCV and may show concurrent electrolyte imbalances. Changes in mental status, such as anxiety and/or restlessness, may occur. Hypervolemia can be associated with congestive heart failure, renal failure, hepatic cirrhosis, steroid use, psychogenic polydipsia, and iatrogenic water loading.

Desired Resolution

Reestablish normal fluid volume with accompanying improvements in lung sounds, return to normal BP and urine concentration, decrease in edema, stable weight, and return to baseline mental status.

Interventions with Rationale/Amplification

1. Obtain vital signs and assess for specific indicators of fluid overload every 4 hours or at intervals ordered by the veterinarian. Critical conditions can warrant more frequent monitoring. Common signs of fluid overload include serous nasal discharge, increased breathing sounds, increased respiratory rate, distended jugular veins, moist coughing, frequent urination, edema, ascites, and exophthalmos. If equipment is available, monitoring of BP is warranted. Lungs should be auscultated every 2-4 hours when animals are placed on IV fluids.

2. Weigh the animal daily. Rapid increases in body weight are associated with fluid retention. Weight loss is an indication that the animal is mobilizing and excreting excess fluids. Each pound of weight loss indicates the reductions of approximately 500 cc of fluid.

3. Monitor and record fluid intake and output daily. As the body mobilizes excess fluid volume, daily output will exceed input. Output is typically estimated. Fluid loss occurs through urination, defecation, vomiting, and insensible loss such as respiration.

4. Obtain samples and conduct tests as directed by the veterinarian. Tests frequently run to assess fluid volume include PCV, total protein (TP), CBCs, urine specific gravity, and electrolytes. Laboratory values will trend toward normal as excess fluid is removed.

5. Institute sodium and fluid restrictions as ordered by the veterinarian. Low-sodium diets are often instituted because "water follows sodium" (i.e., an increase in sodium levels results in an increase in fluid volume levels; conversely, a decrease in sodium levels results in a decrease in fluid volume levels). Suitable diets include Hill's k/d.

6. Administer medications as directed by the veterinarian and record in patient chart. Diuretics such as furosemide are frequently administered. Diuretics help the animal mobilize and excrete excess fluid.

7. Evaluate degree of edema daily using numeric scale. Edema may be rated on the following scale:

* 0 = no edema

* 1 = mild edema

* 2 = moderate edema

* 3 = severe edema

Edema results when excess fluid moves out of the vascular system into interstitial spaces. As fluid volume excess is mobilized and excreted, edema decreases.

8. Evaluate edematous skin for signs of abrasion or trauma and protect from injury if necessary. Edematous skin is very fragile and injures easily. Bandaging high pressure areas or providing additional padding may be warranted.

9. Change body position of recumbent animals every 1-2 hours. Fluid gathers in dependent portions of the body. Frequent changes in body position can help minimize dependent edema.

10. Encourage walking or mild exercise if physically appropriate. Skeletal muscle movement increases lymphatic return, thereby decreasing peripheral edema.

HYPOTHERMIA

Definition/Characteristics

Hypothermia is a decrease in normal body temperature. It is associated with shivering, piloerection, decreased CRT, mucous membrane cyanosis, altered heart rhythm and rate (initially tachycardia, progressing to bradycardia as body temperature falls), altered respirations (initially hyperventilation, progressing to hypoventilation as body temperature falls), altered laboratory values (metabolic acidosis and altered ABGs), and changes in LOC.

Desired Resolution

Body temperature within normal range.

Interventions with Rationale/Amplification

1. Monitor and record temperature, pulse rate, respiratory rate, CRT, mucous membrane color, and LOC. The frequency of monitoring will depend on the severity of the hypothermia. Normal temperature values ([degrees]F): dogs, 99.5-102.5; cats, 100-103. Trending of these parameters over time will indicate whether the animal is responding to treatment.

Severely hypothermic animals will have a decreased LOC.

Animals suffering from postsurgical hypothermia should be monitored very closely. Procedures necessitating prolonged anesthetic time or surgeries requiring opening of the abdominal cavity have a higher likelihood of postsurgical hypothermia. Hypothermia increases the time it takes for anesthetics to be removed from the body.

Neonatal animals such as those born via cesarean section are especially prone to hypothermia. These animals should be maintained in a warm environment (incubator) until the mother is fully recovered from anesthesia.

2. Provide a warm environment for the animal, dry the animal with warm towels if wet, and wrap in warm blankets if possible.

Exercise extreme caution when using heat lamps, hot water bottles and/ or heating pads on a hypothermic animal. The resulting surface vasodilation may lead to hypotension and consequent shock. Thermal burns also are a possible consequence. These rewarming methods should not be used on "critically hypothermic" animals. Warm blankets are much safer.

Recumbent animals or animals with decreased LOC are unable to move away from excessive heat. All animals in the immediate postoperative period should be placed on warm blankets or provided an alternative heat source until fully recovered.

3. Provide warmed fluids at rate and route ordered by the veterinarian. The animal should be given warmed fluids to drink if swallowing and gag reflex is intact. Intravenous fluids must be given judiciously as the hypothermic heart cannot respond rapidly to increased fluid volume. Never warm IV fluids in the microwave. Microwaving fluids can cause "hot pockets" to develop in the fluids, which may cause vascular damage.

4. Provide supplemental oxygen as ordered by the veterinarian. Respiratory effort may decrease with hypothermia. Supplemental oxygen provides optimum oxygen saturation of the blood. Animals requiring more than 1/2 hour of oxygen therapy should receive humidified oxygen.

5. Monitor fluid intake and output, especially noting volume of urine produced. Hypothermia causes decreased cardiac output, which may result in anuria or oliguria.

6. Administer medication as ordered by the veterinarian. Various drugs such as antiarrythmics and cardiac stimulants may be ordered to counter the effects of hypothermia.

HYPOVOLEMIA

Definition/Characteristics

Hypovolemia is a decrease in intravascular, interstitial, or intracellular fluid. This state is associated with decreases in urinary output, pulse strength, and BP. Concurrent increases in urine concentration, CRT, PCV, and heart rate also are noted. Nonquantifiable changes include sunken orbits; dry, pale, or "muddy" mucous membranes; malaise; skin tenting; cool extremities; and changes in LOC.

Desired Resolution

Reestablish normal hydration and fluid balance with accompanying improvements in urine output, pink moist muocus membranes, CRT less than 2 seconds, good skin turgor, normal BP, and return to baseline LOC.

Interventions with Rationale/Amplification

1. Monitor and record fluid intake and output, paying close attention to color and approximate volume of urine produced. Dark-colored urine is suggestive of continued dehydration. Input includes fluid provided through oral, subcutaneous, intravenous, intraosseus, or intraperitoneal routes of administration.

2. Monitor and record ongoing fluid loss due to vomiting or diarrhea. These volumes are typically estimated. The presence of blood, mucus, or foreign material in the fluids should be noted.

3. Provide fluids at the rate and route directed by the veterinarian. Common routes include oral, subcutaneous, and intravenous. The route selected reflects the severity of dehydration and presence of vomiting. Fluids can be classified as crystalloids (substances having small diffusible particles) and colloids (particles with high molecular weights that do not diffuse across the capillary membrane and therefore exert intravascular persistence). Crystalloids frequently used in veterinary medicine for fluid replacement include lactated Ringer's solution (LRS), normal saline, and Normosol-R. Common colloids include whole blood, packed red blood cells (RBCs), plasma, Hetastarch (hydroxyethyl starch), and dextrans (Dextran 70 and Dextran 40).

Fluid requirements are typically calculated using the following formula:

Total fluids (mL) = Rehydration fluids (mL) + Maintenance fluids (mL) + Ongoing losses (mL)

Rehydration fluid (mL) = % dehydration x body weight (kg) x 1,000 mL/L

Maintenance fluid (mL) = 60 mL/kg/day

Ongoing losses (mL) = Estimate of fluid loss through vomiting, diarrhea, etc. (mL)

4. Weigh the animal daily. Sudden weight changes reflect fluid loss. A pound of weight loss is typically associated with a 500 cc fluid loss.

5. Monitor temperature, pulse, respiration, CRT, mucous membrane color, and skin turgor every 4 hours or at intervals ordered by the veterinarian. Specifically assess for tachycardia, a decrease in palpable pulse pressure, and urinary output or increases in CRT, skin tenting, or respiratory rate.

Dehydration can induce changes in many physical parameters.

The percent of dehydration is often estimated based on the following physical indicators:

* Less than 5 percent dehydrated: no visible changes

* 5 percent dehydration: dry mucous membranes

* 6-8 percent dehydration: increased skin turgor and dry mucous membranes

* 10-12 percent dehydration: increased skin turgor, weak and rapid pulse, increased CRT, dry mucous membranes, and depression

6. Administer specific treatments and medications prescribed by the attending veterinarian. Notify the veterinarian if signs of dehydration persist or worsen after prescribed treatment. Most animals appear noticeably brighter after rehydration.

7. Record fluid intake and output every 8 hours or more frequently as ordered by the veterinarian.

IMPAIRED TISSUE INTEGRITY

Definition/Characteristics

Impaired tissue integrity is the loss of or damage to tissues constituting primary defenses against microorganisms, including integumentary, mucosal, and corneal tissues. This state is characterized by lesions, inflammation with erythema, purulent discharge, localized edema, pain at the affected location, and altered laboratory results (e.g., increased WBCs and positive wound cultures).

Desired Resolution

Intact integumentary, mucosal, and corneal tissues.

Interventions with Rationale/Amplification

1. Note and record characteristics including location, size, color, amount and type of discharge, edema, and temperature of surrounding tissues. The initial assessment provides a baseline for monitoring the progression of the lesion.

2. Assist the veterinarian in cleaning and dressing wounds. Open lesions are a pathway for microorganisms to enter the animal's body. Upon initial presentation to the veterinarian, the wound should be cleaned and dressed if necessary.

3. Change dressings, clean wounds (e.g., flushing and irrigation), and medicate (e.g., topical ointments and sprays) as ordered by the veterinarian. Note and record characteristics of lesion during dressing changes or on a daily basis when there is no dressing on the wound. Notify the veterinarian of any adverse changes in wound; if any are noted, have the veterinarian assess wound prior to application of dressing. Dispose of soiled dressings appropriately. Always use sterile or aseptic technique when dressing wounds and wash hands immediately at the conclusion of the procedure. A variety of dressings may be used depending on the type/status of the wound. Follow the veterinarian's orders exactly for type and frequency of dressing change. Irrigation and flushing promote removal of necrotic tissue and exudates. Certain medications such as antibiotics may be applied to the wound to prevent infection. Monitoring the wound status will indicate whether healing is occurring. Proper disposal of soiled dressings prevents spread of infection.

4. Administer medications as ordered by the veterinarian. Certain medications such as antibiotics/antimicrobials may be ordered to prevent or treat infection that has spread systemically.

5. Monitor lab results for findings that indicate presence of infection. Increased WBCs may indicate infection, depending on cell populations. A positive wound culture aids in identifying and choosing appropriate medications to treat infection.

6. Monitor the animal's temperature at intervals ordered by the veterinarian. Fever may indicate presence/intensification of infection or activation of the body's defense system.

7. Provide devices that prevent further injury to the wound. Many animals instinctively lick wounds. An E-collar prevents animals from harming themselves.

8. Educate owner regarding care of the wound, sign of infection, administration of medications, and circumstances that require the animal to be seen by the veterinarian immediately (e.g., dehiscence). An educated owner is more likely to notice complications at an early stage. Timely intervention increases the likelihood of successful treatment.
COPYRIGHT 2009 Delmar Learning
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2009 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Publication:Patient Assessment, Intervention and Documentation for the Veterinary Technician
Date:Jan 1, 2009
Words:12620
Previous Article:Chapter 2: Generating the database.
Next Article:Chapter 3: Technician evaluations with suggested interventions.
Topics:

Terms of use | Privacy policy | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters