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Chapter 4: Medical conditions and associated technician evaluations.

CONDITIONS INVOLVING THE REPRODUCTIVE AND ENDOCRINE SYSTEMS

Abortion

Abortions can occur secondary to fetal abnormalities (chromosomal defects and abnormal development), maternal problems, or infectious disease. Maternal reasons for abortion are numerous and include any generalized systemic disease, nutritional deficiency, decreased progesterone production, hypothyroidism, or toxic insults. Infectious agents commonly cited include Brucella canis, Escherichia coli, herpesviruses, streptococci, Toxoplasma gondii, FeLV, Campylobacter, and Parvovirus. Clinical signs associated with spontaneous abortion can include vaginal discharge, fever, listlessness, and abdominal pain.

Abortifacients (mismate injection) or agents intentionally administered to induce abortion include estrogens and prostaglandins. Ovariohysterectomy (OHE) also is an option.

--Diagnostic Tests: CBC, serum chemistry, radiographs, and ultrasound. Tests used to determine cause of abortions include vaginal culture, serum antibody titers, fetal and placental tissue cultures, and histology.

--Potential Treatments: Antibiotics, IV fluids, and hormones (prostaglandins).

Technician evaluations commonly associated with this medical condition:

Reproductive Dysfunction

--Obtain a complete medical history relating to previous and current pregnancy. Specifically question owner regarding any medications, supplements, or substances administered during the previous week.

Hyperthermia

Risk of Infection

Addison's Disease

Also referred to as hypoadrenocorticism, Addison's disease results from reduced hormone production by the adrenal glands. Hypoadrenocorticism is classified as primary or secondary. Problems arising directly from within the adrenal gland are considered primary, while those resulting from pituitary or hypothalamus abnormalities are termed secondary. The normal hormonal axis for these glands involves release of corticotropin-releasing hormone (CRH) from the hypothalamus, which stimulates pituitary release of adrenocorticotropic hormone (ACTH), stimulating the release of mineral and glucocorticoid hormones from the adrenal gland. Clinical signs can include lethargy, anorexia, vomiting, PU/PD, muscle weakness, weight loss, melena, and hypothermia.

Uncontrolled cases may fulminate in a life-threatening state termed addisonian crisis. Shock results from the severe hyperkalemia and hyponatremia, which induce hypotension, hypovolemia, azotemia, and cardiac arrhythmias.

--Diagnostic Tests: Serum chemistries, serum cortisol, and ACTH stimulation test.

--Potential Treatments: Supportive treatment such as IV fluids (imperative) and steroids. Long-term control: corticosteroids (prednisone) and mineralocorticoids (fludrocortisone).

Technician evaluations commonly associated with this medical condition:

Vomiting

Diarrhea

Hypovolemia

--Normal saline (0.9 percent NaCl) is often the fluid of choice.

Electrolyte Imbalance

--Hyperkalemia and hyponatremia are present in 80-90 percent of animals. Monitoring of these electrolytes during fluid administration is advised.

Hypothermia

--Addisonian animals frequently experience difficulty maintaining body temperature and will exhibit heat-seeking behaviors. Providing a heat source such as warmed blankets will comfort animals.

Underweight

--Use of high-calorie diets is indicated until condition is stabilized and appropriate weight has been attained. A high-energy adult diet such as Royal Canin INTESTINAL HE or Hill's p/d may be used. If a growth diet is used to allow the animal to regain weight, most animals can return to age-appropriate diets once they are stabilized.

Reduced Mobility

--Profound muscle weakness can result in ataxia.

Client Knowledge Deficit

--Client education is imperative as this disease requires lifelong treatment of the animal. In addition to understanding the necessity of prescribed medications and routine blood work, owners should learn how to monitor animals carefully for vomiting, diarrhea, PU/PD, anorexia, or heat-seeking behavior. Blood work is indicated every 6-12 months once the animal is stabilized.

Agalactia

Agalactia is a lack of milk production in the absence of mammary disease. This condition can occur secondary to stress, disease conditions excluding the mammary tissue, premature parturition, or hormonal abnormalities. Agalactia can be temporary, as is seen with most stress-induced cases of the condition. True agalactia is rarely seen in dogs or cats. However, these species can experience a stress-induced decrease in milk production or be hereditarily prone to poor milk production.

--Diagnostic Tests: CBC and serum chemistry.

--Potential Treatments: Tranquilizers and hormones (oxytocin).

Technician evaluations commonly associated with this medical condition:

Ineffective Nursing

--Neonates must be hand-raised using commercial milk replacer but should remain with dam.

Cushing's Disease

Also referred to as hyperadrenocorticism, Cushing's disease results from increased hormone production (cortisol) by the adrenal glands. Hyperadrenocorticism is classified as pituitary-dependent (tumor of the pituitary gland), adrenocortical-dependent (tumor of the adrenal gland), or iatrogenic. Pituitary-dependent is more common than adrenocortical forms. Iatrogenic Cushing's is associated with inappropriate (increased) administration of steroids. Steroids used for treatment of chronic skin and ear infections are frequently implicated. Clinical signs can include PU/PD, polyphagia, panting, a pendulous abdomen, alopecia, muscle wasting, lethargy, calcinosis cutis, hyperpigmentation, and bruising.

--Diagnostic Tests: CBC, serum chemistry, urinalysis, endogenous ACTH, ACTH stimulation, dexamethasone suppression test, ultrasound, radiographs, and MRI.

--Potential Treatments: Mitotane, ketoconazole, adrenalectomy, Anipryl, and radiation therapy of pituitary.

Technician evaluations commonly associated with this medical condition:

Urinary Incontinence

--Previously housetrained animals may urinate inappropriately as a result of polyuria caused by increased cortisol levels. These animals are likely to resume normal behaviors once the disease is controlled. During the interim, owners should be advised to modify the animal's environment to accommodate the increased frequency and urgency of urination.

Risk of Infection

--Animals suffering from Cushing's frequently experience concurrent urinary tract infections. Owners should be instructed to monitor for signs of cystitis. Routine monitoring of urine for infection may be advised.

Impaired Tissue Integrity

--Cutaneous bruising is a common complication of this disease. Caution should be exercised when obtaining blood samples or placing intravenous catheters.

Underweight

--Muscle wasting is associated with elevated steroid (cortisol) levels. The pendulous abdomen, or potbelly, of many animals results from loss of normal abdominal musculature. Animals should receive diets containing a high-quality protein.

Vomiting

--Animals receiving treatment frequently experience vomiting.

Client Knowledge Deficit

--Client education is imperative as this disease requires lifelong treatment of the animal. In addition, the owner should be advised that complications associated with treatment and medications are frequent.

--Prognosis is dependent upon the inciting cause of hyperadrenocorticism. Adrenalectomized animals require daily hormone replacement therapy (prednisone), and owners should be instructed to monitor for signs of hypoadrenocorticism. Animals receiving mitotane should be monitored for signs of continued Cushing's, Addison's, vomiting, neurologic abnormalities, and gastric irritation. Frequent blood work to monitor the animal should be anticipated.

Diabetes Insipidus

Diabetes insipidus is a complex disease resulting from inadequate production of antidiuretic hormone (ADH) or renal insensitivity to ADH. In the normal animal, ADH functions to promote water reabsorption from the renal tubules. Therefore, inadequate ADH results in excessive water excretion and dilute (low specific gravity) urine. Clinical signs include PU/PD, nocturia, weight loss, and incontinence.

--Diagnostic Tests: CBC, serum chemistry, urinalysis, water deprivation test, ADH response test, and CT of pituitary.

--Potential Treatments: ADH (vasopressin) supplementation and fluids.

Technician evaluations commonly associated with this medical condition:

Hypovolemia

--Animals should be provided unlimited access to water. Restricted access to water, even for a short period of time, can lead to catastrophic results in these animals. Instruct owners to monitor closely for signs of dehydration during strenuous exercise, hot weather, or any circumstance that increases water demands.

Electrolyte Imbalance

Urinary Incontinence

--Inability to reabsorb water results in large volumes of dilute urine. Providing environmental modifications such as dog doors minimizes destruction of property while simultaneously meeting the animals increased urine volume and frequency needs. Most animals can be brought to an acceptable level of continence with proper treatment.

Underweight

Sleep Pattern Disturbance

--In many cases, animals must urinate several times during the night. Providing environmental modifications such as dog doors or absorbent pads decreases the frequency of disruptions.

Diabetes Mellitus

Diabetes mellitus is a complex disease involving abnormal glucose uptake and utilization. A decrease in cellular uptake of glucose results in hyperglycemia and glycosuria. This condition can result from a lack of insulin production by the pancreas (insulin-dependent diabetes mellitus [IDDM], type 1) or cellular insensitivity to the effects of insulin (non-insulin-dependent diabetes mellitus [NIDDM], type 2). IDDM is seen with greater frequency than NIDDM. Clinical signs associated with diabetes include PU/PD, polyphagia, cataracts, and weight loss.

Diabetic ketoacidosis is a severe, life-threatening condition resulting from untreated, uncontrolled diabetes. Animals failing to metabolize carbohydrates properly begin to mobilize fat and protein stores, thus inducing the formation of ketones. Excessive ketone production induces a state of metabolic acidosis. Acidotic animals can exhibit a variety of clinical signs, including dehydration, vomiting, lethargy, anorexia, tachypnea, and weakness. The severity of clinical signs typically reflects the degree of acidosis.

--Diagnostic Tests: CBC, serum chemistry, urinalysis, and blood glucose curves (treatment evaluation).

--Potential Treatments: Insulin therapy, glipizide, and dietary modification.

Technician evaluations commonly associated with this medical condition:

Client Knowledge Deficit/Client Coping Deficit

--Treating and managing a diabetic animal is a frightening concept for many people. The prospect of performing injections and checking blood glucose can be daunting. Providing emotional and technical support is fundamental to successful management of this disease. Diet, injection techniques, insulin care, and exercise should be addressed.

--The following are common concepts that must be addressed with owners regarding dietary therapy, injection technique, insulin care, and exercise:

--Insulin Care

* Mix insulin prior to administration by gently rolling in hands. Do not shake bottle.

* Replace insulin every 60 days. Do not use expired products.

--Injection Information

* Demonstrate injection technique to client.

* Provide written instructions for injection techniques to inexperienced owners. (Injections can be administered s.q. anywhere from midneck to caudal aspect of rib cage.)

* Observe owner administering injection to verify technique and ability to draw up correct dose (units of insulin).

* Inform owner that:

** He or she should not "double up the dose" if an injection was missed.

** He or she should not administer a second injection if unsure whether "first one went in."

* Provide instruction on proper disposal of used needles and syringes.

* Instruct owner to inform veterinary staff of diabetic condition if the animal is seen at a clinic other than primary care facility.

--Diet

* Animals must be within normal weight. (Obesity is common.) If weight loss is recommended, it should be slow and gradual. Underweight animals should be fed high-quality, calorie-dense diets.

* High-fiber diets help minimize postprandial fluctuations in glucose (Hill's w/d or Royal Canin DIABETIC HF or CALORIE CONTROL CC HIGH FIBER).

* High-protein diets seem to work well in cats (Hill's m/d, Royal Canin DIABETIC DS, and Purina DM).

* Calorie content of each meal must be consistent.

* The animal should not be fed table scraps or a nonspecified diet.

* Timing of meals and insulin injection must be consistent.

* Water should be available at all times. Monitor the animal's volume of water consumption.

* The animal should be fed at the time of insulin injection if insulin is administered b.i.d. If insulin is administered s.i.d., the animal should be fed at time of injection and 8-10 hours postinjection.

--Exercise

* Moderate daily exercise assists in maintaining glucose levels within a stable range. Strenuous, sporadic exercise that stresses the dog should be avoided. Exercise can be encouraged in cats through daily play, but this is often difficult to achieve.

* Monitor for Inadvertent Hypoglycemia

* Keep corn syrup (any sugar solution can be used) available in case of a hypoglycemic emergency.

* Hypoglycemia can occur if insulin is administered to an anorectic animal or to an animal after strenuous exercise.

* Clinical signs of hypoglycemia include lethargy, weakness, ataxia, head tilt, and seizures. Instruct owners to administer corn syrup, keep the animal warm, and notify the veterinarian if signs of hypoglycemia are observed.

--Monitor for Signs of Uncontrolled or Continued Hyperglycemia, PU/PD, and Cataracts

* Blood glucose level may require monitoring.

Risk for Infection

--Glycosuria predisposes animals to urinary tract infections. Owners should be instructed to monitor for signs of cystitis. Routine monitoring of urine for infection is advised.

Overweight

--See previous dietary recommendations.

Inappropriate Elimination

--Previously house/litter box-trained animals may urinate inappropriately as a result of PU/PD. These animals are likely to resume normal behavior once the disease is controlled. During the interim, owners should be advised to modify the animal's environment to accommodate the increased frequency and urgency of urination.

Altered Mentation

--Ketoacidosis can result in "drunken" behaviors prior to more severe signs.

Impaired Mobility

--Cats with diabetes mellitus polyneuropathy may demonstrate hind limb (plantar grade) ataxia "walking on hocks."

Altered Sensory Perception

--Blindness secondary to retinitis or decreased visual acuity secondary to cataracts may lead to fearful or aggressive behaviors.

Dystocia

Dystocia is difficult labor. Causes are numerous and can result from maternal or fetal conditions. Decreased pelvic diameter secondary to obesity, prior fracture, or genetics is frequently sited in dams. Fetal abnormalities can include malformed fetus, increased size, or abnormal presentation. Uterine inertia (failure of uterus to contract) secondary to prolonged labor or electrolyte abnormalities also is a commonly sited cause of dystocia. Dystocia is considered when active straining occurs for more than 45 minutes or the resting phase (time between puppies) of delivery lasts longer than 4--6 hours. Clinical signs of dystocia include active straining, licking of vulva, or presence of immobile fetus in vulva.

--Diagnostic Tests: Palpation and radiographs.

--Potential Treatments: Oxytocin, manual extraction, IV fluids, calcium supplementation, and c-section.

Technician evaluations commonly associated with this medical condition:

Reproductive Dysfunction

Acute Pain

--Labor and delivery is a painful experience for the animal; however, analgesics are rarely administered for routine deliveries in veterinary medicine. Analgesics may be delivered during an episode of dystocia. Uncontrolled pain may be a precipitating cause in the dam's failure to develop offspring attachment.

Ineffective Nursing

--Dams experiencing difficult delivery may have reduced milk production or fail to bond with offspring. Monitor very closely for the first 24 hours. First-time mothers have a greater likelihood of experiencing difficulties.

Constipation

--Defecation is often painful postparturition. Vulvar tears or swelling, abdominal tenderness, dry stool secondary to decreased fluid intake, or fear of leaving offspring can all contribute to postparturition constipation.

Risk of Infection

--Dams should be monitored closely for abnormal vaginal discharge or other signs of infection. Lochia (normal discharge seen after delivery) will initially be red (bloody color). The discharge should have minimal odor. The color will become browner with time, although some dogs may demonstrate a dark green coloration. A septic smell should never be associated with the discharge. The lochia typically become serious by Day 3. Animals may experience a small volume of serous discharge for 2 weeks postdelivery.

Self-Care Deficit

--Stressed or painful females may require assistance in removing lochia from perineal hair. Females requiring cesarean sections should have all antiseptic washed from teat area prior to puppies or kittens being permitted to nurse.

Anxiety

--Animals should be discreetly and closely monitored postpartum to ensure appropriate maternal behavior. Extremely anxious females may traumatize offspring.

Eclampsia

Also termed periparturient hypocalcemia, lactation tetany, and puerperal tetany, eclampsia results from decreased serum calcium levels. Clinical signs of this life-threatening condition typically develop 1-3 weeks postpartum. Small breed dogs nursing large litters are most commonly affected. Clinical signs include ataxia, muscle weakness, shivering, anxiety, panting, drooling, muscle fasciculations, tachycardia, convulsions, and seizures. Owners should be informed that eclampsia is likely to reoccur with future litters.

--Diagnostic Tests: History, clinical signs, and serum electrolyte (calcium) levels.

--Potential Treatments: IV calcium, IV fluids, and oral calcium supplementation.

Technician evaluations commonly associated with this medical condition:

Electrolyte Imbalance

--Administration of IV calcium and fluids is the treatment of choice.

Hyperthermia

--Muscle fasciculations secondary to low calcium levels cause a rapid and potentially lethal increase in core body temperature.

Inadequate Nursing

--Puppies should not be permitted to nurse until the condition has been completely resolved. This may necessitate removing the puppies from the dam for a period of time. Puppies older than 3 weeks should be removed from the dam. If puppies remain on the dam, nutritional supplementation of a commercial milk replacer must be provided to decrease the lactational stress on the mother.

--Dams that are able to resume nursing should be placed on a quality diet such as Hill's Growth and provided daily oral calcium supplementation. If a relapse occurs after treatment, puppies must be weaned from the mother immediately and be hand-fed for the remainder of the neonatal period.

Client Knowledge Deficit

--Animals experiencing eclampsia are likely to suffer repeat episodes when nursing future litters. Many owners wrongly attempt to avert this condition by supplementing calcium during the pregnancy. This practice is contraindicated and will increase the likelihood of occurrence. Owners should be instructed to feed a quality growth diet during the last third of pregnancy (Hill's Growth or Iams for puppies) and throughout lactation. Oral calcium supplementation should begin after parturition.

Hyperthyroidism

Hyperthyroidism results from excessive thyroid hormone production and occurs most frequently in cats. Given that thyroid hormone affects the cellular metabolic rate of many cell types, clinical signs of this disease can be diverse. Clinical signs associated with hyperthyroidism include weight loss, voracious appetite (10 percent may be anorectic), tachycardia, PU/ PD, hyperactivity, vomiting, diarrhea, poor hair coat, and vocalizations.

--Diagnostic Tests: Physical examination, CBC, serum chemistry, and serology: thyroid hormone (T4), thyroid-stimulating hormone (TSH), thyroid autoantibody, T3 suppression test, and thyrotropin releasing hormone (TRH) stimulation test.

--Potential Treatments: Thyroidectomy, radioiodine therapy, methimazole, antiemetics, and fluids.

Technician evaluations commonly associated with this medical condition:

Underweight

--Hyperthyroid animals often eat large amounts of food yet fail to gain or maintain weight. This phenomenon results from the animal's accelerated metabolic rate (caused by increased thyroid hormone levels). Animals should be placed on a high-quality, high-calorie diet such as Hill's p/d or kitten.

Vomiting

Altered Mentation

Diarrhea

--Cats may produce large volumes of feces due to increased food consumption and metabolic rate. Until the condition is resolved, the litter box may need to be cleaned more frequently.

Cardiac Insufficiency

--Extreme tachycardia and hypertrophic cardiomyopathy can develop secondary to hyperthyroidism. Decreased cardiac output and pulmonary edema is evidenced by dyspnea, tachypnea, exercise intolerance, increased CRT, and pale mucous membranes. Heart rate should be monitored and recorded several times per day in debilitated hospitalized animals.

Self-Care Deficit

--Hyperthyroid cats typically have a greasy, matted, unkempt appearance. Areas of alopecia also may develop. Animals should receive grooming assistance to maintain the hair coat properly. More frequent bathing may be warranted to relieve excessive coat greasiness caused by increased sebum production.

Sleep Disturbance

--Hyperthyroid animals frequently experience difficulty sleeping for normal periods of time. Cats often "night walk" and vocalize. Providing a quiet, secluded area may assist in minimizing sleep awakenings in these animals.

Hypothyroidism

Hypothyroidism results from inadequate release of thyroid hormone. This disease is classified as primary, wherein the abnormality arises directly from the thyroid gland, or secondary, which is associated with disorders of the pituitary gland. (In the normal animal, thyroid-stimulating hormone [TSH] is released from the pituitary; it then stimulates the release of thyroid hormone from the thyroid gland.) This condition is the most common endocrinopathy affecting dogs, yet it is rarely seen in cats. Clinical signs associated with hypothyroidism include lethargy, weight gain, cold intolerance, dermatitis, otitis, alopecia, muscle weakness, hyperpigmentation, bradycardia, anestrus, and infertility.

--Diagnostic Tests: Serology: thyroid (T4) level, TSH level, and TSH stimulation test.

--Potential Treatments: Thyroid hormone supplementation (thyroxine).

Technician evaluations commonly associated with this medical condition:

Reproductive Dysfunction

--Hypothyroid animals frequently experience reproductive problems. Lack of estrus or inability to maintain a pregnancy is common in the female. Males may experience a decrease in conception rates and libido.

Client Knowledge Deficit/Noncompliant Owner

--Client education is imperative as this disease requires lifelong treatment of the animal. The thyroxine level used for most dogs is toxic to humans; therefore, owners should be instructed to comply with use of childproof containers and take appropriate precautions to prevent inadvertent ingestion by children. Owners purchasing larger volumes of medication should be instructed to carefully monitor drug expiration dates.

--Serology should be conducted every 6-12 months (after the animal has been stabilized) to ensure appropriate dose of medication. Blood collection must be within 4-6 hours of hormone administration to ensure accurate results.

Overweight

--Inadequate thyroid hormone levels result in a lowered metabolic rate, making these animals prone to weight gain. Animals can be placed on calorie-restricted diets such as Hill's r/d, Royal Canin CALORIE CONTROL CC HIGH FIBER, CALORIE CONTROL CC HIGH PROTEIN, or Purina OM until weight is within acceptable parameters. Long-term use of a modified-calorie diet such as Hill's w/d or Royal Canin NEUTERED CAT YOUNG ADULT may be required to maintain the animal's weight.

--Animals placed on appropriate T4 dosage should see improvements with weight within 6-10 weeks.

Mastitis

Mastitis is an inflammation of the mammary gland. Although physical and chemical agents can induce mastitis, bacteria account for the majority of cases. This condition is most prevalent in the postpartum period. Bacteria commonly associated with mastitis include Escherichia coli, Staphylococcus, and Streptococcus. Clinical signs include pain, heat and swelling in the affected gland, reluctance to permit nursing, fever, lethargy, anorexia, and changes in milk appearance (clumping, watery, or bloody).

--Diagnostic Tests: CBC, serum chemistry, and milk culture.

--Potential Treatments: Antibiotics, IV fluids, and anti-inflammatory analgesics.

Technician evaluations commonly associated with this medical condition:

Ineffective Nursing

--Nursing can be extremely painful for the dam, causing previously tolerant females to exhibit aggressive behaviors toward offspring. Removal of milk from the affected glands is necessary for recovery. Thus, neonates should be permitted to nurse unless Escherichia coli is suspected or the dam becomes aggressive. If neonates must be removed, alternative methods should be used to remove milk manually from the affected glands.

--Neonates should be hand-raised or supplemented when inadequate nutrient intake is suspected. Neonates should be weighed daily and examined for signs of inadequate nutrient intake such as listlessness, crying, gaunt abdomen, or skin tenting.

Acute Pain

--Nonpharmacological approaches to pain control should be utilized. Warm compresses or a heating pad applied several times a day can provide comfort.

Hypovolemia

--Milk production is directly relation to hydration status. Dehydrated females are unable to produce an adequate volume of milk. Fluid consumption should be closely monitored. Neonates also should be monitored for signs of inadequate fluid intake.

Hyperthermia

--Mastitis can remain a localized condition or progress to a systemic illness. Escherichia coli mastitis patients are most likely to become septic.

Underweight

--Ensuring adequate nutrient intake is critical to milk production. Use of high-calorie diets such as Hill's p/d or Royal Canin INTESTINAL HE is advised.

Paraphimosis

Paraphimosis is the inability of the male animal to withdraw the penis into the prepuce. Clinical signs include an engorged protruding penis, excessive licking, stranguria, and hematuria.

--Diagnostic Tests: Physical examination and CBC.

--Potential Treatments: Manual replacement, antibiotics, and IV fluids.

Technician evaluations commonly associated with this medical condition:

Reproductive Dysfunction

--The ability of males to inseminate females after an episode of paraphimosis is dependent upon the inciting cause. Males are unable to perform in a reproductive capacity during an acute episode.

Acute Pain

--Application of cold packs once the penis is returned to the prepuce will help decrease discomfort. Pain will diminish significantly once the penis is returned to the sheath and swelling subsides.

Risk for Self-Inflicted Injury

--Prevention of further trauma from excessive licking or chewing is imperative. E-collars should be utilized until the condition is completely resolved. Access to females and sexual excitement of male should be restricted.

Impaired Tissue Integrity

--The mucosal surface of the penis is very delicate and is frequently traumatized by excessive licking and swelling.

Prostatitis

The prostate is an accessory sex gland that contributes to the fluid component of the semen/ejaculate. Located at the neck of the bladder, the prostate empties into the urethra. Prostatitis, or inflammation of the prostate gland, is usually secondary to infection. This condition can be acute or chronic; and in severe cases, it can lead to prostatic abscessation. Bacteria commonly associated with prostatitis include Escherichia coli, Pseudomonas, Staphylococcus, and Streptococcus. Clinical signs can include dysuria, hematuria, constipation, gait abnormalities such as moving with apparent stiffness in hind limbs, abdominal pain, fever, preputial discharge, abdominal pain, and vomiting.

--Diagnostic Tests: Physical examination, CBC, urinalysis, urine culture, ultrasound, prostate wash culture, or fine needle aspirate.

--Potential Treatments: Antibiotics, IV fluids, and castration (after episode is resolved).

Technician evaluations commonly associated with this medical condition:

Reproductive Dysfunction

--Prostatitis is painful, and the majority of males will not copulate during acute episodes. Sperm viability is dramatically reduced, and animals should not be used for reproductive purposes for some time following episodes of prostatitis. Castration is often recommended as it quickens recovery time.

Constipation

--Constipation occurs secondary to colon compression caused by the enlarged prostate.

Acute Pain

Hyperthermia

Hypovolemia

Inappropriate Elimination

--As urination is extremely painful, previously housetrained animals may begin to urinate inappropriately. In dogs, this behavior will likely discontinue when the prostatitis has resolved.

Pseudopregnancy

Also termed false pregnancy and phantom pregnancy, this condition is seen in females 40-60 days postestrus. Females can exhibit all signs of impending parturition, such as mammary development, milk production, depression, personality changes, and nesting behaviors. This condition tends to reoccur within the same females.

--Diagnostic Tests: Radiographs and history.

--Potential Treatments: None required. Condition will spontaneously resolve. OHE will prevent reoccurrence.

Technician evaluations commonly associated with this medical condition:

Client Coping Deficit

--Clients believing that their animal is pregnant are often disappointed upon learning the actual pregnancy status. Many clients need reassurance/ confirmation that the female is not gravid.

Pyometra

Pyometra, the accumulation of pus within the uterus, is most common in middle-aged females that experienced a heat cycle within the previous 2 months. Pyometras are classified as open or closed. Although both are potentially life-threatening conditions, the closed pyometra is particularly dangerous. Closing of the cervix causes retention of pus within the uterus and dramatically increases the potential for uterine rupture. Clinical signs of pyometra can include vulvar discharge (open), lethargy, vomiting, PU/PD, dehydration, and abdominal distension.

--Diagnostic Tests: CBC, serum chemistry, radiographs, and ultrasound.

--Potential Treatments: Antibiotics, IV fluids, surgery, and hormones (prostaglandin).

Technician evaluations commonly associated with this medical condition:

Reproductive Dysfunction

--Seventy percent of animals treated medically will experience a second episode of pyometritis within two years. Owners are advised to breed females on the first estrus following treatment. Females undergoing an OHE will be unable to reproduce.

Hypovolemia

--Rehydration prior to surgery is imperative.

Electrolyte Imbalance

--Correction of electrolyte imbalance prior to surgery is imperative.

Hyperthermia

--Fever is present in approximately 30 percent of presenting females.

Vomiting

Self-Care Deficit

Vaginitis

An inflammation of the vagina, vaginitis is a clinical sign of disease, not a disease in and of itself. Manifestations of vaginitis can include erythema, discharge, odor, and edema of the vaginal walls and vulva. Diseases associated with vaginitis can be bacterial, viral, yeast, or congenital.

--Diagnostic Tests: CBC, vaginal culture, vaginal cytology, and serum antibody titers.

--Potential Treatments: Variable dependent upon causative disease.

Technician evaluations commonly associated with this medical condition:

Self-Inflicted Injury

--Vaginitis associated with excessive discharge or moisture can result in perivulvar dermatitis. Females often demonstrate excessive grooming and licking of the vulvar area.

Reproductive Dysfunction

Risk of Infection Transmission

--Diseases such as herpesviruses and Brucella are sexually transmitted diseases. Due to the risk of disease transmission, breeding of affected females should be avoided until the problem has been resolved.

CONDITIONS INVOLVING THE RENAL AND URINARY SYSTEMS

Antifreeze Intoxication (Ethylene Glycol [EG] Intoxication)

EG is the toxic component of antifreeze solutions used in automobiles. The sweet taste of antifreeze entices animals to consume this highly toxic compound. Exposure typically occurs when animals happen upon fluid inadvertently spilled during filling of radiators or dripped from leaky radiators. Antifreeze is extremely toxic, and consumption of even small amounts can result in renal failure. A variety of clinical signs are seen depending on the stage of intoxication. During the acute period of stage 1, ataxia, vomiting, depression, dehydration, PU/PD, and vomiting are evidenced. Owners often state that the animal "appeared drunk." Stage 2 is associated with a resolution of previous clinical signs and the appearance of tachycardia. Owners often mistakenly confuse stage 2 with a resolution of the problem. Stage 3 commences within 24-72 hours of ingestion and is associated with signs of renal failure including depression, vomiting, and oliguria.

--Diagnostic Tests: History of exposure, PRN rapid blood test (detects EG only, not the toxic metabolites during stage 1), physical examination, CBC, and chemistry profile (stage 3).

--Potential Treatments: Induce vomiting for recent ingestion, alcohol dehydrogenase inhibitors (4-methylpyrazole) in dogs only, IV ethanol (ethyl alcohol), IV fluids, sodium bicarbonate, antiemetics, and nutritional support.

Technician evaluations commonly associated with this medical condition:

Altered Urinary Production

--Oliguria is present during stage 3. Monitoring of urine production is critical due to renal tubular damage associated with this intoxication.

Hypovolemia

--A metabolic acidosis occurs concurrent to dehydration. Sodium bicarbonate can be administered in fluids to correct the acidosis.

Electrolyte Imbalance

Vomiting

--Vomiting is associated with stage 1 (acute intoxication phase) and stage 3 (renal failure phase).

--Vomiting can be intentionally induced in animals that consumed antifreeze within the previous 60 minutes. This assists in eliminating the toxin prior to the development of clinical signs.

Client Coping Deficit

--Clients may require assistance dealing with feelings of guilt if they inadvertently provided the source of exposure.

Client Knowledge Deficit

--Educate clients regarding the correct procedure for cleaning up chemical spills. Prevention is ideal using funnels or other devices. Paper or cardboard can be placed under the vehicle during fluid changes (antifreeze, brake fluid, and oil) and then properly disposed of. An absorbent material such as cat litter or paper towels should be used to remove spills, followed by water flush. Owners also should be instructed to monitor the area under vehicles for leaks.

Altered Mentation

--During the acute phase, intoxicated animals may appear "drunk." Severe depression typically accompanies stage 3.

Self-Care Deficit

--Intoxicated animals require assistance with self-care.

Cystitis

Cystitis, an inflammation of the urinary bladder, is a clinical sign commonly associated with urinary tract infections. Ascending bacterial infections of the lower urinary tract account for the majority infectious causes of cystitis. Urease-forming bacteria can alter the urine pH, making it more likely for MgN[H.sub.4] P[O.sub.4] (struvite) crystals or uroliths to form. Noninfectious causes of cystitis can include urolithiasis, neoplasia, trauma, chemical insult, or idiopathic disease. Cystitis is frequently associated with pollakiuria, dysuria, stranguria, hematuria, and inappropriate urination.

--Diagnostic Tests: Urinalysis, urine culture, and radiographs (contrast studies).

--Potential Treatments: Varied depending on inciting cause. Can include antibiotics, IV fluids, dietary management, urolith removal, and chemotherapy.

Technician evaluations commonly associated with this medical condition:

Noncompliant Owner

--Educate owners regarding the importance of administering the full course of antibiotics. Inappropriate administration of antibiotics can precipitate recurrent urinary tract infections.

Urinary Incontinence

--Incontinence is usually temporary and resolves with appropriate treatment.

--Cystocentesis is the method of choice for collection of urine samples. Urinalysis should be performed immediately upon collection to ensure accurate results. Postponing examination can result in lysis of RBC, WBC, and crystals. Samples that cannot be examined immediately should be refrigerated. The sample should be discarded after 12 hours.

--Diet modification is often recommended. Potential diets are often low in magnesium, with added antioxidants and urinary acidifiers. Examples include Hill's s/d and c/d; Eukanuba Low pH/S and Moderate pH/O; Purina UR Urinary and Urinary St/Ox; and Royal Canin URINARY SO (struvite and oxalate), CONTROL FORMULA, and DISSOLUTION FORMULA.

--Consumption of adequate water is vital to ensuring urine production and natural flushing of bacteria. Providing animals, especially cats, access to distilled moving water (bubble fountains) can assist in promoting water intake. The goal of water intake is to decrease urine specific gravity below 1.030. Use of moist foods (> 60 percent moisture) has been shown to increase water intake in cats. Increasing feeding frequency, placing a bowl of moist food alongside the previous diet, or using broths as a top dressing also facilitates increased fluid intake.

--Reduction of stress, environmental enrichment, and adequate litter box maintenance are known to reduce signs of cystitis in cats. Environmental enrichment can include providing climbing poles, hiding boxes, and scratching posts. Use of synthetic facial pheromone therapy (Feliway) can facilitate stress reduction. Appropriate litter box cleaning and placement is imperative.(Refer to the inappropriate elimination interventions.)

Acute Pain

--Cystitis is often accompanied by painful urination. Animals often initiate micturition, then stop midstream secondary to pain.

Renal Failure (Acute and Chronic)

Renal failure can be acute or chronic with classification reflecting the rate of renal function decline. ARF is evidenced by a rapid loss of function with accumulation of uremic toxins and disregulation of fluid and electrolytes. In comparison, chronic renal failure (CRF) is gradual, progressive decline with renal loss taking months to years. Clinical signs for both forms can include anorexia, depression, vomiting, diarrhea, dehydration, oral ulceration and halitosis, seizures, and ataxia. Additional clinical signs consistent with ARF include oliguria, polyuria, tachypnea, and bradycardia. PU/PD, nocturia, ascites, subcutaneous edema, and blindness are further indications of CRF.

--Diagnostic Tests: CBC, serum biochemistry, urinalysis, radiographs, ultrasound, biopsy, serology (ARF), and EG levels (ARF).

--Potential Treatments:

* Both conditions: Sodium bicarbonate, potassium chloride, phosphate binders, and antiulcer medications.

* ARF: Antiemetics, diuretics, and antibiotics.

* CRF: ACE inhibitors, Calcitriol, and erythropoietin.

Technician evaluations commonly associated with this medical condition:

Vomiting

Diarrhea

Self-Care Deficit

--Animals in ARF may fail to maintain adequate hygiene.

Hypovolemia

Electrolyte Imbalance

--Common electrolyte abnormalities include elevated BUN, creatinine, phosphate, and TP with a metabolic acidosis.

Altered Oral Health

--Uremic ulcers present in the oral cavity can impair food consumption.

Altered Urinary Production

--ARF is often associated with reduction in urine output. Normal output is 1 mL/kg/h. Urine production with oliguria is less than 0.25 mL/kg/h, and anuria is classified as 0.1 mL/kg/h.

Altered Mentation

--Clinical appearance is varied, ranging from depression to seizures. Excessive accumulation of uremic toxins and electrolyte disturbances precipitate altered mentation.

Risk of Infection

--Debilitated animals are more susceptible to infectious disease.

Underweight

--Dietary management of CRF patients is vital to slowing disease progression. Use of diets such as Hill's k/d, Purina NF Kidney Function, Eukanuba Multi-Stage Renal, or Royal Canin Renal LP are recommended.

Urinary Bladder Perforation

Bladder perforation occurs secondary to trauma (hit by car [HBC], kicks, or falls), unrelieved obstruction (urolithiasis and neoplasia), or iatrogenic causes (urinary catheters and cystocentesis). Although bladder perforation is a severe condition with a mortality rate approaching 40 percent, clinical signs associated with it are often nebulous. Signs, which may be delayed 24-48 hours posttrauma, can include anuria, abnormal micturition, hematuria, painful abdomen, ascities, vomiting, anorexia, and depression.

--Diagnostic Tests: Physical examination, radiographs (plain film and cystography), and urinalysis.

--Potential Treatments: Surgery, IV fluids, antibiotics, and anti-inflammatories.

Technician evaluations commonly associated with this medical condition:

Altered Urinary Production

--Application of pressure to the abdominal cavity should be strictly avoided. Do not express the bladder. Extreme caution must be exercised during any postoperative bladder palpation. Monitoring of urine content and output is critical.

Electrolyte Imbalance Vomiting

--Uremia and electrolyte imbalances can induce vomiting.

Hypovolemia

--Decreased fluid intake, vomiting, and extravascular fluid movement contribute to dehydration. Ensure urinary bladder integrity prior to administering large fluid volumes.

Risk of Infection

--Animals with bladder perforation are highly susceptible to peritonitis. Extreme caution should be exercised when placing or caring for an indwelling urinary catheter.

Acute Pain

--Exhibition of pain is highly variable. Animals suffering from additional trauma, as with HBC, may exhibit a great deal of pain. Animals perforating secondary to urethral obstruction may temporarily appear to be in less pain immediately following the rupture.

Uroliths

Uroliths, which are calculi, or "stones," in the urinary tract, are a medical condition common to both dogs and cats. The chemical composition of uroliths varies and can include struvite, calcium oxalate, urate, and cystine. Clinical signs typically reflect the size, chemical content, and location of the urolith. Uroliths located in the bladder manifest as hematuria, pollakiuria, and stranguria, while those lodged in the urethra present with abdominal pain, anuria, stranguria, depression, anorexia, and vomiting. The primary danger of urolithiasis remains obstruction of urine outflow, bladder rupture, and severe electrolyte disturbances. Castrated males are at highest risk for urethral obstruction.

--Diagnostic Tests: Physical examination, radiographs, urinalysis, urolith chemical analysis, serum chemistry, ECG, bile acids, and ultrasound. The Minnesota Urolith Center currently provides free stone analysis.

--Potential Treatments: Relief of urethral obstruction if present, surgery, IV fluids, correct electrolyte imbalances, analgesics, and antiemetics.

Technician evaluations commonly associated with this medical condition:

Acute Pain

--Irritation to the bladder epithelium, bladder distension, urethral spasm, and irritation all contribute to pain.

Hypovolemia

--Obstructed animals suffer from severe fluid and electrolyte disturbances. IV fluids commonly selected include 0.9 percent NaCl, Normosol-R, and PLASMA-LYTE.

Electrolyte Imbalance

--Electrolyte disturbances most commonly associated with obstruction include metabolic acidosis, increased PCV/ TP, hyperkalemia, increased BUN, and creatinine.

--Abnormalities seen on the ECG as a result of a severe hyperkalemia include bradycardia, changes in T wave (tented or high-peaked), decreased heart rate, flattened P wave, prolonged PR, widening of QRS intervals, and increased incidence of ventricular premature complex (VPC).

Vomiting

--Emesis is secondary to triggering the chemoreceptor trigger zone (CRTZ) caused by elevated BUN and electrolyte disturbances.

Altered Urinary Production

--Normal urine production is 1 cc/lb/h. Anticipate 4 cc/lb/h for animals undergoing diuresis.

--Obstructed animals typically have an indwelling urinary catheter for 48 hours. During this time, the animal should be placed on an elevated grate to prevent contact with urine. Alternatively, a continuous collection system can be attached to collect all urine and provide exact urine production volumes. Remove the litter box from the cage, as indwelling urinary catheters can be obstructed by litter.

--Application of an E-collar will reduce incidence of unintended removal of the urinary catheter.

--Reobstruction upon removal of an indwelling urinary catheter occurs in 14 percent of cats. Careful monitoring is critical.

--Struvite crystals (triple phosphate) are most commonly associated with feline uroliths (75 percent)/obstruction.

Risk for Infection

--Urine stasis and damage to urinary tract epithelium predispose animals to urinary tract infections. Adhere to strict aseptic technique when placing and caring for urinary catheters. A percentage of animals will have concurrent UTI and uroliths.

Client Knowledge Deficit

--Separation of a single animal for feeding in a multianimal household is often difficult. The number of litter boxes and their cleanliness often poses problems in a multicat household. Because of these issues, many owners disregard suggestions for long-term prevention. Discuss various options that can be employed to resolve these issues.

--General prevention measures:

* Monitor for signs of cystitis and eradicate if present.

* Ensure adequate water intake. Use of moist foods (> 60 percent moisture) is highly recommended in cats with prior urinary tract conditions. Moving/fountain water encourages consumption. Providing multiple feedings, adding ice cubes to the water dish, top-dressing food with broth, and placing multiple water bowls in the area also may facilitate increased water consumption.

* Provide dogs with frequent opportunities to void. Ensure that cats have access to a clean litter box at all times. (Refer to the inappropriate elimination interventions.)

* Monitor urine sediment and pH as directed by the veterinarian.

* Provide diet determined by the veterinarian. Common prescription diets include Hill's s/d, c/d, u/d, and x/d; Eukanuba Low pH/S and Moderate pH/O; Purina UR Urinary and Urinary St/Ox; and Royal Canin URINARY SO, CONTROL FORMULA, and DISSOLUTION FORMULA.

* Reduce stress via environmental enrichment. Consider use of pheromones.

CONDITIONS INVOLVING THE MUSCULOSKELETAL AND NEUROLOGIC SYSTEMS

Arthritis

Arthritis is an inflammation of the joint. Arthritis etiologies are numerous and frequently classified as traumatic, immune-mediated, or septic (infectious) in origin. Bacteria represent the most common infectious agent, although septic arthritis also has been associated with mycoplasma, rickettsia, and fungal and viral infections. The term arthritis is often used synonymously with degenerative joint disease (DJD). Despite virtually identical clinical manifestations seen in these conditions, DJD differs in that it is a progressive noninflammatory disorder resulting in articular cartilage damage and degeneration. DJD has no known cure.

--Diagnostic Tests: Physical examination, radiographs, synovial fluid analysis (joint tap) and culture, biopsy, serology, CBC, and serum chemistry.

--Potential Treatments: Variable dependent upon inciting cause. Antibiotics and antifungal and antiviral agents. Symptomatic: NSAIDS, steroids, dietary management, chondroprotectants, and fatty acid supplementation.

Technician evaluations commonly associated with this medical condition:

Acute Pain or Chronic Pain

--Arthritis is a very painful condition. Pain control for acute arthritis is often achieved through medications such as NSAIDs and analgesics or through diet. Pain relief from chronic arthritis can be addressed through the following measures:

* Maintain animal at ideal body weight. An increased body mass increases mechanical stress, thereby increasing pain in the affected joints.

* Use NSAIDs judiciously.

* Employ diets specifically designed for management of osteoarthritis, such as Hill's j/d, Royal Canin MOBILITY SUPPORT JS or MOBILITY SUPPORT JS LARGE BREED, or Purina JM Joint Mobility.

* Improve general joint health through use of chondroprotectants and supplements.

* Modify environment to provide warm padded areas for resting.

* Encourage moderate exercise to maintain joint range of motion (ROM) and to optimize weight.

Overweight

--Animals suffering from arthritis often gain weight as a result of a sedentary lifestyle. Weight reduction can be accomplished through use of foods such as Hill's w/d, Royal Canin CALORIE CONTROL CC HIGH FIBER or Purina OM. Conversely, animals that develop arthritis are at greater risk for future obesity.

Client Knowledge Deficit

--Owners must be made aware of the importance of maintaining the animal's ideal body weight. In addition, owners should be encouraged to follow the veterinarian's orders for exercise regimes, supplements, or other medications that must be administered on a daily basis.

Reduced Mobility

--Animals suffering from arthritis experience a reduced ROM and pain in affected joints. These factors can combine to limit the animal's ability to exercise, thus contributing to obesity. Continual low-impact movement is critical to maintaining remaining joint health. Swimming or other aquatic activity is ideal for maintaining joint health.

Self-Inflicted Injury

--Animals often lick repeatedly at affected joints. Carpal joints in particular are at risk for repetitive licking. If pain remains uncontrolled despite all medical therapies, animals may require the use of E-collars or other devices to minimize self-traumatization.

Aggression

--Previously even-tempered animals can exhibit aggressive tendencies when they anticipate or experience pain. Owners with small children should ensure that the children do not climb on or pull an arthritic animal's extremities, hips, etc. Encourage owners to provide a designated "dog-safe/child-free" area where the dog can rest comfortably without being disturbed.

Ataxia

Ataxia is a nonspecific clinical sign associated with many disease conditions. Characterized by lack of muscular coordination, ataxia is often described as a "drunken movement" in which the animal moves with a hyper-or hypometric gait, falls easily, demonstrates weakness of movement, shuffles, and has difficulty maintaining direction. Ataxia can be seen whenever the sensory pathways responsible for proprioception are disrupted. Examples of inciting causes include intoxication, infectious disease, congenital lesions, vestibular abnormalities, and trauma to the central nervous system (CNS).

--Diagnostic Tests: Extremely variable depending on inciting cause. CBC, serum chemistry, serology, toxicology tests, radiographs, myelogram, MRI, and CT.

--Potential Treatments: Extremely variable depending on inciting cause. Surgery, specific intoxication therapies, antibiotics, antiparasitics, and anti-inflammatories.

Technician evaluations commonly associated with this medical condition:

Hyperthermia

Hypovolemia

Risk of Aspiration

Vomiting

Reduced Mobility

Acute Pain

Fear

Brachial Plexus Avulsion

The brachial plexus is a nerve bundle formed by the ventral roots of C6, C7, C8, T1, and T2 nerves. Together these nerves function to innervate the front limb. An avulsion is essentially the tearing away or pulling apart of a structure. Avulsion of the brachial plexus occurs when the thoracic limb is severely abducted (moved away from midline). This type of movement is often associated with automobile injuries and other scenarios in which the animal is suspended by a forelimb. Clinical signs associated with this condition include lameness, Horner's syndrome (exophthalmos, elevation of lower eyelid, ptosis of upper eyelid, and miosis), and loss of limb sensation. Muscle atrophy is associated with chronic cases.

--Diagnostic Tests: Physical examination.

--Potential Treatments: Prevent further damage to limb, monitor for return to function for 4-6 months, and amputate the affected limb. Neurosurgery as a treatment option has not been well documented in animals.

Technician evaluations commonly associated with this medical condition:

Impaired Tissue Integrity

--Loss of motor innervation can result in dragging of the front limb. This leaves the skin highly susceptible to ulceration, laceration, and trauma. A variety of bandaging techniques can be used to elevate the limb to prevent dragging. Preventative bandaging is highly recommended as restoration of normal integument postulceration can be clinically unrewarding.

Reduced Mobility

--Denervated muscles undergo severe atrophy in a relatively short period of time. To prevent atrophy and joint contracture, physical therapy should be instituted early in the course of treatment. Heat, ultrasound, massage, and passive ROM exercises are acceptable methods. Whirlpool therapy t.i.d. for 15 minutes is ideal. Care should be taken to prevent overheating of the skin or overstretching of muscles.

Self-Inflicted Injury

--A tingling or itching sensation associated with early nerve regeneration may prompt some animals to self-mutilate the limb. Standard methods of preventing self-mutilation can be employed.

Altered Mentation

--Animals suffering from brachial plexus avulsion have typically experienced a blunt trauma such as HBC. Altered mentation can be associated with injuries that occurred simultaneous to the avulsion.

Decreased Perfusion (Peripheral)

--Damage to the vascular system also can occur during the avulsion. Monitoring of the limb for edema, color changes, temperature, and pulse strength is critical during the acute period.

Coma

Coma is a state of unconsciousness characterized by lack of awareness and inability to respond to environmental stimuli. Animals often appear to be in a state of deep sleep with intact reflex activity. Coma can occur secondary to inflammatory diseases (bacterial, fungal, or viral infection) or to neoplastic, traumatic, toxic (EG, lead, carbon monoxide, or drugs), or metabolic disturbances (diabetes mellitus, hepatic encephalopathy, hypoglycemia, or uremia).

--Diagnostic Tests: Extremely variable depending on suspected cause. Physical examination, CBC, serum chemistries, antibody titers, bile acids, blood ammonia, urinalysis, coagulation profiles, CSF analysis, radiographs, CT, and MRI.

--Potential Treatments: Extremely variable depending on cause.

Technician evaluations commonly associated with this medical condition:

Altered Mentation

Risk of Infection

--Comatose animals are severely debilitated; therefore, they are at much greater risk for infection. Pneumonia is of particular concern.

Hypovolemia

--Unresponsive animals are unable to consume fluids or nutrients. To avert dehydration and cachexia, IV catheters are used to provide appropriate fluids, electrolytes, and TPN. Fluids are limited to maintenance volumes as they can contribute to cerebral edema.

Risk of Aspiration

--Comatose animals do not possess a normal swallow reflex and are very susceptible to aspiration pneumonia. Oral administration of drugs should be avoided. Comatose animals should be monitored closely for signs of pneumonia secondary to aspiration or pulmonary edema. Comatose animals should be examined every 15-60 minutes depending on vital sign status.

Impaired Tissue Integrity

--Reduced tissue perfusion and lack of movement predispose comatose animals to decubital ulcers. Unresponsive animals should be rotated from side to side every 2-3 hours. Frequent turning also helps prevent hypostatic lung congestion. Use of appropriate padding and cage racks prevents wetness and ulceration.

Bowel Incontinence

--The volume of fecal material is reduced secondary to diminished intake of solid food. Altered fecal consistency and constipation also can accompany incontinence.

Urinary Incontinence

--Urinary catheters can be placed to facilitate continual emptying of the bladder and to monitor urine production. Manual expression of the urinary bladder should be performed 2-4 times per day in noncatheterized animals.

Reduced Mobility

--Nonmobile animals are susceptible to muscle atrophy and joint contracture. Passive ROM exercises, massage, and ultrasound therapy can be instituted to minimize such secondary complications.

Self-Care Deficit

--Coma renders self-care impossible. Daily brushing helps maintain hair coat quality and appearance in addition to facilitating circulation. Reduced blinking increases susceptibility to corneal ulceration. Daily application of an intraocular sterile lubricant/ointment is recommended. Open-mouth breathing coupled with a diminished swallowing rate serves to rapidly dry the tongue and gums. Application of glycerin to oral surfaces reduces dryness and discomfort.

Decreased Perfusion

--Coma can be associated with reduced perfusion of kidneys, intestines, and integument.

Client Coping Deficit

--Owners often require quiet, undisturbed bonding time with the animal. If medically appropriate, owners can assist with brushing the animal's coat or with passive ROM exercises. Coma is often associated with a grave prognosis.

Degenerative Joint Disease (DJD)

DJD is a progressive, painful deterioration of the articular cartilage and constitutes the most common joint disease of dogs. Clinical signs typically develop over time with animals initially "warming out" of the lameness or exhibiting signs only during cold or damp periods. As the disease progresses, the severity of the lameness increases and loss of mobility or muscle atrophy can ensue.

--Diagnostic Tests: Radiographs and arthrocentesis with synovial fluid analysis.

--Potential Treatments: Symptomatic: anti-inflammatories (steroids and NSAIDS), chondroprotective drugs, weight loss, and moderate exercise plan. Surgery may be indicated to correct joint laxity.

Technician evaluations commonly associated with this medical condition:

Chronic Pain

--Pain control for DJD is often achieved through medications such as NSAIDs and analgesics. In addition, pain relief can be addressed through the following measures:

* Maintain animal at ideal body weight. An increased body mass increases mechanical stress, thereby increasing pain in the affected joints.

* Improve general joint health through use of chondroprotectants and supplements.

* Apply thermal therapy (conductive or converted), which can be helpful.

* Modify environment to provide warm padded areas for resting.

* Encourage moderate exercise to maintain joint ROM and to optimize weight. Avoid high-impact activities such as running, chasing balls, and jumping. Encourage low-impact activities such as swimming and walking.

* Employ diets specifically designed for management of osteoarthritis, such as Hill's j/d, Royal Canin MOBILITY SUPPORT JS, or Purina JM.

Overweight

--Animals suffering from DJD often gain weight as a result of a sedentary lifestyle.

Client Knowledge Deficit

--Owners must be made aware of the importance of maintaining the animal's ideal body weight. In addition, owners should be encouraged to follow the veterinarian's orders for exercise regimes, supplements, or other medications that must be administered on a daily basis.

Reduced Mobility

--Animals suffering from DJD experience a reduced ROM and pain in affected joints. These factors can combine to limit the animal's ability to exercise, thus contributing to obesity. Continual low-impact movement is critical to maintaining remaining joint health. Swimming or other aquatic activity is ideal for maintaining joint health.

Self-Inflicted Injury

--Animals often lick repeatedly at affected joints. Carpal joints in particular are at risk for repetitive licking. If pain remains uncontrolled despite all medical therapies, animals may require the use of E-collars or other devices to minimize self-traumatization.

Aggression

--Previously even-tempered animals can exhibit aggressive tendencies when they anticipate or experience pain. Owners with small children should ensure that the children do not climb on or pull a painful animal's extremities, hips, etc. Encourage owners to provide a designated "dog-safe/ child-free" area that permits the dog to rest comfortably without being disturbed.

Hip Dysplasia

Hip dysplasia is a developmental DJD affecting the coxofemoral joint of dogs. Affected animals have a high degree of instability or laxity in the hips that ultimately leads to osteoarthritis. Clinical signs associated with this condition include hind limb lameness, bunny hopping gait, decreased ROM, and pain upon palpation of the hips. This disease has high degree of heritability, and breeding of affected animals is not recommended.

--Diagnostic Tests: Radiographs and specific radiographic evaluations including PennHIP and Orthopedic Foundation Association certification.

--Potential Treatments: Surgery: triple pelvic osteotomy, femoral head and neck excision, and total hip replacement. Medical symptomatic treatment for osteoarthritis: NSAIDs, chondroprotective agents, and physical therapy.

Technician evaluations commonly associated with this medical condition:

Overweight

--Although hip dysplasia has a definite genetic component, dietary management has a significant influence on the progression of the disease. Excessive or rapid growth has been shown to increase the risk for hip dysplasia. Owners should be instructed to avoid freechoice feeding and should be encouraged to feed their dogs growth diets that are specifically formulated for large or giant breeds. Supplementation of these diets with vitamins or minerals (calcium) should be discouraged.

--Animals that have received a diagnosis of hip dysplasia will inevitably suffer from osteoarthritis. Pain associated with the arthritis encourages a sedentary lifestyle, which in turn favors obesity. Owners should weigh animals monthly to ensure optimal body mass. The diet selected will reflect the animal's age, weight, and activity level.

Acute Pain or Chronic Pain

--Hip dysplasia is a DJD. This disease can be surgically addressed; however, owners may elect to forego surgical intervention, instead opting to manage the disease using techniques/medications as described for arthritis/DJD.

--Pain relief can be addressed through the following measures:

* Maintain animal at ideal body weight. An increased body mass increases mechanical stress, thereby increasing pain in the affected joints.

* Use NSAIDs judiciously.

* Improve general joint health through use of chondroprotectants and supplements.

* Modify environment to provide warm padded areas for resting.

* Encourage moderate exercise to maintain joint ROM and to optimize weight.

* Employ diets specifically designed for management of osteoarthritis, such as Hill's j/d, Royal Canin MOBILITY SUPPORT JS, or Purina JM.

Reduced Mobility

--Excessive exercise of young at-risk breeds of dogs should be avoided until the animal has reached musculoskeletal maturity (approximately 12-14 months of age).

--Animals undergoing surgery should be postoperatively exercise-restricted. The length and restriction limits are determined by the surgical procedure performed.

--Animals undergoing surgery should receive postoperative physical therapy. This can include ROM exercises, heat therapy, massage, and other intervention. Hydrotherapy, which permits animals to exercise on a water-submersed treadmill, is of great benefit as it promotes joint movement with less mechanical stress.

Aggression

--Previously even-tempered animals can exhibit aggressive tendencies when they anticipate or experience pain. Owners with small children should ensure that the children avoid causing hip pain by climbing on or pushing the dog.

Intervertebral Disc Disease (IVDD)

Two types of IVDD are seen in animals. Type I is characterized by a rapid, sudden extrusion of ruptured disc material into the spinal cord. This type is commonly seen in chondrodystrophic breeds such as the dachshund, shih tzu, basset, and corgi. IVDD Type I is often described by owners as "suddenly going down in the back end." Type II IVDD is associated with a gradual protrusion of an intact disc into the spinal cord. Type II protrusion typically affects larger dog breeds such as the German shepherd, mastiff, and Labrador retriever. Observant owners often describe a gradual onset of a "wobbly hind end." Clinical signs of IVDD reflect the severity of spinal cord damage. Signs range from pain, loss of proprioception, reluctance to move, stiffened appearance, ataxia, mild paraparesis, and paralysis to paraplegia.

--Diagnostic Tests: Radiographs, myelogram, MRI, and CT.

--Potential Treatments: Surgical intervention (laminectomy, hemilaminectomy, and decompression), cage rest, and steroids.

Technician evaluations commonly associated with this medical condition:

Client Coping Deficit

--Owners often experience a high degree of anxiety when IVDD has caused acute paralysis of their pet. It is common for owners to anthropomorphize and express feeling of depression or despair.

Risk of Infection

--Cystitis is a common sequela of reduced bladder innervation secondary to IVDD. Animals with an indwelling urinary catheter are especially at risk for cystitis. Culture of the urine is recommended upon removal of the catheter. Atelectasis secondary to recumbency predisposes animals to respiratory infection.

Overweight

--Chondrodystrophic breeds such as the dachshund also are likely to experience excessive weight gain. This attribute, in conjunction with a conformational predisposition, places additional stress on the vertebral column. Selecting an appropriate diet to reduce weight and to maintain it within normal parameters is highly recommended.

Impaired Tissue Integrity

--Paralysis leaves animals very susceptible to decubital ulcers. Recumbent animals should be placed on a well-padded surface and turned every 3-4 hours.

--The suture line of animals undergoing surgery should be examined b.i.d.

Urinary Incontinence

Bowel Incontinence

Reduced Mobility

--Depending on the location and extent of spinal cord damage, mobility impairment can range from reluctance to ambulate to paralysis. Patient interventions selected by the technician will reflect patient need and the veterinarian's orders.

--Extreme care should be taken when moving patients with spinal cord injuries. Stabilization of the spinal cord to prevent further trauma is of utmost importance. Animals should be moved using a firm, flat surface such as plywood or a stretcher.

--Animals with Type I IVDD may suffer from permanent hind limb paralysis. Mobility carts have been specifically developed for these animals.

--Cage rest: Exercise restriction is critical for spinal cord repair. Cage rest can be combined with surgical intervention or used as a primary medical intervention. Animals must be confined in close quarters to restrict movement. Thus, cages are preferred over runs as a method of confinement. If able to ambulate, animals should remain on a leash at all times when brought outside to urinate or defecate. A harness or another alternative to a collar should be used on animals affected in the cervical area.

--Physical therapy such as passive and active ROM exercises and hydrotherapy is of benefit. IVDD patients typically experience a loss of muscle mass, which further increases susceptibility to pressure sores. Passive manipulation of joints is recommended 4-6 times per day to prevent joint contracture. Therapy should be initiated 2 weeks postoperatively.

Self-Care Deficit

--Paretic animals are unable to maintain normal hygiene and often require assistance with feeding and grooming.

Meningitis

Meningitis is an inflammation of the meninges covering the brain or spinal column. This condition often accompanies encephalitis or inflammation of the brain. Simultaneous occurrence of the two conditions is termed meningoencephalitis. Bacterial, viral, fungal, parasitic, rickettsial, and protozoal causes of meningitis are seen. Clinical signs associated with this condition include pain; fever; cervical hyperesthesia; and an altered state of consciousness such as stupor or depression, incoordination, seizures, and muscle rigidity.

--Diagnostic Tests: Physical examination, CSF culture and analysis, CBC, serum chemistry, and radiographs.

--Potential Treatments: Antibiotics, antivirals, antifungals, antiinflammatories (steroidal and nonsteroidal) supportive fluids, and nutrition.

Technician evaluations commonly associated with this medical condition:

Hyperthermia

--Elevations in body temperature can result from the body's response to infectious agents, seizure activity, or muscle fasciculations.

Risk of Infection Transmission

--Animals suffering from meningitis should be isolated until the risk of transmission has been determined.

Self-Care Deficit

--Meningitis often renders animals incapable of performing basic grooming and other self-care needs. Food and water consumption should be closely monitored.

Acute Pain

--Cervical pain is most common.

Altered Mentation

--Mentation alterations can include varying degrees such as depression, overt stupor, or coma. Supportive measures will reflect the severity of altered mentation. Intravenous fluids and TPN may be warranted.

Osteomyelitis

Osteomyelitis is an infection and inflammation of the cortex, medulla, or periosteum of bone. Orthopedic surgery, bone exposure, or penetrating injuries typically precede this condition. Bacteria most commonly associated with osteomyelitis include Staphylococcus, Streptococcus, and Escherichia coli. Coccidioides, Blastomyces, and Histoplasma are frequently implicated in fungally induced infections. Clinical signs associated with osteomyelitis can include lameness, pain, swelling of the affected area, draining tracts, fever, anorexia, and depression.

--Diagnostic Tests: Radiographs, culture, fine needle aspirates, cytology, and CBC.

--Potential Treatments: Surgical intervention (debridement, bone grafts, sequestrum removal, and implant removal). Medical therapy: antibiotics, anti-inflammatories, and analgesics.

Technician evaluations commonly associated with this medical condition:

Acute Pain or Chronic Pain

--Osteomyelitis can be difficult to resolve. Chronic pain is associated with infections requiring months of treatment. Chronic infections are associated with a very poor prognosis.

Hyperthermia

--Hyperthermia occurs secondary to infection.

Altered Tissue Integrity

--Infections may track to the dermal surface, resulting in localized heat, swelling, redness, or discharge of infection.

Decreased Tissue Perfusion

--The inflammatory reaction with associated tissue destruction, edema, and loss of vascular integrity results in loss of adequate perfusion.

Underweight

--Anorexia secondary to pain can lead to weight loss.

Reduced Mobility

--Varying degrees of lameness are noted.

Self-Inflicted Injury

--Animals often chew or repetitively lick at the affected area.

Panosteitis

Panosteitis is a self-limiting condition affecting young large-breed dogs. It is characterized by shifting leg lameness with dogs showing a marked pain response upon palpation of long bones. Bones most frequently affected include the humerus, radius, ulna, femur, and tibia. In addition to lameness, dogs can exhibit anorexia, fever, and lethargy during acute episodes. The cause of this disease is unknown.

--Diagnostic Tests: Physical examination and radiographs.

--Potential Treatments: Symptomatic treatment, NSAIDS, and steroids.

Technician evaluations commonly associated with this medical condition:

Acute Pain

--Exercise restriction should be implemented during painful episodes. NSAIDs are frequently used to control pain. Nonpharmaceutical measures also should be implemented.

Client Knowledge Deficit

--Caution must be exercised in selecting the appropriate diet for young large-breed dogs. Rapid bone growth may trigger episodes of this condition; therefore, dogs must be maintained on an appropriate ration that encourages an acceptable rate of gain. Suitable diets are commercially available through Hill's, Iams, Purina, and Eukanuba. Inform owners that free-choice feeding a growth diet is medically contraindicated. Owners also should be discouraged from adding vitamin and mineral supplements to balanced diets. Animals experiencing anorexia during acute episodes can be encouraged to eat via warming food or switching to a canned form of the selected diet.

Fever

--Mild elevations in temperature company this condition.

Seizures

Also termed convulsions and epilepsy, seizures result from abnormal brain activity. The condition is divided into three distinct periods: preictal (period just prior to), ictus (actual seizure), and postictal (period immediately after). The type of seizure, which can be described as grand mal, petit mal, focal, partial, generalized, or tetanic, reflects the underlying cause. Seizures may be congenital or acquired in origin. Some of the numerous diseases/disorders that incite seizures include hydrocephalus, bacterial or viral encephalitis, idiopathic epilepsy, hepatic encephalopathy, hypoglycemia, lysosomal storage diseases, cerebral abscess, trauma, and intoxications. Clinical signs associated with this condition include the following:

* Preictal: acting nervous, pacing, whining, and hiding

* Ictus: stiffness, muscle spasm, paddling, vocalization, defecation, urination, salivation, and jaw chomping

* Postictal: weakness, blindness, depression, nervousness, and pacing

--Diagnostic Tests: Extremely variable depending on inciting cause. CBC, serum chemistry, CSF analysis, serology, toxicology tests, radiographs, myelogram, MRI, and CT.

--Potential Treatments: Extremely variable depending on inciting cause. Anticonvulsants, surgery, specific intoxication therapies, antibiotics, antiparasitics, and IV fluids.

Technician evaluations commonly associated with this medical condition:

Altered Mentation

Client Knowledge Deficit

--Animals may suffer a seizure when the owner is not home. Instruct owners to look for evidence of seizure activity such as disturbed furniture, urine or feces on floor, and unexplained cuts or bruises on the animal.

--Treatment of some conditions such as idiopathic epilepsy necessitate long-term use of anticonvulsants. Ensure adequate client education regarding importance of following treatment protocol, signs of toxicity, drug interactions, and need to prevent inadvertent human ingestion.

--Animals receiving anticonvulsant therapy should avoid swimming.

Hyperthermia

--Seizure activity can induce severe hyperthermia secondary to muscle activity.

Hypovolemia

Risk of Aspiration

--Never administer oral medication to animals experiencing seizure activity.

Anxiety

--Petting the animal and providing reassurance can reduce the animal's anxiety during the pre-and postictal periods.

Inappropriate Elimination

--Urinary elimination occurs during the actual seizure. Once control of the seizure is obtained, the inappropriate elimination will resolve.

CONDITIONS INVOLVING THE INTEGUMENT AND SPECIAL SENSES

Conjunctivitis

Conjunctivitis, an inflammation of the conjunctiva, is a clinical sign associated with many ocular diseases. It is characterized by hyperemia, erythema, and ocular discharge. Corneal ulceration, bacterial infections, viral infections, foreign bodies, allergies, keratoconjunctivitis sicca, distichiasis, entropion, and ectropion can all be associated with conjunctivitis.

--Diagnostic Tests: Schirmer's test, fluorescence stain, ocular culture, and serology.

--Potential Treatments: Extremely variable depending on inciting cause.

Technician evaluations commonly associated with this medical condition:

Impaired Tissue Integrity

--Monitor and record degree of hyperemia and ocular discharge.

Acute Pain

--The majority of diseases associated with conjunctivitis also cause a significant amount of ocular pain.

Self-Inflicted Injury

--Ocular pain and irritation can induce self-trauma. E-collars may be necessary to prevent the animal from rubbing its eye.

Risk of Infection

--Conjunctivitis associated with corneal ulceration should be monitored closely for secondary bacterial infection.

Corneal Ulceration

Corneal ulceration is a clinical sign associated with many ocular conditions. Trauma; foreign bodies; distichia; keratoconjunctivitis sicca; entropion; and mycotic, viral, and bacterial infection can all be associated with corneal ulceration. This clinical sign is characterized by ocular pain, blepharospasm, epiphora, and photophobia.

--Diagnostic Tests: Physical examination, fluorescence stain, Schirmer's test, and culture.

--Potential Treatments: Extremely variable depending on inciting cause. Can include surgery, third eyelid flap, tarsorrhaphy, topical or subcon-junctival antibiotics, and other symptomatic treatment as required.

Technician evaluations commonly associated with this medical condition:

Risk of Infection

--Corneal ulceration should be monitored closely for secondary bacterial infection.

Impaired Tissue Integrity

--Antibiotics or other topical medication is often applied to the eye to minimize the adverse effects caused by loss of integrity.

Acute Pain

--Ulceration is an extremely painful condition. Face rubbing is the most common indicator of ocular pain.

Aggression

--Some animals may become aggressive secondary to ocular pain. Exercise caution when examining or applying medication.

Self-Inflicted Injury

--E-collars can be used to minimize self-inflicted injury. Risk for Altered Sensory Perception

Entropion and Ectropion

Rolling of the eyelid margin can occur as an inversion (entropion) or an eversion (ectropion). The outward roll, or everting margin, of ectropion often gives dogs a "sad hound dog" appearance. Clinical signs associated with both conditions can include epiphora, blepharospasm, corneal ulceration, conjunctivitis, face rubbing, and photophobia.

--Diagnostic Tests: Physical examination and fluorescence stain.

--Potential Treatments: Surgical correction and symptomatic treatment of associated clinical signs (intraocular antibiotics or steroids).

Technician evaluations commonly associated with this medical condition:

Risk of Infection

--Chronic irritation of the conjunctiva and corneal surfaces leaves the eye susceptible to secondary bacterial infection.

Impaired Tissue Integrity

--Ulceration of the corneal surface from hair (entropion) or foreign material (ectropion) is common. Antibiotics or other topical medication is often applied to the eye to minimize the adverse effects caused by loss of integrity.

Acute Pain

--Entropion is an extremely painful condition. Ectropion can be associated with pain if foreign material enters the eye. Face rubbing or head pressing are the most common indicators of ocular pain.

Aggression

--Some animals may become aggressive secondary to ocular pain. Exercise caution when examining or applying medication to the ocular area.

Self-Inflicted Injury

--Excessive face rubbing can worsen both conditions. Use of an E-collar is highly recommended postoperatively for animals undergoing surgical correction.
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Publication:Patient Assessment, Intervention and Documentation for the Veterinary Technician
Date:Jan 1, 2009
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