Proceedings of the 33rd World Small Animal Veterinary Congress

Transcription

1 Proceedings of the 33rd World Small Animal Veterinary Congress Dublin, Ireland Next WSAVA Congress : Reprinted in IVIS with the permission of the Congress Organizers

2 27 Vet Nurse Stream Adva n c e s in t h e d e l i v e ry o f p r a c t i c a l n u r s i n g c a r e - p r a c t i c a l e x a m p l e s Hilary A Orpet BSc, DipAVN (surgical), Cert Ed, FHEA, DipCABT, RVN Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Herts AL9 7TA, UK The application of a nursing model is often explained best when worked examples are used, illustrating the process through which the nurse structures the care required by the individual patient. It is essential that nurses have a good understanding of the concept of holistic nursing and fortunately, the underlying principles form the basis of care already delivered by compassionate and conscientious nurses. Central to the many nursing models is the initial assessment of the patient. This provides specific information about the needs of the individual. From the information gained by a thorough assessment, problems can be identified and nursing care can be planned. Models of nursing There are many models of nursing that can be used or adapted to inform the practice of nursing. Unfortunately they are based on the nursing care of humans. Roper, Logan & Tierney s This model is based on the 12 activities of living - the essential requirements for being a healthy human. The patient is assessed against the 12 activities; the nurse decides through the assessment whether the patient is able to independently carry out the activity or whether nursing care is required. This model has been adapted to be used with animals as the assessment of the 12 activities mostly relates to assessment of veterinary patient needs. Orem s model of self care This can also be adapted to a certain extent for veterinary patients (Figure 1). The model focuses on the assessment of the patient s ability to self care. Similar to RLT s activities of living, there are 8 self care requisites - what can the patient do for themselves and what do they need help with or care from the nurse. Often the ability of the patient is affected by the illness or health deficit. The self care deficits are identified and a care plan is drawn up. The Orpet & Jeffery ability model From working with, and adapting the current human nursing models, it became apparent that a model that focused on veterinary care was needed. The work of Roper, Logan, Tierney and Orem influenced the creation of this model. The assessment phase is structured around the abilities of the animal. What is the animal able to do or not do by itself? Ten abilities were selected as the basic requirements for a animal to function, being able to eat, drink and eliminate but also to express normal behaviour. Cultural Financial Owner compliance irth s the animal able to Eat rink rinate efecate reathe normally Maintain body temp Groom & clean itelf Sleep & rest ade uately E press normal behaviour ifespan Figure 1: Orpet & Jeffery Ability Model 2007 eath Application of the model The care of a patient starts when the animal enters the practice, usually with its owner. If the animal is to be admitted, there are certain questions that are required to ensure the correct information is obtained. Most of these are covered during the completion of the consent form or from consultation with the veterinary surgeon, but is that enough information? We constantly take measurements of our patients; temperature, respiration rate, oxygen saturation, and evaluate organ function through measurements of electrolytes, enzymes etc. in the blood. These values are useless unless we know what normal values should be. This should also go for the nursing care for our patients - do you know what the animal s normal routine is? In order to illustrate this model, a worked example is given below based on the following patient. Kitty Kent is an 18 month old female (spayed) domestic short hair cat. She underwent surgery to repair a fractured jaw following a road traffic incident. Due the nature and extent of the injury she will be tube fed via a percutaneous endoscopic gastrostomy (PEG) tube. She is tolerating this well; however, she is a thin cat anyway and observation of weight is necessary. Kitty s owner wishes to be involved fully in all aspects of the cat s care and stays in a campervan in the practice car park! Assessment Initial assessment of the patient can take the form of a questionnaire that the owner completes before or during the admission of their animal (Figure 2). On 656 WSAVA / FECAVA Programme 2008

3 Vet Nurse Stream 27 PATIENT ASSESSMENT FORM Date of Admission: Date of nursing assessment: Case No Patient Name: Kitty Breed : DSH Sex : FN Owner Kent Address Contact No. Clinical summary: (reason for admission) Fractured jaw following road traffic accident PEG tube placed for assisted feeding Previous history (surgery, disease, vaccination status, allergies) Fully vacc. Booster due Oct 08 Neutered july 07 T 37 C Owners perception of problem: Injury to face and jaw - unable to eat P 150 R 20 MM pale pink CRT <2secs Current medication Analgesia prn (prescribed by VS) Wt. 4.7kg Life stage: Age:18mths neonate adult geriatric Assessment of patients abilities Usual routine Actual Problem Potential Problem Long Term Goal 1. eat adequate amount Eats 1 sachet 2x daily Unable to eat due to injury Wt loss 2. drink adequate amounts ~200ml/day Unable to drink dehydration Maintain weight 3. urinate normally outside reduced 4. defecate normally outside reduced constipation 5. breathe normally No problems 6. maintain body temp No problems -sleeps on boiler Dried blood around nose Normothermia maintained since recovery from GA 7. groom itself Owner grooms occasionally Unable to groom due to injury Matted coat. Poor coat condition 8. mobilise adequately No problems None 9. sleep/rest No probs - indoors mostly 10. express normal behaviour Plays with toys Should be normal if breathing clear Buster collar and abdominal bandage may reduce movement & play Pain Boredom Figure 2: Patient assessment form WSAVA / FECAVA Programme

4 27 Vet Nurse Stream Patient Name: Kitty Date: Problem Short term Goal Nursing intervention Reassess/ evaluation Review time/date Unable to eat Maintain fluid status Calculate fluid requirements and monitor IVFT administration Monitor hydration status Monitor weight Unable to drink Maintain fluid intake Continue IVFT as above Assess hydration unable to groom Maintain coat condition Groom with cat comb x2 daily Wipe discharges from face No matts develop and coat condition maintained Normal behaviour affected by condition and Buster collar Encourage as far as possible normal behaviour Regular contact with nursing staff not just when feeding or medicating. Assess pain relief requirements Monitor temperament regularly Unable to eat / drink Maintain weight & hydration status Calculate 1/3 food requirements to feed by tube Ensure no problems occur whilst tube feeding Figure 3: Care plan occasions, however, the first time that information may be obtained from the owner may be after the initial stabilisation of the animal, as in the case above. To guide the assessment the 10 abilities may be used as a checklist to ensure a complete assessment. The types of questions used are important, to elicit enough information and to encourage the owner to expand their answers in order to get as much information about the animal s normal routine as possible. For example: Does your pet eat adequately? would probably result in a yes/ no answer. However What does your pet normally eat, how much and at what times will hopefully give a better picture of the animal s normal eating habits. Of course finding out the animal s favourite food is important when tempting the inappetent animal. The next stage is the nursing assessment of what the animal can or cannot do now it has been admitted. Again this is using the same checklist of 10 abilities from the model. Transfer the information obtained to the nursing assessment form. If the questionnaire can be given prior to the admission, this gives clients an opportunity to think clearly about their answers. It gives a good impression to the client and they often feel that the practice values their pet and the care given to them. The Care Plan From the information gained from the assessment, various problems have been identified. It is important to also consider potential problems that may occur so they can be prevented. This stage is useful in informing students or less experienced nurses. The nursing care required is then based on the problems identified from the assessment (Figure 3). Implementing the care Detail in the care plan is important, everyone needs to know exactly what the nursing intervention is and how often, or how much is required. The decision on the nursing intervention is guided by the goal to be achieved. Setting goals is important to validate the nursing decision made and also to measure the outcomes of the nursing intervention. Evaluation In order to evaluate effectively, the assessment should be carried out again. From each of the 10 abilities, assess what the animal can now do or still not do by itself. Hopefully the nursing interventions have worked and the animal is now more able than when admitted. If not, it will be necessary to look again at the care given and adjust the plan as necessary. Influencing factors The assessment and consequent nursing care that is carried out may be affected by other factors. The life stage of the animal is an important factor to consider - neonates are unable to feed, drink, keep warm, mobilise by themselves and this is when they are healthy. Geriatrics may have their senses affected purely by the fact they are old. Mobility may be decreased due to joint pain, muscle stiffness etc. Cultural and financial influences Cultural differences may affect the care given to the animal. What role does the pet play in the owner s life - working dog? Only companion? Breeding animal? Intensive palliative care may be required if the owner s beliefs prevent the animal from being euthanased. 658 WSAVA / FECAVA Programme 2008

5 Vet Nurse Stream 27 There may be financial implications that prevent the care that the animal requires taking place. What alternatives are there? Working with the owner, the nurse may be able to teach basic care techniques or rehabilitation methods when perhaps full physiotherapy and hydrotherapy is prohibitively expensive for the client. Summary Nursing involves not only caring for your patient but liaising with the owner regarding the nursing care given. The nurse s role is invaluable in maintaining the communication between the client and the practice. Once the animal goes home, the care continues and the nurse needs to ensure the owner is able to administer, and is also compliant in administering the care required. Alternative solutions to a problem may be required and built into the care plan. The influencing factors should always be considered when creating the care plan for the animal and adjustments made appropriately. The templates can be adapted for use in the practice, the idea is to ensure the nursing care is structured and documented and useable for everyone involved in the care of the patient. References 1. Orpet & Jeffery (2006) Moving towards a more holistic approach. VNJournal vol 26 no.5 May Jeffery (2006) Moving Away from the medical model VN Journal vol.21 no.9 September Joiner. T.2000 An holistic approach to nursing. Veterinary Nursing Volume 15 No 4 July Davis, S (2006) Model Answer? Using nursing plans in veterinary pactice. VNTimes p4 vol 6 no.7 5. Peate, I (2006) ed. The compendium of Clinical Skills for student nurses. Whurr. 6. Aggleton & Chalmers (2000) 2nd ed Nursing Models & Nursing Practice. Palgrave 7. Roper, Logan, Tierney (2000) The Roper, Logan and Tierney Model of Nursing. Churchill Livingstone. 8. Holland (2003) Applying the Roper-Logan-Tierney Model in Practice: Elements of Nursing. Churchill Livingstone 9. Pearson, Vaughan & Fitzgerald (2004) Nursing Models for Practice. Butterworth-Heinmann 10. Walsh, M (1997) Models and Critical Pathways in Clinical Nursing: Conceptual Frameworks for Care Planning. Balliere Tindall 11. Kratz, C (1979) The Nursing Process. Balliere Tindall WSAVA / FECAVA Programme