Thank you very much. Welcome back, everybody. So, as you said, this is gonna be a session looking at recumbent patient care.
And for me, a lot of this is gonna go hand in hand with, with some of the stuff that I talked about with geriatric patients. But these patients can really be quite complicated, not just because they are recumbent, but they've obvious, a lot of the time really got a lot going on with them and a lot of things wrong with them. We had a dog that was in with us a couple of months ago, who was a newly diagnosed diabetic that presented with, DKA.
The dog had also had some episodes of vomiting. He had an aspiration pneumonia as a result of it. We were also concerned that he had, acute kidney injury and this dog was completely untuned, he wasn't moving and just had So much going wrong with him.
The nurses, I think most of the nurses were amazed that he actually ever made it home again, but he was a great nursing case cause he was so complex, so complicated. And as nurses, it allowed us to do exactly what we love doing, which was really good nursing care of that patient. So, I do enjoy dealing with these patients.
So, a definition of a recumbent patient, this is my old mastiff. Again, I had a pretty rough year. I lost both my dogs last year.
He spent most of his time lying down on the sofa. I have to say that my new dog is not really much better. He has never slept in a dog bed yet, but that's fine.
I'm his 3rd home, so he kind of gets to do whatever makes him happy. So, the definition of recumbent patient is an animal that is lying down, unable to rise. And if you think about those patients, They, again, we talked about self-care deficits in the previous session.
These animals need us to do for them what they can't do for themselves, what they would do normally. And there are numerous reasons why patients are going to be recumbent. They can have generalised weakness because they're old, because they've got an underlying disease process, because they're hypoglycemic.
You know, whatever's going on, we can see it because associated with snake bites in different countries, so more, not particularly the UK but Australia, places like that. Because they're painful, because if they sustain some sort of trauma, things like neurological disorders, or for hydrogenic reasons, if we give, use epidurals on patients, they're not going to be able to get up and move around for a period of time, or we may have, you know, we may be have these patients on propofol CRIs because of a toxicity, and they're, in effect, anaesthetized and therefore recumbent for long periods of time. And there are all sorts of things that we need to consider with these patients.
They're multi factual, you know, the cardiovascular effects of, of being recumbent, the respiratory effects. Think about good nursing care, bedding, positioning, turning of these patients. Think about urinary and faecal care.
If we can't get these patients up and out, how we gonna manage that? Often overlook things like eye care and oral care, we often don't think about. Analgesia, I banged on about this in that that geriatric session.
But again, just being recumbent, if you've ever lied in bed with, you know, whatever illness, you know that you get really uncomfortable just from lying there. Think about how drug interactions can change, thinking about metabolism of patients, their hydration requirements, and how we're going to get food into them. Behavioural psychological effects.
Thinking about getting early physiotherapy. We want to get these patients up and back to normal as soon as we possibly can do, so we want to try and maintain mobility as much as is possible in these patients. And overall, again, good nursing care, TLC.
So For all of our, our patients in our hospital, we will have a discussion right at we do basically a changeover at the beginning of the day, and we do ward rounds, and we will talk to the vet that's dealing with that patient about what our concerns are, what we think is important in terms of nursing care plans for that patient, and discuss it with them, making sure they're happy, checking if there's anything else that they want to have it add in. And when we put it together that nursing care plan, we think about the whole of that patient. We think about everything that's going wrong, everything that patient can't do, and what do we need to do for it.
And with those recumbent patients, as we mentioned, they've got many more possible complications and many more aspects to the nursing care that we need to really think carefully about. We'll put that plan, that pain plan, that, that nursing care plan together for that individual patient, but it's gonna be changed at least once a day. If not more often, depending on how that patient changes throughout the course of the day.
And as I said, we will discuss with the vet that's dealing with that patient that's in charge of that case, what our, what we are thinking about doing and make sure that they're entirely happy with it. As I said, we can see cardiovascular changes. This happens because we get, a lack of movement, from a reduction of blood flow to and from the periphery.
So often, we've all probably seen, been there when you see these recumbent patients. Peripheral edoema, really, really common in these patients. They're not moving around as normally.
They don't not got normal blood flow. So they start to get these really edematous red limbs. We want to try and stop that happening in the first place, cause when it happens, it's really difficult to get rid of.
Cold extremities, you only, if you lie with one arm out for a long period of time in an awkward position, your hand gets really, really cold and gets really painful and crampy. Same's gonna happen to our patients. We may well see things like pulse deficits.
We, we can, our heart rate and our pulse rate are not necessarily the same. And as we said, we get altered responses to pain. If you are just lie there, lying there and you've got something painful, you know, it's all you can think about.
Yeah? You, I'm not saying this helps, but, you know, when women are in labour, they will move around more. They will do things to create a distraction from that pain.
I'm not saying that it's that much of a distraction when you're in labour. But we do do these things to distract from pain. If you're just lying there, That can, that, those painful things can become much more exaggerated.
So again, these are things we want to consider. So our patients, we, at least every 4 hours, check patients' heart rates, we will auscultate their hearts, we will palpate the femoral pulse. We'll check if we've got a peripheral pulse, making sure our heart rate and our pulse rate match each other.
We'll look at those perfusion parameters, we'll look at some higher hydration parameters. So we'll look at mucous membrane colour, capillary refill time, we'll look at moistness of those mucous membranes to give us indications about perfusion. So mucous membrane colour, refill time will tell us about perfusion.
Hydration and we'll look at how, how moist or how dry that patient's mucous membranes are. At least every 12 to 24 hours, depending on that individual patient, we would get a blood pressure. When we take blood pressure, and this is using osci this is using indirect blood pressure monitoring.
So either Doppler or osciometric, we will take at least 3 readings. We'll take one reading, we disregard that, then we'll take another 3 regions and we use the average of those. We make sure we use the same machine on the patient.
We use the same blood pressure cuff. We note the position that we had that patient in. We know what limb we use so that we're getting consistency.
And what we're ultimately looking for in those patients is looking at trends in blood pressure reading. For some patients, they're gonna be having blood pressure measured more regularly. Again, depending on the reason why they are recumbent, what we don't do is leave that blood pressure cuff on that patient.
It's, you know, it can cause pressure sores, all different sorts of things. It's uncomfortable as well. So we make sure we take it off in between time.
We would at least daily check an ECG on that patient again, for some animals, if we know they've got an arrhythmia. We're more likely to be doing it continuously, but certainly, you know, things like toxicity patients, electrolyte, abnormal with patients with electro electrolyte abnormalities, septic patients, we will be doing it more regularly or Potentially continuously, certainly, we know that patient has got an arrhythmia. Lung function, we also want to, consider really carefully in these recumbent patients.
The purpose of our respiratory system is to allow gas exchange, so allowing air distribution within the lung globes to match the perfusion of the body's tissues. And if we have these patients in abnormal positions, so particularly if we've got recumbent patients, particularly if they're latter recumbent, laterally recumbent patients, this will, what we call alter the biomechanical homeostasis. OK.
So, it will alter the way those lungs function. And this is why, you know, particularly things like positioning and turning of these patients and all those nursing interventions is really, really important. In humans, you know, turning patients in different positions and providing physical therapies are highly recommended.
And in humans, you know, they do lots of respiratory physiotherapy. For them, it's cost effective. It's been proven to improve residual function.
So the air left in, like, the, the, the, the volume of air within your lungs. In humans, it reduces the need for future, hospital admissions as well and it improves quality of life. So, maintaining normal lung function is really, really important in patients.
Ultimately, what this means, and we'll, I'll talk about positioning and, and posturing as well in a second. But for me, getting some early respiratory physiotherapy with these recumbent patients is really, really important. You know, it restores respiratory function.
In humans, it reduces dependency on ventilators. In humans, it reduces the risk of bed rest complications as well. And those postural changes, just moving these patients can actually help reduce the risks of other other disease process.
So it can reduce the incidence of pneumonia. It can reduce the incidence of consolidation of lung low. So I talked in the previous session about a lectosis.
So atelectasis is where you get a collapsed area of lung. So if you're recumbent for long periods of time, normally the underlying lung lobe is going to get squashed over that period of time. It happens as well as things like diaphragmatic ruptures, where you've got other things in that chest that shouldn't be there.
They're squashing lungs. So we get these collapsed bits of lung, which actually aren't contributing to respiratory function as well. And we really want to avoid this from happening.
So respiratory physiotherapy really a bit is about getting these patients to take normal breaths in and actually, if they, we, we have got patients where they have got respiratory abnormalities, is trying to maintain things like cough reflexes. If you get a reduced cough reflex, we can get further problems. We can get mucus plug formation, we get sputum retention.
They're at higher risk of infections, they can get what we call absorption ator ectasis, and they overall get reduced lung, reduced lung function. So trying to maintain these normals is really important. The other thing is, we want to maintain vital capacity.
We want to try and maintain normal lung function, normal tidal volume in these patients, because if they're not getting up and not moving around, they're just not taking normal breaths in. Yeah? Ultimately, what we want to try and do is exercise these patients.
I'm not talking, talking about taking from a walk around the block or throwing balls for them. But for me, if I've got a requirement patient, even just getting them to stand up, even if you just stand up, You take much more of a normal breath in, it maintains normal tidal volume. And for me, trying to do that regularly with my patients is really, really important, because we're gonna get them back to normal.
And, you know, it can, we're thinking about respiratory function and, you know, maintaining oxygenation in these patients. It's so important. If that doesn't happen, things can start to go wrong.
Also, making sure that they've got that effective cough as well. Coughing's really important. They always say, better out than in, in everything.
So in terms of monitoring these patients, we're gonna look at respiratory efforts. So I'm looking at my respiratory rates. Sorry, yeah, your respiratory rates, how much effort they're making and want to regularly auscultate lung sounds, you know, particularly, you know, if we're concerned about things like pneumonias, think, particularly if we're concerned about things like pulmonary edoema.
Pulse oximetry, I mentioned in previous session. If these patients, if we are concerned about lung function, pulse oximetry can be really, really useful. We could use blood gases.
But the reality is, you know, one blood gas on its own is not particularly useful. You have to take serial ones, and we're probably not likely to do that, and most of us probably don't have the capacity to measure arterial blood gases. And if we're looking at oxygenation.
It has to be arterial, which makes it even more complicated. So, pulse oximetry is really, really useful. And for me, if I've got patients that are on oxygen therapy, it helps me titrate that to effect.
I don't want patients to be on more oxygen than they need to be because oxygen's a drug, and we can start to get oxygen toxicity if they're on really high levels for long periods of time, which can give us further problems. So, I really use pulse oximetry to, to, to give that patient just the amount of oxygen that they need. Lung position and I've kind of mentioned, we can see a lexuss, so collapse down of that lung if that patient's in lateral recumbency for long periods of time.
Also, when we do position, reposition patients, I'm really careful, particularly if we know that they've got a leis or a degree of leis. So we will normally go from one lateral, like, so say left lateral to sternal to right lateral to sternal. If we can't keep that patient external recumbency all the time, just because if we could turn them from left to right or sometimes they can kind of decompensate a little bit if they've already got respiratory problems.
Wherever I can do, I will keep these patients in sternal recumbency that allows us to ventilate all the all the alveoli as much as possible. But if not, we will turn every 2 to 4 hours and record that on hospital sheets. Even if we could only keep the thorax external and we rotate the hind limbs, trying to make, maintain sternal recumbency as much as possible is the ideal.
As I said, our big concern is at ectasis. So it's a major complication of prolonged immobility. So prolonged recumbency and anaesthesia related, we can see anaesthesia related at a leis as well, because again, we don't have normal tidal volume, you know, it's going to be reduced significantly with patients under anaesthesia.
So we get collapse of the alveoli, secondary to absorption of gas into the bloodstream. And it happens because we get that mechanical compression of the lung. So we've got the weight of the non-dependent lung squashing that lower lung.
We can also see it because we've got airway obstruction. We can also see it when we get repetitive collapse and re-expansion of lungs when breathing. And the effects that we see from a lysis or we can see a hypoxemia, so low oxygen levels in our tissues.
Mention this in the previous session, ventilation perfusion mismatch. Bits of lung that are receiving oxygen, but not blood flow, they're not perfused, and vice versa, bits of blood that are, I've got blood flow, but they're not getting oxygen to them because of that collapse down. These patients, if we do have a lexis, as we said, are gonna have increased oxygen requirements and we don't want to give them more than they need because they can start to get oxygen toxicity.
If you've got patients on high inspired oxygen concentrations for long periods of time. We'll start to get oxygen toxicity. And another big concern is re-expansion pulmon edoema.
If you've had bits of lungs that are collapsed for long periods of time. And you rapidly expand that lungs, you can get this re-expansion formmon edoema. It's very common in cats that have had diaphragmatic hernias, and have gone to surgery, and we give them a big breath at the end of that procedure.
This is why we re-expand, we drain chests much more slowly, and we don't give them big, big, big breaths now in these diaphragmatic rupture patients when we know that it's happened for long periods of time, because ultimately, we can give these patients further problems and end up killing them if we're not, if we're not careful. So in terms of treatments, we think about predisposition. So again, we're planning, we know this is likely to happen, so that's why we turn these patients, we think about positioning them, careful administration of oxygen if needed.
We may end up, you know, in certain situations going into positive pressure ventilation. We can look at other techniques like nebulization. I'm going to talk about more about physiotherapy in a second, potentially chest percussion, so coupage.
If these patients were on things like ventilators, we'd look at ET tube suctioning, or if you've got these patients indicate intubated as well. And we may ultimately look at using some sort of drug therapy, so things like bronchodilators, antibiotics, muco active agents. We try to avoid this as much as we can do.
But sometimes, you know, if you've got particularly things like aspiration pneumonias, these patients are likely to be, well, they will be on antibiotics. So in terms of postural alterations, as we, a lot of this I've said already, altering body position has a really critical effect on oxygenation. These patients need to be in a normal position to be able to have a normal tidal volume to breathe normally.
And so, positioning these patients and turning them regularly is really important because it'll help reduce the incidence of nosocomial pneumonias, and that's proven in human patients as well. If we can get them kind of even semi-recumbent, so sometimes, and it's not so easy for us kind of positioning, so they are like head higher up, things like that, they can improve oxygenation. That's not always going to be.
Possible for our patients, but we may be able to adapt our kennels, you know, put in mattresses, lifting them up a little bit, things like that, because, you know, we can take some weight off that diaphragm as well, that will help these patients to allow to ventilate more normally. And so really thinking about how we position, how we push to these patients will reduce the risk and the incidence of decubital ulcers, of limb contraction, of secondary problems, things like edoema, also things like urine scaling and faecal soiling as well. So, really, really, these are big considerations.
I mentioned nebuization. This is something that I'm a big fan of as part of respiratory therapy as well. So, as we said, particularly that little dog that we had, particularly if you've got patients that have got airway diseases.
So pneumonias, even things like cat flu cats. I know they're not necessarily going to be recumbent, but if you inhale these little drops of saline, nebulizers are great because that saline will get really down deeper into the alveoli, and they say that saline helps to, break up disulfide bo bonds in mucus, and in purulent material as well in pneumonia patients. And you will see it makes those secretions much more liquidy.
And that's gonna help get those secretions out. Hydration is also really important in patients that have got respiratory disease. You need to be normally hydrated for your mucociliary escalator to work, and that's important because it will waft all that goo and gunge up out of that patient's always.
They can cough it out. So this is a cat that we had in our incubator, and I'm just gonna play this video. And we just, you know, he tolerated that fairly well.
We would just sit, sit that nebulizer in there and that whole incubator would often fill up with kind of this mist of saline drops that that patient's gonna breathe in. Get them lower down into that patient's airways. So as I said, really important, think about early respiratory therapy in these patients.
It's gonna help mobilise secretions, get them out, it's gonna help to maintain normal tidal volume. As I said, you know, just getting these patients standing up will make them take a normal breath in. We, we, we always used to think about using things like coupon.
Coupage is really kind of gone out of fashion because we think it maybe actually causes more problems than it benefits our patients. So it's not something we commonly do. In humans, they talk about rhythmic shaking.
They, in horses have these big kind of like, I don't know how to describe them, these big, almost like a saddle that goes over. That vibrates. Yeah.
So chest wall and that helps to in particularly things like pneumonia cases is really useful. In humans they're using lots of chest wall vibrations, and you can buy, it sounds like something you would get from on summers, but it honestly isn't. You can buy kind of personal massages that vibrate from like Amazon will sell them and they just create little tiny micro vibrations.
But again, shake that that whole chest walls that probably helps to break up and mobilise secretions that we want to get out. But ultimately, Exercise. Yeah.
We've all been there, haven't we? When you've had a really horrible cold, you can hear that I've still got a little bit of woman flu going, the lingering last bits. But you've all been there when you start to go for a walk after having a really bad cold or a flu, and that helps mobilise all those secretions.
You start coughing like an old person, and it's that exercise, that's increasing tidal volume and helping get all those secretions out. So it's really, really important on our patients. Early mobilisation as much as we can do, even if we've got to help them.
The patients, again, I said we may need to supplement them with some oxygen and how you're going to do that is very much going to depend on what you have in your practise. It's gonna very much depend on how long you think this patient's going to be need to be in for. It's going to depend on.
You know, lots of different factors, but we can look at things if it's gonna be long term things like placing nasal oxygen catheters, using nasal prongs. You can make oxygen hoods if need be, you can make them from bustacles and clingfilms, we can have these patients in little incubators. Very severe cases may end up having to require ventilation, but those are probably going to be very few and far between, and certainly very few of us are going to have the, access to ventilators.
But really keep a close eye on all those recumbent patients. They've all got potential to have respiratory complications and things can start to really go downhill. So, these are one of the things that I think about very early on, in my patients kind of nursing care plans.
In terms of temperature, Keep an eye out for hypo or hyperthermia. If we get patients that are pyreexic can become unusually pyorreexic and we kind of weren't expecting it. We think about, could it be related to a, a, a wound or certainly catheter-related infections are not common on, are not uncommon, you know, bloodstream infections are fairly common in patients as a hospital acquired infection, as are pneumonias, as are urinary tract infections.
So again, these recumbent patients are the ones where they like have these indwelling devices. They're at much higher risk of developing hospital acquired infections. I've not really banged on about it, but hand hygiene is so important in these patients.
Making sure people are Either washing their hands or using hand rubs, things like that at appropriate points in time before they deal with these patients before they deal with any devices and putting plans in place. I've included kind of examples of lots of our SOPs in patients all the way through this. But some of our patients, they may require decreased stimulation.
Certainly, if you've ever seen a tetanus patient, you know, we try to keep them as quiet as possible. So, you know, sleep's really important in these patients and if you work in busy hospitals, our patients often Don't get good quality sleep. So we need to think about, do we need to look at any sort of sedation, particularly patients are getting very stressed out by it, if that's appropriate.
We will make them little earplugs from like cotton wool balls. We try to reduce ambient noise. We actually, in our wards, you can buy, music for cats and music for dogs, and we actually have that playing in our wards.
And the nurses definitely think that it makes those patients less stressed. It's basically classical music playing in the background, but it's just creating that nice calm environment for our patients. And if you can't kind of dim areas of the hospital, if you can't put lights out in certain areas, creating things like eye masks for them.
Just to try and get them to get some good quality sleep. It's so important. Again, I keep talking about women in labour, but, you know, if you ever been on a maternity ward, you become exhausted because there's some baby crying somewhere all the time and you're just not getting that good quality sleep.
Not that you're gonna get good quality sleep for probably about the next 14 years, but, so again, it's really important for our patients. You only care, really important. You know, a lot of our patients will really hold on a lot longer than normal because they can't physically get up, go outside or get into a litter tray, so we need to think about.
How we're gonna be able to provide that for our patients. We don't want them to get to the point where their bladders get so full. We start to get bladder dysfunction and we start to cause further problems.
We don't want them overflowing. So we need to think about, can we get these patients up and take them outside? Do we need to manually express those bladders?
Do they need a urinary catheter placed in? You know, if they really need, not that we really want to randomly place you in a catheters, but if we know these patients are going to be recumbent, and it's gonna be a problem, we would place a urinary catheter. Making sure we do it in an aseptic fashion is an absolute and deal with it aseptically.
And the useful thing is we can measure your output in those patients. You know, for us, we measure fluids in, fluids out for our patients to make sure we're maintaining hydration, and that makes it a little bit easier to do. If we're not able to do that, we can put in continent sheets on patients, we can weigh how much that weighs once it's wet.
We can weigh bedding when it comes out when it's wet. If you can get your patient up and out your weigh your patient before he goes out and weigh when he comes back in, and 1 mal will generally be about 1 gramme. If patients haven't gotten dwelling catheters and they all kind of urinate in their bed and we need to be really careful, making sure they're not get urine stalled in, things like that.
And if they do urinate, you have to wash them and you have to dry them, because otherwise they're gonna get really sore. So, being able to clip them up, been able to use, barrier sprays, so things like Cavallo are really, really useful in those patients if this is likely to be a problem. And also, they've got really bad diarrhoea as well.
It's useful to clip them and put this Cavallo on, it creates a physical barrier. So we would at least express that patient's blood every 4 to 6 hours, potentially more if they're on, on large volumes of fluids. Think about catheterization.
Actually, it's probably better to place an indwelling catheter if we think it's going to require it long term than than inter intermittently placing that catheter. But think about that individual patients. As I said, think about the risk of hospital acquired infections.
They're really at high risk. And the duration of catheterization is probably more important when we're looking at urine tract infections. The longer a catheters in, the higher risk is that that catheter animal's going to get a UTI because basically, bacteria will climb over the surface of that catheter and get into that patient's bladder.
So we've got a higher incidence of bacteria urea as well in those patients. So we have protocols in place, as we said, place them aseptically, make sure we're flushing, flushing prep pieces, make sure we're flushing vulvas before we place them, making sure we're dealing with them aseptically, use collection bags and we wipe down our our administration sets from basically from the patient to the bag every 4 hours using chlorhexidine. Before we empty that that urine collection bag, we wipe the exit port with a spirit so swab.
We empty it, we record the volume, the colour turbidity of the urine. We will measure specific gravity will dipstick it if appropriate. We then close that port on that bag, rewipe it.
And we change that bag every 24 hours, and that will help to reduce bacterial growth. That's really important as well when using old fluid bags. You can use a a fluid bag as I think I had on the previous slide, as long as it's never had glucose containing fluids in it.
What we would also do is make sure that bag, we generally put our bags into ziplock bags. And then they sit in a litter tray with an incontinent sheet and what we don't have these bags lying on the floor, again, bacteria to get onto and climb up. Also, we make sure, I think you can see on this cat, we make sure there's no tension on that catheter as well.
Faecal care, also another important factor, these animals are often on reduced food. They're often on lots of drugs that can reduce gastrointestinal mobility. So we don't have normal GI tract function.
We can get reduced gut barrier function as well. So. As well as listening to chest, I'll listen to abdomens as well, making sure we've got bowel sounds, checking how often patients are passing faeces.
They can become constipated, and that's going to be really uncomfortable as well. So, thinking, do we need to give these patients some sort of enema. On the other hand, if they've got diarrhoea, we will wrap their tail up.
As we said, we will clip them and we'll use these barrier sprays. And if they do get contaminated, we really, we bath them and make sure we dry them as well. If they've got really severe diarrhoea, this is the one ones where they are passing diarrhoea and they are lying it and can't get away with it.
We will use these faecal management systems. So this is a a human faecal management system, so it's only useful for bigger patients, but basically, it's a bit like a big foley catheter that it goes up that patient's rectum and you inflate this kind of balloon on the end with saline. And then it gets collected.
You can see the start of some poo here, which is what you want to see at 9:30 on a Saturday morning. But it collects into this bag, which obviously is disposable. In humans, these are designed to be disposable systems, but actually we clean them when we ethylene oxide them, they're gonna go up a dog's bum, but they're great for those animals.
They're big, they're recumbent. They're producing large amounts of liquid diarrhoea. If you don't have these, or if they're smaller patients, we will use the same with a a big foley catheter.
You can see this dog was just producing water and wasn't getting up and moving away from it. We don't do it routinely and I think we've always got a bit of a concern about kind of getting strictures and things like that. But we do do it in those patients where they, they're producing vast amounts of liquid diarrhoea and they're just gonna line it.
Bedding considerations for the obvious ones. So making sure we've got comfortable, well padded, moisture wing, bedding. We can get bedding that's gonna help with, thermoregulation.
Actually, we had a dog that had a really bad high groma removed, so these big lumps over their elbows, last summer. And actually, what we found, so this dog was a big German shepherd that would just flop down. So even post-surgery, we're having issues with it breaking down.
And they actually use these cool mats that you could buy. And I think the owners bought loads of them from kind of like pound shops or one of these really cheap shop shops, and that worked really well for him. And it was great because it kept him cool as well.
So we want to think about that in our patients. Ffoam wedges, whatever, to try and keep those patients in appropriate positions and make sure we change that bedding regularly. One of the big concerns is these patients developing ocupital ulcers.
So these happen because of constant pressure over points of the patient that have got limited fat or muscle covering that bone. So, that combination of pressure, along with moisture and contamination can happen, particularly in areas such as elbows, carcasses, hops, over the pelvis, much more commonly encountered in large breed dogs because they're so heavy, or chondrodystrophic dogs, those bandy leg dogs. So if you've got patients in that recumbent, particularly if they've got long hair, we want to really go in and check and make sure this isn't becoming a problem.
So looking for pain or swelling or heat or moisture, moisture over a localised spot and trying to, ultimately trying to avoid this happening with appropriate bedding. Treating it before, when we get the first clinical signs is much easier. This is a dog with a cubital ulcer, not that it developed in the hospital.
It came in like that. But these, if these are left to continue, you know, we can really end up with further problems. We can see osteomyelitis, we can get further nerve damage, and if we've got sick patients, you know, we can end up with the death of the patients as a result of these ulcers.
So we really want to avoid them. So treatment's gonna be reducing infection, reducing contamination. Dressing these is a nightmare because when you put a dressing on, they end up moving, you apply, you know, you put pressure on a different point.
So we end up using like these donut bandages or using foam dressings with areas cut out of them. But ultimately really looking at appropriate bedding, trying to put those patients in positions to reduce the pressure off that site and just making sure we don't give them further problems in other locations. Eye care is really important in these patients.
They often may have reduced palpable reflexes. So again, part of the nursing plan, we lubricates every 2 to 4 hours. If we're concerned about tear production, we will show them a tear test these patients every 24 hours to make sure we do, we don't need to add more lubricant in.
Ulcer is always a big concern, particularly in those brackets of ale patients with bulge GI. So in those ones we would fluoresce stain them if we've got any concerns, and it may be something worth doing every 24 hours in patients anyway. And just ultimately administering those drugs really carefully so we don't damage the eyes.
And when we are doing these eye checks, we will look at the position, the pupil size, making sure we've got symmetry of pupils as well, just as kind of our normal check. So this is our protocol that we have. So again, hand hygiene.
So decontaminating our hands before we touch the patient after we've done procedures. After we've potentially become contaminated with mucous membranes or body fluids, after we've finished dealing with the patient, and after we finish dealing with that patient's surroundings. We clean all around the eyes with some saline soaps, gauze really gently, look for signs of chemosis, or swelling of that third eyelid or inflammation.
We'll put our lubricant into each eye, ideally, we have a separate tube for each eye. We would generally in our hospital alternate ointment with artificial eye drops, and then every 24 hours we fluoresce stay in the eyes. As I said, making sure if we have got ulcers, we notice where they are, the size and the depth.
And if we're concerned about dry, we'll share a tear test these patients as well. Oral care is the other thing as well, if these patients are not eating or drinking normally. Their mouths are gonna feel pretty rotten.
Yeah. So we need to do something just to make them feel a little bit better. If they are recumbent and we're concerned about pooling of fluids in their, in their mouths, we will suction them at least every 8 to 4 hours and we'll suction them before we change position.
When we do that oral care, we look at the oral mucosa to make sure there's no ulceration or anything like that. And we will moisten the mouths. We'll give them a wipe out as long as we can safely do so with a really dilute lo hexin solution.
So things like hexarins will dilute down. If they are not swallowing normally, we'll keep their tongue moist with wet swabs. If they've got things like pulse oximeter probes, we reposition those every few hours, so we don't get pressure sores from those.
And we also look for things like regurgitation in patients to make sure it's not happening. So that's pretty much what we said, every 4 to 6 hours, move any gags or swabs or pulse ox probes, check for secretions, for ulcers, for mannulars, know if they are present, suction the mouth and the phynx, wipe everything down with a very dilute 0.05l hexane solution.
We will reposition the tongue. You can also use glycerin soak swabs because they're useful because glycerine doesn't dry out the same way if we use saline or anything like that. Replace those probes, and if we did have patients, as we said, if they had lots of oral secretions, if we saw lots of regurgitation, we would think about placing things like nasogastric tubes or or gastric tubes so we can suction out their stomach contents and stop that from happening.
Analgesia, I think I feel like I've talked lots about having done that last session as well, but we really, when we're thinking about analgesia, think about the cause of that recumbency, making sure we're putting really good pain plans together. If pain is a potential, we, will pain score these patients at least every 4 hours, talk to the vets about pain plans, talk about what we can add in if need be. As I said earlier on, just being recumbent, particularly if they're geriatric patients or big patients can cause these patients to be painful overall.
So again, that's another thing that we really want to factor into patient care. Drug metabolism, so thinking about the drugs that we're using, these patients aren't moving around, so we may not have normal metabolism of these drugs. So, We may need to look at dosages, we may need to look at time and how often we give these drugs to patients.
Again, they may have underlying renal or hepatic dysfunction, so we may not get normal metabolism of those drugs and normal excretion of those drugs. So we're thinking about, especially if they're on things like opioids, are we getting accumulation of these drugs within the body, maintaining hydration really important if patients are dehydrated. That will affect metabolism of the drugs as well.
So, particularly if we're giving patients subcutaneous or iron injections, if you're not getting blood flow to your skin, if you're not getting blood flow to your muscles, then those drugs are not going to be absorbed. Also, you know, if I don't have to inject a patient, I am also cut. If it can go.
IV and we've got an IV line in. I'll give that drug IV because I don't want to go stabbing that patient any more than I have to. But just thinking about all those things that can impact.
If you give a drug subcutaneously, or IM and that patient's dehydrated or hyper, not perfusing the skin on the muscles, it's not going to be absorbed. It's not gonna have the effect that we think. Nutrition, we really want to address early on.
What that a patient requires will depend on that individual patient. What disease is going on, their activity level, if they're recumbent, they're not gonna have much activity. So that's gonna reduce their nutritional requirements.
We need to think about ongoing losses. So patients that have got big wounds, patients that have got effusions, things like that can have big protein losses as well. So we need to factor that in.
Can they even eat? And nutrition is really one of those things that can often get overlooked. For us, we have a rule that the patients go no more than 5 days without eating, and that includes the time that they were anorexic at home as well, if that's a factor.
Getting food into these patients is so important. It helps in terms of wound healing. It's going to help us provide electrolytes, protein, fat, carbohydrates.
Food passing through your GI tract is so important because it maintains health of the mucosa. And the villi and all the cells line in your GI tract. The cells, your GI tract relies on food passing through it to maintain those incytes.
It's really important and we can use it as a, a, a, a way of providing hydration fluids to our patients as well. So Once they're in the hospital, none of our patients go more than 36 hours without having some form of nutrition. So whether it's just placing a nasogastric tube into those patients, or whether we need to look at things like oesophagus and tubes if we know it's going to be longer.
As we said, if we don't have that food passing through that GI tract, the GI, the, the, the villa will start to atrophy and things will really start to go wrong. We then don't have a nice intact, barrier, so we can start to get bacterial translocation and we can get further problems associated with that. Also, as you said, making sure that we keep on top of things like protein.
If we start to get protein imbalances, we can start to see, immunocompromised patients. They will start to lose muscle. You need protein to maintain muscle.
We'll start to get, organ, atrophy or dysfunction, and we can get GI motility and atrophy as well. So it's really important we address nutrition earlier on. In nutrition is best, in the majority of patients, and we want to use as much of the GI tract as we possibly can do for those reasons I've just said, it reduces atrophy, it maintainsenty health.
It helps to increase nutritional absorption capacity. So it's really important. If patients are able to eat, you know, we We will, we will, will do so, but we need to be really careful if they are recumbent, making sure we, you know, position them properly, making sure their head is elevated, using solid food.
We don't want to be, have a patient that's lying down and we're putting liquid food into their mouth. We don't want to give these patients an aspiration pneumonia. So that's always in the back of our minds as well.
Hydration. Again, I said we measure fluids in and fluids out in our patients to make sure we're keeping on top of, our patient's hydration. So looking at assessing that patient's individual fluid requirements at least daily.
We can look at assessing hydration by looking at things like blood pressure to a certain extent, but ultimately things like skin turga, mucous membrane, hydration. Put fluids out fluids in, urine output, faecal output, all those things. Make sure we're maintaining that balance, but equally, make sure that we're not overdoing it.
We don't want to overhydrate these patients. And again, this is where, monitoring and reassessment of those patients and things like thoracic auscultation is really important to make sure we're not getting things like pulmonary edoema. We regularly check things like PCB and total solids, total protein and electrolytes in those patients normally every 12 to 24 hours.
But again, it's gonna be very much down to that individual patients. We weigh our patients at least twice a day in our hospital. For some of our patients, we may need to weigh them more than that.
And that's really important to make sure we're, we're, we're getting rid of fluids as well. So, some of our patients will expect to put some weight on. But again, if you've got a patient that's not urinating and is putting weight on, you need to make sure you're alert alerting your vets to that.
You know, you need, we need to make sure that these patients have got kidneys that are working. And some of our patients can come in, particularly things like we said, diabetic ketoacidotic patients, very, very sick patients. We need to make sure they've got appropriate kidney function, all those things or else we can give them really further problems.
So making sure we get that balance of fluids, balance of electrolytes really closely monitored to avoid giving these patients complications. I mentioned this in the geriatric patients, but thinking about how we're going to get IV access on these patients. If they're going to be in for long periods of time.
So, so example, DKA patient, we knew he was recumbent, he was in for a long period of time. We placed the central line into the animal, because we end up with these animals where we've gone through all of their limbs within 2 days and we struggle to get catheters into them, particularly when they're going to be long-term patients. So we think really early on, you know, often if they're very sick, we can get away with just giving them a little bit of sedation, sometimes a little bit of something like fentanyl.
To allow us to place those central lines and it's, you know, a fairly straightforward procedure if I'm honest, it's just learning how it's done. Again, I mentioned earlier on, I'm always very aware and very concerned about hospital acquired infections. When we place our central lines, again, we have, a strict protocol in place for them.
They always dealt with, with staff wearing, with gloves. We also put, put some, little antimicrobial, foam discs around them, because again, bacteria will migrate over the surface of those catheters and get into that patient's bloodstream. So we have strict protocols in place for placing them, dealing with them, so cathetic care, we flush them with just normal saline.
We do that regularly. We dress them in place, and as we said, we use these topical little antimicrobial drift this just to try and reduce the incidence of infection. If we do get a patient that becomes pyrexic, our concern is often that it's a catheter associated infection.
And again, just looking at hydration, just remembering to keep an eye on how much these patients are drinking. If they're not on IV fluids, we need to make sure that they are getting enough fluid in. Sounds fairly obvious, but we will measure a specific amount of fluid into that patient's bowl and then check how much they've consumed during that period of time.
Just again, when we're measuring fluids in and fluids out. Bearing in mind that patients may have increased fluid requirements depending on what their disease processes are, depending on what medication they're on. You only need to have your own dogs on rozamide and you realise how much difference it makes and how often you've got to get up during the night.
And I think we often don't really we don't really factor that in for owners as well when patients are going home. I think it's something really important, you know, we need to look after owners as well. When they've got animals that are kind of on these long term medications.
We, as I said, . We can have these patients that develop these decubital ulcers, but wound care is really important. We want to look up for signs of swelling, heat, redness, I need to sort of discharge if they're postoperative patients, you know.
Checking, for surgical site infections is really important. I would say that we keep all our surgical, our, all our surgical incisions covered for at least 48 hours with the dressing postoperatively, just until we can get a good fibrine seal on that wound. We'll often use skin glue on our patients as well, just to try and reduce the incidence of surgical site infections.
But again, wounds, a big source of hospital acquired infections in patients. I talked about this a lot during the, geriatric lecture, but really, I want to try and get these patients up and moving around as much as we possibly can do. When patients are lying down, we all know this.
When you lie down for any length of time, you know, as you get older, you get up in the morning, you've got to have a good stretch, you've got those stiff, stiff muscles, when patients are recumbent for long periods, and particularly when they're sick as well, this will, they can often develop hypermetabolic states. And they'll start to get muscle atrophy and it can happen fairly rapidly. When they're immobile, they're gonna start to get reduced range of motion in joints, they'll start to become weak, they'll get painful.
They have, we mentioned this earlier, reduced blood flow to the periphery. They can start to get this, this, this edoema in their limbs as well. And what we want to try and do is think about early physiotherapy to try and reduce this effect or slow it down as much as we possibly can do, because when they start to get these problems developing, It's really difficult to then go backwards, so we really want to avoid it as much as we can in the first place.
So, Again, part of that patient's nursing care plan, having structured physiotherapy sessions is really, really important. It can improve healing rates in patients. It can reduce complications in patients.
You know, getting hold of one of these big hoist systems that they use for humans is really useful. Often you'll find that people give them away. And you look at things like eBay, you can look at some of the auction sites, and they're great because you can get these patients up into a standing position.
I said, you know, getting them up, getting them stood up can improve tidal volume in the patients, and we can get them to do that for longer. They're big dogs. It's really hard work, longer than what it would be safe for us to do, as nursing staff as well.
Because we all know, like, you dread having those big patients because You know, we need to look after ourselves as well. The type of physiotherapy that we're gonna be able to do will very much be determined by if those patients have had surgery or if they've got any open wounds, who you've got available, what facilities you've got. There's no point me telling you all to use underwash treadmills if you don't have them.
If there are any contraindications, depending on the underlying disease for that patient, if they've got any urine scaling, if they've got any ulcer formation, how tolerant that patient is. Most patients will tolerate some physiotherapy, but again, it's gonna vary. And the financial implications as well.
So we sadly can't do, you know, extensive physiotherapy sessions for free, but we can do little bits of stuff, I think, to help our patients. So physiotherapy can encompass lots of different techniques. So we do early passive range of motion exercises.
So just, and you can do great YouTube videos for, if you Google a passive range of motion exercises, dogs, this will demonstrate just, again, sometimes it's just tiny movements, just tiny flexion and extension of those joints just to maintain mobility. You can do things like strength training, ball work, stretching out again, maintaining range of motion. Cryotherapy.
So we ice pack. All our orthopaedic patients will have, we, we ice pack them, postoperatively every few hours. And again, we have an SOP in place for that to make sure we're not causing problems that we do it very specifically.
But again, just to limit swelling and provide some analgesia for those patients. We can look at doing things like stability training, massage, again, really important. These patients must feel much better for us, just spending time.
You know, a little bit of massage. But ultimately, things like hydrotherapy are amazing. So, what I, my old mastiff that I had, I got, when I got him, he had bilateral root, cruise ruptures.
And he'd been like that for a long period of time, and he had no muscle, hardly on his hind limbs. And he was meant to go to massive rescue, and we did bilateral cruise ship repairs on him. And then he ended up coming to me.
And I swear if we hadn't had a hydrotherapy, we had, we, if we had not had access to an underwater treadmill like I did, I don't think I'd have gotten back to normal as quickly as I did. So I think it's a really, really useful technique. Again, swimming, all those things.
So, this is my old boy that I don't have anymore. Doing some strength work on a ball. His tails wagging, probably because there was some food involved at some points.
But again, this is just increasing, improving kind of muscle and stability and all those different things. I mentioned this, several times, but thinking about behavioural and psychological considerations for these patients is so important. We need to make sure they get good sleep.
Having a night time to their day is really important. So having periods where we can dim the lights or turn lights off in areas and minimise stimulation is so important. Younger animals, you know, we'll often get owners to bring in a favourite, a, a, a t-shirt or something like that that smells of them.
You know, we can all, you know, it can drive us insane. But actually, for younger patients, and particularly for those older patients, I think it can give them some comfort. I do warn owners that these things often go missing in the hospital if patients urinate on them or what have you.
So, Not to be a, you know, a Chanel blanket or anything like that that they desperately want to get back because they may not get it back. Also, we use pheromones, so we have, feely ways in our cat wards. We use these DAP, diffuse as well.
And I do think they're really, really good. I got a rescue lab from the dogs Trust, and they send them all home with these, DAP collars on them as well, just try and reduce anxiety. Remember, these animals are in strange environments, particularly those geriatric patients, particularly, you know, younger patients, but all patients, strange environments.
We're poking them and prodding, we're doing examinations, we're injecting them. No family. It's very difficult.
It's like children. Yeah. You would want to be with them all the time.
So we actually do kind of encourage within limits, owners to come in and visit. And if we can get them. You know, just, we, we will put those animals into a consult room or we'll get owners to take them for a little potter around if that's safe for them to do so.
Just spending time with them in somewhere outside of their kennel where they're getting a positive stimulus. Because much as we try to avoid that, you know, a lot of what we're doing when we're interacting with our patients ends up being fairly negative for them. So, We try to have positive stimuli, so it's just spending quality time grooming with them, sitting with them, but getting illness to do that is great as well.
And if we can do getting those patients up, taking them outside, just to sit in the, I'd say sunshine, not so lightly at the moment, just somewhere outside of the hospital. And ultimately, TLC, I said, tender loving care is what we do. It's hopefully why we all want to be nurses.
And those recumbent patients really need it more than any. So, as you said, regular grooming, interacting with them without any negative outcomes, just spending that quality time. And I know it's so difficult because we're so busy.
But it, you know, we can do that. It can be, you know, I auxiliary staff, whoever, just spending some really nice quality time with these patients. For us, this is kind of part of our recumbent patient care procedure.
So every 2 to 4 hours we hand hygiene, check that patient's bedding, check the positioning of that patient. We'll make sure their head is elevated as much as we can do. If they're internal recumbency, we will turn their hips, reposition their body slightly.
If they're in lateral, we'll turn them from lateral, one lateral to recumbent to the other lateral. If that's not possible, we would have to go immediately to the opposite lateral, but keep an eye out in terms of the respiratory system to make sure they don't don't decompensate. Checking for signs of ulceration, so ocupital ulcers, dressing them appropriately, doing range of motion exercises and massage, and then we've got all those other protocols on top, eye care, oral care, urinary cathetica.
IV and cathetica, all those different parameters. So, for me, having these protocols in place is really useful because it just makes sure we don't forget things. When you're busy, it's easy to forget some aspects.
And this was a little bulldog that we had in, and this was the only way we could get him to go to sleep. So we've got like one of these little footstools that we have in our cat wards. So we have these little footstools that we cover with blankets in our cat wards.
And what he's got is one of those little footstools over there. And this was the only way he could get comfy. So you can see he's well padded, he looks pretty cosy.
He feels, he looks to me as how I should be this morning. So lied in bed, like, some recumbent with lots of blankets and lots of pillows, pretty cosy. But, I, hopefully that was useful for you.
I just love this photo, this photo. He was such a cute dog. And I will confess that I do just sometimes love to get in there with them and just have a little bit of a snuggle when we can get time to do so.
So if anyone's got any questions, I'm more than happy. I managed to do it with 2 minutes to spare, which is some sort of miracle for me, because you know how much I put into my, my sessions, and I'll hand back over. Yes, Louise, this must be OK.
It's, it's almost like I timed it, knowing I had 2 hours and needed to put some stuff out, but that you also wanted to get. Back into bed, maybe. It's a possibility.
I, I, I, I don't think that's gonna happen this morning. I know that other people have got things planned for me to do today, so. All right.
OK. Well, thank you so much, Louise, for yet another fantastic presentation. We have got, a few questions that have come through.
OK. But again, just before we go to questions, as I mentioned earlier in the session, the webinar vet really appreciate your feedback. So if you could spare.
Just a few seconds to complete the feedback survey that has hopefully popped up in a new tab in your browser. That would be amazing. The feedback survey is anonymous unless you provide your contact details.
So if you would like a response to your feedback, please make sure that you include, your contact details, such as your name and email address. Depending on which device you're using to watch the webinar, we've been told that the survey doesn't always pop up. And also, if you're listening to the recording of the webinar and would like to provide feedback, you're always very welcome to email the team using the email address office at the webinar vet.com.
OK, Louise. So, the first question that came through was actually in relation to the previous presentation. You mentioned that people could obtain a copy of the local anaesthetic techniques notes that you mentioned.
Are you happy to email those notes to the webinar vets. Yeah, I can do that for you. Yeah, it's, yeah, I will.
Yeah, I've, it's, they've got good photos in kind of, of schools, as well as me doing those techniques on real patients as well. So you can see what, what you're trying to aim for. And the one thing I would say, if this is ever at all possible, is, you know, have a practise on a cadaver first.
And cadavers don't have to be cats or dogs. You could look at things like foxes, yeah, cause they're all gonna have a, a, a, a similar anatomy when it comes to those schools. The only thing I would say, and I will say this in the present, in the, in the, the, the notes is be very careful.
So there's one technique which is the infraorbital block, so it's going into the little foramen kind of below the eye. Just be very careful in brass phallics and cats because it's a very short. So, in that technique, I just go to the entrance.
So I just go where that frame and that little hole in that skull is and inject my local aesthetic there. Because in the, in the photos, you can see that in, in normal shaped dog skulls, I will go into that with my needle. I don't want anyone to pop an eye.
I'm sure nobody wants to pop eyes, but just, it'll say that in the notes, but just be aware of that. That's great. Thank you very much, Louise.
Perhaps another webinar in itself. Oh, yeah, maybe. I love, I love local anaesthetic techniques.
I think it makes such a massive difference. You know, I want those patients to go home and be happy and normal, and we, you know, we, I think we forget what we're doing with these old patients a lot of the time. Yeah, that's great.
Thanks, Louise. A question that came in, towards the start of the 2nd presentation. Regarding oxygen therapy, whilst you're talking about that, someone has asked, would a child's humidifier be useful?
I don't actually know what a child's humidifier looks like, if I'm honest. Is this for administering oxygen? The person hasn't said, but I would have thought so.
If that you're welcome to pass on my email details and for them to get in touch and if they want to find me, send me a link and an online link to what it is and then I can. I can answer that one. I don't actually know what one looks like.
All right, thanks, Lou. The next question that's come through with urinary catheter care, do you just use a 50/50 diluted chlorohex or a different concentration? We generally use a 0.05 chlorhexine solution.
I mean, you, yeah, or yeah, we use quite a weak chlorhexidine solution for, for, for wiping down those catheters, particularly if you're going to come into contact with mucous membranes. So we literally wipe them. From vulva or PrEP use all the way down.
Because if we think about how these patients get UTIs related to catheters, is catheters, bacteria will migrate over the surface of that catheter. So we're just doing that regulator, just try and get rid of that bacteria. OK, thanks, Louise.
And then something that I was thinking about, there's clearly lots of factors to consider when dealing with these patients. And you mentioned SOPs and how you then at the end, recommended that it's a good way of making sure that you don't forget anything. And, I was just gonna say, I think a lot of people will be using the webinar recording to either create or update that's SOPs for these, patients, because there's so much fabulous information in there.
I think it's very difficult as well, because we try to make what we do as evidence-based as possible, but there's so So little evidence on what we're having to do is extrapolate from human medicine. If you look at human nursing care, and we're doing it in veinary care, we have these bundles in place and in humans, these bundles are in place to improve outcome in patients, particularly for things like patients on ventilators and all those things. But like these bundles of care, we're going to do things in a very similar way in all our patients.
And so for those recumbent patients, To a lesser or greater extent, we can kind of expect complications. So hopefully having those SOPs, we're just gonna try and minimise that. And I'm getting old, like, I forget what stuff I'm meant to be doing all the time.
So, yeah, it's good to have a prompt, isn't it? Yeah, so if you're feeling a bit stressed and rushed, and the, you know, you're managing lots of different cases, you know, it's a good way of making sure that things aren't overlooked. Things get overlooked all the time and in the best of places.
So, yeah. Yeah. Fantastic.
Thank you very much again for both your presentations within this webinar session this morning, Louise. Your passion for these subjects is, really evident, and thank you so much for sharing your knowledge with us. You're very welcome.
Thanks for having me again speak for you. Oh no, it's an absolute pleasure. Thank you to everyone who attended the live webinar.
It's so lovely to have your company. And, for submitting questions and feedback on the webinar. Thank you also to Josh and our sponsors, JHP recruitment.
And don't forget the link to their website is in the chat box, for you to browse their website. And last but not least, thank you to the very lovely Catherine, who has been co-hosting with me on the webinar this morning. All the sessions will be recorded and you'll be able to access them on the website once they've been uploaded.
So hopefully we'll see you soon and thank you again for joining us. I hope you can join us on some of the other sessions during the virtual congress.
