How to apply your medical knowledge and plan amazing nursing care: part 2
One of my favourite things about medical nursing is how varied the care that we give our patients actually is.
Think about it - yes, diseases are similar, but each of our patients are so individual and different diseases can affect them so differently, dramatically changing how we care for them. And, on top of that, they often have multiple diseases concurrently, complicating things even more!
All of this means lots of opportunities to use our brains, and lots of different skills we can incorporate into the care of our patients.
In this post, we’re continuing to apply our knowledge to real cases, planning the nursing care for Dave, a DSH with lower urinary tract disease. But unlike your ‘standard’ blocked bladder, we need to do a little more to support his kidneys!
Just like in the last post, I’m going to give you an overview of his case, and give you a few prompts to think about when planning your care for him. Imagine he was in your hospital - what would you do? How would you manage him?
Don’t forget, if you want more information on planning care for renal patients, you can grab a copy of the renal pocket guide, which contains an overview of their nursing care, practical skills you can use when nursing them, and much more!
Meet Dave
History
Dave is a 4-year-old male neutered DSH, weighing 6.4kg. He has always been a bit of a stressy boy, and has presented to the clinic on one previous occasion with a urethral obstruction. The last time he had similar signs was 1.5 years ago, and he now is managed with a commercial urinary diet (though does not have struvite crystalluria/stones), GAG replacers and l-tryptophan, and NSAIDs if needed based on cystitis signs, though he has not required this since list last visit.
Dave’s family are currently on holiday and he is being cared for by a neighbour who pops in daily to check on him, feed him and empty his tray. This morning, when he was checked, the neighbour found Dave very lethargic and lying in his litter tray reluctant to move. They bring him straight down to the hospital and you meet them in reception on arrival.
Triage
You assess Dave and find the following:
Bradycardia (heart rate 116 beats/minute, inappropriately normal given the situation)
Tachypnoea (respiratory rate 66 breaths/minute)
Normal respiratory effort
Normal lung sounds on auscultation and no audible heart murmur
Poor quality peripheral pulses
Pale pink and tacky mucous membranes
CRT 2 seconds
Marked caudal abdominal pain with a large, distended and hard bladder
You alert the veterinary surgeon who obtains consent for emergency treatment, general anaesthesia and urinary catheter placement in between consultations.
They ask you to obtain IV access, run bloods for a biochemistry, electrolytes, PCV, total solids and venous blood gas, and give a 10ml/kg bolus of lactated Ringer’s solution over 20 minutes, alongside rescue analgesia with 0.3mg/kg of methadone IV.
How would you calculate Dave’s fluid bolus?
10ml/kg x 6.4kg = 64ml
60 minutes divided by 20 minutes = 3
3 x 64ml = 192ml/hour
Set your fluid rate on the drip pump to 192ml/hour, set the volume to be infused to 64ml and the infusion time to 20 minutes.
Diagnostics and Procedures
You run Dave’s bloods and note the following results:
Creatinine >500 umol/l; after dilution 1248 umol/l
Urea >46mmol/l; after dilution 52.5mmol/l
Potassium elevated at 6.9mmol/l
Moderate metabolic acidosis (pH 7.24, HCO3- 16.2mmol/l, BE -6)
PCV elevated at 52%
Total solids elevated at 92g/L
You are asked to sedate Dave with a fellow VN and place his urinary catheter whilst the veterinary surgeon finishes their last consultation. What would you get ready for this?
Sedation:
Non-cardiovascular depressant medications (the veterinary surgeon gives you a midazolam and alfaxalone sedation plan, alongside the methadone you have already administered)
Oxygen source
Monitoring (ECG due to hyperkalaemia, blood pressure, SpO2 and temperature)
Emergency airway access and induction agent in case conversion to GA is needed (laryngoscope, topical laryngeal anaesthetic spray, ET tubes and tie)
Saline flush syringes
Warming devices
Catheterisation:
Urinary catheter suitable for both unblocking and indwelling use
Sterile gloves
Sterile drape
Sterile lubricant
Sterile saline for flushing
Sterile syringes
Sample containers (plain)
Non-absorbable suture material
Elizabethan collar
Closed collection system
Dave’s catheter is placed uneventfully and you secure it in place, before emptying and flushing his bladder, emptying the bladder again, and attaching a closed collection system.
During his sedation, you note there are no P waves present on his ECG.
Which medications do we use to manage hyperkalaemia in situations like this, and how do they work?
There are four options when it comes to treating hyperkalaemia:
Fluid therapy, e.g. with 0.9% saline or lactated Ringer’s solution
Calcium gluconate, which protects the heart from the effects of the potassium, but does not reduce the potassium levels themselves
Glucose, which stimulates the production of insulin, which moves potassium from the ECF to the ICF
Glucose and insulin together, which moves potassium from the ECF to the ICF.
You alert the vet to the abnormal ECG findings, as they have just finished their consultation and come through to check on your progress. They ask you to administer a dose of calcium gluconate IV (diluted 1:4 and over 10 minutes at a dose of 1ml/kg) and continue ECG monitoring in recovery.
Treatment
As Dave recovers, the veterinary surgeon gives you the following treatment plan:
Continued analgesia with methadone at 0.2-0.3mg/kg every 4 hours depending on pain scores
Measuring of Dave’s urine output every 4 hours, and adjustment of his fluid rate to match ins and outs
Supportive treatment with maropitant (1mg/kg IV every 24 hours)
Daily reassessment of Dave’s renal parameters, acid-base status and PCV/total solids initially
Nursing Care
How would you nurse Dave in the hospital - what would your considerations be for him? Have a think using the prompts below as a rough guide, then let’s discuss his nursing below!
Hydration
Nutrition
Urination
Monitoring
Vascular access and sampling
Comfort
Behavioural considerations
General nursing care
Hydration
Dave was hypovolaemic on presentation, which was corrected with fluid boluses, and he now remains on an appropriate rate to maintain hydration. However, patients with urinary and renal disease have rapidly-changing fluid requirements. There are two main things I would be worried about with Dave. These are:
Post-obstructive diuresis: After a urinary obstruction is relieved, patients often have increased urine output, losing larger volumes of fluid and with that, electrolytes. Further dehydration and electrolyte/acid-base imbalance could result.
Oliguria/anuria: Dave has an acute kidney injury (AKI) secondary to his obstruction. This means his kidneys may have an impaired ability to form urine, and we can see oliguria (a urine output of <0.5ml/kg/hour) or anuria (no urine being formed) as a result. If this happens, he is at an increased risk of fluid overload, since he can’t turn this fluid into urine properly.
Monitoring Dave’s fluid balance is therefore really important. We want to be weighing him regularly and quantifying the amount of fluid going in and out:
Fluids in: the total across IV fluids, oral water intake +/- things like CRIs and liquid diets where used
Fluids Out: urine output +/- additional fluid losses through things like diarrhoea and vomiting/regurgitation where appropriate
We want to avoid his fluid rate significantly differing to the rate at which he’s losing fluid - if it does, we risk either volume overload, or underhydration.
Nutrition
Nutrition is an important consideration in any unwell patient. Dave’s appetite history is reported to be normal, but he is being assessed less regularly and cared for by a neighbour currently. He usually eats a prescription urinary diet, but in the hospital we want to get him eating anything.
We need to calculate his RER and measure the volumes of food offered and eaten, ensuring he is eating >85% of his requirement in the hospital. We also want to address any underlying causes for hyporexia or anorexia, for example pain and nausea, to encourage him to eat voluntarily.
If his food intake remained significantly low in hospital, we could consider something like a naso-oesophageal feeding tube to offer short-term nutritional support. These can be placed by nurses under the direction of the veterinary surgeon.
Urination
Dave’s urination is a key nursing consideration for two reasons. Firstly, he has presented with a primary urinary disease and monitoring this is a vital part of his nursing care. And secondly, because Dave’s urination will give us important clues as to his renal function.
We need to regularly assess Dave’s urine output to determine how well his kidneys are functioning. By converting his total urine volumes into ml/kg/hour rates, we can quickly determine if oliguria is present, or if we need to adjust our fluid therapy rates.
Dave’s urinary catheter should be managed aseptically to minimise the risk of a hospital-acquired infection. Gloves need to be worn when the catheter or collection line are handled, and the catheter, prepuce and line should be cleaned with skin disinfectant solution every 4-6 hours. Where catheters remain indwelling for >48 hours, it may also be useful to perform an in-house sediment examination to look for signs of infection.
Monitoring
There is a lot to keep an eye on in Dave’s case, including:
Heart rate and pulse quality
Heart rhythm (ECG trace) and pulse synchronicity
Blood pressure
Respiratory rate, pattern and effort
MM colour and CRT
Demeanour
Pain scores and comfort levels
Appetite
Hydration status
Bodyweight
Temperature
Evidence of nausea or vomiting
Urine output
Defecation
We should tailor the frequency of these checks to Dave’s clinical status - for example, we’ll likely be monitoring his cardiovascular status much more regularly initially, and then reducing the frequency of these checks as he stabilises and his potassium levels normalise.
Pain and Comfort
Urinary obstructions are painful, and regular pain assessment is a vital part of Dave’s nursing care. Pain levels should regularly be scored using a validated assessment tool, alongside interpretation of his vital parameters. Our options for multimodal analgesia are limited by his kidney injury, since NSAIDs would be contraindicated in his case.
Local anaesthetic techniques can also be considered at the time of catheterisation - for example, a lumbosacral or sacrococcygeal epidural (both of which must be performed by a veterinary surgeon and require deep sedation or general anaesthesia) can provide additional analgesia during and shortly after placement.
Vascular Access and Sampling
We know that Dave needs daily blood samples in addition to his IV fluid therapy and medications. We could utilise something like a sampling catheter to allow repeated blood draws without venipuncture, if the veterinary surgeon is happy with this. These can be placed relatively quickly and easily by nurses, either under sedation for urinary catheter placement, or (sometimes) in conscious patients.
Regardless of the type of venous catheter placed, this should be regularly assessed for signs of thrombophlebitis or perivascular fluid/medication administration. Regular bandage inspection/changing and flushing is indicated, alongside aseptic handling.
Behaviour
In addition to all of our general day-to-day nursing care, behavioural assessments are something I wanted to highlight in Dave’s case. We know that cats with lower urinary tract disease can be a particular challenge in the hospital. They are often very stressed in the clinic, and can be challenging to treat, get eating, and generally keep happy and comfortable in the hospital.
In Dave’s case, we could consider (if the veterinary surgeon feels it would be appropriate) trialling anxiolytics (e.g. gabapentin) and monitoring response, depending on his stress levels within the hospital.
In addition to this, providing a hiding space in his kennel, using pheromones and gentle handling, keeping his ward quiet and calm, and utilising feline-friendly handling are important behavioural considerations for him.
And when Dave goes home…
It is likely Dave will be left with some degree of chronic kidney disease (depending on his recovery from his AKI and his renal parameters at discharge). If this is the case, he will need to be managed as a CKD patient after he is discharged. Ideally this would be done by feeding an appropriate therapeutic renal diet +/- administering other treatments as required, depending on his clinical condition.
We would also need to re-stage his kidney disease at appropriate intervals, and potentially use things like renal nursing clinics to offer long-term support.
Alongside managing Dave’s kidney disease, we also need to think about his lower urinary tract disease. Can we perform an environmental assessment? Do we need to ask his family to make any changes to the number or placement of his resources? Does he live in a multi-cat household? What is the interaction like between the cats, if so?
The opportunities to use our skills don’t end when Dave goes home - there’s lots we can do after this, too!
How would you nurse Dave if he came in to your hospital? Did you have anything else on your list of considerations? I’d love to know your thoughts, so please DM me on Instagram and let me know!
And remember, if you want more information on how to perform these practical skills and plan Dave’s nursing care, as well as your other renal patients, you can find it all in the renal pocket nursing guide here.
